Maxillofacial trauma: Difference between revisions

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==Diagnosis==
==Background==
===Prehospital Care===
*Assess patients ability to speak and protect the airway before and frequently during transport
*Hematomas can significantly distort pharyngeal and facial anatomy making intubation or [[cricothyroidotomy]] difficult
*Increased jaw mobility from a mid face fracture may help with intubation
*Penetrating trauma to the lower third of the face frequently requires intubation or a surgical airway<ref>Hollier L. et al. Facial gunshot wounds: A 4-year experience. Journal of Oral and Maxillofacial Surgery. 2011: 59:277-282</ref>
*Place a protective shield over an eye suspected to have a ruptured globe
*Patients should remain upright or reverse trendelenburg if there is oropharyngeal and [[epistaxis|nasal bleeding]] to avoid aspiration especially if placed in cervical protection
*Temporizing hemostasis with oral and nasal packing in an intubated patient may help with persistent bleeding
*Transport all avulsed pieces of the face including ears and nose


===Pediatric Considerations===
*Cricothyrotomy is contraindicated in patients <8yr old
*Maxillary sinuses do not develop until 6 yr old (reduces midfacial fracture)
*Pediatric orbital floor is more pliable, more likely to lead to entrapment
*Mandible fracture requires prompt referral (1-2d) due to rapid bone remodeling


ALWAYS ASK ABOUT VISION.
==Clinical Features==
[[File:PMC2700599 JETS-02-89-g005.png|thumb|Patient with poly maxillofacial trauma: (a) Bilateral black eyes. (b) X-ray skull: AP view showing multiple fractures of facial bone including mandible. (c) X-ray skull: lateral view showing multiple fractures of facial bone including mandible. (d) CT scan showing details of facial bone fractures.]]
===Ears===
*[[Auricular Hematoma]]
*Signs of [[basilar skull fracture]]
**CSF leak
**Hemotympanum
**Battle Sign


facial numbness, misalignment o teeth, and diploplia (monocular vs binocular)
===Nose===
*Crepitus over any facial sinus suggests sinus fracture
*[[Septal Hematoma]]
*Make sure simple [[nasal fracture]] isn't a complex naso-orbito-ethmoid injury


anesthesia of upper lip and/or maxillary teethmay be due to infraorbital nerve injury fromorbital blowout or orbital rimFx.
===Oral===
*Intraoral palpation of zygomatic arch to distinguish [[zygomatic arch fracture|bony]] from soft tissue injury
*[[Mandible Fracture]]
**Place finger in auditory canal while patient opens and closes jaw to detect condyle fracture
**Tongue blade test
***95% Sn for no fracture if can bite down hard enough to break it when twisted by examiner
**Jaw deviation due to [[mandible dislocation]] or condyle fracture
***Chin will point away from dislocation, towards a fracture
*Malocclusion occurs in [[mandible fracture|mandible]], [[zygomatic arch fracture|zygomatic]], and [[Le Fort]] fractures
*Lacerations and mucosal ecchymosis suggests [[mandible fracture]]


===Other Face===
*[[Numbness]]
**Check supraorbital, infraorbital, and mental nerves
*Assess [[Le Fort]] by rocking hard palate with one hand while stabilizing forehead with other


Exam (finer points): jaw deviation-the chin will point away from a dislocation and towards a fracture.
===Eye===
*''See [[Orbital trauma]]''


The best way to palpate the mandibular condyles is to place a finger in the external auditory canal and press down while pt opens and closes mouth.
===Visual Diagnosis===
<gallery mode="packed">
File:Black eye 2.jpg|Periorbital ecchymosis
File:Cauliflower ear by dr vikram yadav.jpg|[[Auricular hematoma]]
File:PMC5042625 OAMJMS-4-413-g001.png|[[Septal hematoma]]
File:BrokenNose.jpg|[[Nasal fracture]]
</gallery>


==Differential Diagnosis==
{{Maxillofacial trauma DDX}}


Radiology-
==Evaluation==
===Workup===
*Suspect midface fracture > facial CT
*Suspect orbital floor fracture > orbital CT
*Suspect mandibular fracture > CT face


If high suspicion of midface Fx then o directly to facial CT. Orbital floor Fx can be seen w/ orbital CT.
===Diagnosis===
*Frequently on CT


Water's view- can see orbital rims, floors, zygmatic arch, as well as maxillary sinus and maxilla.
===Example Images===
<gallery mode="packed">
File:LeFort109M.jpg|thumb|[[Le Fort]] type 1 fracture
File:NoDisManFracMark.png|thumb|[[Mandibular fracture]]
File:PMC4311579 eplasty15ic05 fig1.png|thumb|[[Zygomatic arch fracture]]
File:PMC4145677 eplasty14ic27 fig1.png|thumb|[[Zygomaticomaxillary complex fracture]]
File:PMC4772575 AMS-5-262-g001.png|thumb|[[Zygomaticomaxillary complex fracture]]
</gallery>


Bucket handle view to examine zygomatic arches.
==Management==
 
*Treat underlying process/diagnosis
Panorex or mandibular series for mndibular Fx. Fractures throughthe mandibular body are best seen on the oblique view. Fractures through theangle and symphysis are best seen on th PA view. Fx through themandibular condyles are best seen through the AP axial(Towne's) view
 
 
==DDx==
 
 
Frontal sinus fractures: ant wall isthick and the posterior wall is thin. Only 18% of frontal sinus fractures are anterior wall only. If ant wall Fx-need CT t evaluate posterior wall. (75% have both walls Fx). Need neurosurg or ENT for post wall since many need surgery and IVABx.
 
