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Otorhinolaryngology: Topic 9 | Module 10 MAXILLOFACIAL TRAUMA Alexander C. Cabungcal, M.D. C. ANATOMY TOPIC OUTLINE I. Maxillofacial Trauma A. Pathophysiology B. Etiology C.Anatomy II. Facial Buttresses A. Vertical Buttresses B. Horizontal Buttresses III. A...
Otorhinolaryngology: Topic 9 | Module 10 MAXILLOFACIAL TRAUMA Alexander C. Cabungcal, M.D. C. ANATOMY TOPIC OUTLINE I. Maxillofacial Trauma A. Pathophysiology B. Etiology C.Anatomy II. Facial Buttresses A. Vertical Buttresses B. Horizontal Buttresses III. Advanced Trauma Life Support A. Primary Survey B. Resuscitation C.Secondary Survey IV. History and Physical Examination A. Signs and Symptoms V. Maxillofacial Region VI. Fractures of Upper Face A. Frontal Sinus/Bone Fractures VII. Fracture of Midface A. Naso-Ethmoidal-Orbital Fractures B. Orbital Blowout Fracture 📝 V. O rbital Blowout Fractures VI. Fractures of Zygoma A. Zygomatic Arch Fractures B. Zygomatic Tripod Fractures VII. Maxillary Fractures A. Le Fort I Maxillary Fractures B. Le Fort II Maxillary Fractures C.Le Fort III Maxillary Fractures D.Other Variations VIII. Fractures of the Lower Face A. Mandibular Fractures IX. Temporal Bone Fractures A. Types B. Treatment X. References XI. Review Questions EGEND L - Notes from Face-to-Face Lecture - Nice to Know Important terms T/N (Transmaker’s notes) 💡 T/N: The flow of this trans was based on the lecture video posted in Moodle. Figure 1.Skull landmarks. Shows the different landmarksof the facial skeleton and the important bones involved in maxillofacial injuries. II. FACIAL BUTTRESSES B ony buttresses of the facial support the bony structure of the face Conceptualized as a system of vertical and horizontal buttresses. Facial buttresses are the part where repair isdone 📝 I. MAXILLOFACIAL TRAUMA Injuriesofthefacialskeletonanditsmanagementincludingtheanterior wall and floor of the anterior cranial fossa Craniomaxillofacial trauma – better term because the anterior wall and the floor of the anterior cranial fossa are included in these injuries. A. PATHOPHYSIOLOGY A mount of force to fracture different facial bones Two causes of maxillofacial trauma → High impact –>50 g-forcesto fracture the: ▪ Supraorbital rim: 200 g-force ▪ Symphysis of the mandible: 100 g-force ▪ Frontal: 100 g-force ▪ Angle of the mandible: 70 g-force → Low impact –≤50 g-forcesto fracture the: ▪ Zygoma: 50 g-force ▪ Nasal bone: 30 g-force 1 g-force = 9.81 m/s2 → Gravitational force ~ 1/d2 → Represent the gravitational acceleration near the earth’s surface 📝 Notes from Face-to-Face Lecture | Dr. Cabungcal H ardest part of the skull – supraorbital rim Weakest part of the skull – nasal bone → The most common fracture of the face ▪ Prominent ▪ Needs less effort to fracture Angle of mandible needs less pressure because it is thinner B. ETIOLOGY Vehicular accidents → Motorcycle > car accidents → Mostlymotorcycleaccidentsduetothepopularitycoupledwithlax enforcement of vehicular safety laws. Severe facial trauma → 60% of have multisystem trauma and the potential for airway compromise → 20-50% concurrent brain injury → 1-4% cervical spine injuries → Blindness occurs in 0.5-3% Group 2B, 3A, & 3B Figure 2.Facial buttresses. . VERTICAL BUTTRESSES A These buttressesdefinetheverticalheightofthefaceandprovidethe bony support required for mastication The vertical buttresses consist of paired: → Nasomaxillary (nasal) ▪ from the nose to maxilla → Zygomatico-maxillary ▪ from zygoma to maxilla → Pterygomaxillary (mid-facial buttresses) ▪ Theonlyposteriorbuttress → Ramus of the mandible 📝 📝 Figure 3.Vertical and horizontal buttresses. Page1of22 MAXILLOFACIAL TRAUMA Otorhinolaryngology - Alexander C. Cabungcal, M.D. 📝 Notes from Face-to-Face Lecture | Dr. Cabungcal Why advance? → Because we are in a hospital setting → If a trauma happens on the road = basic life support Maxillofacial trauma falls under what survey? → Depends on the situation ▪ Foreign objectsblockingtheairwaycausingdifficulty of breathing , Figure 4.Pterygomaxillary buttress B. HORIZONTAL BUTTRESSES L ess well-known than the vertical buttresses Serve as cross-member stability to the facial skeleton They define the antero-posterior and horizontal dimensions of the face The frontal bar → The most superior horizontal buttress → Comprise of the superior orbital rims and thick frontal bone between them Upper transverse maxillary buttress → Most important horizontal buttress → Comprise of the zygomatic arch, zygomatic bone, and inferior orbital rim → Itisextremelyimportantindefiningtheanteroposteriorpositionof the malar eminence which is crucial to the restoration of the symmetrical facial form Lower transverse maxillary buttress → Arch of the hard palate Transverse mandibular buttress → Representedbythearchofthemandible,whichincludestheangle, the body, and the symphysis These last two horizontal facial buttresses, lower and transverse,are important in defining the width of the lower third of the face and the occlusal arch 📝 Notes from Face-to-Face Lecture | Dr. Cabungcal Frontal buttress: Zygomatico-temporal Figure 5.Horizontal Buttresses. Frontal bar (orange),Upper transverse maxillary buttress (red), Lower transverse maxillary buttress (blue), Transverse mandibular buttress (green). III. ADVANCED TRAUMA LIFE SUPPORT Itwasin1976thatimprovingthecareoftheinjuredpatientwasthought ofafteroneofthepioneerswasinvolvedinaplanecrashandwitnessed howill-preparedwasthemedicalresponsebythosecaringforhimand his family. The first course was offered in 1980 ATLS standardized the care oftraumapatientsandalsoeducatedthe trauma community on how to provide optimal care for trauma patients ATLS has four sections: → Primary survey → Resuscitation → Secondary survey → Definitive treatment Group 2B, 3A, & 3B A. PRIMARY SURVEY E ncompassestheABCDEsoftraumacareandidentifieslife-threatening conditions by adhering to this sequence: → A: Airway maintenance with cervical spine control → B: Breathing and ventilation → C: Circulation with hemorrhage control → D: Disability with an assessment of neurological status → E: Exposure and environmental control a. AIRWAY Always check airway patency first → Airway can be directly injured → Airway can be indirectly occluded ▪ Tissue edema ▪ Bleeding ▪ Secretions ▪ Tissue collapse If needed, resuscitation is performed at the same time 📝 Notes from Face-to-Face Lecture | Dr. Cabungcal Most important isairway → When patient comes in, check the patient’s breathing, color (if already cyanotic) Airwayand breathing is related to each other → You can have patent airway but no breathing thus producing same result b. BREATHING A ssess breathing effort If b reathing efforts are inadequate despite a patent airway, assist ventilation. This may be achieved by: → Bag mask ventilation → Intubation via tracheal tube → Laryngeal mask airway → Surgical through cricothyroidotomy or tracheostomy Impaired breathing may be caused by: → Head injury – loss of respiratory drive → Chest injuries, chest wall or intrathoracic ▪ Sucking pneumothorax ▪ Tension pneumothorax ▪ Hemothorax c. CIRCULATION A dequacy of circulation Pulse rate and blood