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Facial TraumaEpidemiologyMortality due to airway compromise / blood loss; if 3+ facial #, 35% incidence of basal skull #AnatomyInfraorbital nerve: cheek, lateral nose, skin and conjunctiva of lower eyelid, antinf nasal septum, skin/mucosa of upper lip, premolars, canines, incisorsEye: medial and lat canthal ligaments prevent globe from extrusion, come medially and laterally from bony wall, divide on surface of globe into inf and sup ligsGradingI: closed # mandibleII: closed # zygomaIII: open # mandible Le Forte III compound # with <20% blood lossIV: >20% blood lossAssessmentHistory: vision, epistaxis, teeth fit, numb, diplopiaExamination: airway (44% with severe maxfax trauma need ETT)Face: inspect from top, front, sides; facial scalloping, bony steps, crepitus; mobilty of midface / teeth; racoon eyes, Battle signDental: jaw movement, malocclusion, mental nerveNasal: septal haematoma, nasal obstruction, deviation, epistaxisNerve: facial nerve, IO nerveEye: enopthalmos (blow out #), exopthalmos (retrobulbar haematoma), proptosis, hypoglobus, monocular diplopia (lens dislocation), binocular diplopia (entrapment of muscle), hyphema, RAPD (ON inj or other inj to visual pathway), VA (6% vision loss), ROM (decr upward gaze = entrapment of IR/IO muscle, OM nerve), pupil response, telecanthus (widening of distance with normal interpupillary distance), lacrimal apparatus, hypertelorism (widening of interpupillary distance (blow out #)Ear: auricular haematoma, CSF, haemotympanumOther: HI, C spineInvestigationFacial views: Waters (occipitomental; for midface, maxilla, infraorbital, zygoma), Caldwell (PA; for frontal, paranasal sinus), skyline (submental; for zygoma, base of skull), Towne’s (for mandibular rami and condyles), mandibular and TMJ, lateralOPG: mandibularCT: do if CT head indicated, ?orbital blow out, gas in orbit, clinically obvious facial deformity, # maxilla / orbit / frontal sinus on XR, high degree of suspicion despite normal XRBloods: do coag if major facial haemorrhage (DIC common)Fractures 1327150-724535Tripod #: separation at zygomatico-frontal / zygomatico-maxillary suture / infraorbital rim flat cheek, asymmetrical ocular level, infraorbital nerve numbness, diplopia, subconjunctival haem, unilateral epistaxis, decr mandibular movement; penicillin; reduction and internal fixation if complex / deformity / open0Tripod #: separation at zygomatico-frontal / zygomatico-maxillary suture / infraorbital rim flat cheek, asymmetrical ocular level, infraorbital nerve numbness, diplopia, subconjunctival haem, unilateral epistaxis, decr mandibular movement; penicillin; reduction and internal fixation if complex / deformity / open-44450-2439035Le Fort:I: # through lower 1/3 maxilla, palate, pterygoid plate body of maxilla separate from base of skull at level of nasal floor / above level of palate / below level of zygomatic arch movement of upper dental arch, malocclusion with premature premolar contactII: # through maxilla towards medial infraorbital rims, into ethmoid sinus, cross bridge of nose movement of nose and upper dental arch, donkey face on frontal; most common midface #; assoc with epistaxis, CSF leakIII: # through fronto-zygomatic suture (or zygomatic arch), med and lat walls of orbits, base of nose movement of entire maxilla and zygoma, cranio-facial dysfunction, dish face on lateral, donkey face on frontal00Le Fort:I: # through lower 1/3 maxilla, palate, pterygoid plate body of maxilla separate from base of skull at level of nasal floor / above level of palate / below level of zygomatic arch movement of upper dental arch, malocclusion with premature premolar contactII: # through maxilla towards medial infraorbital rims, into ethmoid sinus, cross bridge of nose movement of nose and upper dental arch, donkey face on frontal; most common midface #; assoc with epistaxis, CSF leakIII: # through fronto-zygomatic suture (or zygomatic arch), med and lat walls of orbits, base of nose movement of entire maxilla and zygoma, cranio-facial dysfunction, dish face on lateral, donkey face on frontal1327150-3228340Naso-orbito-ethmoid complex fracture: across nasal bridge and ethmoids; avulses medial canthal ligament from lacrimal bone short, laterally displaced medial palpebral fissure; incr intercanthal distance (telecanthus, >1/2 interpupillary distance, >4cm); trt with surgical repair00Naso-orbito-ethmoid complex fracture: across nasal bridge and ethmoids; avulses medial canthal ligament from lacrimal bone short, laterally displaced medial palpebral fissure; incr intercanthal distance (telecanthus, >1/2 interpupillary distance, >4cm); trt with surgical repairMandibular: body (30-40%, esp 1st and 2nd molar region); angle (25%); condyle (20%, cause malocclusion); symphysis (10%, lower incisors displaced laterally); alveolar (<5%); may need IVF; penicillin; ADT; most need internal fixation; if dislocated, press down with thumbs, upward pressure with fingers on one sideTMJ dislocation: mandibular head goes forward and superior; caused by trauma, drugs, epilepsy, prolonged dental procedure; mouth open and unable to closeZygomatic arch: mandibular opening may be limited by masseter muscle entrapment; OT if entrapment / cosmetic probsMaxillary, alveolar: most common # of maxilla; avulsion of teeth; trt with wiringMaxillary, orbital floor blow out #: # orbital floor without # orbital margin; usually med / inf floor; can trap IR, IO; occurs from direct blow to orbit; diplopia in 85%, decr upward gaze (due to IR / IO entrapment), enopthalmos, hypertelorism, corneal abrasion, hyphema, subC emphysema, IO anaesthesia; teardrop on Caldwell; augmentin, decongestants, no nose blowing, OT if diplopia in 1Y position, Sx persist, cosmeticNasal traumaSeptal haematoma – between septal cartilage and mucoperichondrium cartilage necrosis, infection, abscess, cartilage destruction in 24hrsTreatmentGeneral principles: attend to airway and life threatening inj first; if airway compromise, pull maxilla forward, lift tongue and mandible; ensure C spine OK; allow patient to sit when C spine cleared; beware ETT, may be hard to BVM, have back up plan, use etomidate/ketamine to maintain resp if good view, paralyse and intubate; early shock usually due to bleeding elsewhere; immediate reduction of Le Forte # if bleeding / airway compromise; catheter tamponade of epistaxis; gauze packing of oropharynx, nasopharynx, around ETT; inject bleeding sites with adrenaline; consider early OT / embolisation; ADTNasal trauma: review at 5/7; reduce at 5-10/7 if indicated; delayed septoplasty if cartilage inj; drain septal haematoma and cover with anti-staph Abx (review at 24hrs) Indications for reduction: cosmetic deformity due to #, nasal obstructionAntibiotics if: extensive ST inj (contaminated wound, open #, # communicating with intranasal/oral/spinous space, bites, exposed cartilage, immunological compromise; penicillin 1/52 for all # involving maxillary antrumLateral canthotomy: decompress orbit; indicated if IO p > retinal artery p (vision threatening if >2hrs) = visual loss, RAPD, proptosis, hard globe on palpation; incise skin over lateral canthus towards bony orbit retract lower lid divide inf lat canthal lig divide sup if p not dropped enoughNotes from: Dunn, Cameron ................
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