Ce diaporama a bien été signalé.
Nous utilisons votre profil LinkedIn et vos données d’activité pour vous proposer des publicités personnalisées et pertinentes. Vous pouvez changer vos préférences de publicités à tout moment.

18

Partager

Télécharger pour lire hors ligne

Nasal and noe fractures

Télécharger pour lire hors ligne

NASAL & NASO-ORBITAL-ETHMOID FRACTURE AND ITS MANAGEMENT

Livres associés

Gratuit avec un essai de 30 jours de Scribd

Tout voir

Livres audio associés

Gratuit avec un essai de 30 jours de Scribd

Tout voir

Nasal and noe fractures

  1. 1. NASAL & NOE FRACTURES Presented By: GIRIRAJ SANDEEP PG OMFS
  2. 2. CONTENTS • INTRODUCTION • ANATOMY • CLASSIFICATION OF NASAL & NOE FRACTURES • ETIOLOGY • CLINICAL FEATURES • DIAGNOSIS • TREATMENT • CONCLUSION
  3. 3. INTRODUCTION • Fractures of the middle third of the face are known as MAXILLOFACIAL SKELETAL INJURIES and they are associated with varying degrees of injuries of soft tissues.
  4. 4. ANATOMY • The facial skeleton is divided into three parts: - -Upper third -Middle third -Lower third
  5. 5. • The naso-orbito-ethmoidal region is situated in the central upper mid face. • It consists of a strong triangular frame.
  6. 6. • Due to the complexity and the density of the anatomic components of the area, the fracture in this region has been a great challenge in maxillofacial trauma.
  7. 7. OSTEOLOGY • INTERNAL ANGULAR PROCESS OF FRONTAL BONE • NASAL BONES • FRONTAL PROCESS OF MAXILLA • LACRIMAL BONE • LAMINA PAPYRACEA • ETHMOID BONE • SPHENOID BONE • NASAL SEPTUM
  8. 8. SOFT TISSUE ANATOMY • Medial canthal ligament • Lacrimal drainage apparatus
  9. 9. MEDIAL CANTHAL LIGAMENT
  10. 10. LACRIMAL DRAINAGE SYSTEM
  11. 11. Little’s Area • Kiesselbach's plexus or Kiesselbach's area, Kiesselbach's triangle, or Little's area, is a region in the anteroinferior part of the nasal septum, where four arteries anastomose to form a vascular plexus. • The arteries are: Anterior ethmoidal artery (branch of the opthalmic artery.) Sphenopalatine artery (terminal branch of the maxillary artery) Greater palatine artery (from the maxillary artery) Septal branch of the superior labial artery (from the facial artery). • It runs vertically downwards just behind the columella, crosses the floor of the nose and joins venous plexus on the lateral nasal wall. It is a common site for bleeding
  12. 12. BUTTRESS • The horizontal buttress is divided into the superior horizontal buttress and the inferior horizontal buttress, which consists of the frontal bone, superior orbital rims and inferior orbital rims.
  13. 13. • The medial vertical buttress consists of the internal angular process of the frontal bone and the bilateral frontal processes of the maxilla.
  14. 14. BLOOD SUPPLY • The blood supplying for the midface and nasal region comes from the branches of internal and the external carotid arteries. • The maxillary artery from the external carotid artery and subsequent branches play a important role for supporting the midface.
  15. 15. NERVE SUPPLY
  16. 16. NASAL FRACTURES
  17. 17. Surgical Anatomy OSSEOUS FRAMEWORK External Internal CARTILAGENOUS FRAMEWORK External Internal
  18. 18. Osseous framework EXTERNAL • Consists of two nasal bones • Concave/ convex from above downwards • Convex from side to side. • Traversed above downwards by a groove for anterior ethmoidal nerve. • Superior border articulates with nasal portion of frontal bone • Inferior border articulates with lateral cartilage of the nose.
  19. 19. INTERNAL • Perpendicular plate of ethmoid bone articulates posteriorly with the sphenoidal crest of sphenoid. • Postero-inferiorly with superior aspect of vomer. • Each Lateral nasal wall contains 3 conchae.
  20. 20. Cartilagenous Framework EXTERNAL Upper nasal cartilage Lower nasal cartilage
  21. 21. INTERNAL • Septal cartilage is quadrilateral in shape, • Upper portion articulates with internasal suture, • Middle portion articulates with lateral catilages, • Lower portion attached to these cartilages by perichondrium.
  22. 22. CLASSIFICATION OF NASAL INJURIES Rowe and Killey 1968 -Anterior nasal fracture due to impact from anterior direction. -Lateral nasal fracture due to impact from lateral direction.
  23. 23. Stranc & Robertson 1979 -Subdivided frontal impact fracture into 3 planes of injury. Plane 1 Injuries do not extending till the lower end of nasal bones to the anterior nasal spine. Plane 2 Injuries extending till the external nose but not till the orbital rims. Plane 3 Injuries involving orbital and possibly intracranial structures
  24. 24. Rorich et al proposed a simple classification Nasal Fracture Classification Type Description I Simple unilateral II Simple bilateral III Comminuted a. Unilateral b. Bilateral c. Frontal process of maxilla IV Complex (nasal bone fractures with septal disruption) a. Associated with septal hematoma b. Associated with open nasal laceration V Associated NOE fracture/midface fracture
  25. 25. Etiology -Assault -Road Traffic Accidents -Sports Injuries -Industrial Injuries
