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 trendelenberg if there is oropharyngeal and nasal bleeding to avoid aspiration especially if placed in cervical protection
*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===
[[File:Black eye 2.jpg|thumb|A woman with periorbital ecchymosis after maxillofacial trauma.]]
*Numbness
===Ears===
**Check supraorbital, infraorbital, and mental nerves
*[[Auricular Hematoma]]
*Assess Le Fort by rocking hard palate w/ one hand while stabilizing forehead w/ other
*Signs of [[basilar skull fracture]]
===Eye===
**CSF leak
*Exam
**Hemotympanum
**Bird's eye view for exophthalmos w/ retrobulbar hematoma
**Battle Sign
**Worm's view for endophthalmos (blow-out fracture) or malar prominence flattening (zygoma fracture)
 
*Acuity
*[[Diplopia]]
**Binocular diplopia suggests entrapment of EOM
**Monocular diplopia suggets lens dislocation
*Extraocular motion
**Limitation on upward gaze occurs w/ fracture of inf and medial orbital wall
*Pupil
**Teardrop sign (globe rupture), hyphema, reactivity (swinging flashlight test)
*Pressure (only if r/o globe rupture)
**Check in patients w/ exophthalmos, afferent nerve defect or evidence of retrobulbar hematoma
*Fat through wound = septal perforation
*Raccoon eyes
===Nose===
===Nose===
*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===
 
*[[Auricular Hematoma]]
*CSF leak
*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 fracture
*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]]
 
===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===
''See [[Orbital trauma]]''


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


==Diagnosis==
==Evaluation==
===Workup===
*Suspect midface fracture > facial CT
*Suspect midface fracture > facial CT
*Suspect orbital floor fracture > orbital CT
*Suspect orbital floor fracture > orbital CT
*Suspect mandibular fracture
*Suspect mandibular fracture > CT face
**Mandibular series
 
***Body fracture > oblique view
==Management==
***Angle/symphysis fracture > PA view
*Treat underlying process/diagnosis
***Condyle fracture > AP axial (Towne's) view
*Plain Films
**Water's view
***Orbital rims/floors, zygmatic arch, maxillary sinus, maxilla
**Bucket handle view
***zygomatic arches


==Disposition==
==Disposition==

Revision as of 17:52, 4 February 2021

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

A woman with periorbital ecchymosis after maxillofacial trauma.

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

See Orbital trauma

Differential Diagnosis

Maxillofacial Trauma

Evaluation

Workup

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

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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