Management of a type II nasoethmoid orbital fracture and near-penetration of the intracranial cavity with transnasal canthopexy

Ear, Nose & Throat Journal, June, 2007 by Philip A. Young, Dale H. Rice

Postoperatively, we noted that the medial canthus was inferiorly and anteriorly displaced. After some lengthy consultation, the patient felt that the displacement was significant enough to warrant correction, and the next day we took him back to the operating room.

After exposure via our original coronal incision, we used a full-thickness nylon suture with needle to identify the medial canthal tendon. We observed that a significant portion of the medial canthal tendon insertion was located at the site that we had dissected to place the plate and one microscrew. The residual attachment was not strong enough to adequately support the lower lid structures. Therefore, we dissected the rest of the ligament free from the plated central fragment and then placed another microplate deeper within the orbit extending from the nasal root. This microplate was then used to attach our transnasal wire in a posterior and superior relation to the lacrimal fossa. Relating the position of the posterior lacrimal crest with the uninvolved side, we then took a hand drill with a 1.5-mm drill bit and fashioned a through-and-through tunnel that exited near the superior portion of the lacrimal fossa on the contralateral side.

We attempted to trace the frontoethmoid suture line and the anterior ethmoid artery in the involved orbit, while also correlating with the other side, in order to be sure that the direction of our drilling was inferior to the anterior skull base and the cribriform plate, given our knowledge that these are anecdotally reliable markers. We placed a second microscrew superiorly and medially just within the orbit on the uninvolved side to serve as an anchor. (1) We placed the screw on the thick glabellar bone and were careful not to penetrate the frontal sinus. We attached the medial canthal tendon to 26-gauge steel-wire sutures and threaded them through a spinal needle to the other side. The presence of our previously placed throughand-through black nylon sutures allowed us to accurately locate the medial canthal tendon. We then tightened the wire around the screw in the contralateral orbit until the canthus was restored in the posterior and superior position relative to the lacrimal fossa. Externally, we retested the medial canthus and found that it was completely immobile and solid against the miniplate.

Apostoperative CT was ordered to evaluate frontal sinus drainage. Coronal CT demonstrated the proximity of the steel wire to the inferior aspect of the cribriform plate (figure 3, A). Although the wire did not appear to penetrate the intracranial cavity, its proximity to the cribriform plate engendered significant attention. Axial CT showed that the crista galli was along the same coronal plane as the wire and, again, the wire appeared to come very close to the skull base (figure 3, B).

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The patient experienced no postoperative complications. At the 6-month follow-up, his medial canthi were completely symmetrical in all dimensions (he refused to submit to postoperative photography).