Maxillofacial trauma: Difference between revisions
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===Prehospital Care=== | ===Prehospital Care=== | ||
*Assess patients ability to speak and protect the airway before and frequently during transport | *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 | *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 | *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> | *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 | *Place a protective shield over an eye suspected to have a ruptured globe | ||
*Patients should remain upright or reverse | *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 | *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 | *Transport all avulsed pieces of the face including ears and nose | ||
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==Clinical Features== | ==Clinical Features== | ||
===Face=== | ===Face=== | ||
*Numbness | *[[Numbness]] | ||
**Check supraorbital, infraorbital, and mental nerves | **Check supraorbital, infraorbital, and mental nerves | ||
*Assess Le Fort by rocking hard palate with one hand while stabilizing forehead with other | *Assess [[Le Fort]] by rocking hard palate with one hand while stabilizing forehead with other | ||
===Eye=== | ===Eye=== | ||
*Exam | *Exam | ||
**Bird's eye view for exophthalmos with retrobulbar hematoma | **Bird's eye view for exophthalmos with retrobulbar hematoma | ||
**Worm's view for endophthalmos (blow-out fracture) or malar prominence flattening (zygoma fracture) | **Worm's view for endophthalmos (blow-out fracture) or malar prominence flattening (zygoma fracture) | ||
*Acuity | *[[vision loss|Acuity]] | ||
*[[Diplopia]] | *[[Diplopia]] | ||
**Binocular diplopia suggests entrapment of | **Binocular diplopia suggests entrapment of extraocular muscles | ||
**Monocular diplopia | **Monocular diplopia suggests [[lens dislocation]] | ||
*Extraocular motion | *Extraocular motion | ||
**Limitation on upward gaze occurs with fracture of | **Limitation on upward gaze occurs with [[orbital fractures|fracture of inferior and medial orbital wall]] | ||
*Pupil | *Pupil | ||
**Teardrop sign (globe rupture), hyphema, reactivity (swinging flashlight test) | **Teardrop sign ([[globe rupture]]), [[hyphema]], reactivity (swinging flashlight test) | ||
*Pressure (only if rule out globe rupture) | *[[intraocular pressure|Pressure]] (only if rule out globe rupture) | ||
**Check in patients with exophthalmos, afferent nerve defect or evidence of retrobulbar hematoma | **Check in patients with exophthalmos, afferent nerve defect or evidence of [[retrobulbar hematoma]] | ||
*Fat through wound = septal perforation | *Fat through wound = septal perforation | ||
*Raccoon eyes | *Raccoon eyes | ||
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*Crepitus over any facial sinus suggests sinus fracture | *Crepitus over any facial sinus suggests sinus fracture | ||
*[[Septal Hematoma]] | *[[Septal Hematoma]] | ||
*Make sure simple nasal fracture isn't a complex naso-orbito-ethmoid injury | *Make sure simple [[nasal fracture]] isn't a complex naso-orbito-ethmoid injury | ||
===Ears=== | ===Ears=== | ||
*[[Auricular Hematoma]] | *[[Auricular Hematoma]] | ||
*CSF leak | *Signs of [[basilar skull fracture]] | ||
*Hemotympanum | **CSF leak | ||
*Battle Sign | **Hemotympanum | ||
**Battle Sign | |||
===Oral=== | ===Oral=== | ||
*Intraoral palpation of zygomatic arch to distinguish bony from soft tissue injury | *Intraoral palpation of zygomatic arch to distinguish [[zygomatic arch fracture|bony]] from soft tissue injury | ||
*[[Mandible Fracture]] | *[[Mandible Fracture]] | ||
**Place finger in auditory canal while patient opens and closes jaw to detect condyle fracture | **Place finger in auditory canal while patient opens and closes jaw to detect condyle fracture | ||
**Tongue blade test | **Tongue blade test | ||
***95% Sn for no fracture if can bite down hard enough to break it when twisted by examiner | ***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 | **Jaw deviation due to [[mandible dislocation]] or condyle fracture | ||
***Chin will point away from dislocation, towards a fracture | ***Chin will point away from dislocation, towards a fracture | ||
*Malocclusion occurs in mandible, zygomatic, and Le Fort | *Malocclusion occurs in [[mandible fracture|mandible]], [[zygomatic arch fracture|zygomatic]], and [[Le Fort]] fractures | ||
*Lacerations and mucosal ecchymosis suggests mandible fracture | *Lacerations and mucosal ecchymosis suggests [[mandible fracture]] | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
Revision as of 17:55, 28 September 2019
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
Face
- Numbness
- Check supraorbital, infraorbital, and mental nerves
- Assess Le Fort by rocking hard palate with one hand while stabilizing forehead with other
Eye
- Exam
- Bird's eye view for exophthalmos with retrobulbar hematoma
- Worm's view for endophthalmos (blow-out fracture) or malar prominence flattening (zygoma fracture)
- Acuity
- Diplopia
- Binocular diplopia suggests entrapment of extraocular muscles
- Monocular diplopia suggests lens dislocation
- Extraocular motion
- Limitation on upward gaze occurs with fracture of inferior and medial orbital wall
- Pupil
- Teardrop sign (globe rupture), hyphema, reactivity (swinging flashlight test)
- Pressure (only if rule out globe rupture)
- Check in patients with exophthalmos, afferent nerve defect or evidence of retrobulbar hematoma
- Fat through wound = septal perforation
- Raccoon eyes
Nose
- Crepitus over any facial sinus suggests sinus fracture
- Septal Hematoma
- Make sure simple nasal fracture isn't a complex naso-orbito-ethmoid injury
Ears
- Auricular Hematoma
- Signs of basilar skull fracture
- CSF leak
- Hemotympanum
- Battle Sign
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
Differential Diagnosis
Maxillofacial Trauma
- Ears
- Nose
- Oral
- Other face
- Zygomatic arch fracture
- Zygomaticomaxillary (tripod) fracture
- Related
Evaluation
Workup
- Suspect midface fracture > facial CT
- Suspect orbital floor fracture > orbital CT
- Suspect mandibular fracture > CT face
Management
- Treat underlying process/diagnosis
Disposition
- Bedside consult is necessary for:
- Decreased vision
- Tripod Fracture
- Le Fort Fracture
- Open Mandibular Fracture
- Frontal Sinus Fractures with intracranial involvement
See Also
References
- ↑ Hollier L. et al. Facial gunshot wounds: A 4-year experience. Journal of Oral and Maxillofacial Surgery. 2011: 59:277-282