FACIAL TRAUMA INTRODUCTION Up to 60% of facial trauma patients have associated injuries

20-50% brain injury1-4% C spine injury0.5-3% blindness (most commonly with Lefort II and III)

Remember spouse abuse (most common injury is to orbital rim) and child abuse25% of patients with facial trauma will go on to develop PTSD

MECHANISMHigh impact Low impact

Supraorbital rim 200G (multiples of gravity) Zygoma 50GSymphisis of mandible 100G Nasal bone 30GAngle of mandible 70GFrontal Bone 100G

MANAGEMENT Key concept is to manage airway and look for associated injuries

AIRWAY (most important part of management) Look, listen and feelChin lift, jaw thrustSuctioningand remove FBManually displace tongue forward. Consider OPAMaintain C spine immobilizationAvoid nasotracheal intubation because of possible cribriform plate fracture Use RSI cautiously b/c might be a difficult airway Consider awake intubation with ketamine or fibreoptic intubationDon’t be a hero- call for backup, prepare for cricothyroidotomy

HEMORRHAGE CONTROLFacial bleeding should not cause shock or hypovolemia – look for another source3 areas that bleed:

Maxillofacial bleeding: control with direct pressure, don’t blind clampNasal bleeding: consider anterior or posterior packingPharygneal bleeding: pack around the ET tube

HISTORYSame as a general trauma historySpecific questions for facial trauma

Is there pain with eye movement? injury to the globe, orbital bonesAre there areas of numbness or tingling on your face?-nerve entrap or lacerationIs the patient able to bite down without any pain?Is there pain with moving the jaw?- fracture or impingement

PHYSICAL EXAM

Bird’s eye view and Worm’s eye viewPalpate supra and infraorbital rimsGlobe: enopthalmus or exothalmus, abnormal shape of pupil, subconjunctival hemorrhage, visual acuityCheck cornea for abrasions, anterior chamber for hyphemaFundoscopy to assess retinaLids- look for lac. Injuries to medial 1/3 may involve lacrimal apparatusPalpate the medial orbit area to r/o naso ethmoidal orbital fx. (Q tip inside the nose directed towards the medial canthus, place your finger outside the medial canthus. If the bone moves NEO #.) Palpate zygomaticofrontal suture, zygomaticotemporal suture and archPalpate nose: asymmetry, widening of nasal bridge (telecanthus- normal intercathi distance is 32-34mm), septal hematoma, blood, deformity, crepitus, subq air and CSF – halo sign on paper towelPalpate maxilla for facial instability/mobilityPalpate mandible for tenderness, swelling and step offCranial nerve exam- most important- EOM and facial nerveIntraoral exam:

Inspect the teeth for malocclusions, bleeding and step-off.Must account for all teeth.Manipulate each tooth, check for gum lacerations, Tongue blade test. (twist tongue blade while pt bites down. If jaw broke, pt will open mouth) 95% sens and 65% spec.

Palpate the mandible for deformities, step-offs, tender areas

RADIOLOGY Xrays are useful for assessment of:

Bones, fluid-filled spaces, herniation of orbital contents, subQ air Basic Facial Series

1)Water’s: (occipitomental view): Single best xray, good screening view for maxillary #. 37o caudal to canthomeatal line- good to see superior and inferior orbital rims, nasal bones zygoma and maxilla2) Caldwell view (PA or occipitofrontal view): 15o caudal to canthomeatal line - frontal sinus and supraorbital rim

3)Lateral view – anterior wall of frontal sinus and maxillary sinus views4)Submentovertex view:occasionally done. Good for zygomatic arch

Jaw series: 1) PA, 2) lateral obliques, 3) Towne’s view and 4) panorex ( best view of mandible)

CT face Better than Xray; gold standard for facial fractures

Indicated if# suspected on examCan’t cooperate well for x-rayPenetrating injury

FRACTURE/DISLOCATIONS FRONTAL SINUS FRACTURES Palpate along frontal bone and supraorbital rim for deformity or subq airAssociated with dural tears, intracranial injury and injury to orbital roofMUST evaluate posterior wall of sinus with CT Non displaced anterior wall: abx, should still consult neursurg for outpatient followupDepressed anterior wall or posterior wall fractures- assume to have assoc dural tear

