Nasoorbitoethmoid Fractures Research Articles

Facial trauma education in radiology: using surgeon feedback as the benchmark for success

Rationale and objectivesInterpreting CT studies of facial trauma is challenging, and there are often substantial differences in the characterization of complex facial trauma between radiologists and surgeons. We designed a collaborative multidisciplinary project to reconcile differences in facial fracture interpretation through an educational intervention. The effectiveness of this intervention was evaluated through surgeon feedback on radiology reports.Materials and methodsRadiology residents, neuroradiology fellows, and neuroradiology attendings were recruited as participants at a single tertiary care academic center. Otolaryngology residents were recruited as evaluators. Participants completed surveys and provided preliminary reports for example cases of facial trauma before and after attending an educational session. Evaluators performed a blinded review of these preliminary reports based on ideal reports developed by surgical and neuroradiology attendings.Results26 participants (20 residents, 1 neuroradiology fellow, 5 neuroradiology attendings) completed the study. Six otolaryngology residents participated as evaluators. To assess interrater reliability, three evaluators graded a shared set of 15 reports and demonstrated substantial agreement with a Kendall’s W of 0.71. Participants demonstrated significant improvement in overall report accuracy, clarity, and organization. In subunit analysis, there were significant improvements in reporting Le Fort, nasoseptal, and nasoorbitoethmoid fractures. No significant improvements occurred in the reporting of upper face, zygomaticomaxillary complex, or mandibular fractures. In contrast, survey analysis demonstrated significantly improved confidence in interpreting trauma involving all facial subunits.ConclusionCompared with survey results, surgeon assessment of radiology reports better demonstrated areas of improvement after an educational intervention. A multidisciplinary approach to assessing educational efforts may better evaluate the practical effectiveness of educational interventions.

In- Versus Out-Fracture: A Novel Concept in Naso-Orbito-Ethmoid Injury.

A retrospective study. The Markowitz-Manson classification system categorizes nasoorbitoethmoid (NOE) fractures by severity of injury and remaining integrity of the medial canthal tendon. However, this system does not account for direction of bony displacement (in-fracture vs out-fracture), which can greatly affect symptomatology and management. We hypothesize that NOE fractures will present differently based upon their severity: Type I injuries are likely to present with medial nasal bone displacement (in-fracture), whereas Type III fractures will be more prone to lateral displacement (out-fracture). A retrospective review was performed for all patients with NOE fractures who were evaluated by the plastic surgery department at a level 1 trauma center over a 6-year period. Computed tomography data were evaluated to assess for directionality of fracture segment displacement. Frequencies of medial, lateral, and non-displacement across NOE types were compared by Chi-Squared Goodness of Fit and Fisher's Exact Tests. 111 patients met inclusion criteria. The patient population was 73.9% male and averaged 51.2years old. When bilateral fractures were counted independently, there were 141 cases in total: 115 Type I, 20 Type II, and 6 Type III. Type I fractures were most commonly in-fractured (48.7%), while Type III injuries were consistently out-fractured (100%) (p < .001). While Type II and III NOE fractures have dominated clinical focus, this study highlights the prevalence of impaction within Type I fractures. These findings advocate for a more comprehensive approach to the evaluation of Type I NOE fractures and their potential risks, including traumatic hypotelorism and nasal airway obstruction.

Evlauation of Fixation Techniques in Naso-orbito-ethmoidal Fractures: A Comparative Study

ABSTRACT Objective: Comparing fixation procedures for managing naso-orbito-ethmoidal (NOE) fractures. Methods: Group A (plate and screw fixation), Group B (Kirschner wire (K-wire) fixation), Group C (absorbable plate and screw fixation), and Group D (No fixation) were formed from 120 NOE fracture patients. The facial injury severity scale, visual analogue scale, CT scans, and clinical examination examined functional and cosmetic outcomes, complications, and postoperative stability. Results: The study found that plate and screw fixation (Group A) had the highest stability and aesthetic results, followed by absorbable plate and screw fixation (Group C). Conservative management (Group D) had the worst outcomes, while K-wire fixation (Group B) had good results but more complications. Results showed substantial differences in functional, aesthetic, complications, and postoperative stability between groups (P &lt; 0.05). Conclusion: Plate and screw fixation is the most successful and dependable approach for treating NOE fractures, with superior functional and aesthetic outcomes, reduced complications, and higher postoperative stability than K-wire fixation, absorbable plate and screw fixation, and conservative care. Absorbable plate and screw fixation may function instead of metal. Conservative care should be rare. Larger multicenter randomized controlled trials should corroborate these findings.

