68 Facial Trauma Flashcards
What important elements of the physical exam are considered in facial trauma?
What important elements of the physical exam are considered in facial trauma?
- Airway, breathing, and circulation (ATLS)
- Disability: cervical spine and brain injury (ATLS)
- Cranial nerves: motor (CN VII) and sensory (CN V1, V2, V3)
- Eyes: vision (CN II), pupils, movement (CN IV, VI) fields, pressure, globe injury, globe position
- Ears: hearing, hemotympanum, ear canal fracture, temporal bone fracture (CN VII, VIII)
- Bones: calvarium, midface, and mandible for deformity and dysfunction
- Throat: occlusion, TMJ function, bleeding, hematoma, airway, speech and swallow (CN IX, X)
What type of imaging should be ordered to evaluate facial trauma?
What type of imaging should be ordered to evaluate facial trauma?
High-resolution (fine cut) axial computed tomography (CT) with coronal and sagittal reconstruction is ideal. Cervical spine imaging should be included in facial fractures caused by high-energy impacts such as motor vehicle accidents (MVA). Coronal and sagittal reconstructions are helpful in evaluating the orbital floor, frontal sinus outflow tracts, and mandibular condyles. Three-dimensional CT scans are very helpful in surgical planning when multiple fractures are present. Direct radiographic signs of facial fractures are nonanatomic linear lucency, cortical defects or suture diastasis, overlapping bone fragments causing “double density,” and facial asymmetry. Indirect radiographic signs include soft tissue swelling, periorbital or intracranial air and fluid in the paranasal sinus.
What characteristics of the mechanism of trauma are considered important?
What characteristics of the mechanism of trauma are considered important?
Facial fracture results when the tolerance of facial bone is overcome by the kinetic energy (KE = ½mv2) transfer from blunt or penetrating trauma. Mechanisms have variable energy from low (fall from standing) to high (MVA). Understanding the mechanism of injury can help predict the extent of facial injury and the risk of associated cervical or brain injuries. High-impact and low-impact forces are defined as greater or lesser than 50 times the force of gravity (g). Facial bones differ in ability to withstand force: nasal bones can resist 30 g, zygoma 50 g, mandible angle 70 g, frontal-glabella 80 g, midline maxilla and mandible 100 g, and supraorbital rim 200 g. The most common facial fracture is the nasal bone.
How is the facial trauma patient evaluated?
How is the facial trauma patient evaluated?
Each patient must be evaluated and treated according to the ATLS guidelines. Once the patient is medically stable, definitive facial fracture assessment and management can proceed. Facial trauma can range from a minimally displaced nasal fracture to a highly comminuted compound panfacial fracture involving the orbit, brain, and cervical spine. Facial trauma evaluation is best done by dividing the face anatomically into three sections as each has its own unique characteristics. The upper third assesses frontal bone, frontal sinus, and frontal lobe injury. The middle third or “midface” contains nasal, nasal-orbital-ethmoid (NOE), orbit, zygomaticomaxillary complex (ZMC), and maxillary structures. The lower third includes the mandible and temporomandibular joint.
How would you evaluate a suspected frontal sinus injury?
How would you evaluate a suspected frontal sinus injury?
High-resolution thin cut computed tomography (CT) is best to evaluate anterior and posterior table fractures and outflow tract injury. In addition to the standard axial and coronal images, sagittal reconstructions of the paranasal sinuses can enhance visualization of the frontal outflow tract. Additional findings such as NOE complex fractures and anterior skull base injury near the junction of the posterior table and the cribiform plate strongly suggest injury to the frontal outflow tract.
What are the treatment goals of frontal sinus repair?
What are the treatment goals of frontal sinus repair?
- Protection of intracranial structures
- Stopping CSF leak
- Prevention of posttraumatic infection or mucocele (late complications)
- Restoration of facial aesthetics
What are the surgical indications for anterior and posterior table frontal sinus fractures?
What are the surgical indications for anterior and posterior table frontal sinus fractures?
