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1 IN THE NAME OF ALLAH, THE MOST BENEFICENT, THE MOST MERCIFUL
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Nasal and Facial Trauma Brigadier Nasir Ullah Khan Classified ENT Specialist CMH Rawalpindi
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Sequence Facial trauma in general Nasal trauma Mandibular fractures Fractures of the maxilla Zygomatic complex fractures Orbital floor fractures Upper third fracures involving the frontal sinus Soft tissue injuries
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Facial Trauma 10 % of all accidents are related to facial injuries Endanger the airway Associated cervical spine injuries
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Aetiology
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Road Traffic Accidents Physical violence Attempted suicide Sports accidents
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Causes of Mortality Acute –Airway compromise –Exsanguination –Associated intracranial or cervical-spine injury Delayed –Meningitis –Oropharyngeal infections
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Management Primary survey and care –Airway –Breathing –Circulation –Dysfunction –Exposure
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Management Secondary survey –Exclude other injuries –Extent of facial injuries Radiological evaluation - chest, cervical spine and pelvis Intervention
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Management Facial swelling - head up position, ice packs and dexamethasone Facial wounds – closed as early as possible Fractures reduced and fixed Give tetanus prophylaxis
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Nasal Fractures
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Introduction Isolated nasal fractures account for about 40 percent of all facial fractures Delays in management can result in significant cosmetic and functional deformity Management of nasal fractures is an important part of everyday ENT practice
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Nasal trauma More common in young men than women 15 – 30 years Aetiology –In young adults (peak incidence) Assaults Contact sports Adventurous leisure activities –In childhood Accident prone toddlers not infrequently fracture their noses –In elderly Compound and comminuted fractures due to falls
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Nasal trauma Apart from actual fracture of nasal bones, injuries include: - Soft tissue - Septal cartilage fracture - Septal bone fracture - Septal haematoma - CSF leak
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Nasal trauma Injury results from - lateral - frontal - combined
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Extent of deformity Grade 0 : bones perfectly straight Grade 1 : bones deviated less than half of the width of the bridge of nose Grade 2 : half to one full width of the bridge of nose Grade 3 : greater than one full width of the bridge Grade 4:bones almost touching the cheek
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Nasal fractures - classification Class 1 Fracture Class 2 fracture Class 3 fracture – naso-orbito-ethmoid –Type I –Type II
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Nasal trauma May be part of more extensive injury to face, skull, skull-base, neck, chest ……. REMEMBER TO CONSIDER THE AIRWAY AND EXCLUDE CERVICAL SPINE INJURIES
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Clinical features Epistaxis Deformity Nasal obstruction Diplopia Epiphora Visual disturbance Watery rhinorrhoea Naso-fronto-ethmoid fractures
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Clinical features Signs –External deformity, swelling, lacerations –Tenderness, crepitus –Septal haematoma/ abscess There is often periorbitaln swelling and there may be periorbital and subconjunctival echymosis
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Investigations X rays CT scan Beta transferrin
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Management - soft tissue Clean wounds and remove foreign material Anti-tetanus and antibiotic cover if appropriate Abrasions cleaned and left open Steristrips to small lacerations Fine monofilament sutures to large lacerations
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Management - fracture Nothing if no deformity. Reassure and review Class 1- reduce if early - disimpact and realign - if swollen, manipulate and reduce at 5-7 days
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Management - fracture Class 2- septal fracture is often overlapping so fractures redisplace - manipulation of the nasal bones should follow excision of overlapping edges
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Management - fracture Class 3- requires open reduction
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Complications Bleeding Septal haematoma CSF rhinorrhoea Deformity Sensory loss Anosmia
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Septal haematoma
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Saddle deformity
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Mandibular fractures
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Mandible Fracture
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Mandibular fractures clinical features Step deformities Pain Deranged occlusion Blood stained saliva Sublingual haematoma Mobile teeth Lip anaesthesia trismus
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Signs and symptoms of condylar neck fractures Tenderness Trismus Lateral and anterior open bite
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Mandibular fractures treatment Reduction –IMF –IM bone pins –Cast silver splints –Gunning splints Fixation –External –Internal - plating
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Sites of bone plating
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Fractures of the midface Central midface ( maxilla, nasal, naso- orbito-ethmoid) fractures Lateral ( zygomatic) fractures
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Fractures of the Maxilla
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Maxillary fractures classification Le fort 1 Le Fort 2 Le Fort 3
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Le Fort 1
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Le fort 2
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Le Fort 3
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Differentiating Le Forts Pull forward on maxillary teeth Le Fort 1: maxilla only moves Le Fort 2: maxilla & base of nose moves Le Fort 3: whole face moves
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Le Fort fractures signs and symptoms Epistaxis Circumorbital ecchymosis Facial oedema Surgical emphysema Infraorbital anaesthesia Anterior open bite ( in Le Fort 1&2) Haematoma at the junction of hard and soft palate Floating palate and teeth ( Le Fort 1)
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Treatment Emergency treatment Reduction Fixation –Imf –External – Levant frame –Internal suspension –Internal fixation – miniplates
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Zygomatic Fractures Tripod (tri-malar) fracture Depression of malar eminence Fractures at temporal, frontal, and maxillary suture lines
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Zygomatic Fractures Isolated arch fracture Less common Shows best on submental-vertex x-ray view Painful mandible movement Usually treated with fixation wire if arch depressed
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Zygomatic Fractures Tripod S & S Unilateral epistaxis Depressed malar prominence Subcutaneous emphysema Orbital rim step-off Altered relative pupil position Periorbital ecchymosis Subconjunctival hemorrhage Infraorbital hypoesthesia
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Orbital floor fractures “Blow out” fracture of floor Symptoms and signs Diplopia: double vision Enophthalmos: sunken eyeball Impaired EOM’s Infraorbital hypoesthesia Maxillary sinus opacification “Hanging drop” in maxillary sinus
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Upper facial third Fractures Frontal sinus fracture Often associated with intracranial injury Often show depressed glabellar area If posterior wall fracture, then dura is torn
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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.)
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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
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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
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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)
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Thank you
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