Pediatric Nasoorbitoethmoid Fractures: A Single Institution's 15-Year Experience.

Nasoorbitoethmoid (NOE) fractures impact growth of the craniofacial skeleton in children, which may necessitate differentiated management from adult injuries. This study describes characteristics, management, and outcomes of NOE fractures in children seen at a single institution. A retrospective review of patients under 18 years who presented to our institution from 2006 to 2021 with facial fractures was conducted; patients with NOE fractures were included. Data collected included demographics, mechanism of injury, fracture type, management, and outcomes. Fifty-eight patients met inclusion criteria; 77.6% presented with Manson-Marcowitz Type I fractures, 17.2% with Type II, and 5.2% with Type III. The most common cause of injury was motor vehicle accidents (MVAs, 39.7%) and sports (31%). Glasgow Coma Scale and injury mechanism were not predictive of injury severity in the pediatric population ( P =0.353, P =0.493). Orbital fractures were the most common associated fractures (n=55, 94.8%); parietal bone fractures were more likely in Type III fractures ( P =0.047). LeFort III fractures were more likely in type II fractures ( P =0.011). Soft tissue and neurological injuries were the most common associated injuries regardless of NOE fracture type (81% and 58.6%, respectively). There was no significant difference in type of operative management or in the rates of adverse outcomes between types of NOE fractures. These findings suggest that pediatric NOE fractures, although rare, present differently from adult NOE fractures and that revisiting predictive heuristics and treatment strategies is warranted in this population.

Increased Reliability in Medial Canthal Tendon Reposition in Nasoorbitoethmoidal Fractures with Computer-assisted Surgery and Surgical Navigation

Summary: Avulsion of the medial canthal tendon secondary to nasoorbitoethmoidal fractures leads to severe aesthetic and functional impairments. The tendon should be repositioned at the posterior lacrimal crest. Owing to the complexity of nasoorbitoethmoidal fractures, accurate location of this point during surgery can be challenging. With the aid of computer-assisted planning and surgical navigation, the point at which the medial canthal tendon should be repositioned can be easily and precisely located. We have developed an innovative navigation-assisted technique that increases the reliability and safety of internal canthus repositioning. We performed a case series of three consecutive patients who underwent medial canthal tendon repositioning using computer-assisted planning and surgical navigation. We believe that this innovation provides a new and useful application of computer-assisted planning and surgical navigation in craniomaxillofacial surgery.

D77. In-fracture and Out-fracture: Novel Conceptions of Nasoorbitoethmoid Injury

PURPOSE: Nasoorbitoethmoid (NOE) fractures are commonly categorized by the Markowitz-Manson classification system, which grades severity of injury by degree of comminution and involvement of the medial canthal tendon. However, this system does not account for directionality of bony injury, which may impact clinical findings. We propose these fractures may be conceived as either in-fractured, resulting in nasal airway obstruction, or out-fractured, resulting in traumatic telecanthus. METHODS: A retrospective review was conducted of all patients with NOE fractures referred to plastic surgery at a tertiary academic medical center from 2017—2022. Radiographic data (CT) were evaluated to assess for directionality of NOE segment involvement. Frequencies of in-fracture and out-fracture across NOE type were compared by chi-squared test. RESULTS: Among 57 adults, 73 NOE fractures were identified with 39.7% (29) as Type 0 (non-displaced), 43.8% (32) as Type I, 12.3% (9) as Type II, and 4.1% (3) as Type III. Type I fractures were significantly associated with in-fracture (p < 0.0001), whereas Type III fractures were more likely out-fractured (p = 0.02). Type II fractures were not significantly associated with either presentation (p = 0.32). CONCLUSION: We discover that Type I NOE fractures more frequently present with in-fracture, whereas comminuted injuries such as Type III are typically out-fractured. Further study will validate these findings in a larger cohort and correlate radiography with clinical symptoms.