  26. 26. Clinical Features of Nasal Fractures • Flattened nasal bridge with splaying of nasal complex. • Saddle shaped deformity of nose from side. • Epistaxis. • Tenderness ,crepitus and mobility of nasal complex • Reduced nasal projection and height. • Septal deviation or dislocation. • Anosmia caused by damage to the cribiform plate. • Nasal congestion secondary to septal hematoma
  27. 27. Clinical features of NOE fractures • Gross facial edema may show firstly in the early stage of fracture, which will result in distortion of soft tissue landmarks. • Laceration in the nose and forehead. • Intracranial involvement. • Eye, forehead, and nose pain • Forehead paraesthesia • Mongoloid slant.
  28. 28. Associated occular injuries • Enopthalmus • Diplopia • Loss of globe integrity • Traumatic telecanthus • Circumorbital oedema and ecchymosis • Subconjuctival haemorrhage • Possible supraorbital/ supra trochlear nerve parasthesia.
  29. 29. • Oedema, • Emphysema, • Echymosis • Traumatic telecanthus • Rounding of medial canthal angle • Mongoloid slant
  30. 30. CSF leakage • Fracture of floor of anterior cranial fossa/base of skull. • Escape of CSF through a) Ethmoidal sinus b) Sphenoidal sinus c) Cribriform plate d) Frontal sinus
  31. 31. Classification Of NOE fractures AYLIFF CLASSIFICATION Type I : En bloc with minimum displacement. Type II : En bloc displaced # with large pneumatized sinus and minimum fragmentation. Type III : Comminuted # with inatct MCT attached to large bone. Type IV : Comminuted # with free MCT attacheD to bone not large enough for plating. Type V :Gross comminution needing grafting.
  32. 32. Yaremchuk Classification Type I: Isolated bony NOE Type II: Bony NOE and central maxilla II A: Central maxilla only II B: Central and unilateral maxilla. II C:Central and bilateral maxilla. Type III: extended NOE III A ;with craniofacial injuries IIIB: with LF II and LF III Type IV: NOE with orbital displacement IV A: with occulo-orbital displacement IV B: with orbital dystopia (displacement) Type V: NOE with bone loss
  33. 33. Rowe & Williams Classification Isolated NOE and frontal region # without other midface fractures a) Unilateral b) Bilateral Isolated NOE and frontal region # with other midface fractures. a) Unilateral b) bilateral
  34. 34. Markhowitz Classification TYPE 1 Involves single segment central fragment fractures. TYPE 2 Comminuted central fragment with fracture lines remaining peripheral to the MCT insertion. TYPE 3 Comminuted central fragment with fracture lines extending beneath the MCT insertion.
  35. 35. EXAMINATION OF NASAL & NOE FRACTURES • Examine the nasal cavity for the presence of CSF. • Query all conscious patients about the presence of watery rhinorrhea or salty postnasal drainage. • Test bloody fluid that is suspicious for CSF rhinorrhea • Examine facial lacerations under sterile conditions to assess depth of penetration or intracranial violation.
  36. 36. • Measure telecanthus • Palpate the nasal bones for crepitus and comminution. • Evaluate the septum for septal hematoma. • Evaluate the degree of nasal or midface retrusion. Pre injury photographs may be helpful.
  37. 37. • The following diagnostic procedures can be performed if there is a suspected CSF leak (clinical sign: straw-colored or clear nasal drainage): a) Tilt test with positive halo sign/double target sign/tram line effect. b) Comparison of the concentration of CSF glucose and serum glucose.
  38. 38. • Bloody rhinorrhea suspicious for CSF can be placed on filter paper and observed for a halo sign. • If CSF is present ,it diffuses faster than blood and results in a clear halo around the central stain. • Routine chemistry analysis of the rhinorrhea may reveal an elevated glucose content consistent with CSF.
  39. 39. Lab investigations to confirm CSF leak • Beta 2 transferrin is the definitive test for CSF rhinorrhoea. -Presence of Beta2-transferrin in the nasal discharge is diagnostic for a CSF leak.
  40. 40. Clinical Assesment for MCL • Bowstring test • Bimanual palpation
  41. 41. Bowstring test: • In the bow string test ,the eyelid is pulled laterally while the tendon area is palpated to detect movement of fracture segments. • A lack of resistance or movement of the underlying bone is indicative of a fracture.
  42. 42. Bimanual Palpation • It requires placing an instrument (kelly clamp) high into the nose,with its tip directly beneath the MCT . • Gentle lifting with the contralateral finger palpates the canthal tendons and allows an assessment of instability of the tendon attachement.
  43. 43. Management Of Nasal fractures
  44. 44. Nasal trauma algorithm
  45. 45. Closed manipulation of the fractured nose Closed manipulation is required for reduction of nasal fractures. - Radiographs taken in 2 directions are required for accurate diagnosis and closed manipulation. - Nose must be cleaned of debris, blood clot, loose bone fragments by suctioning. - Then nasal septum should be examined.
  46. 46. Techniques of closed manipulation Instruments required are a) Walsham’s Forceps b) Asch’s septal forceps c) Boies elevator
