1. 1 IN THE NAME OF ALLAH, THE MOST BENEFICENT, THE MOST MERCIFUL

2. Nasal and Facial Trauma Brigadier Nasir Ullah Khan Classified ENT Specialist CMH Rawalpindi

3. 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

4. Facial Trauma 10 % of all accidents are related to facial injuries Endanger the airway Associated cervical spine injuries

7. Aetiology

12. Road Traffic Accidents Physical violence Attempted suicide Sports accidents

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

14. Management Primary survey and care –Airway –Breathing –Circulation –Dysfunction –Exposure

15. Management Secondary survey –Exclude other injuries –Extent of facial injuries Radiological evaluation - chest, cervical spine and pelvis Intervention

16. Management Facial swelling - head up position, ice packs and dexamethasone Facial wounds – closed as early as possible Fractures reduced and fixed Give tetanus prophylaxis

17. Nasal Fractures

18. 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

19. 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

20. Nasal trauma Apart from actual fracture of nasal bones, injuries include: - Soft tissue - Septal cartilage fracture - Septal bone fracture - Septal haematoma - CSF leak

21. Nasal trauma Injury results from - lateral - frontal - combined

24. 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

25. Nasal fractures - classification Class 1 Fracture Class 2 fracture Class 3 fracture – naso-orbito-ethmoid –Type I –Type II

29. 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

30. Clinical features Epistaxis Deformity Nasal obstruction Diplopia Epiphora Visual disturbance Watery rhinorrhoea Naso-fronto-ethmoid fractures

31. 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

32. Investigations X rays CT scan Beta transferrin

33. 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

34. 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

35. Management - fracture Class 2- septal fracture is often overlapping so fractures redisplace - manipulation of the nasal bones should follow excision of overlapping edges

36. Management - fracture Class 3- requires open reduction

37. Complications Bleeding Septal haematoma CSF rhinorrhoea Deformity Sensory loss Anosmia

38. Septal haematoma

39. Saddle deformity

40. Mandibular fractures

41. Mandible Fracture

42. Mandibular fractures clinical features Step deformities Pain Deranged occlusion Blood stained saliva Sublingual haematoma Mobile teeth Lip anaesthesia trismus

43. Signs and symptoms of condylar neck fractures Tenderness Trismus Lateral and anterior open bite

44. Mandibular fractures treatment Reduction –IMF –IM bone pins –Cast silver splints –Gunning splints Fixation –External –Internal - plating

45. Sites of bone plating

46. Fractures of the midface Central midface ( maxilla, nasal, naso- orbito-ethmoid) fractures Lateral ( zygomatic) fractures

47. Fractures of the Maxilla

48. Maxillary fractures classification Le fort 1 Le Fort 2 Le Fort 3

49. Le Fort 1

50. Le fort 2

51. Le Fort 3

52. 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

53. 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)

54. Treatment Emergency treatment Reduction Fixation –Imf –External – Levant frame –Internal suspension –Internal fixation – miniplates

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

56. 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

57. 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

58. 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

59. 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

60. 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.)

61. 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

62. 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

63. 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)

64. Thank you