Maxillofacial Trauma

Anatomy

Anatomy

Maxillofacial Region 1. Fractures of the Nasal Pyramid 2. Fractures of the Central Midface Le Fort Fractures

Maxillofacial Region 3. Fractures of the Lateral Midface 4. Fractures of the Frontal bone 5. Fractures of the Anterior Skull Base Escher Classification

Maxillofacial Region 6. Fractures or dislocation of the mandible

Etiology Sports Vehicular Accidents Mauling Women – consider the possibility of domestic violence

Etiology Patients with severe facial trauma: multisystem trauma potential for airway compromise concurrent brain injury cervical spine injuries blindness

Emergent Management Primary Survey Secondary Survey Airway Breathing Circulation Secondary Survey

Emergent Management Airway: Chin lift. Jaw thrust. Oropharyngeal suctioning Manually move the tongue forward Maintain cervical immobilization Emergency management consists of Controlling the airway: Chin lift. Jaw thrust. Oropharyngeal suctioning. Manually move the tongue forward. Maintain cervical immobilization

Emergent Management Avoid nasotracheal intubation  cricothyroidotomy Adverse effects: Nasocranial intubation Nasal hemorrhage  cricothyroidotomy The cribiform plate may be disrupted- avoid nasotracheal intubation. Nasotracheal intubation can result in: 1) nasocranial intubation or 2) nasal hemorrhage. These include failure to intubate and subsequent failure to ventilate with a bag valve mask 2nd to facial distortion and should also be avoided. Consider awake intubation and use Benzodiazepines or another induction agent that minimizes resp. depression. If paralytics are used, be prepared for immediate backup cricothyroidotomy.

Emergent Management Circulation: Direct pressure Anterior and posterior nasal packing Packing of the pharynx around ET tube Bleeding from facial injuries typically is profuse but rarely causes hypovolemia or shock. In hypotensive patients, look for other sources of blood loss such as intrathoracic, intraabdominal, and retroperitoneal hemorrhage. Try to control bleeding with direct pressure. Avoid blind clamping because it can lead to injury of important nonvascular structures such as the facial nerve and parotid duct can result. Anterior and posterior packing may be needed in patients with nasal bleeding that does not resolve with direct pressure alone. Pharyngeal bleeding may require packing around the ET tube. Once the airway is secured and gross hemorrhage is controlled, search for life threatening injuries to the chest, abdomen and pelvis.

History Place, Time, Date, Mechanism of injury Detailed description of the circumstances surrounding the injury Allergies, other medical problems, medications, tetanus immunizations

History Questions: Was there LOC, nausea/vomiting, headache? (Head Trauma related questions) How is your vision? Hearing problems? Is there pain with eye movement? Are there areas of numbness or tingling on your face? Able to bite down without any pain? Is there pain with moving the jaw? Ask specific questions.: Is there pain with eye movement?-injury to the globe, orbit Are there areas of numbness or tingling on your face?-nerve entrap. Is the patient able to bite down without any pain? Is there pain with moving the jaw?-fx, impingement temporalis m.

Physical Examination Inspection Open wounds for foreign bodies Facial asymmetry Nose for deviation, widening of bridge Nasal septum for septal hematoma, CSF or blood Ears for blood or CSF Malocclusion Inspection of the face for asymmetry. Ask the patient to smile, frown, whistle, raise their eyebrows, close their eyes. Inspect open wounds for foreign bodies. Inspect the nose for asymmetry, telecanthus, widening of the nasal bridge. Measure the distance between the medial canthi. In normal patients the distance is 35-40mm. If its greater then 40 mm you should suspect nasoethmoid-orbital trauma. Inspect nasal septum for septal hematoma, CSF or blood. (place a drop of blood on a paper towel and look for a halo sign, nonspecific). Note ecchymosis (Battle’s sign, Raccoon eyes)

Physical Examination Inspection Battle’s sign Raccoon eyes

Physical Examination Inspection Not sensitive or specific but can be used as a preliminary test for CSF in blood Dipstick Beta transferrin Battle’s sign, Raccoon eyes Halo Sign Otorrhea, Rhinorrhea

Physical Examination Palpation Palpate the entire face. Supraorbital and Infraorbital rim Zygomatic-frontal suture Zygomatic arches Nose - crepitus, deformity and subcutaneous air Zygoma along its arch and its articulations with the maxilla, frontal and temporal bone Mandible for tenderness, swelling Palpate nose for crepitus, deformity and subcutaneous air. Palpate the zygoma along its arch and its articulations with the maxilla, frontal and temporal bone. Palpate the entire face. Supraorbital and Infraorbital rim Zygomatic-frontal suture Zygomatic arches

Physical Examination Intraoral examination: Inspect the teeth for malocclusions, bleeding Manipulation of each tooth Check for lacerations Mandibular movements Open pts mouth and grasp the maxilla arch, place the other hand on the forehead. Push back and forth, up and down and check for movement. Inspect the teeth for malocclusions, bleeding and step-off. If teeth are missing, account for to be sure they have not been aspirated. Intraoral exam: Manipulate each tooth, check for lacerations, stress the mandible, tongue blade test. (Bite down on the tongue blade, Twist the blade to try to break it. Pts with broken jaw will reflexively open their mouth.) Palpate the mandible for tenderness, swelling and step-off.