AdmitNeurosurg consultationAbx and tetanus

Complications of posterior wall fracture: mucocele, CSF leak, epidural empyema, meningitis, associated orbital fracture

MAXILLARY FRACTURES- LeFort fracturesHigh force mechanism, consider associated injuriesLeFort Classification (rarely isolated, most commonly occur in combination)

LeFort I - maxilla at level of nasal fossa Maxilla mobile, nasal bridge stableMalocclusion of teeth

LeFort II - maxilla, nasal bones, medial aspect of orbits (pyramidal dysfn) nose and upper jaw mobile on exam

LeFort III - maxilla, zygoma, nasal bones, ethmoid, vomer, cranial base (craniofacial dysfunction)

dish face deformity ( elongation of eyes with flat sunken face)At risk for airway obstruction

Management : plastics consult for ORAirway is most important: ETT –> cric Rhinorrhea uncommon with I, more common with LF II/III admit for abx prophylaxis (not proven) and elevation of head of bed 40-60% if C spine cleared

ZYGOMATIC FRACTURES 2nd MC facial # Two types: arch and tripodArch fracturePain over arch +/- bony deformityPain with opening mouth or impingement of temporalis muscle/coronoid process

Look for flattened cheekSubmental view (bucket handle view)Management: refer for outpt ORIF

Tripod fractureFracture through 1) arch (or zygomaticotemporal suture) 2) zygomaticofrontal suture 3) infraorbital rim and floorPresents with flat cheek, infraorbital nerve damage (anesthesia), diplopia, change in consensual gaze, step defect, globe injuryWater’s is best Xray but you should CT faceRefer for ORIF (may be outpt if non displaced and without eye involvement)

NASO-ETHMOIDAL-ORBITAL FRACTURESuspect if trauma to nose or medial orbitPain with EOMAssociated lacriminal disruption and dural tearsLook for flat or saddle shaped nasal bridge, telecanthus, epistaxis or CSF rhinorheaQ tip testNeeds CTConsult plasticsAbx?

ORBITAL BLOWOUT FRACTURES Can be isolated or combined (commonly with zygomatic #) Blow out fracture: force transmitted to thin orbital floor (or medially) Direct globe pressure from object < 5 cm radius. Also from direct blow to infraorbital rim that causes orbital floor to bucklePossible herniation of fat or muscle into maxillary sinus (tear drop sign) Presentation

Step off of infraorbital rimDiplopia due to muscle/fat entrapment, intramuscular hematoma, V2 neuropraxia

True entrapment will be vagal, vomiting, refuse to move eyeEnopthalmos (sunken eye) and limited EOM (limited upward gaze)Infraorbital anesthesiaOrbital emphysema

Should have a CT but on xray look for Tear drop sign (herniated fat into maxillary sinus)Open bomb bay sign (bony fragments protrude into maxillary sinus)Air fluid level in sinus

Management Refer to plastics and ophthalmologyTetanus and abxAvoid valsalvaDecongestant for 3 daysMost observe for 10 - 14d then decide on OR based on enopthalmos/diplopia

Orbital emphysema May present with visual acuity loss b/c of pressure on orbit causing central retinal artery occlusion Emergent decompression with needle or canthotomy w/ cantholysis

NASAL FRACTURES

MC facial # - 3 kinds: nondisplaced, depressed and laterally displacedAsk pt if they have broken nose before, how is your breathing, does it look normalCrepitus, deformity, swelling, tenderness, edema Epistaxis usually mild but can be heavyClinical dx: NO Xrays although can sometimes see on facial lateral xrayManagement