Surgical indications for anterior table fractures include bony displacement causing a deformity or frontal sinus outflow tract impairment. Surgical indications for posterior table fracture include displacement of the posterior table greater than one table width, dural injury, CSF rhinorrhea, or frontal sinus outflow impairment.
How do you treat a frontal sinus fracture of the anterior table?
How do you treat a frontal sinus fracture of the anterior table?
Isolated, nondisplaced, or minimally displaced anterior table fractures are not treated. Displaced fractures are treated by open reduction and internal fixation. Management options include osteoplastic flap with open reduction and internal fixation of anterior table fracture with or without obliteration, or an attempt at outflow tract reconstruction. Observation and medical management with future endoscopic surgery if needed is also an option.
How would you treat a posterior table frontal sinus fracture?
How would you treat a posterior table frontal sinus fracture?
Uncomplicated nondisplaced posterior table fractures are generally not treated, but nondisplaced posterior table fractures with continued CSF leakage despite initial conservative measures require repair. Surgery is generally recommended for displaced posterior table fractures greater than one posterior table width, or severely comminuted fractures. The risk of dural injury in these cases is high and consultation with a neurosurgeon is recommended for possible dural repair. Mucosal removal and obliteration with abdominal fat or cranialization of the frontal sinus may be considered.
What is the “osteoplastic flap with frontal sinus obliteration” procedure?
What is the “osteoplastic flap with frontal sinus obliteration” procedure?
The osteoplastic bone flap is created by a frontal sinus outline marked on the cranium classically using a template from a 6 ft. Caldwell radiograph. Osteotomies are performed and the sinus is opened. The mucosa of the sinus is completely removed, the frontal recess is occluded with temporalis fascia or muscle, abdominal fat is used to fill the sinus, and the bony flap is replaced. Postoperative CT/MR surveillance imaging is used for detection of postoperative mucocele formation; however, imaging is often difficult to interpret.
What is “frontal sinus cranialization”?
What is “frontal sinus cranialization”?
The posterior wall of the frontal sinus is removed and the sinus mucosa is stripped away from the remaining bone. The brain and dura are evaluated by a neurosurgeon for possible debridement and dural closure. A previously mobilized anterior pericranial flap is inserted beneath the brain to separate it from the paranasal sinuses. The brain and dura are permitted to rest against the repaired anterior wall in the area originally occupied by the frontal sinus, which no longer exists.
What are the complications of frontal sinus fractures?
What are the complications of frontal sinus fractures?
Early complications include wound infection, CSF leak, meningitis, acute sinusitis, deformity, pain, hypesthesia, and brain abscess. Late complications include mucocele, mucopyocele, osteomyelitis, cosmetic defect, brain abscess, and headache.
What are the surgical approaches to repair the frontal sinus?
What are the surgical approaches to repair the frontal sinus?
- Frontal sinus trephination and elevation of the anterior wall with limited exposure
- Frontoethmoidectomy using a Lynch incision or endoscopic repair of the outflow tract
- Open reduction and internal fixation through the laceration or by coronal flap
- Frontal sinus obliteration
- Frontal sinus cranialization
- Frontal sinus ablation (Reidel) with removal of the anterior wall (rarely used today)
- Endoscopic frontal sinus surgery (delayed)
What are the dangers of raising a bicoronal flap for facial fracture repair and how are they avoided?
What are the dangers of raising a bicoronal flap for facial fracture repair and how are they avoided?
- Injury to the frontal branch of the facial nerve can be avoided by incising the superficial layer of the deep temporal fascia at the temporal line of fusion so elevation can be deep to this layer.
- Injury to the supraorbital and supratrochlear nerves at the supraorbital rims is prevented by removing the inferior lip of the nerve foramen with an osteotome to allow the nerve to move inferiorly.
- Laxity of the midface soft tissues occurs if the fascia is not resuspended at the time of closure.
What endoscopic procedure is used to treat severe chronic frontonasal outflow obstruction?
What endoscopic procedure is used to treat severe chronic frontonasal outflow obstruction?