Local Approaches for the Reconstruction of Frontal and Naso-Orbito-Ethmoidal (NOE) Fractures: Presentation of a Clinical Case and Literature Review

Naso-orbito-ethmoidal (NOE) fractures are considered a challenge in reconstruction, due to the anatomical structures involved, such as the medial canthal ligament and the lacrimal apparatus [1], which leads to a complex functional and aesthetic compromise. For surgical access to the area, the use of the coronal, Lynch-Howarth, glabellar “open sky”, “gull wings” and a combination of the last two are described. However, the severity of the trauma and mainly the neurological compromise of the patient will dictate the choice of the approach that allows functional and comprehensive repair of the affected region. In cases where there is no neurological compromise and it is not necessary to carry out a subcranial approach, the use of local approaches is justified, providing adequate visibility and direct access to the fractured region, allowing an adequate reduction and placement of fixing material. A clinical case of anterior frontal sinus wall fracture and NOE fracture are presented, performing the combination of the gull-wing and open-sky approach, described as butterfly wings, achieving adequate visibility and reconstruction.

Comparing diagnosis of midfacial fractures by radiologists and plastic surgeons.

Clinicians who manage facial fractures often rely on radiologist interpretations to help with assessment and management. Among treating physicians, facial fractures are categorized into clinically relevant patterns of injury. On the other hand, while radiologists are unsurpassed at identifying individual breaks in the bone, larger fracture patterns are not always conveyed in radiology reports. This study aims to assess the frequency with which the terminology describing midfacial fracture patterns is concordant among radiologists and treating clinicians. The authors identified patients with different patterns of midfacial injury including Le Fort I, Le Fort II, Le Fort III, naso-orbito-ethmoid (NOE), and zygomaticomaxillary complex (ZMC) fractures. Plastic surgery consult notes and radiological imaging reports were reviewed for concordance in documentation of injury patterns. Identification of individual fractures consistent with the diagnosed fracture pattern was also recorded. Radiologists were noted to be highly successful in describing individual fractures of the facial bones, identifying at least two defining components of a fracture pattern in 96% of Le Fort, 88% of NOE, and 94% of ZMC injuries. However, when injury patterns were considered, only 32% of Le Fort, 28% of ZMC, and 6% of NOE fractures were explicitly identified in radiology reports. Radiologists are highly skilled in discerning individual fractures in facial trauma cases. However, less reliability was seen in the identification of fracture patterns in midfacial injury, with particular weaknesses in descriptions of NOEand ZMC fractures. This data suggests that greater focus on patterns of midfacial injury would improve the clinical applicability of radiological reports.

Transnasal Medial Canthopexy Supported with Autogenous Bone Graft: A New Method for Repair of Traumatic Telecanthus.

The medial canthus is an important structure to maintain the shape of the eye and assist in drainage of the lacrimal sac. Traumatic telecanthus is a difficult deformity to treat which involves both esthetic and functional aspects. Transnasal wiring remains the gold standard for repair of the medial canthal tendon (MCT) avulsion; however, it is often complicated by canthal drift, extrusion of wires, and in-fracture of the contralateral orbital bones from pressure by tied wires. In order to overcome traditional transnasal wiring technique pitfalls, this study proposes a transnasal wiring fixation method supported with a bone graft to treat patients presenting with telecanthus following complex nasoorbitoethmoid fractures. From December 2018 to October 2020, 12 patients with traumatic telecanthus underwent transnasal wiring fixation of the MCT supported with bone graft. The wire holding the MCT was delivered through a single hole to the contralateral side and secured to a small bone graft by passing the wire through 2 holes in the graft in a button-like fashion. Then the wire end is pulled again to the affected side through the same hole and the 2 wires ends are tightly twisted after setting the MCT posterior to the lacrimal crest. Restoration of the MCT to its normal position was achieved in all patients. There were no observed major complications. Only 2 cases of wound infection and 1 case of dacrocystitis were encountered, which settled with conservative management. The preoperative palpebral fissure width (mean: 28.33mm ± 2.188mm) was significantly lower than the postoperative palpebral fissure width (mean: 34.17mm ± 1.03mm) ( P< 0.05). This study introduces a modified technique of transnasal wiring fixation to restore palpebral shape and intercanthal distance. The proposed technique could eliminate most of the frequently observed complications of the traditional methods.

