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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4416_Библиотеки_им_академика_М_И_Перельмана
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Section 4 Trauma224
A B
C
Figs. 17.7A to C: Combined Le Fort type
1 and 3 fracture. (A) Horizontal Le Fort I
fracture line (arrow); (B) Le Fort III fracture
involving medial and lateral orbital wall
and zygoma (thick arrows). Hemosinus
(asterisk); (C) Le Fort III fracture line (III)
and Le Fort I fracture line (I).
A B
Figs. 17.8A to C: Combined Le Fort
type 2 and 3 fracture. (A) Fracture in
posterior maxillary wall (block arrows)
and pterygoid plate (thin arrow); (B) Le
Fort II fracture involving medial and inferior
orbital wall, and lateral maxillary wall
(block arrows); (C) Lateral orbital wall
fracture as a part of Le Fort III fracture. Le
Fort III fracture line (III). Le Fort II frac ture
C
line (II).
Other Complex Fractures
Naso-orbitoethmoid Complex Fractures
■ ese are comminuted fractures, involving unilateral or bilateral maxillary buttresses which occur as a consequence of high impact force to the
nose.
■ ey involve nasal bones, nasal septum, medial orbital walls and
ethmoid sinuses. e nasoorbitoethmoid area is involved in this type of
injury (Fig. 17.9).
■ ese fractures are subclassied into three types (Markowitz and
Manson classication) based on whether medial canthal tendon is
involved or not.3 Medial canthal tendon cannot be directly visualized on
CT; however, when the fracture is comminuted, it is more likely to cause
avulsion of the tendon which inserts on the medial orbital wall.
■ Type 1: Single large NOE fragment bearing the medial canthal tendon
(Fig. 17.10).
■ Type 2: Comminuted NOE fragment, but medial canthal tendon remains
attached to one fragment.
■ Type 3: Comminuted fracture, medial canthal tendon is detached
(Figs. 17.11A and B).
225Chapter 17 Imaging in Sinonasal Trauma
Fig. 17.9: Nasoorbitoethmoid complex
(dashed line).
Fig. 17.10: Type 1 nasoorbitoethmoid
fracture (arrow).
Section 4 Trauma226
A B
Figs. 17.11A and B: Type 3 nasoorbitoethmoid fracture (arrows) with tetrapod fracture
(asterisk).
Zygomaticomaxillary Complex Fractures
■ Synonym: Tetrapod or quadripod fracture.
■ Mechanism of injury for these injuries is direct blow to malar eminence.
■ Zygomatic bone becomes dissociated from the rest of face or calvarium
(Figs. 17.12A and B).
■ Result in orbital complications and mastication diculties.
A B
Figs. 17.12A and B: (A) Tetrapod fracture (asterisk); (B) Hemosinus (white asterisk).
(A: Zygomaticofrontal suture; B: Zygomaticotemporal suture; C: Zygomaticomaxillary suture).
Fractures Involving Single Bone or Single Buttress
Frontal Sinus Fractures
■ Frontal sinus walls are thin and hence are often involved in injuries
involving the upper jaw region, and the anterior wall is frequently involved.
■ Posterior wall fractures are more ominous as these are associated with
cranial complications.
■ Inferomedially placed fractures result in obstruction of nasolacrimal
duct and impaired drainage (Figs. 17.13A and B).
A B
Figs. 17.13A and B: (A) Frontal sinus fracture (bilateral); (B) Left frontal sinus posterior
wall fracture.
227Chapter 17 Imaging in Sinonasal Trauma
Nasal Bone Fractures
■ ese are the commonest facial fractures, as nasal bone is thin and
supercially located.
■ Mechanism of injury may be an anterior or lateral blunt force.
■ Classication (based on the anatomical plane): ese are divided into
three types:
• Type 1: Below the anterior nasal spine, septum not involved.
• Type 2: Septum and anterior nasal spine also involved.
• Type 3: Septum, orbital bone involved. Intracranial structures may be
involved.
■ Nasal septum injury may be associated with disruption of perichondrium
and hematoma formation. As a long-term sequelae, this can result in
ischemia, cartilage necrosis and septal perforation.
Imaging:
■ Plain radiographs are most frequently used.
• Low kVp settings and coned view are required (Fig. 17.14).
• Ancillary views such as axial view, lateral and Water’s view are
complementary to conrm diagnosis.
Section 4 Trauma228
• Radiological signs include a horizontal lucency with displaced or
overlapping fragments.
• Imaging pitfall: Nasomaxillary suture or nasociliary groove may be
mistaken for fracture (Figs. 17.15 and 17.16).
• Vertical lucent lines which are grooves for anterior ethmoidal nerves
can also be confused as fractures.
■ Computed tomography is more accurate than radiographs.
■ High resolution ultrasonography has also been advocated especially
in children.
Fig. 17.14: Right nasal bone comminuted
fracture.