The modified Lothrop procedure (Draf III procedure) may be used to restore severely obstructed frontal outflow pathways after trauma.
What key features are evaluated in nasal trauma?
What key features are evaluated in nasal trauma?
Nasal fractures are commonly identified by epistaxis and bony nasal deformity. Often the patient complains of nasal obstruction. The external exam should include evaluation of deformity, mobility, step-offs, and telecanthus. The internal exam should examine for septal deviation, mucosal tears, or septal hematoma. Clear rhinorrhea may indicate cerebrospinal fluid (CSF) leak. Epistaxis in severe facial trauma may be life threatening and require surgery or embolization of the feeding arteries if packing fails.
What are the dangers of a nasal septal hematoma and how is it treated?
What are the dangers of a nasal septal hematoma and how is it treated?
A septal hematoma is a collection of blood under the nasal septal perichondrium following trauma. The lack of blood supply to the cartilage can lead to cartilage necrosis or septal abscess and can produce a saddle nose deformity. Urgent treatment is required to evacuate the clot or purulence.
How is a nasal fracture treated?
How is a nasal fracture treated?
Timing is critical. Acute nasal fractures are treated best by closed reduction immediately following the fracture (1 to 2 hours) or after swelling has subsided (5 to 10 days). The bones are repositioned and splinted for 7 to 14 days. Chronic nasal fractures (>10 days) may be more difficult to treat and often require complete healing (3 to 6 months) followed by formal septorhinoplasty.
What is an NOE fracture?
What is an NOE fracture?
The nasal-orbital-ethmoid (NOE) complex is the confluence of the frontal sinus, ethmoid sinuses, anterior cranial fossa, orbits, frontal bone, and nasal bones. An NOE fracture is a telescoping fracture of the nasal, lacrimal, and ethmoid bones, which occurs from blunt trauma at the nasal bridge. Injury to the bony septal attachment at the cribiform plate can produce a CSF leak and anosmia. NOE fractures involve the attachment of the medial canthal tendons (MCT) and can produce telecanthus. Failure to diagnose and repair an MCT can lead to functional and cosmetic complications that are difficult to repair secondarily. Long-term sequelae of NOE fractures include blindness, telecanthus, enophthalmos, midface retrusion, cerebrospinal fluid (CSF) fistula, anosmia, epiphora, sinusitis, and nasal deformity.
How are medial canthal tendon injuries classified?
How are medial canthal tendon injuries classified?
Markowitz classified NOE fractures based on the status of the MCT and the degree of comminution of the “central fragment” of bone to which it remains attached. In Type I fractures the fracture lines leave a single noncomminuted central fragment with MCT attached. In Type II the central fragment gets comminuted but the MCT stays attached to its fragments. In Type III fractures there is severe central fragment comminution and the MCT is detached. Type II and III are the most difficult to repair and require transnasal wiring in a posterior superior direction to keep medial orbit deformity to a minimum.
What is a blowout fracture?
What is a blowout fracture?
An orbital blowout fracture results from hydraulic compression of the orbital contents into the paranasal sinuses through the weakest portions of the orbit. This usually occurs through the thin portion of the orbital floor (0.5 mm) and less frequently through the thin lamina papyracea (0.25 mm), which is supported by the honeycomb structure of the ethmoid sinuses. The pure form is purely hydraulic without rim injury; the impure form is caused by rim deformation and fracture extending posteriorly to create the blowout fracture.
How are middle third (midface) facial fractures classified?
How are middle third (midface) facial fractures classified?
In 1901, French military surgeon René Le Fort published a classification of midface fractures that is still in use today. All three fracture types traverse the pterygomaxillary fissure to interrupt the pterygoid plates (Figure 68-1). Le Fort I fracture is a horizontal fracture above the maxillary alveolus producing a floating palate. The fracture usually involves the nasal aperture and extends above the apices of the teeth, causing the maxilla and hard palate to move separately. Le Fort II fracture is a pyramidal fracture that usually involves the inferior orbital rim. It extends from the nasion through the lacrimal bones and inferior orbital floor and rim through or near the inferior orbital foramen, and inferiorly through the anterior wall of the maxillary sinus. The Le Fort III fracture is a transverse fracture that separates the face from the skull, which is known as craniofacial dissociation. It includes fractures through the zygomatic bone, nasofrontal and frontomaxillary sutures, and orbit. The thick greater wing of the sphenoid bone usually prevents the continuation of the fracture into the optic canal thus preserving vision. Le Fort fractures often present in “mixed combinations” and should be reported as such (Figure 68-2).