Physical Examination Ophthalmologic exam Visual acuity Pupils for shape and reactivity Eyelids for lacerations Extra ocular muscles Palpate around the orbits Check visual acuity. Snell chart, finger counting or presence or absence of light perception. Check pupils for roundness and reactivity. Tear drop pupil – ruptured or penetrated globe injury. Examine for exopthalmus or enopthalmus Examine the lids for lacerations. Check for injuries to the medial 3rd of the eyelids for damage to the lacrimal apparatus. Check for disruption of the levator palpebral muscles. Test extra ocular muscles.Testing for restriction. Restriction of upward gaze can be seen with zygomatic or infra orbital wall fx’s. Palpate around the entire orbits. Tenderness, subcutaneous air and deformity. Palpate the medial orbit area to r/o naso ethmoidal orbital fx. (place a Q tip inside the nose to the medial canthus, place your finger outside the medial canthus. If the bone moves - nasoethmoidal fracture.)

Physical Examination Examine and palpate the exterior ears Otoscopic examination Look for lacerations TM rupture Examine and palpate the exterior ears. Look for ecchymosis, hematomas,battle sign. Examine the ear canal. Look for lacerations, TM ruptures, Place your finger into the ear canal and have the pt open their mouth to check for condylar fx or dislocation. Check nuero distributions of the supraorbital, infraorbital, inferior alveolar and mental nerves. Supraorbital n.- forehead and vertex of scalp. Infraorbital n.- midface,maxillary incisors and premolar teeth, upper lip, lower eyelid, side of nose. Inferior alveolar n.- mandibular teeth, lower lip and chin. Mental n.- chin and lower lip.

Diagnostic Imaging Plain films CT scan Confirm suspected clinical diagnosis Determine extent of injury Document fractures CT scan

General Treatment ATS, TeAna Thorough evaluation of all wounds All foreign bodies must be removed Debridement Suturing of lacerations as needed Minimize scarring Antibiotics

Nasal Fractures Most common bone injury in the face Open or closed Signs Depression or displacement of nasal bones Edema of nose Epistaxis Fracture of septal cartilage with displacement or mobility Crepitus on palpation

Nasal Fractures All nasal injuries should be evaluated for septal hematoma Note mass on the nasal septum. If untreated, this can result in septal necrosis and a saddle nose deformity. Untreated- result in septal necrosis and saddle nose deformity Can become infected- result in a septal abscess

Nasal Fractures Treatment: Radiographs: Surgical Lateral projection Treatment: Surgical After reduction, nasal cavities should be packed – “internal splinting” Note mass on the nasal septum. If untreated, this can result in septal necrosis and a saddle nose deformity.

Maxillary Fractures Le Fort’s classification Le Fort I (transverse maxillary) Le Fort II (pyramidal) Le Fort III (craniofacial dysjunction)

Le Fort I Low transverse fracture of maxilla involving palate Facial edema Mobility of hard palate and upper teeth Malocclusion

Le Fort II Pyramidal fracture with detachment of maxilla Facial edema Epistaxis Bilateral periorbital edema and ecchymosis

Le Fort III Complete disruption of attachments of facial skeleton to cranium Movement of all facial bones in relation to the cranial base with manipulation of the teeth and hard palate Open patient’s mouth and grasp the maxilla arch Place the other hand on the forehead Gently move back and forth, up and down - check for movement of maxilla

Le Fort III

Le Fort III Massive edema with facial elongation, flattening – “Dish faced deformity” Epistaxis and CSF rhinorrhea Motion of the maxilla, nasal bones and zygoma

Management of Le Fort Fractures Open reduction and intermaxillary fixation should be performed to establish correct occlusion Followed by rigid fixation at the piriform rims and zygomaticomaxillary buttress.

Zygoma Fractures The zygoma has 2 major components: Zygomatic arch Zygomatic body Two types of fractures can occur: Isolated Arch fracture -most common Tripod fracture - most serious The zygoma has 2 major components, the zygomatic arch and the body. The arch forms the the inferior and lateral orbit, and the body forms the malar eminence of the face. Fractures to the zygoma are usually the result of blunt trauma. Direct blow to the arch can result in isolated arch fractures. These are the most common. While tripod fractures are more serious and are caused by more extensive trauma.

Zygoma Arch Fractures Palpable bony defect over the arch Flattening of the cheek Pain in cheek and jaw movement Limited mandibular movement Clinical findings: Palpable bony defect over the arch Depressed cheek with tenderness on palpation. Pain in cheek and jaw movement and limited mandibular movement which is due to impingement of the coronoid process of the mandible on the arch during mouth opening or impingement of the temporalis muscle. Picture: patient with blunt trauma to the zygoma. Flattening of the right malar eminence is evident.