pressure Shock (determine if the patient is in shock) → A patient is in shock if the circulation cannot be maintained → This may be due to the following: ▪ Loss of blood volume ▪ Loss of vascular resistance ▪ Decreased cardiac output ▪ Increased venous capacity Hemorrhage control → Essential in maintaining circulation → Maxillofacial bleeding ▪ Controlled by direct pressure ▪ Avoid blind clamping in wounds - Mayinjureimportantnonvascularstructuressuchasthe facial nerve and parotid duct → Nasal bleeding ▪ Direct pressure ▪ Anterior and posterior packing - Maybeneededwithnasalbleedingthatdoesnotresolve with direct pressure alone → Pharyngeal bleeding ▪ Packing of the pharynx around ET tube Page2of22 MAXILLOFACIAL TRAUMA Otorhinolaryngology - Alexander C. Cabungcal, M.D. nce the airway is secured and gross hemorrhage is controlled, itis O onlywhenthesearchforlife-threateninginjuriestothechest,abdomen, and pelvis can be resumed. d. DISABILITY apid assessment of neurological disability is made by noting the R patient's response on four point scale → A: response appropriately – aware → V: response to verbal stimuli → P: response to painful stimuli → U: does not respond – unconscious May also utilize the Glasgow coma scale (GCS) to assess thedepth and duration of the coma andimpairedconsciousness.Itisbasedon motor responsiveness, verbal performance, and eye-opening on appropriate stimuli GCS score interpretation: → 8 or less: severe – indicates poor prognosis → 9-12: moderate → 13-15: mild head injury Figure 6.Head tilt – chin lift maneuver Table 1.Glasgow Coma Scale Eye opening Motor response Verbal response Spontaneous 4 Move to command 6 Converse 5 To speech 3 Localizes to pain 5 Confused 4 To pain 2 Withdraw from pain 4 Gibberish 3 Flexes 3 Grunts 2 Extends 2 None 1 None 1 Figure 7.Jaw thrust None 1 e. EXPOSURE AND ENVIRONMENTAL CONTROL Completely undress the patient, usually by cutting off his or her garments to facilitate thorough examination and assessment Aftercompletingtheassessment,coverthepatientwithwarmblankets or an external warming device → To prevent thedevelopmentofhypothermiainatraumareceiving area Warm intravenous fluids before infusing them, and maintain warm environment B. RESUSCITATION a. FIRST STEP: SECURING A PATENT AIRWAY Airway maintenance can be done through the following procedures: → Jaw thrust/chin lift/head tilt maneuver → Naso/oropharyngeal airway using endotracheal tubes → Manually clearing the oral cavity of fractured teeth, blood clots, dentures and identification of obstruction → Manually moving the tongue forward to free the oropharyngeal area → Supplemental oxygen to all trauma patients Airway establishment is done ifeffortstosecureapatentairwayfails. This is done through: → Bag-mask ventilation → Endotracheal tube with cuff (oral or nasal) → Laryngeal mask airway (LMA) → Surgical airway ▪ Cricothyroidotomy ▪ Tracheotomy → Supplemental ventilation ▪ Hand ventilation ▪ Mechanical ventilation → Be aware that decreased ventilation may be caused by pneumothorax or hemothorax and should also be addressed appropriately. Group 2B, 3A, & 3B Figure 8.Airway establishment procedures b. SECOND STEP: RESTORATION OF ADEQUATE CIRCULATION Assessment of underlying mechanism of shock → Hypovolemic shock ▪ Due to hemorrhage and loss of intravascular volume ▪ Fundamental treatment principle – rapid replacement of intravascular volume until there is physiologic evidence of adequacy → Cardiogenic shock ▪ Secondary to tension pneumothorax, cardiac tamponade,or myocardial contusion ▪ Clinicalsigns:distendedjugularveins,adequateCVPinthe presence of hypotension ▪ May not be apparent in presence of hypovolemic shock → Neurogenic shock ▪ Seen in patients with adequate volumeandcardiacfunction but with persistent systemic hypotension ▪ Decreased peripheral vascular resistance due to CNS injury ▪ Clinical manifestations: warm extremities and absence (lack) of tachycardia despite hypotension ▪ Management: maintenance of adequate volume and vasopressors and reversal of CNS injury (if possible) ▪ Diagnosis of last resort even with presence of head trauma Page3of22 MAXILLOFACIAL TRAUMA C. SECONDARY SURVEY F ollowsafter primary surveyis completed Extract anAMPLEhistory by asking about: → A: Allergies → M: Medications that the patient is taking → P: Past medical history → L: Last meal (when) → E: Events leading to injury Completion of head-to-toe evaluation X-rays and specialized diagnostic tests (CT, US, scope) may be necessary Secondary survey should not be performed until hemodynamic stabilization is achieved Exposure (during the secondary survey) → Alltraumapatientsneedtobeexposedtoawarmenvironmentto disclose any other hidden injuries When the airway is adequately secured, the secondary surveyofthe whole body is to be carried out to: → Arrive at an accurate diagnosis → Maintain a stable state → Determine the priorities in treatment → Appropriate specialist referral 📝 Otorhinolaryngology - Alexander C. Cabungcal, M.D. b. MONOCULAR DIPLOPIA Distorted light transmission through the eye to the retina → Structural defect in the eye’s optical system → More than 2 images simultaneously ▪ One of the images of normal quality ▪ The rest are of inferior quality Less common cause of double vision This may be due to: → Cataract → Corneal shape problems such as keratoconus, or surface irregularity, or scarring → An uncorrected refractive error usually astigmatism Figure 9.Retinal detachment (yellow line) Notes from Face-to-Face Lecture | Dr. Cabungcal When asking about last meal, it also includes last drink → Ask about what and when Evaluate from head-to-toe → Usually undress the patient to look for injuries ▪ Sometimespatienthasbluntinjuriesthatyoucannot easily recognized Important isGCS → Neurologically is the patient stable? → Does the patient respond to your question, to pain? Ask for an x-ray, if youthinkthepatientneedsitorrequesta specialized test like ultrasound or CT scan if the patient is stable enough Figure 10.Lens dislocation (yellow line). IV. HISTORY AND PHYSICAL EXAMINATION T/N: this part was not discussed face-to-face but was included in the video lecture hrough a good history and physical examination,youcantentatively T arrive at a logical diagnosis. Ask specific questions to help you gather data about the patient’s injuries. A. SIGNS AND SYMPTOMS a. SPECIFIC QUESTIONS hese will help you assess the patient’s condition T Was there LOC (loss of consciousness)? If so, how long? Is there pain with eye movement? Hearing problems? Are there areas of numbness or tingling on your face? Is the patient able to bite down without any pain? Is there pain with moving the jaw? Is there malocclusion? Change in regards to your bite? How is your vision? → Patient may complain that they cannot see from one or both eyes → No vision or blurred ▪ May also claim that their vision is blurred ▪ Mostofthetime,debrisorbloodmaybeblockingthepatient’s vision → Monocular or binocular diplopia ▪ May also complain of diplopia (doubling of vision) ▪ Must distinguish between the two Table 2.Monocular vs. binocular diplopia Type Monocular diplopia Binocular diplopia Group 2B, 3A, & 