Fig. 17.15: Lateral radiograph of normal
right (a) and left (b) nasal bones showing
naso maxil lary suture (arrows) and naso
ciliary groove (arrowheads).
A B
Figs. 17.16A and B: (A) Left nasal bone fracture associated with nasoorbitoethmoid
fracture (arrow); (B) Bilateral nasal bone comminuted fracture.
Maxillary Sinus Fractures (Figs. 17.17A and B)
■ Isolated displaced or undisplaced fractures of the anterior and lateral
walls of the maxillary sinus may be seen in lesser degrees of trauma.
■ As the maxillary alveolar process constitutes the oor of the sinus, its
fractures involve the maxillary sinus too.
■ Similarly orbital trauma involving its oor aects the sinus.
■ Posterior maxillary fractures occur as part of the Le Fort fractures
involving pterygoid plates and even sphenoid sinus.
229Chapter 17 Imaging in Sinonasal Trauma
A B
Figs. 17.17A and B: (A) Anterior and lateral wall of right maxillary sinus fractures (arrows).
(B) Posterior maxillary fracture involving pterygoid tubercle (arrow) and pterygoid plates
(small arrows).
Orbital Blowout Fractures
■ Isolated fractures of the orbit result from direct blunt force received on
the globe. is causes outward displacement of its walls with resultant
increase in orbital volume and enophthalmos.
■ Most commonly aected wall is the inferior, followed by the medial wall.
■ e fractured inferior wall protrudes into the maxillary sinus along with
the orbital fat, with or without the inferior rectus muscle (Figs. 17.18A
and B).
■ Medial wall injury involves the adjoining ethmoid sinuses (Figs. 17.19A
and B).
Section 4 Trauma230
A
B
Figs. 17.18A and B: (A) Left inferior orbital wall blowout fracture, post repair. Note the
infraorbital nerve entrapment (arrow). (B) Right inferior orbital blowout fracture.
A B
Figs. 17.19A and B: (A) Leftsided medial wall orbital blowout fracture (arrow). (B) Medial
rectus muscle entrapment (arrowhead).
COMPLICATIONS OF SINUS FRACTURES
■ In the acute phase, sinuses are opacied due to hemorrhage (hemosinus).
As the hemosinus resolves, residual soft tissue or mucosal thickening
remains.
■ Pneumocephalus (intracranial air) may result from sinus fractures of
ethmoid and frontal sinuses that violate the skull base.
Region-wise complications of these fractures are enlisted in Tables
17.4 and 17.5 and illustrative care.
Table 17.4: Complications of the complex facial fractures.
231Chapter 17 Imaging in Sinonasal Trauma
Nasoorbitoethmoid
(NOE) complex
fractures
Zygomaticomaxillary
complex fracture
(tetrapod fracture)
• Enophthalmos (as the orbital volume increases)
• Cerebrospinal uid rhinorrhea (due to cribriform plate
disruption) (Figs. 17.20A and B)
• Telecanthus (due to avulsion of medial canthal tendon)
• Epistaxis (following injury to anterior/posterior ethmoidal
arteries)
• Lacrimal sac/duct injury leading to epiphora, dacryocystitis
(Figs. 17.21A and B)
• Intracranial infection (meningitis, epidural abscess, cerebral
abscess)
• Orbital apex syndrome
• Optic nerve injury
• Globe injury (vision loss)
• Increased orbital volume and enophthalmos
• Other orbital complications like globe injury/extraocular
muscle injury, hematoma
• Orbital apex syndrome
• Superior orbital ssure syndrome
• Difculty in mastication
A B
Figs. 17.20A and B: (A) Cerebrospinal uid rhinorrhea secondary to traumatic defect in right
cribriform plate (arrow); (B) Magnied image showing the defect (arrow).
Section 4 Trauma232
A
B
Figs. 17.21A and B: (A) Rightsided canalicular block by a fracture fragment (arrow); (B)
Note normal right (R) and left (L) bony NLDs.
Table 17.5: Complications of the facial fractures
involving single bone or single buttress.
Frontal sinus fractures • Cerebrospinal uid rhinorrhea
• Brain herniation, intracranial infection (posterior wall
fractures)
• Nasofrontal duct obstruction and mucocele (medially
located fractures)
Nasal bone fracture
involving septal cartilage
Maxillary sinus roof
fractures (orbital blowout
fractures)
Posterior maxillary
fractures
Maxillary alveolar
process fractures
• Septal hematoma and impaired breathing
• Secondary infection, abscess leading to septal perforation
• Extraocular muscle entrapment following herniation
• Infraorbital nerve injury
• Globe injury
• Pterygoid plate disruption, sphenoid bone extension
leading to carotid artery injury/carotid cavernous stula
• Skull base foramina disruption (e.g. foramen ovale)
• Dental complications (tooth avulsion, tooth fractures, etc.)
• Secondary infection of sinus (due to oral ora)
Illustrative Case
233Chapter 17 Imaging in Sinonasal Trauma
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