Facial Trauma
Abdullah Al-Harkan, BA, DMD, MSc, FRCD (C)
Specialist, Oral and Maxillofacial Surgery
Farwaniya Hospital
Facial Trauma
• Who is involved in facial trauma?
– General Surgery/Trauma team
– Anesthesia
– Plastic Surgery
– ENT
– Oral & Maxillofacial Surgery
– Neurosurgery
– Ophthalmology
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
Primary Survey – ABC’s
• A – airway with cervical spine control
– Establishment and maintenance of a patent
airway
– Airway obstruction may be due to:
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tongue
severe maxillofacial fractures
bleeding from oral or facial structures
aspiration of foreign materials
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
Secondary Survey
• History
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Illness
Allergies
Medications
Last meal
History of event
• Comprehensive Exam
– Detect all injuries
• Continued monitoring and reassesment of ABC’s of
primary survey
Definitive Care
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After Primary and secondary survey
Resuscitation is complete
Patient is stabilized
Appropriate referral – (i.e. maxillofacial surgery)
Surgery
Non operative management
Evaluation of Maxillofacial Injuries
• History
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PMH/Medications/Allergies
Mechanism of injury
Events surrounding injury
Other injuries
• Exam
– General
• Vital Signs
• GCS
Evaluation of Maxillofacial Injuries
• What are we looking
for?
• Damage to structures of
the head and neck
• Need to know Signs and
Symptoms
Evaluation of Maxillofacial Injuries
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1- Scalp
2- Ears
3- Forehead
4- Orbits
5- Zygoma/Zygomatic arches
6- Nose
7- Maxilla
8- Mandible
Evaluation of Maxillofacial Injuries
• Scalp
– Lacerations
– Hematomas
– Important:
• Bleeding
• Underlying fractures
Evaluation of Maxillofacial Injuries
• Ears
– Lacerations
– External auditory meatus
(EAM) and membrane
– Battle’s Sign
– CSF otorrhea
– Hearing
Evaluation of Maxillofacial Injuries
• Forehead/Frontal Sinus
Evaluation
- Lacerations
- Hematomas
- Palpate for steps or
depressions
- Check for any sensory
deficit
Forehead/Frontal Sinus Evaluation
• CT scan for this area is to evaluate:
– Severity of anterior and posterior tables
– Injury to Nasal frontal outflow tract
Evaluation of Maxillofacial Injuries
• Frontal sinus injuries
• Usually severe injuries
• Due to severity, you
should suspect
intracranial and/or
spine injuries.
• Hence involvement of
Neurosurgery
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, 2Mucosal entrapment in intracranial space.
– Obstruction of nasal frontal outflow
– Surgery versus follow up
Treatment of Maxillofacial Injury
Bicoronal flap
Evaluation of Maxillofacial Injuries
• Orbital region
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Edema/ecchymosis
lacerations
Orbital step defects
Sensory loss - forehead
• Eyes
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Subconjunctival ecchymosis
Visual acuity
Pupils
Extraocular muscles
Retinal Exam (Ophthalmology)
Evaluation of Maxillofacial Injuries
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
Retrobulbar Hematoma
RACCOON EYES
RACCOON EYES??!!
Orbital blow out fractures
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:
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Titanium mesh
Medpore
Prolene mesh
Autogenous bone
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
Evaluation of Maxillofacial Injuries
• Zygoma/Zygomatic Arch
Treatment of Orbital/ZMC fractures
Evaluation of Maxillofacial Injuries
• Nose
– Epistaxis/laceration
– Deviation of dorsum or septum
– Septal hematoma
– CSF Rhinorrhea
– CT cisternography
– β2Transferrin
– Palpate nasal bones
Nose injuries
Nose injuries
Nose injuries
Nose injuries
Nose injuries
Evaluation of Maxillofacial Injuries
• Middle 1/3rd of the face
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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
Le Fort Classifications
Le Fort Classifications
Treatment of Le Fort injuries
Evaluation of Maxillofacial Injuries
• Mandible
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Lacerations/ecchymosis
Hematomas
Swelling
Tenderness
Step defects/Mobile segments
Malocclusion
Loss of sensation
Loss of dentition
Evaluation of the mandible
Evaluation of the mandible
Mandible fractures
Mandible fractures
Mandible fractures
Closed reduction (IMF/MMF)
Open Reduction and Internal fixation
Thank You