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XXI Oral and Maxillofacial Surgery Brazilian Congress Vitória, ES, Brazil

“Naso-ethmoid & Zygomatic “NasoTrauma – a personal perspective” peter ward booth fds frcs uk


Most interesting facial fractures? • Naso Naso--ethmoid – Uncommon • Zygomatic – Very common


Why so interesting ? Because the outcomes are not always good enough


Aetiology of mid face trauma in the UK • Road traffic

accidents • Work • Assaults • “falls” • sports


Cars are much safer today • Pedestrians

still at risk in urban areas • Children at risk in inner cities


Less heavy industry & much safer • Work related

facial injuries very rare


“falls” • Usually a

medical problem in the elderly • Not common to get a facial injury


sports • Increasing

problem • Nasal and

zygoma fractures


assaults • Several studies

in the UK by Jon Shepherd • •

Hutchison I, Magennis P, Shepherd JP, Brown AE The BAOMS United Kingdom survey of facial injuries. Part I: aetiology and the association with alcohol consumption. Br J Oral Maxillofac Surg 1998


Assaults main cause of facial injuries in the UK • Victims & culprits – Young males – Unemployed or menial jobs – Alcohol usually involved


Naso-- ethmoid injuries Naso


My “key points” • The injury is a “spectrum” &

needs a good classification • Open access & fixation needed • immediate grafting should be

considered


Nasoethmoid fractures • Must be seen as a

spectrum

• Severity increases with – Comminution – Soft tissue damage – displacement


Simple nasal fracture to severe nasonaso-ethmoid fracture


So we need a “helpful” classification • Rowe & Williams (1994) – bibi-lateral – uni uni--lateral – isolated – with frontal #


classification • Gruss (1984) – nasoethmoid – nasoethmoid & central maxilla – +Le Fort II or III – +Orbital dystopia – +loss of bone


classification • Markowitz (1991) –good • – single unit with canthus – comminution but not to canthus – comminution involving canthus – uni or bi -lateral


classifications • Markowitz

–recognises the importance of: • comminution • canthal attachment


a new classification • Peter Ayliffe (Consultant at Gt.Ormond St. London)

• aims to identify all the

aspects which are likely to produce a POOR outcome – i.e. “difficult case”


Ayliffe’s classification of Nasoethmoid fractures • Type 0 • Type I • Type II • Type III • Type IV


• Type 0 UnUn-displaced


• Type I

Comminuted, but “platable”


• Type II

Requiring bone graft


• Type III Canthal disruption, requiring canthoplexy


• Type IV Lacrimal reconstruction


Should there be a V type? Other fractures for example orbital


Why the need for classification? • Surgical planning • Measuring outcomes


Examination & diagnosis


General appearance • nasal

deformity – “pig’s snout” !! – Deviation – broadening


Soft tissue • inspect lacerations

for:

– foreign bodies – damage to VII nerve or

lacrimal apparatus

– tissue loss


Soft tissue • mobility of canthus

peter.wardbooth@btope nworld.com


Evaluate the orbit standard eye examinations • visual acuity • movements /diplopia (Hess

chart)

• Enophthalmos • intra ocular


Bone damage • Clinical

examination still important • radiological


radiological • look for: – fractures lines – comminution – bone + canthal attachment – other relevant #, intracranial bleeds


Radiological AFTER clinical examination • basic screen – occipital mental – lateral skull


radiological • if NOE # suspected – C.T. essential –dycrocystogram rare in

acute situation


C.T. essential for NN-E fractures?


DCR


It is said most audiences loose concentration after 15 minutes • But how do I get

the attention of females?


