Maxillofacial Trauma

1. Maxillofacial Trauma Dr. Yael Moussadji Feb 8, 2007

2. Objectives • To review a general approach to facial injuries • To review specific bony injuries of the face • To discuss general wound repair principles and management of soft tissue injuries of the face by anatomic location

3. Epidemiology • Result from intentional violence (assults – 33%) and unintentional (MVC’s – 50%, falls, sports – 10%) • The overall incidence of fractures in facial trauma patients is 37% • Alcohol abuse increases the likelihood of facial fracture, so have a high index of suscpicion • Airbags and seatbelt requirements have decreased the severity and incidence of facial injury, but they remain common among riders of other motorized vehicles including ATVs and motorcycles • Facial injuries are a common presentation for victims of domestic violence (one quarter of all women who present to the ED with facial injury) and child abuse

4. Associated Injury • Associated injuries are common and include brain injury (25%), C-spine injury (6%), basal skull fractures, chest injuries (29%), abdominal injuries (38%), and extremity fractures (33%) • Isolated facial fractures are uncommon – only 11% of patients with facial injury will not have brain, chest, or abdominal injuries • Common associated nerve injuries include facial paralysis (CN VII), blindness (CN II), diplopia (CNIII), deafness (CN VIII) • Minor damage to the dura can also occur with fractures involving the frontal sinus, nasal bones, and midface, resulting in CSF leaks

5. Airway Management • Recognize the facial trauma patient as a potentially difficult airway and prepare alternatives before proceeding; try to stay 1-2 steps ahead! • Be cautious with timing and use of paralytics; awake and fiberoptic intubation may be the best alternatives when dealing with distorted anatomy • The use of minimal IV sedation and topical anesthesia allows the EP to perform laryngoscopy without committing to oral intubation; if the cords are visualized, you have the option to intubate or perform RSI knowing you can access the cords • Use nasal packing first (if there is time) to slow down hemorrhage

6. Overview • Force of gravity required for fracture • Nasal (30) • Zygoma (50) • Angle of the mandible(70) • Frontal (80) • Midline maxilla (100) • Midline mandible (100) • Supraorbital rim (200)

7. General Approach • Assess visual acuity and for the presence of diplopia (binocular vs monocular) • Sensation of the face should be checked in all three trigeminal branches • The patient should be asked about malocclusion • A standard set of facial films includes the Waters (occipitomental view) which is best for maxillary, maxilla and orbital fractures, and the Caldwell (occipitofrontal) view which shows the ethmoid and frontal sinuses

8. Frontal Sinus Fracture • Forces involved and proximity of brain make these fractures high risk for brain injury and other facial fractures • The key distinction to make is the integrity of the posterior sinus wall • Anterior wall fracture can be fixed on a non-urgent basis; these patients can have their wounds closed, be given prophylactic antibiotics, and referred for outpatient repair • If a posterior wall fracture exists, presume a dural tear exists; admit to neurosurgery

10. Orbital Fractures • Implies a significant mechanism of trauma; 40% are ultimately diagnosed with significant globe pathology including globe rupture, and up to 77% have other facial fractures • Classified as pure (only orbital floor) or impure (extending into orbital rim) • Patients with pure orbital fractures are 3 times as likely to have concomitant ocular injuries (5.6% vs 2.0%) than patients with impure fracures • Patients without an orbital fracture are twice as likely to have globe pathology (in allcomers with blunt orbital trauma) • The object striking the eye must have a radius of <5cm to produce a blowout fracture (fist) • Blowout fractures most commonly involve the floor, then the medial, lateral, and superior walls

11. Clinical Findings • Diplopia on upward gaze, subcutaneous emphysema, enophthalmos*, palpable step-off, and anesthesia in the infra-orbital nerve distribution • Numbness is more commonly detected on the upper lip • Subcutaneous or intraorbital air indicates a medial wall fracture with direct connection from the sinus to the orbit; the patient should be instructed not to blow their nose • If air accumulates in the orbit it can cause occlusion of the central retinal artery from increased orbital pressure; patients will complain of a sudden loss of vision • A lateral canthotomy or aspiration of the air can prevent permanent vision loss