Isolated Medial Maxillary Buttress Displacement in Naso-Orbito-Ethmoid Fractures: A Surgical Indication to Resolve Nasal Airway Obstruction.

The aim of this study was to present a case series emphasizing low medial maxillary (pyriform) buttress displacement in naso-orbito-ethmoid (NOE) fractures as an operative indication, in the absence of the typical NOE surgical indications (medial canthus displacement, midface bony comminution, nasal bone collapse, and orbital indications), to prevent nasal airway obstruction. Five cases of minor NOE fractures are reviewed, where only the low medial maxillary buttress was displaced. The typical surgical indications for NOE repair were absent. In each case, the pyriform buttress was medially and posteriorly displaced, creating nasal airway obstruction in each patient. The medial canthal tendons were all nondisplaced, there was no diplopia, and the other 2 cardinal buttresses (infraorbital rim and nasofrontal junction) were minimally displaced or greensticked. In the acute setting, patients were treated with open reduction and internal fixation. With delayed presentation, septorhinoplasty or osteotomy and fixation were used. Among the patients who had adequate follow-up, nasal airway obstruction was resolved. This series suggests that, in NOE fractures with isolated displacement at the medial maxillary buttress, nasal airway obstruction should be considered an operative indication (independent of the classical indications) in order to prevent or resolve nasal airway obstruction.

The Association of Zygomaticomaxillary Complex Fractures with Naso-Orbitoethmoid Fractures in Pediatric Populations.

Naso-orbitoethmoid fractures associated with ipsilateral zygomaticomaxillary complex fractures are more challenging injuries than zygomaticomaxillary complex fractures alone. However, there is a paucity of information on this complex fracture pattern in the pediatric population. This study investigated the cause, treatment, and outcomes of combined zygomaticomaxillary complex and naso-orbitoethmoid fractures versus isolated zygomaticomaxillary complex fractures in pediatric patients. This was a 25-year retrospective cohort study of pediatric patients who presented to a single institution with zygomaticomaxillary complex fractures. Baseline patient demographics and clinical information, and concomitant injuries, treatment/operative management, and postoperative complications/deformities were recorded and compared between patients with combined zygomaticomaxillary complex and naso-orbitoethmoid fractures and patients with isolated zygomaticomaxillary complex fractures. Forty-nine patients were identified to have had zygomaticomaxillary complex fractures in the authors' 25-year study period, of whom 46 had adequate clinical documentation and follow-up. Seventeen patients had combined zygomaticomaxillary complex-naso-orbitoethmoid fractures, of whom six had panfacial fractures. Both patient groups (zygomaticomaxillary complex only and combined zygomaticomaxillary complex-naso-orbitoethmoid fractures) were similar in terms of demographics. However, a significantly greater proportion of combined fracture patients experienced postoperative complications compared to isolated zygomaticomaxillary complex fracture patients, even after excluding those with panfacial fractures (87.5 percent versus 35.3 percent; p < 0.001). Enophthalmos (37.5 percent) and midface growth restriction (37.5 percent) were the two most common complications/deformities in all combined fracture patients. High-impact trauma can lead to zygomaticomaxillary complex fractures with associated naso-orbitoethmoid fractures in children. This injury pattern was found to cause significantly greater postoperative morbidity than isolated zygomaticomaxillary complex fractures alone. Thus, pediatric patients presenting with this complex facial fracture pattern should be closely monitored. Risk, II.

Management of Pediatric Nasoorbitoethmoid Complex Fractures at a Level 1 Trauma Center

