Temple University School of Medicine Maxillofacial Trauma Joe Lex, MD, FACEP, FAAEM Temple University School of Medicine Philadelphia, PA USA Joseph.Lex@TUHS.Temple.edu

Lecture Outline Emergency management Facial exam Fractures FACE Major Minor Soft tissue injuries Unusual injuries FACE

Causes of Mortality Acute FACE Delayed Airway compromise Exsanguination Associated intracranial or cervical-spine injury Delayed Meningitis Oropharyngeal infections FACE

Epidemiology Estimated 3,000,000 facial trauma cases per year in USA Estimated 40 to 50% of motor vehicle victims have facial injury No uniform reporting or registry of cases FACE

Functions of Face Respiratory  upper airway Visual Olfactory FACE Mastication Cosmetic Communication Individual recognition FACE

Management Sequence Airway control / immobilize cervical spine Bleeding control Complete the primary survey Secondary survey Consider NG or OG tube placement FACE

Management Sequence Plain radiographs if fractures suspected CT if suspect complex fractures FACE

Management Sequence Repair soft tissue immediately if no other injuries Delay soft tissue repair until patient in OR if surgery for other injuries necessary FACE

Initial Management Step 1: Airway control Oxygen for all patients May need to keep patient sitting or prone Stabilize C-spine early Large bore (Yankauer) suction available FACE

Initial Management Step 1: Airway control Orotracheal intubation preferred over nasotracheal if possible midfacial fracture and invasive airway needed Combitube®, retrograde wire, or cricothyroidostomy if unable to orotracheally intubate FACE

Initial Management Step 2 : Bleeding control Can be major threat to life Use universal precautions Direct pressure dressings initially Contraindicated: blind vessel clamping FACE

Initial Management Step 2 : Bleeding control Rapid nasal packing may be necessary Be sure blood is not just running down posterior pharynx FACE

Initial Management Step 2 : Bleeding control Rarely: emergent cutdown and ligation of external carotid artery needed to prevent exsanguination Note: Although shock in facial trauma patient is usually due to other injuries, it is possible to bleed to death from a facial injury FACE

Airway Compromise Blood in airway “Debris” in airway FACE Vomitus, avulsed tissue, teeth or dentures, foreign bodies Pharyngeal or retropharyngeal tissue swelling Posterior tongue displacement from mandible fractures FACE

Secondary Survey Scalp Check for lacerations, hematomas, stepoffs, tenderness Bleeding maybe brisk until sutured Can use stapler for rapid closure FACE

Secondary Survey Ears Examine pinnae, canal walls, tympanic membranes Suction gently under direct vision if blood in canal Put drop of canal fluid on filter paper for “ring sign”  CSF leak Assess hearing FACE

Secondary Survey Eyes Pupils, anterior chamber, fundi, extraocular movements Conjunctivae for foreign bodies Palpate orbital rims No globe palpation if suspect penetration FACE

Secondary Survey Eyes Lid injury can leave cornea exposed FACE Use artificial tears or cellulose gel FACE

Secondary Survey Overall facial appearance Assess for symmetry, deformity, discoloration, nasal alignment Palpate forehead & malar areas FACE

Secondary Survey Nose Check septum for hematoma & position FACE Check airflow in both nares Palpate nasal bridge for crepitus Check fluid on filter paper for “ring sign” (for CSF leak) FACE

Secondary Survey Mouth Check occlusion Reflect upper & lower lips FACE Check Stenson's duct for blood Palpate along mandibular and maxillary teeth (be careful !) FACE

Secondary Survey Mouth Palpate along exterior of mandible Pull forward on maxillary teeth FACE

Secondary Survey Neurologic Skin fold symmetry at rest Motor: each division of CN-VII Sensation: 3 divisions of CN-V Sensation on tongue Gag reflex FACE

Fracture Classification Major Lefort I, II, III Mandibular Minor Nasal Sinus wall Zygomatic Orbital floor Antral wall Alveolar ridge FACE

Forces Required FACE Nasal fracture  30 g Zygoma fractures  50 g Mandibular (angle) fractures  70 g Frontal region fractures  80 g Maxillary (midline) fractures  100 g Mandibular (midline) fractures  100 g Supraorbital rim fractures  200 g FACE

