NASO-ORBITO-ETHMOID FRACTURES: PERSPECTIVE AND PRACTICES OF NIGERIAN SURGEONS

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O.A. Akadiri

Department of Oral & Maxillofacial Surgery, Faculty of Dentistry, College of Health Science, University of Port Harcourt, Port Harcourt, Rivers State, Nigeria

Abstract

Objective: The study was to appraise the level of expertise in the management of Naso-Orbito-Ethmoid (NOE) fractures and to provide recommendation for necessary improvement in an African population.

Materials and Methods: A questionnaire was designed and electronically mailed to Nigerian Oral & Maxillofacial surgeons, Plastic and Reconstructive surgeons, and Ear, Nose and Throat surgeons to assess their perspectives and practices in the diagnosis and management of NOE fractures. Further administration of questionnaire was done at the AO (Association of Osteosynthesis) principle course in Lagos, January, 2010. Information generated were coded and processed with statistical package for Social Sciences version 15.0, Chicago Illinois, USA.

Results: The questionnaire was delivered to 214 surgeons, there were 112 respondents out of which 78 expressed no interest in the management of NOE fractures and 34 had interest and so completed the questionnaire. Diagnosis is largely based on plain radiographs; only 22 surgeons perform NOE trauma surgery, majority (63.9%) use existing laceration or more conservative approaches like Lynch or open sky incisions. Mini and micro-plates are employed by only 31.8% of the surgeons. Bone grafting is rarely performed but when required, the iliac crest is preferred. Repair of the nasolacrimal duct system is rarely done.

Conclusion: The management of NOE fractures in Nigeria, falls short of the current best evidence in the world literature. Internationa collaboration for improvement is recommended.

Keywords: nasoethmoid complex, diagnosis, treatment, complications

Introduction

Naso-Orbito-Ethmoid (NOE) fractures are arguably the most difficult facial fractures from diagnostic and therapeutic points of view.¹ This is largely because the anatomic region consists of an intricate articulation of several small bony processes of the frontal, nasal, maxillary, lacryma, vomer, ethmoid and sphenoid bones. It incorporates delicate structures such as the nasolacrimal drainage system and medial canthal ligaments.² The region is contiguous with vital anatomical areas including the anterior cranial fossa, the orbit and their respective contents. Because of the functional and aesthetic implications of injuries to this region, appropriate, timely and adequate diagnosis and treatment is crucial to avoid unfavourable sequelae which are often difficult or sometimes, impossible to correct.^3,4

Longitudinal studies on the outcome of management of NOE complex fractures are generally rare in the world literature.³ Anecdotal evidences and case reports are mostly found.^5,6 However, no publication of Nigerian origin documenting experience in the management of NOE fractures was found following a rigorous electronic and manual library search. On the other hand, the author has encountered a sizable number of patients presenting with secondary deformities resulting from improperly diagnosed and inadequately treated NOE complex fractures in Nigeria. Therefore, this study was embarked upon to assess the level of knowledge and appropriateness of management of NOE complex fractures in the country. Measures to improve the quality of care are recommended based on the findings of this study.

METHODOLOGY
We performed a literature search to identify the major surgical specialties involved in the management of Naso-Orbito-Ethmoid complex fractures all over the world. Three groups of specialists were identified namely Plastic surgeons, Otorhinolaryngologists and Maxillofacial surgeons. Hence, the lists of names and electronic mail addresses of surgeons in these three areas of specialization in Nigeria were obtained from the register of the National associations of the respective professional groups. These are Nigerian Association of Oral & Maxillofacial Surgeons (NAOMS), Nigerian Association of Plastic, Reconstructive and Aesthetic Surgeons (NAPRAS), and Oto-Rhino-Laryngology Society of Nigeria (ORLSON).

A questionnaire was designed and mailed electronically to members of the associations and they were requested to complete and send back the questionnaire to the author by electronic mails. A recipient who does not have interest in the treatment of NOE trauma was asked to simply reply the mail stating the phrase “NO INTEREST”. It was also emphasized that no reply to mail will be interpreted as lack of interest in the subject. Three reminders (each time with attached copy of the questionnaire) were sent to the recipients at one month intervals. E-mail delivery confirmations were received in all cases. The whole process of sending and receiving feedbacks spanned a period of one