A universally accepted treatment algorithm for rare pediatric nasoorbitoethmoid (NOE) fractures has yet to be established. In this study, the authors examine how severity of pediatric NOE fractures interplays with patient characteristics, management choices, and complications from injury and surgical intervention at our institution. A retrospective chart review was performed for all cases of pediatric NOE fracture at a level 1 trauma center (University Hospital in Newark, New Jersey) between 2002 and 2014. Fifteen of 1922 patients met our inclusion criteria. Ten (66.7%) demonstrated Markowitz type I injuries, 2 (13.3%) had type II NOEs, and 3 (20%) sustained type III fractures. Five (33.3%) of our patients were only monitored. Six (40.0%) were treated with plate fixation. One patient (6.7%) required enucleation alone, while 1 (6.7%) warranted enucleation with medial canthoplasty and plate fixation. Transnasal canthopexy was performed for 1 patient (6.7%). Zero patients managed without surgery had complications at 1-year follow-up. Surgical intervention was associated with complications in 4 of 15 patients. Both nonoperative treatment and plate fixation were associated with a higher rate of complications from initial injury or subsequent therapy when than other mentioned forms of treatment (P = .004). Nonoperative management for nondisplaced fractures is associated with zero complications at 1-year follow-up in our data; plate fixation and watchful waiting yield significantly fewer postoperative complications and injury sequelae than surgical intervention for medial canthal tendon and globe injuries.

Facial Fractures and Mixed Dentition – What Are the Implications of Dentition Status in Pediatric Facial Fracture Management?

The stage of maturation of the pediatric facial skeleton at the time of injury has a significant impact on both facial fracture patterns and management strategies. For instance, the relative prominence of the pediatric cranium during the early years of life affords protection to the structures of the midface, whereas delayed aeration of the frontal sinuses may predispose younger patients to frontal bone fractures. The dentition status of a pediatric patient may have similar implications in the setting of facial fracture. In this study, the authors examine the effect of dentition status on facial fracture patterns and management strategies at an urban, level 1 trauma center. A retrospective chart review was performed for all cases of facial fracture occurring in the pediatric patient population at a level 1 trauma center (University Hospital in Newark, NJ) between 2002 and 2014. A database including patient demographics, facial fracture, and concomitant injury patterns, and operative management data was constructed and analyzed. A total of 72 patients with mixed dentition met inclusion criteria for our study and were compared against patients with primary (n = 35) and permanent (n = 349) dentition. The mean age at presentation was 9.2 years, with a male predominance of 68%. The most common fracture etiology was pedestrian struck accident (n = 23), fall (n = 21), motor vehicle collision (n = 12), and assault (n = 9). The most frequently identified facial fractures were that of the orbit (n = 31), mandible (n = 21), nasal bone (n = 19), and frontal sinus (n = 14). Additionally, 8 Le Fort and 4 nasoorbitoethmoid fractures were identified. Twenty-one patients (29%) required operative management for 1 or more facial fractures. Operative intervention was required in 38% of mandibular fractures, with 6 patients requiring only maxillomandibular fixation and 2 requiring open reduction and internal fixation with titanium plating. Nine cases of orbital fracture (29%) were managed operatively - 4 with absorbable plates, 3 with Medpor implants, and 8 with titanium plating. Management of all nasal fractures requiring operative intervention was accomplished through closed reduction. Concomitant injuries included traumatic brain injury (TBI) (n = 35), skull fracture (n = 24), intracranial hemorrhage (ICH) (n = 20), and long bone fracture (n = 12). Seventeen patients required admission to the intensive care unit. Patients with mixed dentition were significantly more likely to sustain frontal sinus and Le Fort fractures (P < 0.01), as well as skull fracture, ICH, and TBI (P < 0.01) as compared to those with permanent dentition. The dentition status of a pediatric patient may have significant implications in both patterns of injury and operative management strategies in the setting of acute facial trauma. Our study finds that Le Fort and frontal sinus fractures were significantly more common in patients with mixed dentition. Severe concomitant injuries such as ICH and TBI were also significantly more likely in this cohort. A patient's dentition status may also play a role in the decision for ridged fixation of mandibular and orbital fractures, as well as the method of maxillomandibular fixation in maxillary and mandibular alveolar fracture.

Nasoorbitoethmoid fractures in a tertiary care hospital of eastern India: A prospective study.

