The nasoorbitoethmoid (NOE) complex is the confluence of the frontal sinus, ethmoid sinuses, anterior

cranial fossa, orbits, frontal bone, and nasal bones. The intricate anatomy of this area makes NOE injuries one of the
most challenging areas of facial reconstruction. Inadequately repaired NOE fractures often result in secondary
deformities that are extremely difficult (or impossible) to correct. Long-term sequelae of NOE fractures include
blindness, telecanthus, enophthalmos, midface retrusion, cerebral spinal fluid (CSF) fistula, anosmia, epiphora,
sinusitis, and nasal deformity. Accurate diagnosis and prompt surgical treatment of NOE fractures are critical to
avoid complications and to obtain an aesthetic surgical result. The image below depicts the nasoorbitoethmoid
complex.
General goals of surgical therapy include protection of orbital and intracranial contents, prevention of early
and late complications (eg, blindness, epiphora), and restoration of aesthetic facial contour (eg, normal intercanthal
distance, orbital volume).[3]
The insertion of the medial canthal tendon onto the bony central fragment is the focal point of
nasoorbitoethmoid (NOE) complex reconstruction. The medial canthal tendon-central fragment complex maintains
the normal intercanthal distance and outward appearance of the midface.
NOE injuries are the most challenging of all facial fractures, and surgical repair is often complex and arduous.
Inadequate surgical exposure, imprecise fracture reduction, or poor medial canthal tendon repair almost certainly
yields suboptimal results.
Signs and symptoms of NOE fractures include the following:
o Nasal and forehead swelling or lacerations
o Eye, forehead, and nose pain
o Forehead paraesthesias
o Diplopia
o Telecanthus
o CSF rhinorrhea
Initial evaluation
o Establish ABCs.
o Diagnose any associated injuries.
o After stabilization, perform a thorough head and neck examination to reveal injuries to the brain,
spine, orbits, and facial skeleton.
o A team approach involving the otolaryngologist/plastic surgeon, neurosurgeon, and ophthalmologist
is recommended.
o Ophthalmologic consultation is mandatory.
Inform all patients undergoing nasoorbitoethmoid (NOE) complex repair of the following risks:
o Scarring, particularly in patients with male-pattern baldness
o Bleeding
o Infection
o Forehead paresthesias
o External deformity (eg, telecanthus, nasal deformity)
o Enophthalmos, diplopia, blindness
o Epiphora
o Anosmia
o CSF leak, meningitis
o Sinusitis
o Death

Type I fractures represent a single noncomminuted central fragment without medial canthal tendon disruption.
Type II fractures involve comminution of the central fragment, but the medial canthal tendon remains firmly
attached to a definable segment of bone.
Type III fractures are uncommon and result in severe central fragment comminution with disruption of the medial
canthal tendon insertion.

Disruption of the delicate ethmoid complex and comminution of the nasal bones can make the repair of
nasoorbitoethmoid (NOE) complex fractures extremely difficult. These injuries often test the capabilities of even the
most experienced surgeons. To obtain an aesthetic surgical result, the surgeon must meticulously identify, accurately
reduce, and rigidly fixate the medial canthal tendon and central fragment. Special attention also must be focused on
the overlying soft tissue to avoid hematoma, chronic induration, and pseudotelecanthus.