12. Imaging and Managment • Plain films are only diagnostic in 8% • CT is 100% accurate and demontrates fat or soft tissue protruding into the maxillary sinus, bony fragments, and blood in the maxillary sinus • Fluid in the maxillary sinus with a mechanism is a blowout fracture until proven otherwise • Outpatient management is the general rule • Most surgeons wait 1-2 weeks before attempting repair

13. Nasal Fractures • The nose is the most commonly fractured bone in the face, comprising 45% of all facial fractures • Can be thought of as simple or complex • Simple involves only the nasal bones, and complex involves other facial bones • Simple nasal fractures do not need imaging • Diagnosis is clinical based on crepitus, pain and tenderness, epistaxis, obstruction, ecchymosis, and deformity • Most EP’s will not attempts reduction in the ED since perception of deformity is based largely on the edema present • If indicated, you can use cocaine for anesthesia and perform closed reduction by exerting firm quick pressure toward the midline with your thumbs • Patients can be discharged to follow-up within 4-7 days IF NEEDED (deformity or obstruction)

15. Septal Hematoma • Occurs with cartilage fractures and results from collection of blood beneath the perichondrium • If left untreated, septal hematomas can cause permanent damage by infection of necrosis of the septum • Septal cartilage is dependent on blood supply from the perichondrium, and elevation of the perichondrium reduces blood supply; pressure from the hemotoma worsens the ischemia • Irreversible damage can occur in 72 hours and result in saddle nose deformity, retraction, voice changes, or constant nasal obstruction

16. Management • Can usually be seen with an otoscope, appearing as a bluish or purple swelling on the septum (grapes) • The should be incised, drained and packed to prevent reaccumulation • Prophylactic antibiotics (keflex) should be prescribed, and patients should be rechecked in 24-48 hours • Outpatient ENT consultation is recommended

17. Parotid Gland or Duct Injury • The parotid duct is 7cm long and courses parallel to the jaw; it is found on the line from the lower ear to the corner of the mouth • It exits the anterior parotid gland superficial to the masseter muscle before piercing the buccinator muscle and entering the oral cavity at Stenson’s duct • Parotid duct injuries occur in only 0.2% of facial traumas, but the consequences of missed injuries can be severe • Have a high index of suspicion with any lacerations to the cheek and fractures of the mandible or zygomatic arch

18. Anatomy

19. Management • After direct examination of the wound, milk the parotid gland and look for blood at Stenson’s duct (just inside the cheek at the level of the upper second molar) • Give prophylactic antibiotics (ceftriaxone 1g) and consult ENT

20. Facial Nerve Injury • The danger zone is bordered by a line from the lateral canthus to the corner of the mouth, and from the zygomatic arch to the angle of the mandible; any wound or trauma in this area is at significant risk for facial nerve injury • Must examine all five branches: temporal, zygomatic, buccal, mandibular, cervical • Lifting the forehead and brow, opening and shutting the eyes, smiling and frowning, and shrugging the shoulders accomplish this

21. Maxillary Fractures • The maxilla comprises the middle third of the face, and functions to support mastication; it also houses the maxillary and ethmoid sinuses • It can therefore withstand large vertical forces, but is vulnerable to lateral or anterior forces • These high energy injuries are known as Le Fort fractures, and once the butress of the maxilla begins to break, it fractures on three recurring lines of weakness • It is rare when a pure fracture pattern exists; most midface fractures are combinations

22. Involves the maxilla only at the level of the nasal fossa Usually occurs from a downward blow on the upper alveolar ridge Separates the body of the maxilla from the lower portion of the pterygoid plate and nasal septum The nose does not move with the midface Le Fort I

23. Also called a pyramidal fracture Fracture of the maxilla, nasal bones, and medial orbits (like a Le Forte I involving the nose) Nose moves freely with the maxilla Le Forte II