Purpose:The purpose of this study was to report on the pattern of occurrence of nasoorbitoethmoid (NOE) fractures in Odisha and the various factors that influence their distribution.Methods:The study period was from January 1, 2016 to December 15, 2017. After approval from the Institutional Ethics Committee, all patients diagnosed with naso-orbito-ethmoid fractures reporting to the department of OMFS and Level-1 trauma centers were included in the study. Sociodemographic data along with the etiology and type of fracture were mentioned. Associated injuries to other body parts were noted. Open reduction was possible only in five cases of NOE fractures. The treatment plan including the operative approach and postoperative results was evaluated.Results:A total of 1192 patients with facial fracture were seen, of which 52 (4.36%) patients had NOE fractures. Males far outnumbered females in a ratio of 9:1. Thirty-three patients (63.46%) had unilateral NOE fracture, while the rest 19 (36.54%) had bilateral NOE fracture. Sixteen (30.76%) cases were classified as Type I, 35 (67.30%) as Type II, and 1 (1.92%) as Type III. Road traffic accidents were the most common cause of NOE fractures (69%), followed by fall (17%) and assault (10%). The most common neurological injury to be associated with NOE fractures was pneumocephalus (29%), followed by diffuse axonal injury (8%). Telecanthus (100%) was found to be the primary clinical feature in patients of NOE fracture, followed by a depressed nasal bridge (92%). Fracture of the nasal bone was invariably associated with NOE fracture. Complications observed due to untreated NOE fractures included a shortened and retruded nose, shortened palpebral fissures, telecanthus, and enophthalmos.Conclusion:Contemporary management of NOE complex fractures demands precise diagnosis and immediate surgical management with anatomic reduction and rigid fixation of the involved bone segments. With an improvement in socioeconomic status and increased awareness among maxillofacial surgeons, hopefully, a greater number of NOE fracture patients will avail the benefits of open reduction in future.

An Endonasal Incision Adds a Second Vector of Manipulation During Percutaneous Reduction of Fractures Involving the Frontonasal Region.

A case report. To describe a modification of percutaneous reduction of frontal sinus and/or naso-orbito-ethmoid (NOE) fractures, adding an endonasal intercartilaginous incision to provide a second vector of manipulation. Case report with particular attention paid to surgical technique, followed by a brief review of relevant literature. Technique: A Carroll-Girard screw is used to engage the thickest part of the anterior wall of the frontal bone through a stab incision just superior to the frontonasal junction. An endonasal intercartilaginous incision is then made and a Cottle elevator is introduced to manipulate the fracture from the inferior aspect of the frontonasal junction. The percutaneous screw and the endonasal elevator provide perpendicular vectors for manipulation, thereby improving ability to reduce fractures when percutaneous traction alone is not successful. The technique is described here in a patient with anterior table frontal sinus fractures combined with posteriorly displaced Markowitz type 1 NOE fractures. While percutaneous reduction of frontal sinus fractures has been previously described, this report adds a subtle but important modification both in indication and technique for optimizing reduction while maintaining surgical simplicity and minimizing morbidity.

Variability in Current Procedural Terminology Codes for Craniomaxillofacial Trauma Reconstruction: A National Survey.

Current Procedural Terminology (CPT) codes are an important part of surgical documentation and billing for services provided within the United States. This limited coding language presents a challenge in the heterogenous and rapidly evolving field of craniofacial surgery. The authors aimed to survey members of the American Society of Maxillofacial Surgery (ASMS) to characterize the variability in coding practices in the surgical management of craniofacial trauma. A cross-sectional of 500 members of the ASMS survey was carried out. Descriptive statistics were calculated. The effect of various practice characteristics on coding practices was evaluated using Chi-squared tests and Fisher's exact tests. In total, 79 participants responded including 77 plastic surgeons. About 75% worked in academic centers and 38% reported being in practice over 20 years. Coding practices were not significantly associated with training background or years in practice. Unilateral mandibular and unilateral nasoorbitoethmoid fractures demonstrated the greatest agreement with 99% and 88% of respondents agree upon a single coding strategy, respectively. Midface fractures, bilateral nasoorbitoethmoid fractures, and more complex mandibular demonstrated considerable variability in coding. There is a wide variability among members of the ASMS in CPT coding practices for the operative management of craniofacial trauma. To more accurately convey the complexity of craniofacial trauma reconstruction to billers and insurance companies, the authors must develop a more descriptive coding language that captures the heterogeneity of patient presentation and surgical procedures.

