General Principles

Management for nasoethmoid orbital injuries can be divided into two parts, bony fracture and soft tissue injuries which are divided into two subgroups, medial canthal tendon injuries, and lacrimal drainage system injuries.

Management of lacrimal drainage system injuries and medial canthal tendon injuries include the following [16]:

1. Early one-stage repair

2. Exposure of all fracture fragments

3. Precise anatomic rigid fixation

4. Immediate bone grafting, if needed

5. Definitive soft tissue management

Using these principles most late functional and aesthetic sequelae have been diminished or eliminated. The precise concept of management for these frac-

tures is to do as much as possible at the first time [36]. It is unusual for the medial canthal tendon to be directly injured in this type of trauma (blunt trauma) [9] and, because of that repositioning of the bony complex, the proper intercanthal relationship should be adequately restored [37-40].

The management of fractures in this area, when extensive, is completed utilizing open reduction, rigid osteological fixation, and plate implants as required [3, 5, 9, 11, 16, 36].

The lacrimal system is not frequently injured in nasolacrimal injuries in the absence of medial canthal avulsion or obvious lacrimal system transection [11, 13]. The incidence of late lacrimal obstruction requiring dacryocystorhinostomy was 5-10% following acute fracture management [43].

The indications for surgery in a nasolacrimal trauma are those outlined above. Restoration of pre-injury facial aesthetics and function is the goal of treatment. Since these injuries are usually associated with significant cosmetic and functional sequelae, expeditious restoration of injuries and function prevents latent cosmetic and functional deficits. Longer-term follow-up allows the surgeon to assess for both early and late sequelae of injuries.

Definitive treatment of nasolacrimal injuries should be deferred until the patient has been stabilized regarding any concomitant, compromising, or life-threatening trauma. During this time, systemic deficits can be corrected while giving the surgeon time for an accurate assessment prior to the operative procedure. As with any operative procedure, the risks of general anesthesia and the stresses of surgery must be weighed against medical contraindications. Ocular contraindications include optic nerve injury and globe injury (e.g., hyphema, rupture, laceration). These injuries should be addressed and stabilized prior to surgical intervention, since osseous manipulation may exacerbate damage to the eye. Some injuries may not need correction, provided that the patient is satisfied with the appearance and function.

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