  47. 47. Walsham’s forcep : -Used for manipulation and reduction of nasal bone fractures. -One nasal blade is placed externally while the other blade goes into the nose and supports the nasal bone upto medial canthus and parallel to frontal process of maxillary bone, -Rotation medially or laterally results in in-or- outward movement of the fracture and results in reduction. -Base of the nose should be held by thumb of the opposite hand to provide stability to the manipulation procedure.
  48. 48. Asch’s Septal forceps: -Nasal septum can be reduced. -Both the blades are introduced into the floor of the nose, and gentle pressure is used to manipulate the septum by rotating upwards and forward to hold the septum, -Forward traction can then be applied to elevate the nasal bridge.
  49. 49. Boies elevator Boies elevator is inserted into the nostril deep to displaced nasal bone • Blade of elevator opposes thumb placed outside the nose • Raise & depress misaligned bones to their original.
  50. 50. Immobilisation of Nasal fractures Intranasal Splintage External Splintage
  51. 51. INTRANASAL SPLINTAGE a) Ribbon gauze b) Sialastic c) Stainless steel intranasal splint
  52. 52. Ribbon gauze: Indications- Nasal bone and nasal septum fracture Haemostasis in early post operative period. Procedure: 2.5 cm ribbon gauze soked in paraffin/bismuth iodoform paraffin paste is inserted into the nose in layers above downwards. Disadvantages: -Obstructs the airway -Source of potential infection in case of CSF rhinorrhea. -Do not provide antero-posterior support -May lead to post operative telecanthus due to over lack of external pressure to balance the pressure of ribbon gauze.
  53. 53. Silastic -According to Wadley 1979, -Intranasally silicone rubber wedges are placed followed by reduction, -Externally leads plates or plaster are placed to provide internal support of unstable nasal fractures.
  54. 54. Stainless steel intranasal splints: - Described by Sear 1977 - Oval section soft stainless steel 0.3mm bent in the form of figure 7 with widest diameter flat. -Insertion of the bent wire should be introduced intranasally, by flat end placing first. - The bent portion of the steel wire should reach the nasal bone such that, the fractured nasal bone gets reduced.
  55. 55. Advances in intranasal splints Doyle Open Lumen Splint/Airway splint obturator The Doyle Open Lumen Splint is designed to keep the nasal airway patent while maintaining support of the septum
  56. 56. Doyle Combo Splint • The Doyle Combo Splint combines all the benefits of the original nasal airway splint with the expandability and comfort of sponge.
  57. 57. Bivalve Nasal Splint • The Bivalve Nasal Splint is designed to provide septal support and reduce or prevent adhesions between the septum and lateral nasal wall following surgery. The splint is available in four models: standard or large, 0.25 mm or 0.50 mm thick.
  58. 58. Nasal Elliptical Septal Button • The Nasal Septal Button is designed for non-surgical closure of septal perforations. • The device is constructed using soft silicone and can be trimmed at the time of placement. • Studies have shown that use of a nasal septal button increases nasal respiration while decreasing symptoms of nasal perforations which include epistaxis and crusting.
  59. 59. EXTRANASAL SPLINTING a) Plaster of paris splint b) Collodium gauze and soft metal sheet c) Aluminium nasal splints d) Skin-friendly adhesive tapes/Steri-Strips e) Denver splint set
  60. 60. Plaster of Paris splint: -’Butterfly shaped’ can be cut or moulded to shape to the required size to be applied. -Plaster of paris bandage to be moistened in water, excess to be removed. -The bandage then moulded carefully over the forehead and glabella, nasal bridge line till the upper 2/3rd of the nose. -Care should be taken to limit the bandage just medial to the inner canthus of the eye. -When the plaster has set, it has to e secured by dynaplast or any adhesive tapes. -Bandage has to be changed for every 3-4 post operative day as the swelling reduces at the fractured site, plaster of paris bandage shrinks resulting in poor prognosis.
  61. 61. Collodion gauze and soft metal sheet - Several layers of gauze are soaked in collodian solution, then applied over the nose and contoured , - Then a soft metal sheet is cut and applied over the layers of gauze soaked with collodian solution, - Then again gauze containing collodion solution placed over the soft metal sheet,, after it sets, the splint is moulded and external pressure is applied just medial to the medial canthus.
  62. 62. Aluminium/thermoplastic Nasal Splint: • They can be applied quickly and efficiently, offer stable protection. • Thermoplastic is used to describe a substance that changes its consistency and stability under temperature influence. • The material should be heated in a water bath. The material changes its color from white to transparent and becomes malleable under the influence of warmth. The process is reversed by cooling.
