Introduction

Telecanthus is a condition which is defined as an increased distance between the inner corners (medial canthi) of the eyes, while the distance between the pupils remains normal.¹ This condition often results from the disrupted or abnormal positioning of the medial canthal tendon. Telecanthus is also often associated with Nasoethmoidal fractures, which occur when there are injuries to the naso-orbito-ethmoid (NOE) complex. Nasoethmoidal fractures often occur due to high-impact facial trauma such as falls and road traffic accidents. This leads to instability within the structure of the midface area, which can therefore affect functional aspects of the face, such as eyelid positioning.² The ability to recognise Telecanthus is crucial in aiding the diagnosis of a Nasoethmoidal fracture as it indicates disruption of the medial canthal tendon.

Anatomy and pathophysiology

Normal anatomy of the medial canthus and nasoethmoidal region

The Medial canthal Tendon (MCT) is a band of fibrous tissue that supports the medial canthus to the bony orbit and ensures correct eyelid positioning, stability and supports the lacrimal system. The MCT attaches to the frontal process of the maxilla and lacrimal bone. The nasal and ethmoid bones form the nasal bridge and medial orbital wall to provide structural support.² Due to these structures being unstable, they are prone to fracture and therefore disrupt facial aesthetics.

Mechanism of injury leading to telecanthus

A fracture within the medial orbital walls from blunt trauma, such as road accidents and other injuries, can disrupt the MCT.¹ This causes Lateral displacement and widens the intercanthal distance. Telecanthus may worsen further as a result of ethmoid fractures, which further destabilise the medial orbital wall. For appropriate therapy and the restoration of facial symmetry, early diagnosis is essential.

Clinical presentation and diagnosis

Symptoms and signs

Telecanthus is often characterised by the widened intercanthal distance. Nasoethmoidal fractures are often present alongside telecanthus due to the MCT being disrupted. Clinically, you may see patients exhibiting bruising, periorbital swelling and nasal deformity, which reflects the underlying fracture. There is also a possibility for a patient to experience Epiphora, which is excessive tearing due to the lacrimal duct being affected. In more severe cases, double vision may be a symptom too.³

Clinical examination and imaging studies 

When carrying out a clinical examination, this would involve checking for abnormal mobility of the medial canthal tendon and measuring the intercanthal distance. (>35mm would suggest telecanthus in adults)⁴. The restriction of eye movement and lacrimal system involvement will also need to be assessed. Imaging studies are essential when confirming this diagnosis, as CT scans can provide detailed images of the fractures and the soft tissue involvement. X-rays generally have a limited role in this case; however can play a part in identifying severe bone abnormalities.³

Classification of nasoethmoidal fractures

Markowitz and manson classification

The Markowitz and Manson classification system bases nasoethmoidal fractures on the degree of bony fragmentation and medial canthal tendon (MCT) involvement:

• Type I: A single fragment fracture with an intact MCT, which means that the medial canthus remains stable. These fractures require minimal intervention and are likely to heal with conservative management or minor surgical fixation
• Type II: A multi-fragmented fracture that has a partially detached MCT with mild to moderate telecanthus. Surgery is often needed to restore medial canthal positioning
• Type III: A severely fragmented fracture with complete MCT avulsion, causing significant telecanthus and instability of the medial canthus. This type requires complex surgical reconstruction, including tendon reattachment and possible bone grafting or implant placement for structural support⁵

Management and treatment approaches

Conservative management

Coming across mild fractures whilst the medial canthal tendon remains attached can be managed conservatively. The treatment often involves applying ice to help with reduction of swelling and pain medication. However, it is still recommended to be followed up closely to monitor in case of delayed complications. The patient should avoid activities that can worsen the injury.

Surgical management

Surgery is often required for significant telecanthus (Types 2 and 3), displaced fractures, or lacrimal system injury to restore functions.

• Open reduction and internal fixation (ORIF): Plates and screws stabilise fractured bone segments
• Medial canthal tendon reattachment: Transnasal wiring or miniplates secure the MCT to restore normal intercanthal distance
• Medial orbital wall reconstruction: Bone grafts or implants (e.g., titanium, porous polyethylene) rebuild structural integrity if severe comminution is present⁵

Postoperative care

After the surgery, the care involves continuous monitoring in case of complications like infections, excessive tearing or persistent telecanthus. Patients would also undergo rehabilitation follow-up to assess the stages of healing and make sure eyelid function and facial symmetry are on track to heal.

Complications and prognosis

Potential complications

Nasoethmoidal fractures can lead to multiple complications if they are not managed properly:

• Persistent telecanthus: This can occur due to the medial canthal tendon being inadequately repaired, which results in ongoing cosmetic and functional issues
• Lacrimal duct injury: This can progress and lead to chronic epiphora (excessive tearing). If this occurs, it would require additional surgical intervention to restore normal tear drainage
• Orbital dystopia, or misalignment of the eye: This may develop if the fracture affects orbital positioning, potentially leading to vision disturbances or diplopia
• Secondary deformities: this can involve nasal asymmetry or midface depression and would require revision surgery to correct residual defects and restore facial symmetry⁶

Prognosis

The prognosis generally depends on the quality and time of intervention. If the surgical repair has been completed earlier and appropriately, then this generally leads to good functional and cosmetic outcomes as it preserves facial symmetry and eyelid stability. However, if a delayed diagnosis and therefore a delayed or inadequate surgical correction is performed, this can result in persistent issues and will require secondary procedures.⁶

Summary

The early detection of telecanthus is important when it comes to detecting nasoethmoidal fractures because it is involved in potential medial canthal tendon displacement and underlying structural injury. The severity of fractures is primarily determined by imaging tests, especially CT scans, and classification schemes such as the Markowitz and Manson framework aid in directing the best course of therapy. Restoring function and facial appearance requires appropriate surgical treatment, which includes medial canthal tendon restoration and fracture fixation. Prompt action enhances therapeutic results, reduces problems, and guarantees the best possible long-term recovery for impacted individuals.