IN THE NAME OF ALLAH, THE MOST
1
BENEFICENT, THE MOST MERCIFUL
Nasal and Facial Trauma
Brigadier Nasir Ullah Khan
Classified ENT Specialist
CMH Rawalpindi
Sequence
•
•
•
•
•
•
•
Facial trauma in general
Nasal trauma
Mandibular fractures
Fractures of the maxilla
Zygomatic complex fractures
Orbital floor fractures
Upper third fracures involving the frontal
sinus
Facial Trauma
• 10 % of all accidents are related to facial
injuries
• Endanger the airway
• Associated cervical spine injuries
Aetiology
Aetiology
•
•
•
•
Road Traffic Accidents
Physical violence
Attempted suicide
Sports accidents
Causes of Mortality
• Acute
– Airway compromise
– Exsanguination
– Associated intracranial or cervical-spine injury
• Delayed
– Meningitis
– Oropharyngeal infections
Management
• Primary survey and care
–
–
–
–
–
Airway
Breathing
Circulation
Dysfunction
Exposure
Management
• Secondary survey
– Exclude other injuries
– Extent of facial injuries
• Radiological evaluation - chest, cervical
spine and pelvis
• Intervention
Management
• Facial swelling - head up position, ice
packs and dexamethasone
• Facial wounds – closed as early as possible
• Fractures reduced and fixed
• Give tetanus prophylaxis
Nasal Fractures
Introduction
• Isolated nasal fractures account for about 40
percent of all facial fractures
• Delays in management can result in
significant cosmetic and functional
deformity
• Management of nasal fractures is an
important part of everyday ENT practice
Nasal trauma
• More common in young men than women
• 15 – 30 years
• Aetiology
– In young adults (peak incidence)
• Assaults
• Contact sports
• Adventurous leisure activities
– In childhood
• Accident prone toddlers not infrequently fracture
their noses
– In elderly
Nasal trauma
• Apart from actual fracture of nasal bones, injuries
include:
- Soft tissue
- Septal cartilage fracture
- Septal bone fracture
- Septal haematoma
- CSF leak
Nasal trauma
• Injury results from
•
- lateral
- frontal
- combined
Extent of deformity
• Grade 0 : bones perfectly straight
• Grade 1 : bones deviated less than half of
the width of the bridge of nose
• Grade 2 : half to one full width of the bridge
of nose
• Grade 3 : greater than one full width of the
bridge
• Grade 4:bones almost touching the cheek
Nasal fractures - classification
• Class 1 Fracture
• Class 2 fracture
• Class 3 fracture – naso-orbito-ethmoid
– Type I
– Type II
Nasal trauma
• May be part of more extensive injury to face,
skull, skull-base, neck, chest …….
REMEMBER TO CONSIDER THE AIRWAY
AND EXCLUDE
CERVICAL SPINE INJURIES
Clinical features
• Epistaxis
• Deformity
• Nasal obstruction
• Diplopia
Naso-fronto-ethmoid fractures
• Epiphora
• Visual disturbance
Clinical features
• Signs
– External deformity, swelling, lacerations
– Tenderness, crepitus
– Septal haematoma/ abscess
• There is often periorbitaln swelling and
there may be periorbital and
subconjunctival echymosis
Investigations
• X rays
• CT scan
• Beta transferrin
Management - soft tissue
• Clean wounds and remove foreign material
• Anti-tetanus and antibiotic cover if appropriate
• Abrasions cleaned and left open
• Steristrips to small lacerations
• Fine monofilament sutures to large lacerations
Management - fracture
• Nothing if no deformity. Reassure and review
• Class 1 - reduce if early
- disimpact and realign
- if swollen, manipulate and reduce
at 5-7 days
Management - fracture
Class 2
- septal fracture is often overlapping so
fractures redisplace
