Maxillofacial trauma: Difference between revisions
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==Exam==
==Background==
===Face===
===Prehospital Care===
*Numbness
*Assess patients ability to speak and protect the airway before and frequently during transport
**Check supraorbital, infraorbital, and mental nerves
*Hematomas can significantly distort pharyngeal and facial anatomy making intubation or [[cricothyroidotomy]] difficult
*Assess Le Fort by rocking hard palate w/ one hand while stabilizing forehead w/ other
*Increased jaw mobility from a mid face fracture may help with intubation
===Eye===
*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>
*Exam
*Place a protective shield over an eye suspected to have a ruptured globe
**Bird's eye view for exophthalmos w/ retrobulbar hematoma
*Patients should remain upright or reverse trendelenburg if there is oropharyngeal and [[epistaxis|nasal bleeding]] to avoid aspiration especially if placed in cervical protection
**Worm's view for endophthalmos (blow-out fx) or malar prominence flattening (zygoma fx)
*Temporizing hemostasis with oral and nasal packing in an intubated patient may help with persistent bleeding
*Acuity
*Transport all avulsed pieces of the face including ears and nose
*Diplopia
 
**Binocular diplopia suggests entrapment of EOM
===Pediatric Considerations===
**Monocular diplopia suggets lens dislocation
*Cricothyrotomy is contraindicated in patients <8yr old
*Extraocular motion
*Maxillary sinuses do not develop until 6 yr old (reduces midfacial fracture)
**Limitation on upward gaze occurs w/ fx of inf and medial orbital wall
*Pediatric orbital floor is more pliable, more likely to lead to entrapment
*Pupil
*Mandible fracture requires prompt referral (1-2d) due to rapid bone remodeling
**Teardrop sign (globe rupture), hyphema, reactivity (swinging flashlight test)
 
*Pressure (only if r/o globe rupture)
==Clinical Features==
**Check in pts w/ exophthalmos, afferent nerve defect or e/o retrobulbar hematoma
[[File:Black eye 2.jpg|thumb|A woman with periorbital ecchymosis after maxillofacial trauma.]]
*Fat through wound = septal perforation
===Ears===
*Raccoon eyes
*[[Auricular Hematoma]]
*Signs of [[basilar skull fracture]]
**CSF leak
**Hemotympanum
**Battle Sign
 
===Nose===
===Nose===
*Crepitus over any facial sinus suggests sinus fx
*Crepitus over any facial sinus suggests sinus fracture
*[[Septal Hematoma]]
*[[Septal Hematoma]]
*Make sure simple nasal fx 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 pt opens and closes jaw to detect condyle fx
**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 fx 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 fx
**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 fx
*Malocclusion occurs in [[mandible fracture|mandible]], [[zygomatic arch fracture|zygomatic]], and [[Le Fort]] fractures
*Lacerations and mucosal ecchymosis suggests mandible fx
*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]]''


==Imaging==
==Differential Diagnosis==
*Suspect midface fx > facial CT
{{Maxillofacial trauma DDX}}
*Suspect orbital floor fx > orbital CT
*Suspect mandibular Fx
**Mandibular series
***Body fx > oblique view
***Angle/symphysis fx > PA view
***Condyle fx > AP axial (Towne's) view
*Plain Films
**Water's view
***Orbital rims/floors, zygmatic arch, maxillary sinus, maxilla
**Bucket handle view
***zygomatic arches


==DDx==
==Evaluation==
*[[Frontal Sinus Fracture]]
===Workup===
**If ant wall fx need CT to evaluate posterior wall (75% have both walls fractured)
*Suspect midface fracture > facial CT
**Need neurosurg or ENT for posterior wall fx since many need surgery and IV abx
*Suspect orbital floor fracture > orbital CT
*Naso-Ethmoid Fracture
*Suspect mandibular fracture > CT face
**Diffuse tearing and increased intercanthal distance are suggestive
**Intranasal palpation w/ hemostat while palpating along bony rim for crepitus
**Complications include:
***Lacrimal disruption
***Medial canthal ligament rupture
***Dural tears
***Intracranial injury seen in up to 70%
*[[Nasal Fracture]]
*[[Zygomatic Arch Fracture]]
**Unlikely isolated
*[[Tripod Fracture]]
*[[Orbital Fracture]]
*[[Zygomatic Arch Fracture]]
*[[Mandible Fracture]]
*[[Le Fort Fractures]]


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


==Disposition==
==Disposition==
#Bedside consult is necessary for:
*Bedside consult is necessary for:
##Decreased vision
**Decreased vision
##Tripod fractures
**[[Tripod Fracture]]
##Lefort fractures
**[[Le Fort Fracture]]
##Open mandibular fractures
**Open [[Mandibular Fracture]]
##Frontal sinus fractures with intracranial involvement
**[[Frontal Sinus Fractures]] with intracranial involvement


==See Also==
==See Also==
*[[Head Trauma (Adult)]]
*[[Head Trauma (Main)]]
*[[Head Trauma (Peds)]]
 
==Source==
Tintinalli's


==References==
<references/>
[[Category:ENT]]
[[Category:ENT]]
[[Category:Orthopedics]]
[[Category:Trauma]]
[[Category:Trauma]]

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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