3B ision V Cause Thereisdoublevisioneven Retinal detachment when the other eye is Lens dislocation covered. Corneal disruption Extraocular motion The double vision stops if impairmentcausedby either eye is covered. bone, nerve, or muscle injury Figure 11.Corneal laceration (yellow line). c. BINOCULAR DIPLOPIA More common type of double vision It occurs due to the misalignment of both eyes due to functional problems within the vision system. This could be due to: → Stroke → Aneurysm → Increased intracranial pressure from a brain tumor → Increased pressure inside the brain from trauma/bleeding/infection → Anyextraocularmusclesnervepalsy(intracranialnervesIII,IV,and VI) → Entrapment or injury to extraocular muscles Figure 12.Extraocular motion impairment causes themisalignment of the eyes causing diplopia. d. EYES AND VISION isual acuity V Pupils: roundness and reactivity Eyelids: lacerations Extraocular muscle movement Palpate around entire orbits Cornea: abrasions and lacerations Anterior chamber: blood or hyphema Fundoscopic exam: posterior chamber and the retina Page4of22 MAXILLOFACIAL TRAUMA Otorhinolaryngology - Alexander C. Cabungcal, M.D. Figure 13.Evaluate extraocular motions in all directionswhile asking the patient about diplopia. In this patient (left), the left eye failed to gaze upwards. MARCUS GUNN TEST Swinging flashlight test It is performed in patients who suffer from ocular trauma → Swing the penlight back and forth between the pupils → If a pupil dilates when initially struck by light, an optic nerve or retinal injury is likely Figure 17.Facial anesthesia or paresthesia: mentalnerve. Affected areas of the face when the mental nerve is injured. Figure 18.Facial anesthesia or paresthesia: supratrochlearand supraorbital nerve. Affected areas of the face when both supratrochlear and supraorbital nerves are injured. Figure 14.Marcus Gunn Test SUBCONJUNCTIVAL HEMORRHAGE Usually observed in patients with injuries to the face Figure 19.Signs of malocclusion. Improper alignmentof teeth (upper left), mucosal laceration (upper and lower right), displaced dentition (lower left). Figure 15.Subconjunctival hemorrhage (right eye) e. FACIAL ANESTHESIA OR PARESTHESIA A sk for areas of numbness or tingling on the face Facial anesthesia or paresthesia → Patients may complain of numbness in some areas and inmost cases, you have to elicit this because the patient may fail to volunteer this condition, especially if the patient issufferingfrom more pressing injuries Infraorbital nerve → Often secondary to a blowout or rim fractures → Manifests as anesthesia of the upper lip Mentalormandibular nerve → Result from mandibular fractures → Patient complaints of lower lip anesthesia Supratrochlear nerve → Result from frontal bone fracture → Result to numbnessonthebridgeofthenose,themedialpartof the upper eyelid and medial forehead Supraorbital nerve → Manifest as periorbitalnumbness,foreheadnumbnessinaddition to eye pain and photophobia. Look forsigns of malocclusion → Improper alignment of teeth → Mucosal laceration → Displaced dentition f. FACE PHYSICAL EXAMINATION Inspect the face for asymmetry Inspect open wounds for foreign bodies Palpate the entire face with emphasis on the following: → Supraorbital and infraorbital rim → Zygomatic-frontal suture → Zygomatic arches Figure 20.Areas of the facial bone to palpate: Supraorbitaland infraorbital rim (yellow), zygomatic-frontal suture (red), zygomatic arches (green) RACCOON’S EYES Manifests as bilateral periorbital ecchymosis This may indicate the following: → Basilar skull fracture → Le Fort fracture → Naso-ethmoidal-orbital (NEO) injuries Figure 16.Facial anesthesia or paresthesia: infraorbitalnerve. Affected areas of the face when the infraorbital nerve is injured. Group 2B, 3A, & 3B Page5of22 MAXILLOFACIAL TRAUMA Otorhinolaryngology - Alexander C. Cabungcal, M.D. h. INTRAORAL EXAMINATION Manipulation of each tooth and note if there are: → Malocclusions → Bleeding → Step-off Check for lacerations Stress the mandible through manipulation or tongue blade test Palpate the mandible for tenderness, swelling, and step-off Check for facial stability Detect areas of tenderness, bony crepitus, subcutaneous air, and anesthesia Figure 21.Raccoon’s eyes. Basilar skull fracture(red) BATTLE’S SIGN Manifests as bluish discoloration of the postauricular region It is usually associated with temporal bone fracture Figure 25.Step off (upper red circle) and laceration(lower red circle) Figure 26.Palpation of mandible Figure 22.Battle’s sign . NOSE PHYSICAL EXAMINATION g Inspectthenoseforasymmetry,telecanthus,andwideningofthenasal bridge Inspect the nasal septum for septal hematoma, CSF leak, or blood Palpate the nose for crepitus, deformity, and subcutaneous air Palpatethezygomaalongitsarchanditsarticulationswiththemaxilla, frontal, and temporal bone TRAUMATIC TELECANTHUS It is an important finding in naso-ethmoidal-orbital (NEO) injuries It is present when the distance between the medial ends of the palpebral fissures of both eyes, exceeds the distance measured between the medial and lateral canthi of an individual eye In normal patients, the distance is35-40 mm Figure 27.Checking for facial stability DRAWER’S SIGN Rocking of the palate Pathognomonic of Le Fort fractures Executethismaneuverbygraspingtheanteriormaxillaryarchandthen pull and push firmly, keeping the opposite hand on the patient’s forehead to prevent motion of the neck Figure 23.Traumatic telecanthus. Red line: distancebetween the medial ends of the palpebral fissures of both eyes; Green line: distance between the medial and lateral canthi of one eye SEPTAL HEMATOMA Observe the bulging of the septum laterally Figure 28.Maneuver to test for Drawer’s sign Figure 24.Septal hematoma Group 2B, 3A, & 3B SPATULA/TONGUE BLADE TEST If no fracture is obvious, stress the mandible to detect mobility or pain Perform with a tongue blade Have the patient bite down on the tongue blade and twist forcibly Patientswithmandibularfracturesreflexivelyopentheirmouthsandthe tongue blade will not bend or break Page6of22 MAXILLOFACIAL TRAUMA Otorhinolaryngology - Alexander C. Cabungcal, M.D. → Lower face ▪ Where fractures are isolated to the mandible Figure 29.Spatula/Tongue blade test i. EXTERNAL EAR EXAMINATION Examine and palpate the exterior ears and the ear canals Look for hematoma of the pinna, hemotympanum, b leeding, or perforation of the tympanic membrane Hemotympanum Figure 33.Maxillofacial region. Upper face (blue),midface (yellow), lower face (pink) VI. FRACTURES OF THE UPPER FACE A. FRONTAL SINUS/BONE FRACTURES a. PATHOPHYSIOLOGY R esults from a direct blow to the frontal sinus/bone with a blunt object Associated with: → Intracranial Injuries → Injuries to the orbital roof → Dural tears Figure 30.External ear and hematoma of the pinna HEMOTYMPANUM Presenceofbloodinthemiddleearthatcausesabluishdiscolorationof the eardrum Figure 34.Frontal bone fracture Figure 31.Hemotympanum with bluish discoloration(yellow) TYMPANIC MEMBRANE PERFORATION Presents with ragged edges and bleeding from the ear b. CLINICAL FINDINGS ltered forehead contour A Superior orbital rim crepitance or disruption