Nasofrontomaxillaryethmoid Fracture Patterns: Challenges to Current Clinical Nomenclature
Evan Mostafa, BS, Frank Lalezar, MD, Brandon De Ruiter, BS, Avinoam Levin, BA, Daniel Baghdasarian, BS, Edward H. Davidson, MD.
Montefiore Medical Center/Albert Einstein College of Medicine, New York, NY, USA.
PURPOSE: Naso-orbito-ethmoid (NOE) fractures present a significant clinical challenge in diagnosis and management. Currently adopted classifications stratify severity of injury but do not actively guide clinical management. Furthermore, there is no orbital bone, and hence the term NOE creates vague terminology. This study proposes novel nomenclature (Naso-frontal-ethmoidal (NFE), Naso-maxillary-ethmoid (NME), and Naso-frontal-maxillary-ethmoid (NFME) fracture types) that guides surgical approach and predicts risk of associated soft tissue injuries.
METHODS: A five year (2014-2018) single-center retrospective analysis of NOE fractures was performed, NFE/NME/NFME classification types were assigned and verified by two investigators, correlated with treatment course (surgical approach if operative) and soft tissue sequelae (incidence of CSF leak, nasofrontal duct injury, medial canthal tendon injury and nasolacrimal injury).
RESULTS: Sixteen patients had a diagnosis of an NOE fracture and were reclassified as NFE (6.25%), NME (81.25%) and NFME (12.5%). Twelve patients were treated operatively (due to comminution or soft tissue injury). NFE fractures were characterized by increased risk of CSF leak and/or nasofrontal duct injury (100%), and optimally approached by coronal incision (+/- eyelid/glabella incision). NME fractures were characterized by increased risk of medial canthal tendon injury (7.7%) and nasolacrimal duct injury (61.5%), and optimally approached by eyelid incision and intraoral upper gingivobuccal sulcus incision (+/- glabella incision). NFME fractures were characterized by increased risk of CSF leak and/or nasofrontal duct injury (50%), and nasolacrimal duct injury (100%), and optimally approached by coronal and intraoral upper gingivobuccal sulcus incision (+/- eyelid/glabella incision).
CONCLUSION: This novel classification system provides an anatomic basis for guiding management of surgical approach to midface fractures with each fracture type demonstrating an optimal surgical approach and soft tissue sequalae profile.
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