24. Craniofacial dysjunction; the face is no longer connected to the skull The maxilla, zygoma, nasal bones, ethmoids and bones of the cranial base are all fractured The entire face can be moved independently of the skull Le Forte III

25. Zygoma Fractures • Two varieties: arch fractures (more common) and tripod fractures (more serious) • Isolated arch fractures are best seen using the submental vertex (bucket handle) view which isolates the arches • 60% of arch fractures are displaced, and 45% of patients complain of trismus (fracture fragment impinges on the coranoid process) • They do not require admission, but will most likely require surgical repair

27. Tripod Fractures • Combination of intraorbital rim fracture, diastasis of the zygomaticofrontal suture, and disruption of the zygomaticotemporal junction of the arch • The bony fragment is usually depressed and pulls the lateral canthus away from the eye giving it a tilted appearance • 50-90% of patients will have infraorbital anesthesia, 12% will have diplopia • Admit to plastics

29. Maxillary Sinus Fractures • The walls are not very strong, and isolated fractures can occur from direct blows to the face • Patients complain of facial pain, but may not have swelling • Plain films or CT will show an air fluid level in the maxillary sinus • In isolation, can be discharged with prophylactic antibiotics and outpatient follow up with ENT

31. Mandible Fractures • Second most commonly fractured facial bone • The condyle is the most frequently fractured (36%), followed by the body (21%) and angle (20%) • The “U” shape of the mandible makes the likelihood of multiple fractures high (46%); the fracture site may be distant from the actual site of impact • Condylar fractures can be associated with fractures of the temporal bone and TM rupture, and can be difficult to detect on plain films

32. Mandible Fractures

33. Clinical features • Complaints of malocclusion, trismus, facial assymetry, and sublingual ecchymosis • Fractures are often open inside the mouth, and any intraoral or gingival laceration need to be detected • In some cases the only evidence of an open fracture is bleeding around the teeth • Have the patient grasp a tongue blade between the teeth and resist while the examiner twists the blade • Patients with fractures will open their mouths against resistance, while those without can hold enough pressure until the blade breaks; this has a 95% sensitivity for mandible fractures

34. Management • Any patient with evidence of an open fracture should be admitted to IV antibiotics (Pen G or clinda) • Antibiotics reduces the rate of infection from 50% to 5% • For patients with closed fractures, outpatient follow-up with plastics is appropriate

36. Mandible dislocations • Can dislocate with or without trauma • Traumatic dislocations require imaging before reduction to r/o condylar fracture • Atraumatic dislocations can occur from increased masseter muscle tone, TMJ laxity, EPS, laughing, yawning, vomiting, taking a large bite, dental work • Dislocation is usually bilateral but can be unilateral, and anterior dislocation is most common • Anterior dislocation is commonly followed by spasm of the temporalis and lateral pterygoid muscles which holds the mandible in place and resistant to reduction

38. Clinical features • Patients complain of pain anterior to the tragus, have difficulty speaking, and may complain of malocclusion • Physical exam will show an open mouth that cannot be closed, palpable preauricular depression, and mandibular deviation opposite to the side of the dislocation

39. Reduction • Can be accomplished with patient seated with head against the wall and examiner facing patient, or patient supine and examiner standing at the head • Examiners thumbs are placed inside the patients mouth on the surface of the molars with fingers wrapped around the angle and body of the mandible • Downward and backward pressure is applied • The reduction is complete when the patient is able to close their mouth

40. Management • Patients can be discharged with instructions to eat a soft diet, not open the mouth wider than 2cm for 2 weeks, and to support their jaw when they yawn • NSAIDS for analgesia, and outpatient follow up in 2 weeks

41. Wound Repair of the Face

42. Primary Closure & Bite Wounds • Nearly all facial wounds can be closed by primary closure • Dog bites to the face can be closed provided that wounds are aggressively irrigated and debrided as needed; use of antibiotics is up for debate since the infection rate is only 1.4% without • Cat bites could be closed if required for cosmetic reasons, although most recommend not closing (usually puncture wounds with higher infection rate) • Repair of human bites to the face is safe; primary close after irrigation and debridement and a 1 week course of antibiotics yields a 90% rate of complete healing at time of suture removal • Close clean facial wounds less than 24 hours old • Refer lacerations that involve the eyelid margins, nerves or other deep structure injuries, deep foreign bodies, ear wounds with significant cartilage damage, large flaps, tissue loss