Subcutaneous emphysema Laceration Associated with: → CSF Leak → Intracranial damage → Obstruction of nasofrontal duct → Injury of: ▪ Superior rectus ▪ Superior oblique or ▪ Levator muscles Figure 32.Tympanic membrane perforation with raggededges (yellow circle) and bleeding (arrow). This is from trauma which we don’t usually see in infections. V. MAXILLOFACIAL REGION Divided into: → Upper face ▪ Involves fractures of the frontal bone and sinus → Midface ▪ Upper midface - Maxillary Le Fort II and Le Fort III fractures - Nasal bone fractures - Naso-ethmoidal and zygomaticomaxillary complex fracture - Orbital floor fractures ▪ Lower midface - Le Fort I fractures - Maxillary alveolar fractures Group 2B, 3A, & 3B Figure 35.Frontal sinus fracture 📝 Notes from Face-to-Face Lecture | Dr. Cabungcal Page7of22 MAXILLOFACIAL TRAUMA Otorhinolaryngology - Alexander C. Cabungcal, M.D. It depends on the extent of fracture; sometimes it is just a fracture but once you go lower into the frontal bone, a lotof other structures are involved. c. CLASSIFICATION 📝 Notes from Face-to-Face Lecture | Dr. Cabungcal Frontal sinus has two walls and a floor: → Anterior wall → Posterior wall → Inferior wall (floor) ANTERIOR WALL FRACTURES May be linear, depressed, or comminuted May present with intact skin or open wound Associated with deformities of the forehead Can extend to the posterior wall and/or floor Figure 40.Posterior wall fracture. Linear (upper),depressed (middle), comminuted (lower) 📝 Notes from Face-to-Face Lecture | Dr. Cabungcal W heneveryouhaveaposteriorwallfracture,thereisalwaysa possibilitythatyouhaveinvadedtheintracranialareatherefore you may have dural tears, epidural or subarachnoid hematoma. Figure 37.CT scan of frontal sinus/bone. Normal (left),anterior wall fracture (right) INFERIOR WALL FRACTURES Considered primarily as fractures of anterior skull base May cause nasofrontal duct obstruction, stasis of secretions, and sinusitis May involve the cribriform and orbital plates and sphenoid bone This is the area where you have a lot of other symptoms Common sequela → Dural tears → Pneumocephalus → CSF leaks → Obstruction of nasofrontal duct Figure 38.Anterior wall fracture. Linear (upper),depressed (middle), comminuted (lower) POSTERIOR WALL FRACTURES May be linear, depressed, or comminuted Damage to the protective shell of the cranium Associated with dural tears and CSF leaks Intracranial damage includes epidural and intracranial hematomas Figure 41.Inferior wall fracture. d. IMAGING STUDIES PLAIN RADIOGRAPHS Paranasal sinus series → Views should include: ▪ Waters ▪ Caldwell– best evaluates the anterior wall fractures ▪ Lateral projections Figure 39.Posterior wall fracture (sagittal view).Normal (left), posterior wall fracture (right). Group 2B, 3A, & 3B Page8of22 MAXILLOFACIAL TRAUMA Otorhinolaryngology - Alexander C. Cabungcal, M.D. Head x-ray Figure 45.The patient after the surgery (motor vehicularaccident). Figure 42.Caldwell view of anterior wall fracture. 📝 Notes from Face-to-Face Lecture | Dr. Cabungcal Treatment → Admit if posterior wall fracture is present and for neurosurgical clearance. → Antibiotics → Open Reduction Internal Fixation (ORIF) ▪ Depends on the condition of the patient ▪ If it is only a crack then you don’t have to do anything ▪ For depressed fracture, it is lifted to maintain the contour of the forehead CT SCAN OF FACIAL BONES Frontal sinus fractures Orbital rim fractures Naso-ethmoidal fractures Rule out brain injuries or intracranial bleed f. COMPLICATIONS ssociated with intracranial injuries A Orbital roof fractures Dural tears Mucopyocoele/mucocele → Happens when nasofrontal duct is blocked ▪ If the nasofrontal duct is obliterated,mucopyocele/mucocele may develop after 5 or 10 years after Epidural empyema CSF leaks Meningitis Figure 43.CT scan of the facial bone. Frontal sinusfracture (top circle), orbital rim fracture (lower right circle), naso-ethmoidal fracture (lower left circle) 📝 Notes from Face-to-Face Lecture | Dr. Cabungcal T he best imaging is the cranial CT scan In the figure above, multiple fractures are seen. → Frontal bone fracture → Nasal bone fracture → Infraorbital rim fracture Figure 46.Epidural empyema e. TREATMENT In patients with depressed skull fractures or with posterior wall involvement: → Admission is required → ENT and neurosurgery consultation is necessary → IV antibiotics should be started → Tetanus prophylaxis should be given → Open reduction and internal fixation (ORIF) if necessary Patients with an isolated anterior wall,non-displacedfracturescanbe treated as outpatient after consultation with neurosurgery VII. FRACTURES OF THE MIDFACE Nasal bone fractures → Most common of all facial fractures → More common in children than in adults → More commonly involves the cartilage than the bone → More common in men than in women Injuries may occur to other surrounding bony structures Has 3 types: → Depressed → Laterally displaced → Nondisplaced Figure 44.ORIF of frontal bone fracture during andafter surgery. Group 2B, 3A, & 3B Page9of22 MAXILLOFACIAL TRAUMA Otorhinolaryngology - Alexander C. Cabungcal, M.D. Figure 47.Nasal bone fractures 📝 Figure 49.Nasal bone fracture as seen on CT scan c. HISTORY AND PHYSICAL EXAMINATION A thorough history and physical examination is compulsory Notes from Face-to-Face Lecture | Dr. Cabungcal More common in men than in women because nasal bone fractures are associated (movements/sports/altercations) with a. CLINICAL FINDINGS Ask these pertinent questions: → “Have you ever broken your nose before?” ▪ Becausetheremightbeapre-existingfractureoraneglected fracture which may complicate the repair → “How does your nose look to you? Is there a change?” → “Are you having trouble breathing?” “Can you breathe properly through your nose?” 📝 d. TREATMENT activity C ontrol of epistaxis Drainage of septal hematomas Open/close reduction 📝 In close reduction, forceps is passed intothenosetoputthe broken nasal bones back into place and then left to heal General anesthesia is preferred over local anesthesia due to less pain For those who cannotaffordgeneralanesthesia,theywilljust suffer the pain Notes from Face-to-Face Lecture | Dr. Cabungcal nlyabout50%ofthepopulationhaveastraightnasalseptum. O That's why itisimportanttoaskifthereisapriorinjuryandif there is a change after the injury. During injury, the nose would normally get congested. If the congestionarisesfromtheturbinates,itmightjustbeduetoan allergic reaction; however, presence of a laterally deviated nasal septum could be the cause of the difficulty of breathing. Notes from Face-to-Face Lecture | Dr. Cabungcal e. INDICATIONS FOR REPAIR A bnormal nasal function Abnormal appearance Presence of early post-injury complications b. IMAGING STUDIES Soft tissue lateral x-raywith or without Waters view → Gold standardfor nasal bone fracture → The neck view can also be requested if laryngeal pathology is suspected CT scan of the facial bones Figure 50.Abnormal appearance. Figure 51.Before and after closed reduction of nasalbone fracture Figure 48.Nasal bone fracture and soft tissue lateralx-ray view of the nose 📝 Notes from Face-to-Face