Facial Trauma Abdullah Al- Harkan , BA, DMD, MSc , FRCD (C)

1. Facial TraumaAbdullah Al-Harkan, BA, DMD, MSc, FRCD (C) Specialist, Oral and Maxillofacial Surgery Farwaniya Hospital

2. Facial Trauma • Who is involved in facial trauma? • General Surgery/Trauma team • Anesthesia • Plastic Surgery • ENT • Oral & Maxillofacial Surgery • Neurosurgery • Ophthalmology

3. ATLS • initial evaluation and stabilization of the multiply injured patient • Primary Survey • life-threatening conditions are identified and reversed quickly • based on ABCs • Secondary Assessment • does not begin until the primary assessment has been completed and management of life-threatening conditions has begun • head to toe evaluation

4. Primary Survey – ABC’s • A – airway with cervical spine control • Establishment and maintenance of a patent airway • Airway obstruction may be due to: • tongue • severe maxillofacial fractures • bleeding from oral or facial structures • aspiration of foreign materials

5. Primary Survey – ABC’s • assume cervical spine injury with any injuries above the clavicle • avoid hyperextension or hyperflexion of the neck during attempts to establish an airway • cervical spine is maintained in the neutral position with the use of backboards and collars • Injury to C-spine is assessed by clinical and radiographic examination in the second survey

6. Secondary Survey • History • Illness • Allergies • Medications • Last meal • History of event • Comprehensive Exam • Detect all injuries • Continued monitoring and reassesment of ABC’s of primary survey

7. Definitive Care • After Primary and secondary survey • Resuscitation is complete • Patient is stabilized • Appropriate referral – (i.e. maxillofacial surgery) • Surgery • Non operative management

8. Evaluation of Maxillofacial Injuries • History • PMH/Medications/Allergies • Mechanism of injury • Events surrounding injury • Other injuries • Exam • General • Vital Signs • GCS

9. Evaluation of Maxillofacial Injuries • What are we looking for? • Damage to structures of the head and neck • Need to know Signs and Symptoms

10. Evaluation of Maxillofacial Injuries • 1- Scalp • 2- Ears • 3- Forehead • 4- Orbits • 5- Zygoma/Zygomatic arches • 6- Nose • 7- Maxilla • 8- Mandible

11. Evaluation of Maxillofacial Injuries • Scalp • Lacerations • Hematomas • Important: • Bleeding • Underlying fractures

12. Evaluation of Maxillofacial Injuries • Ears • Lacerations • External auditory meatus (EAM) and membrane • Battle’s Sign • CSF otorrhea • Hearing

13. Evaluation of Maxillofacial Injuries • Forehead/Frontal Sinus Evaluation • Lacerations • Hematomas • Palpate for steps or depressions • Check for any sensory deficit

14. Forehead/Frontal Sinus Evaluation • CT scan for this area is to evaluate: • Severity of anterior and posterior tables • Injury to Nasal frontal outflow tract

15. Evaluation of Maxillofacial Injuries • Usually severe injuries • Due to severity, you should suspect intracranial and/or spine injuries. • Hence involvement of Neurosurgery • Frontal sinus injuries

16. Frontal sinus injuries • Indications to operate: • Trend now to be conservative due to advancements in endoscopic sinus surgery • Fracture of Anterior table  in case of severe displacement • Fracture of Posterior table  1- CSF leak, 2- Mucosal entrapment in intracranial space. • Obstruction of nasal frontal outflow • Surgery versus follow up

17. Treatment of Maxillofacial Injury Bicoronal flap

18. Evaluation of Maxillofacial Injuries • Orbital region • Edema/ecchymosis • lacerations • Orbital step defects • Sensory loss - forehead • Eyes • Subconjunctivalecchymosis • Visual acuity • Pupils • Extraocular muscles • Retinal Exam (Ophthalmology)

19. Evaluation of Maxillofacial Injuries

20. Evaluation of Maxillofacial Injuries • Retrobulbar hematoma (bleeding in the potential space surrounding the globe) • Symptoms: Severe eye pain, nausea, vomiting, diplopia, and decreases in both visual acuity and eye movement. • Signs: proptosis, decreased ocular motility, visual loss, elevated IOP (measured by tonometry). • Management: Lateral canthotomy and cantholysis

21. Retrobulbar Hematoma

23. RACCOON EYES

24. RACCOON EYES??!!

25. Orbital blow out fractures

26. Orbital blow out fractures • Indications for treatment: • Mechanical Diplopia (I.e. entrapment of inferior rectus muscle) • Enophthalmus > 2mm • Loss of more than 50% of orbital floor • Type of reconstruction material: • Titanium mesh • Medpore • Prolene mesh • Autogenous bone

27. Orbital blow out fractures • Orbital fractures can be isolated fractures or they maybe associated with: • ZygomaticoMaxillary Complex (ZMC) fractures • Le Fort II and Le Fort II fractures

28. Evaluation of Maxillofacial Injuries • Zygoma/Zygomatic Arch

29. Treatment of Orbital/ZMC fractures

30. Evaluation of Maxillofacial Injuries • Nose • Epistaxis/laceration • Deviation of dorsum or septum • Septal hematoma • CSF Rhinorrhea • CT cisternography • β2Transferrin • Palpate nasal bones

31. Nose injuries

32. Nose injuries

33. Nose injuries

34. Nose injuries

35. Nose injuries

36. Evaluation of Maxillofacial Injuries • Middle 1/3rd of the face • Echymosis, laceration and edema • Decreased AP projection • Sensory loss – infraorbital nerve • Facial Palsy – CN VII • Malocclusion • Vestibular echymosis • Intraoral laceration • Loss of dentition • Maxillary mobility

38. Le Fort Classifications

39. Le Fort Classifications

40. Treatment of Le Fort injuries

41. Evaluation of Maxillofacial Injuries • Mandible • Lacerations/ecchymosis • Hematomas • Swelling • Tenderness • Step defects/Mobile segments • Malocclusion • Loss of sensation • Loss of dentition

42. Evaluation of the mandible

43. Evaluation of the mandible

45. Mandible fractures

46. Mandible fractures

47. Mandible fractures Closed reduction (IMF/MMF) Open Reduction and Internal fixation

49. Thank You