  63. 63. Skin-friendly adhesive tapes/Steri-Strips - Several overlapping strips are placed across the nasal dorsum, and two longer strips are slung over the nasal tip. A Gelfoam strip has been placed on the nasal dorsum beneath the dressing.
  64. 64. Denver splint set - Consists of an adhesive strip with Velcro and an aluminum strip, also with Velcro.
  65. 65. MANAGEMENT OF NOE FRACTURES
  66. 66. Ellis had given eight steps that were critical in the treatment considerations for NOE fractures: (1)Exposure, (2) Identification of the medial canthal tendon, (3) Reduction/ reconstruction of the medial orbital rims, (4) Reconstruction of the medial orbital wall, (5) Tansnasal Canthopexy, (6) Naso-lacrimal apparatus repair, (7) Nasal reconstruction, and (8) Soft tissue re-adaptation.
  67. 67. Surgical approaches to NOE fractures • Existing lacerations • H shaped approach • Bilateral Z approach • Midline vertical approach • W shaped incision • Coronal approach
  68. 68. • Can be modified & extended by incorporating parts of the transverse W shaped incision Leaves scar over the nasal bridge EXISTING LACERATION
  69. 69. H shaped approach/ Open Sky approach • Excellent approach for nasal bridge, canthal ligaments • MUSTARDE advocated a curved lateral nasal incision over ant.lacrimal crest for exposure of lacrimal sac,to identify structures around medial canthal ligament •inadequate exposure of the frontal bone to allow bone plating or direct Trans osseous wiring of fractures
  70. 70. Bilateral Z approach Dingman(1969) Ant.to medial canthal area on lateral aspect of nose Horizontal incision -base of nose
  71. 71. Midline vertical approach • Soft tissues are undermined to reveal various fractures of nasal skeleton and the medial canthal ligament • Visibility is excellent Stranc (1970)
  72. 72. W shaped incision • By careful dissection of soft tissues, supra orbital nerves are identified & preserved • Provides excellent visibility & access for repositioning & direct plating or wiring of the bone fragments • Medial canthal ligament can be readily identified & repaired Bowerman-1975 •Leaves a scar across the bridge of nose Curved Transverse incision within skin crease Lateral extension Below eyebrow
  73. 73. • Bicoronal flap • Exposure: Frontal bone, upper part of nose roof, medial & lateral walls of the orbit • Soft tissues are divided down to subaponeurotic areolar tissue just superficial to pericranium. Pre-auricular incisions are extended across the scalp within the hairline Coronal approach
  74. 74. • Periosteum is divided just above supraorbital ridges • Dissection is completed subperiosteally degloving the forehead Flap is raised by dissection along this plane & gradually turned downwards & forwards
  75. 75. 77 • Dissection is carried down over the structures in relation to bridge of nose, canthal ligament can be identified in respect to adjacent fragments • When nasoethmoidal complex has been repaired ,flap is turned back, taking care to re-suture periosteal incision in order to ensure reattachment of eyebrows Advantages: 1. Whole facial skeleton can be laid bare 2. Accurate reduction & fixation of fractures together with replacement of missing bone by grafting facilitates superior cosmetic results 3. Cosmetic result is excellent,scarlines lie within the hairline 4. preauricular extensions are sited in the fold between the pinna & facial skin
  76. 76. Advancements in the exposure • To avoid facial scars, some authors paid more attention to midfacial degloving (MFD) approach which provides exposure of the entire midfacial skeleton via maxillary sublabial incision and can be extended superiorly and laterally according to the range of fracture. • However, the MFD approach will also produce complications, such as temporary infraorbital anesthesia, nasal obstruction and nasal cosmetic deformity. The management of naso-orbital-ethmoid (NOE) fractures Chinese Journal of Traumatology Volume 18, Issue 5, October 2015, Pages 296-301
  77. 77. Advancements in the exposure -Kim et al reported an oblique transnasal wiring that was performed by a Y–V epicanthoplasty incision rather than the well-known classical bicoronal approach, which could assist in minimizing unsightly scar formation. The management of naso-orbital-ethmoid (NOE) fractures Chinese Journal of Traumatology Volume 18, Issue 5, October 2015, Pages 296-301
  78. 78. REPAIR OF BONY SKELETON -Medial canthal ligament must be identified before reparing bony skeleton. -The activity of lacrimal system to be assessed -Initially nasal bridge should be aligned to the frontal bone and directly wired by using stainless steel wire of 0.4mm diamter trans- nasally. - Cyanoacrylate glue has been used to stabilise bony fragments and bone grafts in this region.
  79. 79. REPAIR OF MEDIAL CANTHAL LIGAMENT TransnasalCanthopexywire
  80. 80. • Transanasal Canthopexy wire is required to secure  Medial Canthal Tendon • Technique to assure the position of the Medical Canthal Tendon is necessary • 4th plate is utilized to hold the Medial Canthus in proper posterior and horizontal position (3dimensionally) • Achieved using Anchor Technique
