The incidence of facial injuries is high because the face is in an exposed position . A study  confirmed that the nasal area is the weakest portion of the facial skeleton and fractures may occur with a blunt impact load of 35-80 g. With trauma the maintenance of a patent airway in severe naso-orbital trauma is paramount. It is essential to carefully check for any associated injuries such as neurological, thoracic, and abdominal trauma when significant facial trauma occurs.
The physical examination should begin with an assessment of the soft tissues. Swelling, ecchymoses, and lacerations are noted. Lacerations in the medial canthal region should be assessed to determine the integrity of the lacrimal drainage system and medial canthal tendon. A disruption of the medial canthal tendon can be assessed by a "traction test" [2, 9]. It is done by grasping the edge of the lower eyelid or upper eyelid laterally and pulling against the medial attachment. If the eyelid margin does not become taut and bowstring, or you feel asymmetry in the two sides, then with avulsion the medial portion of the tendon has likely been disrupted.
The other important structures in this area are the upper and lower canaliculi. Firstly, inspection of the lacrimal and canthal area is completed. A cotton-tipped swab is used to gently palpate eyelid tissue.
This can help define the location and extent of the injury. In addition, an accurate evaluation of the lacrimal drainage effectiveness, irrigation, and probing should be performed. The presence of canalicular laceration requires silicone intubation and repair of the laceration. The distal lacrimal system, including the lacrimal sac and the nasolacrimal duct, tends not to be affected by trauma because they are well protected by the bony structures.
Inspection and physical examination of the patients with nasoethmoid-orbital injuries can help predict the sites and extent of fractures prior to radio-graphical studies. The palpation over the bones onto the medial canthal tendon attachment will give good information . This palpation may demonstrate bony crepitus or clicks depending on the degree of instability. The width and the symmetry of the medial canthi should be assessed for telecanthus. The normal intercanthal width ranges from 30 to 35 mm in whites [9, 24, 25], or half of interpupillary distance [9, 26], which is a more reliable guide. The third guide which might be used for the intercanthal width is equal to the alar-alar width at the base of the nose. The other obvious sign is saddle nose deformity which means loss of nasal skeletal support. Furthermore, typically, the medial aspect of the palpebral fissure may lose its sharpness and become rounded and slack with varying degrees of downward and outward displacement.
An ocular examination should be performed. Injuries in this area may be associated with ophthalmic emergency and problems such as ruptured globe or traumatic optic neuropathy especially when the principle fracture or displacement involves bones of the apex of the orbit [27-30]. There is no accurate incidence of ocular injuries associated with nasolacrimal injuries, because many studies vary in the level of ophthalmic evaluation; however, a study by Holt et al.  found 59% of nasal fractures showed concomitant eye injuries and 76% of midfacial fractures were associated with eye injuries. For the severity of ocular injuries, 79% were temporary or minor, and 18% were serious, defined as sustained visual loss or adnexal sequelae requiring subsequent reconstructive measures; 3% resulted in blindness. Therefore, an initial ocular evaluation in mid-facial fractures is necessary [32-34]. Useful guidelines are as follows:
1. Develop a brief historical profile of pre-injury vision, current subjective visual status, current eye disease, and previous intraocular surgery.
2. Obtain an objective baseline visual acuity, examine the pupils and afferent papillary defect (APD), eyelids, anterior segment, posterior segment, and ocular motility.
3. Evaluate the above findings to determine if ophthalmic consultation is needed.
In conclusion, patients with nasoethmoid-orbital injuries are evaluated in three ways. The bony involvement, such as nasoethmoid fracture or nasolacrimal, naso-orbital fractures, or complex fractures, should be considered. The soft tissue injuries are especially concerned in medial canthal tendon area and lacrimal drainage system which includes canaliculi and lacrimal sac. The third part is appropriate ocular examination and visual assessment.
A facial CT scan is required in any patients suspected of having nasoethmoid injuries. Axial and coronal images, spaced at 1.5 mm, are most effective in evaluating and classifying nasoethmoid-orbital fractures . The CT scans not only define the presence and extent of the fractures, but additionally can show direct injury to the lacrimal sac and lacrimal duct.
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