ResidentTraumaFINALhighres

If no saline is observed after irrigation, there is a complete blockage

of the nasolacrimal system at some level, which should be obvious

from the extent of the traumatic pathology.

E. Isolated Orbital Fractures

Typically, orbital fractures in NOE injuries are isolated to the region of

the lamina papyracea and inferior-medial orbit. While medial orbital

fractures can result in entrapment of periosteum, fat, and ocular

muscle, it is not common because of the lack of gravitational force and

because the ethmoid cells provide an additional support to the lamina.

When entrapment does occur, it must be differentiated from a neuro-

praxia of the oculomotor nerve to the medial rectus by forced duction

testing.

F. Diagnostic Evaluations

1. Full-Body Trauma Assessment

Like most patients with facial trauma, it is usually necessary for the

trauma team to clear the patient from more serious injuries before the

full evaluation and decision-making process on the facial trauma can

take place. This includes the full-body trauma assessment, particularly

of the circulation, airway, breathing, and neuro status, as well as the

remainder of the bodily assessment. It is helpful for the otolaryngology

resident to be present for this total body trauma assessment, as

positive findings will impact the evaluation and treatment of facial

fractures. Additionally, after the primary and secondary assessments,

the otolaryngology resident will be able to focus specifically on a

detailed head and neck examination.

2. Head and Neck Examination

Particularly pertinent to NOE injuries, the head and neck examination

should closely assess neurological status, nasal airway, vision (including

pupillary examination and range of motion), CSF leak, epistaxis, nasal

airway patency, and eyelid tension. Eyelid tension, when tested with the

“bowstring test,” may demonstrate a laxity of the medial canthal tendon

when the eyelid is grasped by eyelashes and pulled laterally. A normal

attachment of the medial canthal tendon will demonstrate a firm

resistance to distraction, while a disrupted attachment will feel lax.

Since isolated NOE fractures are not common, but more often are a part

of panfacial fractures, the entire facial skeleton must be adequately

evaluated.

3. Ophthalmological Evaluation

Any trauma at or around the orbit justifies an ophthalmological

evaluation, preferably before any surgical procedure is planned. An