Figure front: Le Fort fractures. Le Fort I fracture (1) is a horizontal fracture above the maxillary alveolus. Lefort II fracture (2) is pyramidal and usually includes the infraorbital rim. Le Fort III fracture (3) includes the zygoma and orbit and is considered a craniofacial dissociation when present bilaterally.
FIgure back: A, Left photo is a preoperative 3DCT of a patient with a right Le Fort II, left Le Fort I-II-III, and a palate fracture and left coronoid fracture. B, Right is a postoperative 3DCT showing the nose and zygoma repositioned and fixed to the skull base. The maxillary buttresses were repaired in relation to both the upper stabilized segments and the mandibular occlusion. Note the untreated coronoid fracture in correct position following zygoma repositioning.
What are the anatomic regions of the mandible?
What are the anatomic regions of the mandible?
The mandible is divided into horizontal and vertical parts. The horizontal mandible has four anatomic regions: the dense basal bone consisting of the symphysis, parasymphysis, body, and less dense alveolar bone which holds the dentition. The vertical mandible has four anatomic regions: the angle, ramus, condyle, and coronoid. Fractures can occur in any of these regions but more frequently in the angle and condyle regions (Figure).
Figure: Common mandibular fracture sites: (1) condylar head, (2) condylar neck, (3) subcondylar, (4) coronoid, (5) ramus, (6) angle, (7) body, (8) symphysis (symphysis and parasymphysis), (9) and alveolar.
What are the indications for open reduction and internal fixation (ORIF) of a condyle fracture?
What are the indications for open reduction and internal fixation (ORIF) of a condyle fracture?
Absolute and relative indications for surgery are discussed by Zide and Kent (Table 68-1). Unfortunately there is no consensus on the treatment of condylar fractures in adults. The type of treatment must be chosen on a case by case basis and by professional experience. Functional therapy (early jaw mobilization) is essential to avoid ankylosis of the TMJ. Three treatments advocated for adults with condylar process fractures include: (1) a period of maxillomandibular fixation (MMF) followed by functional therapy, (2) functional therapy without a period of MMF and, (3) open reduction with or without internal fixation. ORIF in children is becoming more accepted due to technical experience and improvements in rigid fixation.
How is tension and compression related to mandibular healing?
How is tension and compression related to mandibular healing?
During chewing, a functional load creates tension which separates the superior border of the mandible (Figure). This opens the fracture site and will allow bacteria and food to enter and produce a poor result. Compression occurs on the inferior border at the same time and closes the fracture. During repair it is important to place a tension plate on the superior border to reduce separation. This fixes the fracture and reduces risks of nonunion and infection.
Figure: Under chewing load a mandibular angle fracture opens at the superior border (open arrows). This is considered the “tension” or distracting site, which can be held together with a lightweight mini-plate. “Compression” or closure occurs on the inferior border during loading and needs no plate to keep the fracture reduced. Some surgeons feel additional help on the inferior border may be necessary.
Explain the angle classification of occlusion.
Explain the angle classification of occlusion.
Class I is considered normal and the mesiobuccal cusp (MBC) of the permanent maxillary first molar occludes in the buccal groove (BG) of the permanent mandibular first molar. Class II (retrognathia) is a posterior mandible, so the upper MBC is now in front of (mesial) the lower BG. Class III (prognathia) is an anterior mandible in which the upper MBC is behind (distal) the lower BG.
Figure: Angle classification of occlusion. A, Class I, normal occlusion. B, Class II, malocclusion. C, Class III, malocclusion.
