Management of a type II nasoethmoid orbital fracture and near-penetration of the intracranial cavity with transnasal canthopexy.

Nasoethmoid orbital fractures are perhaps the most complicated aspect of craniomaxillofacial trauma. Involvement of the medial canthal tendon markedly increases the complexity of the repair. We report a case of type II nasoethmoid orbital fracture in a 32-year-old man that was managed without formal medial canthal tendon repair; instead, we used open reduction and internal fixation of the central fragment and the nasoethmoid complex. However, during the immediate postoperative period, we noted anterior and inferior displacement of the medial canthus. We took the patient back to the operating room to address the detachment. Revision surgery was successful, and at the 6-month follow-up, his medial canthi were completely symmetrical in all dimensions. We describe our intraoperative technique and measures to prevent complications that can help the surgeon intraoperatively. We also discuss an important point that has not been adequately addressed in the literature to date--that is, the fact that the use of the frontoethmoid suture line and the anterior ethmoid artery as a guide to the skull base can be inaccurate. Problems associated with this inaccuracy can be avoided by carefully reviewing preoperative computed tomography, which can help keep the surgeon from entering the intracranial cavity while fixing the medial canthal tendon during transnasal canthal repair.