- manipulation of the nasal bones
should follow excision of
overlapping edges
Management - fracture
• Class 3 - requires open reduction
Complications
•
•
•
•
•
•
Bleeding
Septal haematoma
CSF rhinorrhoea
Deformity
Sensory loss
Anosmia
Septal haematoma
Saddle deformity
Mandibular fractures
Mandible Fracture
Mandibular fractures
clinical features
•
•
•
•
•
•
•
•
Step deformities
Pain
Deranged occlusion
Blood stained saliva
Sublingual haematoma
Mobile teeth
Lip anaesthesia
trismus
Signs and symptoms of condylar
neck fractures
• Tenderness
• Trismus
• Lateral and anterior open bite
Mandibular fractures
treatment
• Reduction
–
–
–
–
IMF
IM bone pins
Cast silver splints
Gunning splints
• Fixation
– External
– Internal - plating
Sites of bone plating
Fractures of the midface
• Central midface ( maxilla, nasal, nasoorbito-ethmoid) fractures
• Lateral ( zygomatic) fractures
Fractures of the Maxilla
Maxillary fractures
classification
• Le fort 1
• Le Fort 2
• Le Fort 3
Le Fort 1
Le fort 2
Le Fort 3
Differentiating Le Forts
Pull forward on maxillary teeth
• Le Fort 1: maxilla only moves
• Le Fort 2: maxilla & base of nose moves
• Le Fort 3: whole face moves
Le Fort fractures
signs and symptoms
•
•
•
•
•
•
•
Epistaxis
Circumorbital ecchymosis
Facial oedema
Surgical emphysema
Infraorbital anaesthesia
Anterior open bite ( in Le Fort 1&2)
Haematoma at the junction of hard and soft
palate
Treatment
• Emergency treatment
• Reduction
• Fixation
–
–
–
–
Imf
External – Levant frame
Internal suspension
Internal fixation – miniplates
Zygomatic Fractures
Tripod (tri-malar) fracture
• Depression of malar eminence
• Fractures at temporal, frontal, and maxillary
suture lines
Zygomatic Fractures
Isolated arch fracture
• Less common
• Shows best on submental-vertex x-ray view
• Painful mandible movement
• Usually treated with fixation wire if arch
depressed
Zygomatic Fractures
Tripod S & S
• Unilateral epistaxis
• Depressed malar
prominence
• Subcutaneous
emphysema
• Orbital rim step-off
• Altered relative
pupil position
• Periorbital
ecchymosis
• Subconjunctival
hemorrhage
• Infraorbital
hypoesthesia
Orbital floor fractures
• “Blow out” fracture of floor
Symptoms and signs
• Diplopia: double vision
• Enophthalmos: sunken eyeball
• Impaired EOM’s
• Infraorbital hypoesthesia
• Maxillary sinus opacification
• “Hanging drop” in maxillary sinus
Upper facial third Fractures
Frontal sinus fracture
• Often associated with intracranial injury
• Often show depressed glabellar area
• If posterior wall fracture, then dura is torn
Orbital Fracture: Treatment
• Sometimes extraocular muscle dysfunction
can be due to edema and will correct
without surgery
• Persistent or high grade muscle entrapment
requires surgical repair of orbital floor
(bone grafts, Teflon, plating, etc.)
Facial Soft Tissue Injuries
• Before repair, rule out injury to:
–
–
–
–
–
Facial nerve
Trigeminal nerve
Parotid duct
Lacrimal duct
Medial canthal ligament
• Remove embedded foreign material to
prevent tattooing
Facial Soft Tissue Rules
• For lip lacerations, place first suture at
vermillion border
• Never shave an eyebrow: may not grow
back
• If debridement of eyebrow laceration
needed, debride parallel to angle of hairs
rather than vertically
Facial Soft Tissue Rules
• Most face bite wounds can be sutured
primarily
• Clean facial wounds can be repaired up to
24 hours after injury
• Place incisions or debridement lines parallel
to the lines of least skin tension (Lines of
Langer)
Thank you