ResidentTraumaFINALhighres

i. Internal Transnasal Wiring

Internal transnasal wiring can be applied after the medial canthal region

has been exposed bilaterally. In the past, transnasal wiring was per-

formed without necessarily exposing the bony fragments, with the

wires tightened over skin buttons. This led to a high incidence of skin

necrosis, so the preferred method currently is to use internal wiring.

Small holes are drilled adjacent to the anterior lacrimal crest and just

superior to the posterior lacrimal crest, avoiding the lacrimal sac and

common canaliculus. Stainless steel wire is then threaded through the

holes, across the septum and back again to cerclage the NOE complex,

tightening the wires after manual reduction to achieve the correct

intercanthal distance. The wires will normally remain in place beneath

the periosteum, unless they cause discomfort to the patient at a later

date or become exposed.

ii. Low-Profile Miniplates

The more preferred method of fixating the NOE fractures is to apply

low-profile miniplates to the fracture sites after reducing the fractures

and achieving proper intercanthal distances. The area for plate attach-

ment is small, so 2–4 hole plates are usually the surgeon’s choice. The

plates will be secured in place with short screws, and caution is taken

not to drill the holes too deeply to jeopardize the region of the ethmoid

fovea or the cribriform plate. Exposure is normally gained for plate

application through either a gull-wing incision medial to the attachment

of the medial canthi, or a coronal forehead approach. It is important to

plan the exposure incision well away from the plate, to lessen the risk of

plate exposure. The plates may be left in place, unless they cause

discomfort to the patient in the future.

iii. Polymer Canalicular Tube

Reconstruction of a damaged lacrimal drainage system will likely

require the insertion of a polymer canalicular tube (Figure 3.27).

Figure 3.27

Polymer canalicular tube

stent for damaged

lacrimal drainage system.

Note the blunt metal tips

for threading into

canaliculi via the puncta.