Lecture | Dr. Cabungcal n the photos above, this is anexampleofthesamepatient O pre and post-op Asshown,thereflectionoflightisnotstraight–thatisthefirst thing to look at. However, ifthepatienthadafracturebefore, the light is already that way → Itisimportanttoalwaysaskthepatient“Wereyouinjured before? Was thereanaccidentbeforethis?”becausethe reflection of light might be broken beforehand Group 2B, 3A, & 3B Page10of22 MAXILLOFACIAL TRAUMA Once you repair it, it’s already straight → The best time todothereductioniswithinoneweek,atmost one month. After that,itwillbemoredifficultbecauseitmight not reduce so you will have to opt for an open surgery A. NASO-ETHMOIDAL-ORBITAL FRACTURE Involves injury to the anteromedial wall of the orbit Fractures extend into the nose and through the ethmoid bones Associated with lacrimal disruption and dural tears Suspect if there is trauma to the nose or medial orbit Patients will complain ofpain on eye movement → Most common symptom May be misdiagnosed as simple nasal bone fracture Mayoccurasisolatedinjuryormaybeapartofmorecomplex(LeFort) facial fractures May produce disruption of critical aesthetic and functional area Otorhinolaryngology - Alexander C. Cabungcal, M.D. b. IMAGING STUDIES CT scan of the face with coronal cuts through the medial orbits A produces the best result Plain radiographs are insensitive and not recommended Figure 54.CT scan of the face shows ethmoids pushedinwards. c. TREATMENT Early treatment is much more effective than late treatment Involves: → Reduction of the impacted nasal bone → Medial canthal tendon repair Usually, 1.2 or 1.5 mm microplates are used for rigid fixation Figure 52.Naso-ethmoidal-orbital fracture a. CLINICAL FINDINGS lattened nasal bridgeorsaddle-shaped deformityof the nose F Widened nasal bridge(telecanthus) CSF rhinorrheaorepistaxis Tenderness, crepitus,andmobilityof the nasal complex Upon intranasal palpation, there ismovement of themedial canthus Telescopingof ethmoid sinuses as nasal bones arepushed posteriorly Intraorbital air “Pig snout”deformity Epiphora Figure 55.Nasal bones are fixed with lead plates Figure 56.Medial canthal tendon repair Figure 53.Flattened nasal bridge or saddle-shapeddeformity of the nose and widened nasal b ridge (telecanthus) and telescoping of the ethmoid sinuses. The nasal bone and ethmoid are affected. Notes from Face-to-Face Lecture | Dr. Cabungcal hisisimportantbecausethismightbemisdiagnosedasa T nasalbonefracturebecauseitisinthesamearea,butthe extentoftheinjuryisdeeper–itisnotjustthenasalbone,it also involves the ethmoid What characteristics or signs should you look for? → Saddle-shaped deformity or flattening of the nose → Widening of the nasal bridge (telecanthus) ▪ Attachmentoftheorbitisalsoaffectedthat’swhy you also have pain when you try to move your eyes → Thisisintimatelyrelatedtoyourcraniumyoucanhave CSFrhinorrheaandsinceitinvolvesthenoseyouwill haveepistaxis. → Take note of the movement of themedialcanthus on intranasal palpation. → “Pig snout”deformity ▪ Loss of nasal bridge What is injured here? → Nasalbonebuttheethmoidsarealsoaffectedandare pushed inwards Group 2B, 3A, & 3B Figure 57.Before and after treatment of naso-ethmoidal-orbitalcomplex fracture 📝 Notes from Face-to-Face Lecture | Dr. Cabungcal O n imaging, the ethmoids are pushed inwards May present as a simple nasal bone fracture → Inhistory,ifthepatientwasonlypunched–itisprobably just a nasal bone fracture → Ifthepatient'snosehitsthedashboard–considerdeeper injury Case: The patient hit her nose on the dashboard → nose bridge was very flat but on CT scan there was only a nasal bonefracturebutnoethmoidfracturebutshewantedtohavea rhinoplasty. Is it possible? → Yes. Butitisboundtofailbecauseatthattimethenasal bone was unstable → Stabilize it first since it also has a weight Page11of22 MAXILLOFACIAL TRAUMA lastic surgery is not doneduringtheinitialsurgerysincethe P area is still dirty Afteraninjury,donotpromisethepatientfullrecoveryoftheir face due to scar formation B. ORBITAL BLOWOUT FRACTURE O ccurs when theglobe sustains a direct blunt force 2 mechanisms of injury: → Blunt trauma to the globe which has a bigger sphere → Direct blow to the infraorbital rim Otorhinolaryngology - Alexander C. Cabungcal, M.D. 📝 Notes from Face-to-Face Lecture | Dr. Cabungcal Pure blowout fracture → Rim is not involved Impure blowout fracture → Involvement of infraorbital and lateral rim Medial wall is more common than lateral wall → Thinner wall – lamina Superior wall – least common → 200g-force of gravity is needed to fracture this site Periorbital hematoma – most common clinical finding Involvement of infraorbital nerve → Infraorbital anesthesia up to the upper lip Step off deformity – palpation → Normal: smooth → Injury: step up or step down Figure 58.Orbital blowout fracture a. CLASSIFICATION Pure blowout fracture → Trap-door rotation ofbonefragmentsinvolvingthecentralareaof the wall Impure blowout fracture → Associated with fracture line extending to one of the orbital rims → Commonly associated with other fractures Figure 61.Periorbital ecchymosis of the right eye Figure 62.Restriction of eye movement of the righteye. Figure 59.Pure blowout fracture (left) and impureblowout fracture (right) b. BLOWOUT SITES Most common blowout sites in descending order: → Orbital floor→ medial wall → lateral wall → superiorwall FORCED DUCTION TEST Performed to determine whether the absence of movementofthe eyeisdue to neurological disorder or mechanicalrestriction Theanesthetizedconjunctivaisgraspedwithforcepsandanattemptis made to move the eyeball in the direction where movement is restricted If a mechanical restriction is present, it will not be possible to induce passive movementof the eyeball Figure 63.Forced duction test Figure 60.Blowout sites c. CLINICAL FINDINGS Periorbital tenderness, swelling, ecchymosis Enophthalmos or sunken eyes Hypophthalmus or inferior globe displacement Impaired ocular motility resulting in diplopia → Some of the muscles may be trapped in the fracture area Infraorbital anesthesia Step off deformity Restriction of eye movement → Important clinical finding → Which can be elicited through forced duction test Group 2B, 3A, & 3B d. IMAGING STUDIES Plain radiographs → Water’s and Caldwell’s View → Pathognomonic signs ▪ Hanging teardrop sign ▪ Open bomb bay door → Air fluid levels → Orbital emphysema CT scan of facial bones → Will rule out intracranial injuries CT scan of orbits → Will show details of the orbital fracture → Excludes retrobulbar hemorrhage Page12of22 MAXILLOFACIAL TRAUMA Otorhinolaryngology - Alexander C. Cabungcal, M.D. Figure 64.Plain radiograph showing hanging teardropsign showing areas of opacity. Figure 67. Zygomatic arch (yellow arrow) and Zygomaticbody (red arrow) A. ZYGOMATIC ARCH FRACTURES an fracture 2 to 3 places along the arch C Lateral to each end of the arch Fracture in the middle of the arch Patients usually present withpain on the openingof their mouth Figure 65.CT scan 📝 Notes from Face-to-Face Lecture | Dr. Cabungcal If the radiotech is well-versed, all they need to requestisfor paranasal sinus x-ray → Water’s or Caldwell’s view Request for the following: → CT scan of facial boneswithoutcontrast → 3D reconstruction to visualize it and show patients the extent of the damage or injury e. TREATMENT Open reduction internal fixation(ORIF) Goals of surgery: → Elevate orbital contents out of the fracture site → Release any adhesions betweentheorbitalcontentsandfracture site → Prevent any re-adhesion → Restore orbital wall to its normal shape Use of 1.2 or 1.5 mmtitanium microplates Figure 68.Zygomatic arch fractures lateral to eachof the arch (L) and fractures in the middle of the arch (R). a. CLASSIFICATION alpable defect over the arch P Depressed tender cheek Pain in cheek and jaw movement Limited mandibular movement Figure 69.Clinical finding b. IMAGING STUDIES Plain Radiograph → Submental view (bucket handle view) CT scan of the facial bones Figure 66.ORIF (L) and titanium microplate (R). 