  81. 81. Identifying the medialcanthus • First step in Canthopexy is identifying the Medial Canthus • BY Forceps , through Coronal or Extended glabellar approach • Find and pull on the medial canthus area to confirm that the proper structure has been identified
  82. 82. Wire placement intoMCT • Once medial canthus has been found – Transnasal wire is placed through the medial canthus • Metal wire with a swedged-on needle that can be detached from the wire should be used
  83. 83. Adaptfourthboneplateand passwirethough • If transnasal wire not in proper 3-D position, plate is needed to support the transnasal wire. • Pass the wire through the most posterior hole of the fourth plate and check for position
  84. 84. Create hole for thewire • Depending on stability of bone in NOE, surgeon may drill hole from – contralateral side , or • Use an awl to create passage way • Extreme caution – not to advance too far , injuring the globe • Malleable or spoon retractor to protect the globe.
  85. 85. Pull the wire throught thehole • Smaller needle should be used to pass needle through the ligament to avoid shredding the ligament • Two ends of the wire are placed through the lumen of the needle and both the spinal needle and wire are pulled out of the contralateral side of NOE
  86. 86. Fixation of the Fourthplate • Fourth plate is placed to secure the transnasal wire to its proper location • Plate is secured superiorly to the frontal bone
  87. 87. Securing Transnasalwire • Transnasal wire is secured to a screw placed in the frontal bone. ( on the contralateral side) • And tightened with appropriate tension needed to secure the medial canthus into its proper position
  88. 88. Proper position of Transnasalwire • Upper illustration – wire that has been placed anteriorly,  resulting in lateral splaying of bone supporting medial canthus & worsening of the telecanthus
  89. 89. Alternative support for Transnasal canthopexywire • Using mesh on one of the two sides to support the transnasal wire in its proper 3-D location. • Particularly useful when NOE combined with Medial Orbital Wall Fracture
  90. 90. Post -Op
  91. 91. ExternalSplint • Problem with NOE fracture – even after perfect bony reduction – lack of definition in the medial canthal area (Epicanthal fold) • Placing external nasal splints at the end of procedure
  92. 92. Nasolacrimal Apparatus Repair The incidence of nasolacrimal obstruction after open reduction of NOE fractures ranges from 5% to 21%. • In few cases of trauma, irrigation or lacrimal drainage tests are not indicated because of edema and inflammation of the nasolacrimal duct. • If a sac or duct laceration exists, an attempt should be made to place a silicone tube, If difficulty is encountered, no tube should be placed because traumatizing the canaliculi may compromise later surgery. •In this manner, a delayed assessment is recommended and secondary dacryocystorhinostomy should be performed if obstruction exists.
  93. 93. Complications Nasal Congestion Deviated nasal prominence Saddle nose appearance MALUNION Malunion is usually the result of improper reduction and fixation, resulting in such complications as malocclusion, facial asymmetry, enophthalmos, and ocular dystopia. CSF LEAK Although not common, CSF leaks that were not noted preoperatively have been reported after the treatment of midface fractures.
  94. 94. EPIPHORA • Injuries to the lacrimal system, either from trauma at the time of injury or as a result of iatrogenic causes secondary to open reduction and internal fixation, can result in epiphora. Posttraumatic ectropion, again from injury or secondary to lower lid surgical approaches, can also lead to epiphora. GLOBE INJURIES • The more common globe injuries would include injury to the cornea or penetrating injuries from scalpels, wires, or drill bits. • Fluorescein drops on the cornea can demonstrate abrasions or lacerations
  95. 95. Advances in management of NOE fractures Three-Dimensional Pre-Bent Titanium Implant
  96. 96. Ultra-high molecular weight polyethylene Comparison of pre-bent titanium mesh versus polyethylene implants in patient specific orbital reconstructions October 2013, DOI: 10.1186/1746-160X-9-32
  97. 97. Bone tissue engineering -Bone tissue engineering (BTE) is taken into consideration to restore the craniofacial bone defect, - Bone regeneration can be achieved by the reaction of three essential constituents: scaffolds, signals and cells -The scaffolds can be fabricated by CAD/CAM. -As to signals, the studies of bone morphogenic proteins (BMPs) have achieved significant results. -As for cells, Bone marrow-derived mesenchymal stem cells and adipose-derived mesenchymal stem cells which can differentiate into osteoblasts. The management of naso-orbital-ethmoid (NOE) fractures Chinese Journal of Traumatology Volume 18, Issue 5, October 2015, Pages 296-301
  98. 98. References • Peterson’s Principles of Oral and Maxillofacial Surgery – 2nd Edition • Rowe & Williams Maxillofacial Injuries • Fonseca’s Trauma • Complications in oral and maxillofacial surgery – Kaban
  • PankajGarg184