Lefort Fractures Lefort fractures can coexist with additional facial fractures Patient may have different Lefort type fracture on each side of the face FACE

Differentiating Leforts Pull forward on maxillary teeth Lefort I: maxilla only moves Lefort II: maxilla & base of nose move: Lefort III: whole face moves: FACE

Lefort I: Nasomaxillary Horizontal fracture extending through maxilla between maxillary sinus floor & orbital floor Crepitus over maxilla Ecchymosis in buccal vestibule Epistaxis: can be bilateral Malocclusion Maxilla mobility FACE

Lefort I: Nasomaxillary Closed reduction Intermaxillary fixation: secures maxilla to mandible May need wiring or plating of maxillary wall and / or zygomatic arch Antibiotics: anti-staphylococcal FACE

Lefort II: Pyramidal Subzygomatic midfacial fracture with a pyramid-shaped fragment separated from cranium and lateral aspects of face FACE

Lefort II: Pyramidal Signs & symptoms Midface crepitus Face lengthening Malocclusion Bilateral epistaxis Infraorbital paresthesia Ecchymoses: buccal vestibule, periorbital, subconjunctival FACE

Lefort II: Pyramidal Hemorrhage or airway obstruction may require emergent surgery Treatment can often be delayed till edema decreased FACE

Lefort II: Pyramidal Usually require Intermaxillary fixation Interosseous wiring or plating of infraorbital rims, nasal-frontal area, & lateral maxillary walls May need additional suspension wires Antibiotics FACE

Lefort III Craniofacial dissociation Bilateral suprazygomatic fracture resulting in a floating fragment of mid-facial bones, which are totally separated from the cranial base FACE

Lefort III Signs and Symptoms Face lengthening: “caved-in” or “donkey face” Malocclusion: “open bite” Lateral orbital rim defect Ecchymoses: periorbital, subconjunctival FACE

Lefort III Signs and Symptoms Bilateral epistaxis Infraorbital paresthesia Often medial canthal deformity Often unequal pupil height FACE

Lefort III Usually associated with major soft tissue injury requiring emergent surgery for bleeding control Surgery can be delayed till edema resolves Intermaxillary fixation FACE

Lefort III Transosseous wiring or plating FACE Antibiotics Frontozygomatic suture Nasofrontal suture May need extracranial fixation if concurrent mandibular fracture Antibiotics FACE

Forces Required FACE Nasal fracture  30 g Zygoma fractures  50 g Mandibular (angle) fractures  70 g Frontal region fractures  80 g Maxillary (midline) fractures  100 g Mandibular (midline) fractures  100 g Supraorbital rim fractures  200 g FACE

Mandible Fractures Airway obstruction from loss of attachment at base of tongue >50 % are multiple Condylar fractures associated with ear canal lacerations & high cervical fractures High infection potential if any violation of oral mucosa FACE

Mandible Fractures Signs and symptoms Malocclusion Decreased jaw range of motion Trismus Chin numbness Ecchymosis in floor of mouth Palpable step deformity FACE

Mandible Fractures Tongue blade test: have patient bite down while you twist. If no fracture, you will be able to break the blade. FACE

Mandible Fractures Treatment Prompt fixation: intermaxillary fixation (arch bars), +/- body wiring or plating FACE

TMJ Dislocation Can occur from direct blow to mandible Can occur “spontaneously” from yawning or laughing Mandible dislocates forward & superiorly Concurrent masseter & pterygoid spasm FACE

TMJ Dislocation Symptoms Patient presents with mouth open, cannot close mouth or talk well Can be misdiagnosed as psychiatric or dystonic reaction FACE

TMJ Dislocation Treatment Manual reduction: place wrapped thumbs on molars & push downward, then backward Be careful not to get bitten Usually does not require procedural sedation or muscle relaxants FACE

Forces Required FACE Nasal fracture  30 g Zygoma fractures  50 g Mandibular (angle) fractures  70 g Frontal region fractures  80 g Maxillary (midline) fractures  100 g Mandibular (midline) fractures  100 g Supraorbital rim fractures  200 g FACE

