Maxillofacial trauma: Difference between revisions

(43 intermediate revisions by 3 users not shown)
Line 1: Line 1:
==Exam==
==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 trendelenberg 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===
===Face===
*Numbness
*Numbness
**Check supraorbital, infraorbital, and mental nerves
**Check supraorbital, infraorbital, and mental nerves
*Assess Le Fort by rocking hard palate w/ one hand while stabilizing forehead w/ 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 w/ retrobulbar hematoma
**Bird's eye view for exophthalmos with retrobulbar hematoma
**Worm's view for endophthalmos (blow-out fx) or malar prominence flattening (zygoma fx)
**Worm's view for endophthalmos (blow-out fracture) or malar prominence flattening (zygoma fracture)
*Acuity
*Acuity
*Diplopia
*[[Diplopia]]
**Binocular diplopia suggests entrapment of EOM
**Binocular diplopia suggests entrapment of EOM
**Monocular diplopia suggets lens dislocation
**Monocular diplopia suggets lens dislocation
*Extraocular motion
*Extraocular motion
**Limitation on upward gaze occurs w/ fx of inf and medial orbital wall
**Limitation on upward gaze occurs with fracture of inf 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 r/o globe rupture)
*Pressure (only if rule out globe rupture)
**Check in pts w/ exophthalmos, afferent nerve defect or e/o 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
===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===
===Ears===
*[[Auricular Hematoma]]
*[[Auricular Hematoma]]
Line 32: Line 49:
*Intraoral palpation of zygomatic arch to distinguish bony from soft tissue injury
*Intraoral palpation of zygomatic arch to distinguish 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, zygomatic, and Le Fort fracture
*Lacerations and mucosal ecchymosis suggests mandible fx
*Lacerations and mucosal ecchymosis suggests mandible fracture
 
==Imaging==
*Suspect midface fx > facial CT
*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==
*Frontal Sinus Fracture
**If ant wall fx need CT to evaluate posterior wall (75% have both walls fractured)
**Need neurosurg or ENT for posterior wall fx since many need surgery and IV abx
*Naso-Ethmoid Fracture
**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
**Fx through:
***1. inferior orbital rim
***2. lateral orbital wall
***3. zygomatic arch
**Must r/o associated ocular injuries
**Usually requires admission and surgical repair


==Fracture Types==
==Differential Diagnosis==
*[[Frontal Bone Fracture]]
{{Maxillofacial trauma DDX}}
*[[Orbital Fracture]]
*[[Zygoma Fracture]]
*[[Mandible Fracture]]


===Midface===
==Evaluation==
====Classification====
===Workup===
#Le Fort I
*Suspect midface fracture > facial CT
##Transverse fx separating body of maxilla from pterygoid plate and nasal septum
*Suspect orbital floor fracture > orbital CT
##Only hard palate and teeth move (when rock hard palate while stabilizing forehead)
*Suspect mandibular fracture > CT face
#Le Fort II
##Pyramidal fx through central maxilla and hard palate
##Movement of hard palate and nose occurs, but not the eyes
#Le Fort III
##Craniofacial dysjunction (fx through frontozygomatic sutures, orbit, nose, ethmoids)
##Entire face shifts w/ globes held in place only by optic nerve)


====Management====
==Management==
*CT Face
*Treat underlying process/diagnosis
*Control hemorrhage w/ nasal and oral packing if needed
*Admit for IV abx and sx
 
==Pediatric Considerations==
*Cricothyrotomy is contraindicated in pts <8yr old
*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==
*[[Mandible Fracture]]
*[[Head Trauma (Main)]]
*[[Orbital Fracture]]
*[[Head Trauma (Adult)]]
*[[Head Trauma (Peds)]]
 
==Source==
Tintinalli's


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

Revision as of 18:49, 21 November 2017

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 trendelenberg 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 EOM
    • Monocular diplopia suggets lens dislocation
  • Extraocular motion
    • Limitation on upward gaze occurs with fracture of inf 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

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 fracture
  • Lacerations and mucosal ecchymosis suggests mandible fracture

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