 
Naso-ethmoid fractures- diffuse tearing and increased intercanthal distance are suggestive. intranasal palpation w/ hemostat while palpating along bonyrim for crepitus useful.
 
complications include lacrimal disruption, medial cathal ligament rupture, and dural tears. intracranial injury seen in up to 70%. can develop malignant periorbital emphysema and blinndness. cover w/ABx and have pt see maxillofacial surgeon.
 
 
Nasal Fx-clincal diagnosis (no xrays) drain septal hematomas and f/u with ENTin 7-10 days
 
 
Zygomatic arch fractures- unlikely isolated
 
 
Tripod Fractures-
 
Fx through 1)inf orbital rim, 2) lateral orbital wall, 3) fx/disocation of zygomatic arch.
 
-must rule out associated ocular injuries. usually requires admission and surgical repair.
 


==Disposition==
==Disposition==
 
*Bedside consult is necessary for:
 
**Decreased vision
bedside consult is necessary for:
**[[Tripod Fracture]]
 
**[[Le Fort Fracture]]
decreased vision, tripod fractures, Lefort fractures, openmandibular fractures, frontal sinus fractures with intracranial involvement, NEO injuries.
**Open [[Mandibular Fracture]]
 
**[[Frontal Sinus Fractures]] with intracranial involvement


==See Also==
==See Also==
*[[Head Trauma (Main)]]


 
==References==
Trauma: Mandible Fx
<references/>
 
[[Category:ENT]]
Optho: Orbital Blowout Fx
[[Category:Orthopedics]]
 
 
 
 
[[Category:Trauma]]
[[Category:Trauma]]

Latest revision as of 19:41, 1 March 2023

Background

Prehospital Care

  • Assess patients ability to speak and protect the airway before and frequently during transport
  • Hematomas can significantly distort pharyngeal and facial anatomy making intubation or cricothyroidotomy difficult
  • Increased jaw mobility from a mid face fracture may help with intubation
  • Penetrating trauma to the lower third of the face frequently requires intubation or a surgical airway[1]
  • Place a protective shield over an eye suspected to have a ruptured globe
  • Patients should remain upright or reverse trendelenburg if there is oropharyngeal and nasal bleeding to avoid aspiration especially if placed in cervical protection
  • Temporizing hemostasis with oral and nasal packing in an intubated patient may help with persistent bleeding
  • Transport all avulsed pieces of the face including ears and nose

Pediatric Considerations

  • Cricothyrotomy is contraindicated in patients <8yr old
  • Maxillary sinuses do not develop until 6 yr old (reduces midfacial fracture)
  • Pediatric orbital floor is more pliable, more likely to lead to entrapment
  • Mandible fracture requires prompt referral (1-2d) due to rapid bone remodeling

Clinical Features

Patient with poly maxillofacial trauma: (a) Bilateral black eyes. (b) X-ray skull: AP view showing multiple fractures of facial bone including mandible. (c) X-ray skull: lateral view showing multiple fractures of facial bone including mandible. (d) CT scan showing details of facial bone fractures.

Ears

Nose

  • Crepitus over any facial sinus suggests sinus fracture
  • Septal Hematoma
  • Make sure simple nasal fracture isn't a complex naso-orbito-ethmoid injury

Oral

  • Intraoral palpation of zygomatic arch to distinguish bony from soft tissue injury
  • Mandible Fracture
    • Place finger in auditory canal while patient opens and closes jaw to detect condyle fracture
    • Tongue blade test
      • 95% Sn for no fracture if can bite down hard enough to break it when twisted by examiner
    • Jaw deviation due to mandible dislocation or condyle fracture
      • Chin will point away from dislocation, towards a fracture
  • Malocclusion occurs in mandible, zygomatic, and Le Fort fractures
  • Lacerations and mucosal ecchymosis suggests mandible fracture

Other Face

  • Numbness
    • Check supraorbital, infraorbital, and mental nerves
  • Assess Le Fort by rocking hard palate with one hand while stabilizing forehead with other

Eye

Visual Diagnosis

Differential Diagnosis

Maxillofacial Trauma

Evaluation

Workup

  • Suspect midface fracture > facial CT
  • Suspect orbital floor fracture > orbital CT
  • Suspect mandibular fracture > CT face

Diagnosis

  • Frequently on CT

Example Images

Management

  • Treat underlying process/diagnosis

Disposition

See Also

References

  1. ↑ Hollier L. et al. Facial gunshot wounds: A 4-year experience. Journal of Oral and Maxillofacial Surgery. 2011: 59:277-282
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