💡 Notes from Face-to-Face Lecture | Dr. Cabungcal 💡 Notes from Face-to-Face Lecture | Dr. Cabungcal If a CT scan is available, it is always preferred. rafts in extensive bone loss are used to address possible G enophthalmos complications. Grafts should be placed before bone heals so the fibrosis can be cleared. If there is a presence of bone loss, place either cartilage or synthetic material (silicon) over the damaged area. III. V FRACTURES OF ZYGOMA 2 major components → Zygomatic arch → Zygomatic body Blunt traumais themost common cause of injury Two types of fractures can occur: → Arch fracture– more common → Tripod fracture –more serious Group 2B, 3A, & 3B Figure 70.Zygomatic arch fracture in pain radiograph(L) and in 3D CT scan (R) c. TREATMENT Conservative management is recommended for: → Minimal/Undisplaced fractures → Patients with medical contraindications → The very elderly patients Page13of22 MAXILLOFACIAL TRAUMA Otorhinolaryngology - Alexander C. Cabungcal, M.D. losed reduction is required for symptomatic patients such as C those with: → Cosmetic deformity → Impaired mandibular movement → Diplopia → Infraorbital para/anesthesia Figure 74.Periorbital ecchymosis H ypoesthesia of the cheek and upper definition is due to the involvement of the infraorbital nerve Step deformity may be observed on palpation Figure 71.Open reduction 💡 Notes from Face-to-Face Lecture | Dr. Cabungcal If the force islateral, it is a zygomatic arch fracture. If the force is on the frontal part of the face, it is usually a zygomatic tripod fracture. In open reduction → We put a simpleincisionneartheeyebrowsothatitcan be hidden. Then, we put the instrument underneath the zygoma and lift it. → Noneedtouseplatingunlessit'snecessary.Why?Weare avoiding the temporal branchofthefacialnerve.Ifwe injure that, you cannot raise your eyebrows anymore. B. ZYGOMATIC TRIPOD FRACTURES Consists of fractures through: → Zygomatic arch → Zygomaticofrontal suture → Inferior orbital rim and floor Figure 75.Fracture of the inferior orbital rim andfloor leading to the involvement of the infraorbital nerve Figure 76.The flatness of the lateral cheek area Figure 77.Diplopia on upward gaze. The left orbitfails to move upward when the patient is asked to gaze upward. Figure 72.Zygomatic tripod fracture: Zygomaticofrontalsuture (Upper circe), Zygomatic arch (Middle circle), and Inferior orbital rim (Lower circle) a. CLASSIFICATION eriorbital edema and ecchymosis P Hypoesthesia – cheek and upper dentition Palpation – step off deformity Flat lateral cheek Diplopia on upward gaze Inferior displacement of ocular globe Inability to open mouth Hyperophthalmos – exophthalmos Enophthalmos – hypophthalmos Figure 78.Inferior displacement of the ocular globe.Occurs when the zygoma is pushed downwards due to Lockwood’s ligament which attaches to the inferior part of the orbit to the zygoma. E nophthalmos and/or hypophthalmos occur when the zygoma is depressed and is rotated clockwise → Expansion of the orbital walls Exophthalmos orhyperophthalmosoccurswhenthezygomaisrotated inwards → Orbit is smaller Figure 73.Patient with Zygomatic tripod fracture Group 2B, 3A, & 3B Page14of22 MAXILLOFACIAL TRAUMA Otorhinolaryngology - Alexander C. Cabungcal, M.D. IX. MAXILLARY FRACTURES Associated withhigh energy injuries → Impact 100 times the force of gravity is required Patients often have significant multisystem trauma Involve buttresses and beams that maintain the height, width, and projection of the face → Once there are these injuries, there will be a noticeable disparity of the features of the patient pre- and post-injury Classified asLe Fort fractures 📝 A. LE FORT I MAXILLARY FRACTURES A lso known asGuerin’s fracture The fracture crosses the nasal septum → lower portion of piriform apertures → canine fossa → zygomaticomaxillary buttress Horizontal fracture of the maxilla at the level of the nasal fossa Figure 79.Enophthalmos/Hypophthalmos & Exophthalmos/Hyperophthalmos Figure 82.Guerin’s Fracture or Le Fort fracture b. IMAGING STUDIES Plain Radiograph → Water’s, submental, and Caldwells’ views CT of the facial bones → With 3D reconstruction → Very helpful with fractures of the zygoma 📝 Notes from Face-to-Face Lecture | Dr. Cabungcal he importance of Le Fort I isthepalatehasseparatedfrom T the face. Sowhendoingthedrawer’stest,holdtheanteriorincisorsand then carefully move it, do not use too much force Whenperformingthedrawer’stestinaLeFortIIfracture,hold the area of the nose, and also be careful. TheworstinjuryistheLeFortIIIsincethereisaseparationof the facial skeleton from the cranium a. CLINICAL FINDINGS F acial edema Malocclusion of the teeth Motionofthemaxillawhilethenasalbridgeremainsstableondrawers test Figure 80.3D imaging c. TREATMENT Nondisplaced fracture without eye Involvement → Ice and analgesics → Delayed operative consideration for 5 to 7 days → Decongestants → Broad spectrum antibiotics → Tetanus prophylaxis Displaced tripod fracture → Admissionforopenreductionandinternalfixation(ORIF)using1.2 or 1.5 mm microplates Figure 83.Clinical findings of maxillary Fracturefrom a motorcycle accident 📝 Notes from Face-to-Face Lecture | Dr. Cabungcal With this injury do you expect the patient to have epistaxis? → Yes,sincetheroofofthemouthisthepalateandthefloor of the nose is the palate The most common symptom is malocclusion → As the upper part of the arch is moved Also common is palatal split due to the force of the accident Figure 81.Open Reduction and Internal Fixation (ORIF)of Tripod Fracture. The patient with a flattened cheek is corrected by reducing the fracture and fixation using a titanium plate implant placed on the inferior orbital wall (L). Immediate post-operative condition of the patient (R). Group 2B, 3A, & 3B b. IMAGING STUDIES CT scan of the face and head shows → Fracture line which involves ▪ Nasal aperture ▪ Inferior maxilla ▪ Lateral wall of maxilla Coronal cuts and 3D reconstruction are helpful Page15of22 MAXILLOFACIAL TRAUMA Otorhinolaryngology - Alexander C. Cabungcal, M.D. 