Abstract QS10: Zygomaticomaxillary Complex Fractures Associated With Naso-orbito-ethmoid Fractures In Pediatric Patients: A 25-year Experience At The Johns Hopkins Children’S Center

Purpose: Naso-orbito-ethmoidal (NOE) fractures associated with ipsilateral ZMC fractures are more challenging injuries than ZMC fractures alone. However, there is a paucity of information on this complex fracture pattern in the pediatric population. Because of differences in the craniofacial skeleton between children and adults, it is important to characterize combined ZMC-NOE fractures in children specifically, especially given that this injury pattern in adults leads to poorer long-term outcomes. This study investigated the etiology, treatment, and outcomes of combined ZMC and NOE fractures versus isolated ZMC fractures in pediatric patients. Methods: This was a 25-year retrospective cohort study of pediatric patients who presented to a single institution with ZMC fractures. Patient data/outcomes were derived from the medical record and comparatively investigated between (1)combined ZMC-NOE and (2)isolated ZMC fracture cohorts. Results: Forty-nine patients had ZMC fractures in our 25-year study period, of whom forty-six had adequate clinical documentation and follow up. Seventeen of these patients had ipsilateral NOE injuries associated with their ZMC fracture. Both patient groups (isolated ZMC fractures versus combined ZMC and NOE fractures) were similar in terms of demographics. However, patients with combined ZMC-NOE fractures had longer median hospital lengths of stay than patients with ZMC fractures alone (9 vs. 5.5 days), and a greater proportion of patients with combined ZMC-NOE fractures required more extensive surgical approaches with coronal incision (57.1% vs. 11.8%, p=0.007). Approximately 88.2% of patients with combined ZMC-NOE fractures suffered complications versus 31.0% of patients with isolated ZMC fractures. Furthermore, patients with combined ZMC-NOE fractures had greater incidence of postoperative facial deformity than those with ZMC fractures alone (adjusted odds ratio 6.72, p=0.032). Enophthalmos (41.2%), orbital dystopia (29.4%) and midface growth restriction (35.3%) were the most common postoperative deformities in patients with combined ZMC-NOE fractures, and were observed disproportionately in these patients compared to patients with isolated ZMC fractures. In fact, midface retrusion was seen exclusively in patients with combined ZMC-NOE fractures who had deciduous dentition. Conclusion: This is the largest longitudinal study of combined ZMC-NOE fractures in pediatric patients. Our results demonstrate that high impact trauma can cause NOE fractures in association with ZMC fractures relatively commonly in this patient population. This injury pattern was found to cause significantly greater postoperative complications and deformity than isolated ZMC fractures alone, possibly due in part to inadequate surgical reduction in the context of a more complex fracture. Thus, pediatric patients presenting with this facial fracture pattern require greater attention at the time of operative repair to ensure adequate bony reduction, possibly through use of low-dose intraoperative imaging and custom splints. Furthermore, these patients require more extensive clinical follow-up and monitoring given a greater risk for long-term morbidity.

&lt;p&gt;Submental Intubations in Panfacial Fractures&lt;/p&gt;

IntroductionAirway management in patients with panfacial fracture remains a challenge to anesthesiologists and surgeons. Submental intubation is an effective and less invasive alternative to tracheostomy during intraoperative airway management where orotracheal and nasotracheal intubation are not appropriate options. In addition, submental intubation allows proper access to oronasal airways and occlusion during intraoperative management.MethodsThe descriptive retrospective study was carried out and evaluated the outcomes of submental intubation in the management of panfacial fracture, complex maxillary or mandible fracture associated with nasal bone fracture and naso-orbito-ethmoid (NOE) fracture. The medical records of 23 patients who received submental endotracheal intubation were reviewed at UCMS College of Dental Surgery, Bhairahawa, Rupandehi, Nepal from March 2014 to December 2018. The following parameters were evaluated: mode of trauma, time required for intubation, accidental extubation, accidental perforation of the pilot balloon during its insertion, period of hospital stay, post-operative complications, such as the healing of submental scars both intraorally and extraorally.ResultsThe submental intubation was successfully done in all patients with minimal obvious post-operative complications. The mode of trauma for majority of cases of panfacial fracture who underwent submental intubation was road traffic accident (69.56%). The mean time required for intubation was 8.43 (±0.84) minutes. No accidental extubations occurred. Accidental perforation of the pilot balloon was seen in one patient (4.35%) during tube manipulation which was managed successfully by changing the tube. The healing of submental scars was uneventful intraorally and extraorally in almost every case. The mean period of hospital stay in patients with submental intubation was 7.95 (±1.49) days.DiscussionSubmental intubation is an effective and safe method as it is not associated with complications of tracheostomy during management of panfacial fracture, NOE fracture and craniofacial fracture. In addition, it does not interfere with IMF during intraoperative period.