Surgery • Timing • Access • fixation


timing • ? as soon as possible – other injuries frequently delay – let swelling reduce • long delays = poor results


A delayed case


access • Use lacerations • Coronal flap usually enough – Transconjunctival may be

needed for medial wall/floor of orbit


operative sequence • Commonsense! Build up from

the foundations – fix the mandible – start laterally in the maxilla – central mid face last


Have a logical plan! • The “pillars” for

reconstruction

– These are obvious as the

bone is thickest and easiest to plate

• Restoring the

zygomatic arch is more easily “missed”


fixation • Use the smallest plates


Supplementary fixation • The special problem of the

completely detached canthus • However most canthal

attachments remain if only to small fragments of bone


Complete canthal detachment • Requires canthoplexy – Is simple trans nasal wiring

enough???


• As shown in this diagram the

wire will: – “cut through” the ligament – And is too far forward


Trans nasal canthoplexy – Wire –

pulling – Acrylic

button pushing


When to graft • Grossly comminuted bone • Missing bone – Don’t delay and plan a

secondary procedure


Missing or grossly comminuted bone


Some cases


• Direct access to ensure good

reduction (via laceration)


• Direct plating

onto lachrymal bone • medial canthus still attached


• Check

x-ray • C.T. -yes ideally


complications • Poor reduction • Soft tissue •Lids •Drainage • (Orbital)


telecanthus • Poor canthal reduction


• Lacerations will always be less

satisfactory – but they mature


Lachrymal damage • Despite

immediate canalisation of duct with tubes


Zygoma trauma • Zygoma & orbital

walls • Globe • Soft tissue – Skin & periperi-orbital tissues


My “key points” • Ocular injury likely • Access, fixation &

reconstruction • Don’t delay surgery


Ocular injury – A separate topic but covered

well by Leo Stassen’s paper

al al--Qurainy IA, Stassen LF, Dutton GN, Moos KF, elel-Attar A. • Br J Oral Maxillofac Surg. 1991 Oct;29(5):302Oct;29(5):302-7


Leo Stassen BJOMS 1991

• The definitive work –363 pts (prospective study –2 year study


Leo Stassen -ocular injuries

• 63% minor • 16% moderate • 12% severe


Most ocular problems resolve – Swelling – Diplopia – Loss of

motility


Ocular injuries

• Severity of injury

increases risk

• Reduction in visual acuity -

main problem

• 2.5% optic neuropathy


Conclusion: • Use a scoring system • Involve ophthalmologist


My question! • But how many injuries were

important and could be treated? • Diplopia • Visual loss – Retro bulbar hemorrhage (0.5%) – Optic nerve compression


what should we do?

• Examine and document the

problem

• Treat those who will

benefit i.e. •potentially reversible damage


reversible damage

â&#x20AC;˘ Retro bulbar hemorrhage â&#x20AC;˘BUT very rare <1%


At least you can say you have seen one!


Cook et al 1996

• Meta analysis of treatment

of traumatic neuropathy –Treatment improves outcome –Unable to show benefit of different treatments


The treatments

• Steroids • Surgery • Surgery & steroids


Zhonghua 2004

• 118 pts, 5 levels of

neuropathy

• Blind • Hand movement • Finger count • Light perception • Acuity lowest score


Endoscopic decompression • 50% of the blind

“effective” • 100% of those with

minimal acuity “effective”


“effective” means?

• Move up one or more

grades ie not a “cure”

• Treat within 3 days • Steroids not used


The common “reversible” with treatment ocular problems • Diplopia – Loss of motility – Displaced globe


A “full house” –the perils of delay • Loss of

motility • Diplopia • Dystopia • Ectropion


Management zygoma trauma • Diagnosis – Clinical – radiological


clinical • Ocular • Bone • neurological


Ocular examination

• visual acuity

(Chart or paper!) • Examine the eye


Eye examination • Intra ocular – Specialist

opinion?


Diplopia & motility examination â&#x20AC;˘ Record

findings â&#x20AC;˘ Hess chart


Position of the globe

â&#x20AC;˘ Enophthalmos/ dystopia


bone â&#x20AC;˘ Most of the

information you need is at your finger tips!


neurological • Sensory – IO nerve • Motor – VII & ocular movements


radiological • Plain film – Occipital

mental 30 • CT (gold standard) • u/sound MRI ??