Zygoma Arch Fractures Radiographic imaging: Treatment: Submental view “bucket handle view” - Arches may not be seen in usual views (anterior, lateral) Treatment: Symptomatic - surgical X-ray: bucket handle view of the zygomatic arch demonstrating a depressed fracture.

Zygoma Tripod Fractures Tripod fractures consist of fractures through: Zygomatic arch Zygomaticofrontal suture Inferior orbital rim and floor Symptoms Periorbital edema Sensory disturbances along the infraorbital nerve Tripod fractures consist of fractures through: Zygomatic arch Zygomaticofrontal suture Inferior orbital rim and floor Picture: Diagram of a tripod fracture. Note the disruption of both the lateral orbital rim and the orbital floor, as well as the zygomatic arch.

Zygoma Tripod Fractures Waters Caldwell Submental Coronal CT Treatment: Symptomatic - surgical Plain films including the waters, submental and caldwell views. Can demonstrate the fracture and evaluate the zygomaticomaxillary complex, but a Coronal CT of the facial bones will best show involvement and the degree of displacement.

Orbital Blow Out Fractures Isolated fracture of the orbital floor with partial herniation of orbital contents Facial asymmetry Enophthalmos Diplopia on upward gaze- impingement of inf. Rectus Check for sensory disturbances – cheek, upper lip, lateral nasal wall

Orbital Blow Out Fractures CT scan Management: Indicated for displaced fractures or for symptomatic fractures

Frontal Sinus Fracture Uncommon Depression of anterior table of frontal sinus Intracranial injuries Dural tears Epistaxis CSF rhinorrhea (disruption of posterior table of frontal sinus with dural rupture)

Frontal Sinus Fracture Radiographs: Facial views should include: Waters Caldwell lateral projections Caldwell view best evaluates the anterior wall fractures Patients with a suggested mechanism or PE should get either skull films, or a caldwell view of the face. (Caldwell view is the best for anterior wall fx’s.). Picture: Caldwell view

Frontal Sinus Fractures Cranial CT with bone window Frontal sinus fractures. Orbital rim and nasoethmoidal fractures R/O brain injuries or intracranial bleeds CT scan of the head with bone windows should be done to r/o intracranial pathology, but also to r/o depressed or posterior fx’s. Picture: CT of a patient which demonstrates a fracture of the anterior table of the frontal sinus.

Frontal Sinus Fractures Patients with depressed skull fractures or with posterior wall involvement. ENT or nuerosurgery consultation. Admission. IV antibiotics. Tetanus. Patients with isolated anterior wall fractures, nondisplaced fractures can be treated outpatient after consultation with neurosurgery. Patients with depressed skull fractures or with posterior wall involvement require: ENT or nuerosurgery consultation. Admission. IV antibiotics. Tetanus. Patients with isolated anterior wall fractures, nondisplaced fractures can be treated outpatient after consultation with neurosurgery.

Frontal Sinus Fractures Associated with intracranial injuries Orbital roof fractures Dural tears Mucopyocoele Epidural empyema CSF leaks Meningitis Associated with with intracranial injuries: Orbital roof fractures. Dural tears. Mucopyocoele. Epidural empyema. CSF leaks. Meningitis.

Anterior Skull Base Fractures

Mandibular Fractures 2nd most commonly fractured facial bone Signs and symptoms Malocclusion of teeth Tooth mobility Intraoral lacerations Pain on mastication Bone deformity

Mandibular Fractures Mandibular pain Malocclusion of the teeth Separation of teeth with intraoral bleeding Inability to fully open mouth Preauricular pain with biting Positive tongue blade test These fractures manifest clinically with mandibular pain, tenderness and malocclusion. A step off in the dental line or ecchymosis to the floor of the mouth are often present and is highly suggested of a mandibular fracture. Patients are unable to fully open their mouth. Patients may have preauricular pain with biting when there is a fracture of the condyle. Picture 1: The open fracture line is evident clinically. There is slight mal-alignment of the teeth. Picture 2: Hemorrhage or ecchymosis in the sublingual area is pathognomonic for an mandibular fracture.

Mandibular Fractures Radiographs: Panorex Plain view: PA, Lateral and a Townes view The best view for evaluating mandibular trauma is the dental panorex. If that is not available, plain films should include AP, bilateral oblique and a townes view to evaluate the condyles. Picture: Dental panorex of the mandible. Note fractures in the area of the left angle and right body.

Mandibular Fractures Treatment: Nondisplaced fractures: Analgesics Soft diet Dent/ORL surgery referral Displaced fractures, open fractures and fractures with associated dental trauma Urgent oral surgery consultation All fractures should be treated with antibiotics and tetanus prophylaxis. Nondisplaced fractures: Analgesics Soft diet oral surgery referral in 1-2 days Displaced fractures, open fractures and fractures with associated dental trauma Urgent oral surgery consultation, these patients are usually admitted, These patients either need closed reduction with occlusion fixation or open reduction. All patients with mandibular fractures should be treated with antibiotics and tetanus prophylaxis. Antibiotics of choice are PCN, clindamycin or a 1st generation ceph.