Nasal Bone Fractures Often diagnosed clinically: x-ray not needed Emergent reduction not necessary except to control epistaxis Usually do not need antibiotics Early reduction under local anesthesia useful if nares obstructed FACE

Nasal Bone Fractures Nasal septal hematoma: incise & drain, anterior pack, antibiotics, follow-up at 24 hours Follow-up timing for recheck or reduction: Children: 3 to 5 days Adults: 7 days FACE

Forces Required FACE Nasal fracture  30 g Zygoma fractures  50 g Mandibular (angle) fractures  70 g Frontal region fractures  80 g Maxillary (midline) fractures  100 g Mandibular (midline) fractures  100 g Supraorbital rim fractures  200 g FACE

Zygomatic Fractures Tripod (tri-malar) fracture Depression of malar eminence Fractures at temporal, frontal, and maxillary suture lines FACE

Zygomatic Fractures Isolated arch fracture Less common Shows best on submental-vertex x-ray view Painful mandible movement Usually treat with fixation wire if arch depressed FACE

Zygomatic Fractures FACE Tripod S & S Unilateral epistaxis Depressed malar prominence Subcutaneous emphysema Orbital rim step-off Altered relative pupil position Periorbital ecchymosis Subconjunctival hemorrhage Infraorbital hypoesthesia FACE

Forces Required FACE Nasal fracture  30 g Zygoma fractures  50 g Mandibular (angle) fractures  70 g Frontal region fractures  80 g Maxillary (midline) fractures  100 g Mandibular (midline) fractures  100 g Supraorbital rim fractures  200 g FACE

Supraorbital Fractures Frontal sinus fracture Often associated with intracranial injury Often show depressed glabellar area If posterior wall fracture, then dura is torn FACE

Supraorbital Fractures Ethmoid fracture Blow to bridge of nose Often associated with cribiform plate fracture, CSF leak Medial canthus ligament injury needs transnasal wiring repair to prevent telecanthus FACE

Orbital Fractures “Blow out” fracture of floor Rule out globe injury Visual acuity Visual fields Extraocular movement Anterior chamber Fundus Fluorescein & slit lamp FACE

Orbital Fractures Symptoms and signs Diplopia: double vision Enophthalmos: sunken eyeball Impaired EOM’s Infraorbital hypesthesia Maxillary sinus opacification “Hanging drop” in maxillary sinus FACE

Orbital Fractures Diplopia with upward gaze: 90% FACE Suggests inferior blowout Entrapment of inferior rectus & inferior oblique Diplopia with lateral gaze: 10% Suggests medial fracture Restriction of medial rectus muscle FACE

Orbital Fracture: Treatment Sometimes extraocular muscle dysfunction can be due to edema and will correct without surgery Persistent or high grade muscle entrapment requires surgical repair of orbital floor (bone grafts, Teflon, plating, etc.) FACE

Facial Soft Tissue Injuries Before repair, rule out injury to: Facial nerve Trigeminal nerve Parotid duct Lacrimal duct Medial canthal ligament Remove embedded foreign material to prevent tattooing FACE

Facial Soft Tissue Rules For lip lacerations, place first suture at vermillion border Never shave an eyebrow: may not grow back If debridement of eyebrow laceration needed, debride parallel to angle of hairs rather than vertically FACE

Facial Soft Tissue Rules Antibiotics for 3 to 5 days for any intraoral laceration (penicillin VK or erythromycin) and if any exposed ear cartilage (anti-staphylococcal antibiotic) – no evidence Remove sutures in 3 to 5 days to prevent cross-marks FACE

Facial Soft Tissue Rules Most face bite wounds can be sutured primarily Clean facial wounds can be repaired up to 24 hours after injury Place incisions or debridement lines parallel to the lines of least skin tension (Lines of Langer) FACE

Questions??

Summary Assess ABC's first Do complete exam as part of secondary survey Obtain standard X-rays and / or CT scan as indicated Decide if specialist referral and / or operative repair indicated FACE

Summary Arrange followup after repair to assess for delayed complications or cosmetic problems FACE