43. Anesthesia • Use small gauge needles (25-27g) unless nerve block is being performed (23-25g) • Injecting pH balanced anesthetic subcutaneously (buffered 1% lidocaine) will significantly reduce pain • Max dose of lidocaine is 300 mg for a 70 kg adult, or 500 mL of lidocaine with epinephrine (30 mL 1% plain, or 50 mL 1% with epi) • Lidocaine has a rapid onset and lasts 30-60 minutes • Bupivicaine has a slower onset of action and lasts 4-8 hours

44. Facial Nerve Blocks • Forehead • Nerve blocks of the supraorbital nerve are easy to perform and give total anesthesia of the forhead when done bilaterally • Find the supraorbital foramen (near midline) and insert a 1.5 inch needle parallel to the eyebrow just above the bone • Inject 2-3 mL along the needle tract • A hematoma may form and cause subsequent swelling and ecchymosis of the upper lid

45. Facial Nerve Blocks • Midface • An infraorbital nerve block anesthetizes the lower lid, medial cheek, upper lip, and lateral nose • Intraoral approach is less painful • Pretreat oral mucosa with viscous lidocaine, then insert a ¾ inch needle to the hub toward the infraorbital foramen • Insertion is through the gingival-buccal margin just above the maxillary canine tooth • Inject 2-3 mL at foramen or 3-5 mL in a fan across the area

46. Facial Nerve Blocks • Lower face • A mental nerve block provides good anesthesia of the lower lip and chin • Helpful for lip lacs that cross the vermillion border • Locate the mental foramen midway between the upper and lower edges of the mandible 2.5 cm from the midline • Pretreat mucosa with viscous lidocaine, then insert a ¾ inch needle in the gingival-buccal margin below the lower canine • Inject 1-2 mL of anesthetic

47. Wound Closure & Follow-up • Subcutaneous sutures should be 4-0 or 5-0, and skin should be closed with 6-0 non-absorbable • Place sutures 1-3 mm apart, 1-2 mm from the wound edge; space deep sutures as widely as possible • A thin layer of antibiotic ointment applied after closure cuts infection rates in half • Wounds on the forehead and chin are suited to closure with tape • Similarly, wound adhesives are as good as sutures, staples, and tape for simple lacs under no tension; wound strength is equivalent to sutures at 7 days (not during first 4 days) and cosmetic outcome is comparable • Sutures should be removed at 4-5 days (7-10 in scalp), and reinforced with tape for a further 7-10 days

48. Scalp Closure • There are 5 anatomic layers of the scalp (skin, superficial fascia, galea, subaponuerotic connective tissue, periosteum); the first 3 layers are fused as an outer layer which contains the blood supply • For quick closure in heavily bleeding wounds, use staples or a 3-0 suture taking deep bites through skin, SC fascia, and galea • Wounds that gape involve the galea, which should be closed (serves as anchor for frontalis muscle resulting in distorted facial expression)

49. Forehead Lacerations • Deep wounds require closure for approximation of frontalis muscle fascia • Large periosteal defects should also be closed to prevent adhesion of skin to skull (use 5-0 or 6-0 absorbable for deep sutures) • Use judgement; excess deep sutures can lead to increased scarring • Simple lacerations can be closed using fine suture and by placing sutures close to the wound edge; align major forehead wrinkles

50. Eyebrow & Eyelid Repair • Don’t debride tissue – excision removes hair follicles and creates alopecia • Irrigate lightly with saline • Line up edges of eyebrow to ensure brow margins are aligned correctly • Wounds that cross the lid margin are best left to ophthalmologist since they are at high risk of eversion or inversion • Deep lid lacerations in the medial aspect of the upper or lower lid are at high risk for involvement of canalicular system or lacrimal duct; both are repaired surgically