Ipsilateral transnasal medial canthopexy to correct secondary telecanthus after naso-orbito-ethmoid fracture

Telecanthus results from medial canthal tendon (MCT) disruption, which can result from traumatic naso-orbito-ethmoid (NOE) fractures. Several methods, using different anchoring materials, incision approaches, or fixation positions, have been proposed for MCT reconstruction. Herein, we report our experience in treating MCT disruption using ipsilateral transnasal medial canthopexy with a Y-V approach. Between 2008 and 2017, seven patients with traumatic NOE fractures underwent ipsilateral transnasal MCT fixation with Y-V epicanthoplasty. The length ratio, defined as the length of the affected side divided by that of the normal side, was calculated preoperatively and postoperatively. A modified Y-V epicanthoplasty incision was made, after first marking the site in the apex of the caruncular fornix. The nasal wall was exposed and the MCT was accessed carefully. Bulky MCT tissue was trimmed. The lacrimal bone was ground using a bur, creating a concave shape to reposition the MCT, and two holes were drilled into the ipsilateral lacrimal fossa and frontomaxillary process. The MCT was fixed to the frontomaxillary process using no. 2 transnasal wire, which was secured by a 6-mm screw. Finally, the Y-V epicanthoplasty was repaired using 5.0 nylon. The preoperative length ratio (mean±standard deviation: 83.3%±6.0%; range: 73.7%-92.0%) was significantly lower than the postoperative length ratio (mean±standard deviation: 99.4%±0.6%; range: 98.5%-100%) (p<0.05). No major complications were observed, with an average of 13 months of follow-up. Ipsilateral transnasal wiring fixation with Y-V epicanthoplasty is a useful and adequate method for MCT reconstruction after NOE fractures, without remarkable complications.

Underdiagnosis of Nasoorbitoethmoid Fractures in Patients with Zygoma Injury.

Nasoorbitoethmoid fractures commonly accompany midface fractures and may be underdiagnosed, resulting in incomplete reconstruction or inadequate treatment following facial trauma. To better understand the nasoorbitoethmoid fracture diagnosis and treatment tendencies, the authors analyzed concomitant nasoorbitoethmoid injuries in the setting of zygoma fractures. The facial trauma database at a level I trauma center was evaluated. All patients with diagnosed zygoma fractures from June of 2011 to March of 2016 were assessed for a concomitant nasoorbitoethmoid injury. Documentation of these fractures in radiology, plastic surgery, and operative notes was recorded, as was the rate of nasoorbitoethmoid fracture surgical repair. The authors identified 339 eligible patients and completed retrospective analysis of computed tomographic images for their 356 zygoma fractures. The incidence of concomitant nasoorbitoethmoid fractures was 30.6 percent (109 of 356). Documentation rates of nasoorbitoethmoid fractures were 0 percent, 3.7 percent, and 8.3 percent in radiology, plastic surgery, and operative notes, respectively. The rate of surgical correction of nasoorbitoethmoid injuries was 22.9 percent (25 of 109). Of those fractures identified, 44.9 percent (49 of 109) were minimally displaced or nondisplaced. Subset analysis of only significantly displaced fractures yielded an incidence of 16.8 percent (60 of 356). Of significantly displaced fractures, documentation rates were 0 percent, 6.7 percent, and 16.8 percent in radiology, plastic surgery, and operative notes, respectively. The surgical repair rate of significantly displaced fractures was 31.7 percent (19 of 60). These findings suggest a high concomitance rate of nasoorbitoethmoid fractures with zygoma fractures and identify a tendency to underdocument and undertreat this injury pattern. Clinicians managing patients with midface trauma should have a high suspicion for nasoorbitoethmoid trauma. Plastic surgeons and radiologists should be better trained in identifying the nasoorbitoethmoid fracture pattern.