Maxillofacial trauma: Difference between revisions

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==Prehospital Care==
==Background==
===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


==Exam==
===Pediatric Considerations===
===Face===
*Cricothyrotomy is contraindicated in patients <8yr old
*Numbness
*Maxillary sinuses do not develop until 6 yr old (reduces midfacial fracture)
**Check supraorbital, infraorbital, and mental nerves
*Pediatric orbital floor is more pliable, more likely to lead to entrapment
*Assess Le Fort by rocking hard palate w/ one hand while stabilizing forehead w/ other
*Mandible fracture requires prompt referral (1-2d) due to rapid bone remodeling
===Eye===
 
*Exam
==Clinical Features==
**Bird's eye view for exophthalmos w/ retrobulbar hematoma
[[File:PMC2700599 JETS-02-89-g005.png|thumb|Patient with poly maxillofacial trauma: (a) Bilateral black eyes. (b) X-ray skull: AP view showing multiple fractures of facial bone including mandible. (c) X-ray skull: lateral view showing multiple fractures of facial bone including mandible. (d) CT scan showing details of facial bone fractures.]]
**Worm's view for endophthalmos (blow-out fx) or malar prominence flattening (zygoma fx)
===Ears===
*Acuity
*[[Auricular Hematoma]]
*[[Diplopia]]
*Signs of [[basilar skull fracture]]
**Binocular diplopia suggests entrapment of EOM
**CSF leak
**Monocular diplopia suggets lens dislocation
**Hemotympanum
*Extraocular motion
**Battle Sign
**Limitation on upward gaze occurs w/ fx 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 pts w/ exophthalmos, afferent nerve defect or e/o retrobulbar hematoma
*Fat through wound = septal perforation
*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===
*[[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]]''
===Visual Diagnosis===
<gallery mode="packed">
File:Black eye 2.jpg|Periorbital ecchymosis
File:Cauliflower ear by dr vikram yadav.jpg|[[Auricular hematoma]]
File:PMC5042625 OAMJMS-4-413-g001.png|[[Septal hematoma]]
File:BrokenNose.jpg|[[Nasal fracture]]
</gallery>
==Differential Diagnosis==
{{Maxillofacial trauma DDX}}
==Evaluation==
===Workup===
*Suspect midface fracture > facial CT
*Suspect orbital floor fracture > orbital CT
*Suspect mandibular fracture > CT face


==DDx==
===Diagnosis===
*[[Frontal Sinus Fracture]]
*Frequently on CT
*[[Naso-Ethmoid Fracture]]
*[[Nasal Fracture]]
*[[Zygomatic Arch Fracture]]
*[[Zygomaticomaxillary (Tripod) Fracture]]
*[[Orbital Fracture]]
*[[Mandible Fracture]]
*[[Le Fort Fractures]]
*[[Dental Problems]]
*[[Skull Fracture]]


==Imaging==
===Example Images===
*Suspect midface fx > facial CT
<gallery mode="packed">
*Suspect orbital floor fx > orbital CT
File:LeFort109M.jpg|thumb|[[Le Fort]] type 1 fracture
*Suspect mandibular Fx
File:NoDisManFracMark.png|thumb|[[Mandibular fracture]]
**Mandibular series
File:PMC4311579 eplasty15ic05 fig1.png|thumb|[[Zygomatic arch fracture]]
***Body fx > oblique view
File:PMC4145677 eplasty14ic27 fig1.png|thumb|[[Zygomaticomaxillary complex fracture]]
***Angle/symphysis fx > PA view
File:PMC4772575 AMS-5-262-g001.png|thumb|[[Zygomaticomaxillary complex fracture]]
***Condyle fx > AP axial (Towne's) view
</gallery>
*Plain Films
**Water's view
***Orbital rims/floors, zygmatic arch, maxillary sinus, maxilla
**Bucket handle view
***zygomatic arches


==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 Fracture]]
**[[Tripod Fracture]]
##[[Le Fort Fracture]]
**[[Le Fort Fracture]]
##Open [[Mandibular Fracture]]
**Open [[Mandibular Fracture]]
##[[Frontal Sinus Fractures]] with intracranial involvement
**[[Frontal Sinus Fractures]] with intracranial involvement


==See Also==
==See Also==
*[[Head Trauma (Main)]]
*[[Head Trauma (Main)]]


==Source==
==References==
Tintinalli's
<references/>
<references/>
[[Category:ENT]]
[[Category:ENT]]
[[Category:Ortho]]
[[Category:Orthopedics]]
[[Category:Trauma]]
[[Category:Trauma]]

Latest revision as of 19:41, 1 March 2023

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

Patient with poly maxillofacial trauma: (a) Bilateral black eyes. (b) X-ray skull: AP view showing multiple fractures of facial bone including mandible. (c) X-ray skull: lateral view showing multiple fractures of facial bone including mandible. (d) CT scan showing details of facial bone fractures.

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

Visual Diagnosis

Differential Diagnosis

Maxillofacial Trauma

Evaluation

Workup

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

Diagnosis

  • Frequently on CT

Example Images

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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