    Jan. 18, 2021
  • KaramSujitha

    Nov. 7, 2020
  • NivieSajeev

    Nov. 7, 2020
  • dragwani

    Nov. 6, 2020
  • Anuragvats6

    Oct. 21, 2020
  • MohammadAbdAlkader2

    Jul. 25, 2020
  • mYsf2

    Apr. 27, 2020
  • GouthamiChowdary1

    Mar. 8, 2020
  • HarshVerma162

    May. 31, 2019
  • TameemHussain3

    Apr. 13, 2019
  • NatnaelTsegaye

    Nov. 23, 2018
  • drshikhajangir

    Aug. 17, 2018
  • arvindyuvarajnarasim

    Jul. 3, 2018
  • khadri_afifa

    Jun. 3, 2018
  • drsalahghany

    May. 22, 2018
  • MohamedFalougy

    May. 19, 2018
  • mahboobehiranmanesh

    May. 18, 2018
  • DrNoorNajjar

    May. 16, 2018

NASAL & NASO-ORBITAL-ETHMOID FRACTURE AND ITS MANAGEMENT

Vues

Nombre de vues

1 965

Sur Slideshare

0

À partir des intégrations

0

Nombre d'intégrations

0

Actions

Téléchargements

128

Partages

0

Commentaires

0

Mentions J'aime

18

×