📝 Notes from Face-to-Face Lecture | Dr. Cabungcal B e gentle when doing the examination as one might add additional injury to the patient If the nasal bone is involved, it is a pyramidal fracture a. CLINICAL FINDINGS arked facial edema M Nasal flattening Traumatic telecanthus Epistaxis or CSF rhinorrhea Movement of the upper jaw and the nose on drawers test Figure 84.CT scan of Le Fort I maxillary fracture(encircled red lines are the fractures) 📝 Notes from Face-to-Face Lecture | Dr. Cabungcal T hisisduringthesurgery(Figure84),thisiswhythebuttresses are important for the repair → Nasomaxillary on the right → Nasomaxillary on the left → Zygomaticomaxillary on the left → Zygomaticomaxillary on theright(thisdependssinceitis still intact) At least, in this case, the patient would have 3 plates The anteriorwallisnotload-bearingevenifthereisaholeso there is not need to repair it → Sometimesbonewillregenerateinthatareaorthefibrosis will cover the gap c. TREATMENT O penreductionandinternalfixationsurgery(ORIF)ofthefractured fragment to achieve preinjury occlusion Figure 87.Le Fort II Maxillary Fracture from a motorcycleaccident b. IMAGING STUDIES C T scan of the faceis theimaging study of choice Fracture involves: → Nasal bones → Frontal process of the maxilla → Medial orbit → Maxillary sinus Figure 88.CT scan of the Le Fort II Fracture 📝 Figure 85.Shows how the fracture fragments are rescuedand stabilized using the titanium plates 📝 Notes from Face-to-Face Lecture | Dr. Cabungcal After the surgery this is where the plates are placed (figure 85) → in this patient there are 4 plates since when the patient was open there was an additional fracture that was running upwards also seen are the plates higher Notes from Face-to-Face Lecture | Dr. Cabungcal Plates put in the patient (Figure 88) → Zygomaticomaxillary buttress → Nasomaxillary → Mandibular (usually in Le Fort III) c. TREATMENT pen reduction and internal fixation surgery (ORIF)withcorrectionof O malocclusion as the main goal. . LE FORT II MAXILLARY FRACTURES B Also known aspyramidal fracture The fracture involvedthenasofrontalsutureline→lacrimalbones→ inferior orbital rim → anterior lateral wall of the maxilla The following structures are also involved: → Maxilla → Nasal bones → Medial aspect of the orbits Figure 89.Surgery with the placement of titaniumplates with the immediate postoperative result showing facial edema due to the surgery C. LE FORT III MAXILLARY FRACTURES Also known ascraniofacial disjunction → Most serious fracture Thefracturerunsthroughthenasofrontalsutureline→medialwalland floor of the orbit → inferior orbital fissure → lateral orbital wall → zygomaticofrontal suture → There is separation of the frail bones to the cranial bones The fracture line extends across the temporal surface of the zygoma and zygomatic arch → maxilla → pterygoid plates 📝 Figure 86.Le Fort II Maxillary Fractures Group 2B, 3A, & 3B 📝 Page16of22 MAXILLOFACIAL TRAUMA Otorhinolaryngology - Alexander C. Cabungcal, M.D. Fractures involve the: → Maxilla → Zygoma → Nasal bones → Ethmoid bones → Base of the skull Figure 93.Surgery with postoperative result 📝 A nother patient (figure 93) with an anteriorandposteriorwall fracture → This involved the frontal bonecontinuoussuctioningwas done due to an increased amount of pus → Although,thebrainwasalsosuctioned,thepatientisalive with no neurological deficits Figure 90.Le Fort III Maxillary Fracture a. CLINICAL FINDINGS D ish face deformity Epistaxis and CSF rhinorrhea Severe airway obstruction → due to the separation of the face from the cranium Motion of the maxilla, nasal bones, and zygoma on drawers test 📝 Notes from Face-to-Face Lecture | Dr. Cabungcal D. OTHER VARIATIONS Can occur alone or in combination with other midface fractures → Medial maxillary ▪ Skeletal depression between the nose and maxilla → Split palate ▪ Occurs withLeFortIIorLeFortIIIorfracturesinvolvingthe malar bone → Alveolar or segmental maxillary ▪ Commonly associated with Le Fort I fractures X. FRACTURES OF THE LOWER FACE A. MANDIBULAR FRACTURES Figure 91.Clinical Finding showing dish face deformity 📝 Notes from Face-to-Face Lecture | Dr. Cabungcal a. PATHOPHYSIOLOGY 3rd most common facial fracture Assaults and falls on the chin Multiple fractures seen in greater than 50% Associated C-spine injuries are seen in 0.2-6% This is a unique accident (Figure 91) → Hewasstaringwhiletherewasrepairmentoftheringand the board → Someoneissteppingontheringandthepatienthappens tobebelowtheringlookingupandtheboardfellwiththe person and it hit his face (with the red line) → Ittook14hourstorepairasalmostnothingwasleftinhis face all are fractured → The only good thing that happened is he is alive and normal b. IMAGING STUDIES C T scan of the faceis the imaging study of choice. Fracture is through the following: → Zygomaticofrontal suture → Zygoma → Medial orbital wall → Nasal bone Figure 94.Mandibular Fracture b. CLINICAL FINDINGS andibular pain M Malocclusion of the teeth Separation of teeth with intraoral bleeding Inability to fully open mouth Preauricular pain with biting Positive tongue blade Anesthesia Swelling, hematoma Crepitus Figure 92.CT scan showing the involved fractures c. TREATMENT pen reduction andinternalfixationsurgery(ORIF) withcorrectionof O malocclusion as the main goal. Figure 95. Gross Mandibular fracture c. CLASSIFICATIONS (LOCATION) The following is the order of classifications: Group 2B, 3A, & 3B Page17of22 MAXILLOFACIAL TRAUMA Otorhinolaryngology - Alexander C. Cabungcal, M.D. Condyle → → Coronoid → Ramus → Angle → Body → Parasymphysis Figure 96.Mandibular fracture frequency by location CONDYLE Figure 100.Types of ramus fracture ANGLE Figure 97.Condylar fracture in 3D imaging (L) andin plain radiograph (R). CORONOID Figure 101.Angle fracture BODY Figure 98.Coronoid fracture (L) and combination ofcondylar and coronoid fracture (R) RAMUS Figure 102.Body fracture PARASYMPHYSIS Figure 99.Site of ramus fracture Figure 103.Parasymphyseal fracture 📝 Notes from Face-to-Face Lecture | Dr. Cabungcal Bilateral condylar fracture → face is shortened because of loss of projection of the mandible → consequence is lifetime pain Which has a better prognosis? Body or parasymphyseal? → Body,becauseitisthinnerandhasabetterbloodsupply than the parasymphyseal which is the thickest. In parasymphyseal, healing is lesser and slow. Group 2B, 3A, & 3B Page18of22 MAXILLOFACIAL TRAUMA Otorhinolaryngology - Alexander C. Cabungcal, M.D. → principle in reducing the fracture isdifferentbetweenthe twobecauseinparasymphyseal,haveatleast2platesto hold while in thebody, 1 is enough. d. CLASSIFICATION (TYPE OF FRACTURE) Mandibular fractures can be classified by type of fracture: → Simple– mucosa and skin intact → Compoundoropen– exposure of bone intraorally → Greenstick– incomplete, only one cortical surface → Comminuted– several small fragments of bone → Complex– with fractures of other areas of mandible → Complicated– involves both mandible and maxilla Figure 109.Mandibular x-ray series: PA view (left),oblique view (right) Figure 104.Classification of Mandibular Fractureby Type of Fracture Figure 110.CT scan: facial bones (left), mandible(right) Figure 105. Comminuted fracture Figure 106.Complex fracture f. TREATMENT C orrection of malocclusion is the maingoaloftreatment.Itmaybe this or Intermaxillary fixation or Open reduction and internal fixation (ORIF), using: → Interosseous wiring, → Lag