Surgery


Timing â&#x20AC;&#x201C; as soon as possible â&#x20AC;&#x201C; if not before!


Surgical access

• All have potential

complications • Except intra oral approach, but inadequate access • ?endoscopic approaches


Very traditional approaches


Surgical access of choice • Lacerations • Trans Trans--conjunctival ++- lateral

extension


Surgical Access To The Orbit Mr Kenneth Sneddon FDSRCS, FRCS


Surgical Approaches to the Orbital Skeleton Transconjunctival + canthotomy


Follow--up Follow Complete followfollow-up to 6 months 49 80.3% Ongoing followfollow-up 10 16.4% Lost to followfollow-up 2 3.3%


Chemosis Immediate 1 month

27.8%

0%

3 months

0%


Scleral Show 1 month

3 months

6 months

18%

6.4%

3.2%

(11pts)

(4 pts)

(2 pts)


Other Complications Webbing at outer canthus

1pt

Canthal malposition

1pt

Temporary weakness upper branch of VII nerve

1pt


• Avoids two separate incisions • Superior surgical access • Simultaneous visualisation of

FZ & orbital rim • Excellent cosmesis & low

morbidity


surgical access • lacerations • sub sub--conjunctival • coronal flap for displaced

malar/multi wall injuries


coronal flap • quick ‘n easy • still needs to be

in the right place! • Only needed in

complex cases


coronal flap


fixation


Internal fixation • Orbito Orbito--zygoma trauma

needs the smallest plate in the box???

• Don’t remove them


Degradable plates • “degradable” plates

??

•Large screws •Swell before

degrading


Orbital wall repair

• Close the holes • Maintain the volume • Which material?


Orbital wall repairs â&#x20AC;˘ Are we over obsessed by

precise reconstructions?

â&#x20AC;˘ Does not need to be exactly

the correct volume ++-5%?


What really matters? • Good motility • No diplopia • Position of globe – least

important


Poor motility reasonable position


Poor position good motility & no diplopia


Know your anatomy


key points • optic nerve

to rim • the “ridge” in

orbital floor


Lecturerâ&#x20AC;&#x2122;s nightmare


bone • Biocompatible • Cheap


other materials

• Titanium mesh •Effect of further

trauma? •Usually in young people and difficult to remove •effective


other materials

• Silicone •Well proven •Minimal tissue

reaction •Only small defects •May get infected, but easy to remove


other materials

• “degradable” materials •F.B. reaction -

?scarring •Shrink on degradation •Swell before shrinking •Not rigid for large defects


other materials • Medpore • Expensive • Lot of fibrosis • Rigid • Polyether ether ketone (PEEK) – can be custom made


Increasing the accuracy of the reconstruction


If you want a perfect reconstruction (+ oror- 1mm) then get a navigation system


Surgical navigation in craniomaxillofacial Surgery: expensive toy or useful tool Lubbers JOMS 2011 • A very good question ! • But does not give the answer !! • Invaluable in oncology


Computer Assisted Planning Bell B et al JOMS 2009 â&#x20AC;˘ Describes his experience â&#x20AC;˘ AND acknowledges the problems

of scarring in fully correcting dystopia & diplopia


Or use a 33-D models • Much cheaper • Also allows titanium

plate to be made pre--op pre

– Reduces

operating time


Still limitations • Rely on “mirroring” • Artefacts with thin bones • In secondary reconstruction

scar tissue may prevent rerepositioning


But is it that simple ?


Why are children a special problem

â&#x20AC;˘ Can we learn

from them?


Remember whatâ&#x20AC;&#x2122;s happening

â&#x20AC;˘ Plast. Reconstr Surg 57:23357:233-235, 1976. 3. Korneef L:

Orbital septa: Anatomy and function. Ophthalmology 86: 876--. 880, 1979 876


Early diagnosis & treatment essential


mid face trauma is fascinating and we do not have all the answers


I am very grateful to your President & Committee for their kind invitation & hospitality

muito obrigado


Thank you


09-09-2011-14H_PETER WARD-BOOTH