Pack bleeding R/o septal hematoma: drain, pack, ENT follow up if present

Immediate reduction: can do if full edema not yet dev’t (within 3 hours) Delayed reduction: if already dev full edema- refer for reduction in 6-10 days If you choose to reduce- intranasal cocaine, bilateral infraorbital nerve blocks and bilateral external nasal nerve. Use boies elevator or scalpel handle to elevate depressed bone and forceps to reduce deviated septumPeds: do not reduce, refer for evaluation in 4/7 Consider assoc injuries: Bridge of nose: nasoethmoid # -----> rhinorrhea, CT face, abx, neurosurg consult

MANDIBULAR FRACTURES Mandibular pain/tenderness, malocclusion, separation of teeth, periauricular pain Trauma + malocclusion = mandibular # Ecchymosis on floor of mouth very suggestive Multiple locations in > 50%; may be distant from site of trauma Locations Condylar 35% Body 21% Angle 20% Symphysis 14% Ramus 3% Coronoid 3%

Panorex view best CT may be needed for condylar #Non-displaced: soft diet, analgesic, orif in 1-2 daysDisplaced and open #’s are closed soonerAntibiotics if open: usually penicillin

MANDIBULAR DISLOCATIONSRisks

Weak TMJShallow articular eminenceOverstretched joint capsuleNeuromuscular disordersTrauma to jawExcessive mouth opening

Mostly anterior but posterior (direct blow to chin), lateral (associated with fracture) and superior can occurMostly bilateralFor anterior: jaw will jut out forward and will deviate away from dislocated side if unilateralMuscles of mastication spasm preventing spontaneous reductionX-ray if mechanism suggests potential #

To reduce: Thumbs or fingers in buccal sulcus or wrapped in gauze on mandibular teethDownward backward pressure with rotation so chin goes upward and angle of mandible goes backcwardMay be easier to reduce one side at a timeD/C home with soft diet x 2wks and outpatient F/U with oral surgery

WOUND MANAGEMENTDon’t forget tetanusMay close facial lacerations up to 24hrs Indications for delayed primary closure

Wound older than 24 hrs FB that can’t be removed Severe contamination can close early if thoroughly debride but if > 6 hours, should treat with abx for 4 days and then close Presence of # requiring further evaluation/therapy

When to consult plastics? Uncomfortable w/ lac Underlying nerve injury Injury requiring OR Delayed primary closure

Wound Management Avoid epi in ear, nose, tarsal plate of eyelid Regional blocks, LAT useful Vigorous scrubbing for abrasions to prevent traumatic tattooing Careful exploration for FB Copious, forceful irrigation Deep: 4-0, 5-0 vicryl Skin: 5-0, 6-0 prolene/ethilonNo drsg, polysporin, remove 3-5d (minimizes scar)

Indications for antibiotics in facial injuriesBite wounds

DevascularizationThrough-and-through buccal mucosaCartilage involvement (nose/ear)Extensive contamination

SPECIFIC INJURIES Always consider nerve blocksLips

Close vermillion border first Tongue

Close big lacs and flaps, midline lacs, avulsions, nonlinear lacerationsOral cavity

Refer if salivary ducts involvedEar

Auricular nerve blockApproximate cartilage with 5-0, 6-0 absorbable; Staph abx coverage b/c avascularity of cartilage is high risk for condritis Subperichondral hematoma: will develop “cauliflower” ear if not drained; aspirate and compressive dressing for 7d with close f/u and repeat aspiration prn

Periorbital Refer to optho: lid margin and medial canthus lacs

Through-and-through cheekBegin intraoral and work outwardsCopious irrigateion after each layer closedAbx prophylaxis

EyelidPlastics for lid margin, canalicular, lacrimal6-0 Ethilon for superficial lacs

Retro orbital hematoma-proptosis, decreased visual acuity, IOP > 40, afferent papillary defectManagement: time is EYE therefore pt needs lateral canthontomyLateral canthotomy steps:

Local anesthesia and sedationCrimp skin downward from lateral eye with kellys to reduce bleeding x 1 minuteCut the skin (canthotomy)Lift inferior skin flap to identify tendon (tendon feels like guitar string)Cut the tendon (cantholysis) Goal IOP < 40

Repeat same steps for superior lateral canthal tendon