screws, or → Rigid plates ▪ Use 2.0, 2.4, or 2.5 mm plates Figure 111.Surgical treatment of mandibular fracture Figure 107.Complicated fracture 📝 Notes from Face-to-Face Lecture | Dr. Cabungcal You can see Greenstick fracture in children e. IMAGING STUDIES Panoramic view of the mandible → More commonly known as Panorex Mandibular x-ray series → PA and oblique views Towne’s view CT scan Figure 112.Intermaxillary fixation Figure 113.Lag screws Figure 114.Interosseous wiring Figure 115.Rigid plates Figure 108.Panoramic view of the mandible Group 2B, 3A, & 3B Page19of22 MAXILLOFACIAL TRAUMA Otorhinolaryngology - Alexander C. Cabungcal, M.D. IMPORTANT GUIDELINES IN TREATMENT FOR PEDIATRIC PATIENTS More conservative Should have regard to the growth of jaw and injury to developing teeth Use smaller plates Resorbable plates are preferred if available If titanium plates are used, remove within 3-6 months Figure 116.Pediatric patient with plates ith the disruption of ossicles there is perforation of the w tympanic membrane Bleeding from the ear canal - due to tympanic → membrane perforation b. TRANSVERSE L ess common Perpendicular to the axis of petrous pyramid Clinical findings: → Severe sensorineural hearing loss → Unsteadiness and vertigo due to loss of vestibular function → Facial paralysis at the onset → Hemotympanum XI. TEMPORAL BONE FRACTURES M ore common inyoungmen Mostly due tomotor vehicular accidents> falls >assaults > weapons Figure 119.Transverse fracture (left), Hemotympanum(right) Figure 117.Temporal bone fractures 📝 Transverse temporal bone fracture clinical findings: → Sensorineural hearing loss – the injury is beyond the middleearsinceitinvolvesthefacialnerveareawhichis close to your SCC and labyrinth → Loss of vestibular function – manifestation is severe vertigo → Immediate facial paralysis – because the fracture passes through the facial nerve → Hemotympanum–sinceitdoesnotinvolvetheroofofthe middle ear, bleeding can also occur, but since the tympanicmembraneisintactwhatyouseeisbloodbehind the tympanic membrane which is hemotympanum (color dark red or black) A. TYPES Classified into 3 types: → Longitudinal → Transverse → Mixed Notes from Face-to-Face Lecture | Dr. Cabungcal a. LONGITUDINAL ost common M Parallel to the long axis of petrous pyramid Involves roof of middle ear and anterior petrous apex Clinical findings: → Tympanic membrane perforation → Delayed onsetof facial nerve (CN VII) paralysis → Disruption of ossicles → Bleeding from the canal c. MIXED B. TREATMENT U suallynon-surgical and supportive When correcting the bony structures, do not forget the soft tissues → Soft tissue damage is easily seen and observed by the patients and relatives → Repair of soft tissue is as vital as the repair of bony component Figure 118.Longitudinal fracture (left), Tympanicmembrane perforation and bleeding from the ear; this is from trauma (sharp edges and active bleeding which we don’t usually see in infections) (middle), CSF otorrhea; if the injury is severe enough (right) 📝 Notes from Face-to-Face Lecture | Dr. Cabungcal Longitudinal temporal bone fracture clinical findings: → Tympanic membrane perforation - because it involves the middle ear, on otoscopy, iftherearethepresenceof lacerations and perforations it is probably a longitudinal temporal fracture → Delayed onset VII paralysis (facial nerve) - patients usually would get out of the hospitalwithanintactfacial nerve, enabling them to smile and raise eyebrows. However, aftertwoweeks,theyfindthemselvesincapable ofclosingtheireyes,canonlysmileononeside,andspill water while drinking → Disruption of ossicles - when you do an audiometry, patients have conductive hearing loss, because along Group 2B, 3A, & 3B Figure 120.Soft tissue damage; Wire entanglement(first row), Fell from the bus (2nd & 3rd rows), Motorcycle accident (4th row) 📝 Notes from Face-to-Face Lecture | Dr. Cabungcal Treatment: → Usually observe → Treat symptomatically for pain, balance,givesteroidsfor facial nerve paralysis → In any area, don’t neglect the soft tissues, also address the wound of the soft tissues Page20of22 MAXILLOFACIAL TRAUMA Otorhinolaryngology - Alexander C. Cabungcal, M.D. XII. REFERENCES Dr. Alexander C. Cabungcal’s video lecture(s) XIII. REVIEW QUESTIONS SYNCHRONOUS QUIZ 1 -3. Most common fractures of the face. 4. Immediate facial nerve paralysis is seen in this type of fracture. 5. Most severe Le Fort fracture. Answers:1-3. Nasal, zygomatic and mandibular fracture,4. Transverse fracture of temporal bone, 5. Le Fort III maxillary fracture PAST EVALS (2024) 1. In patients with severe nerve injury, how many would have concurrent spinal injury? a. 2% b. 4% c. 10% d. 20% 2. One of the clinical manifestations of neurogenic shock a. Adequate CVP b. Loss of intravascular volume c. Distended jugular vein d. Hypotension without tachycardia 3. This is the horizontal buttress a. Frontal bone b. Pterygomaxillary c. Zygomaticomaxillary d. Nasomaxillary 4. Fracture in this area is considered as midface fracture a. Ascending ramus b. Condyle c. Frontal bone d. Nasoethmoid 5. This type of fracture may have dural tears a. Subcondylar b. NEO c. Le Fort II d. Tripod 6. Enophthalmus may be seen in this type of fracture: a. Nasal bone b. Le Fort I c. Tripod d. Symphyseal 7. Diplopia on upward gaze may be seen in: a. Zygomatic bone fracture b. Le Fort II fracture c. NEO fracture d. Frontal bone fracture 8. One of the following is seen in longitudinal temporal bone fracture: a. Imbalance b. Delayed facial nerve paralysis c. Hemotympanum d. Sensorineural hearing loss 9. Amongthefollowingcraniofacialskeleton,whatismorevulnerabletocomplication in result for decreased blood supply a. Zygomatic bone b. Mandibular bone c. Nasal bone d. Maxillary wall 10. Which among these structures is derived from the paraxial mesoderm? a. Occipital bone b. Skull base c. Frontal bones d. Nasal septum Answers:1B, 2D, 3A, 4B, 5B | 6C, 7A, 8B, 9B, 10B Group 2B, 3A, & 3B Page21of22 MAXILLOFACIAL TRAUMA Otorhinolaryngology - Alexander C. Cabungcal, M.D. APPENDIX A able Summay of the Le Fort Fractures T Le Fort I Fracture Le Fort II Fracture Le Fort III Fracture Description A.k.a Guerin’s fracture A.k.a Pyramidal fracture Course of fracture rosses the nasal septum → lower C portion of peri form apertures → canine fossa → zygomaticomaxillary buttress Though the nasofrontal suture line → asofrontal suture line → lacrimal bones N edial wall and floor of the orbit → m → inferior orbital rim → anterior lateral inferior orbital fissure → lateral orbital wall of the maxilla wall → zygomaticofrontal suture Clinical Findings F acial edema Malocclusion of the teeth Motion Of the maxilla while the nasal bridge remain stable on drawers test Imaging Studies CT scan CT scan CT scan Treatment ORIF ORIF ORIF arked facial edema M Nasal flattening Traumatic telecanthus Epistaxis of CSF rhinorrhea Movement of the upper jaw and the nose on drawers test A.k.a Craniofacial dysfunction ish face deformity D Epistaxis and CSF rhinorrhea Severe airway obstruction Motion Of the maxilla, nasal bones, and zygoma on drawers test Image of the fracture Group 2B, 3A, & 3B Page22of22
