Facial Trauma
Epidemiology
Anatomy
Grading
Assessment
Investigation
Mortality due to airway compromise / blood loss; if 3+ facial #, 35% incidence of basal skull #
Infraorbital nerve: cheek, lateral nose, skin and conjunctiva of lower eyelid, antinf nasal septum, skin/mucosa of upper lip, premolars, canines, incisors
Eye: medial and lat canthal ligaments prevent globe from extrusion, come medially and laterally from bony wall, divide on surface of globe into inf and
sup ligs
I: closed # mandible
II: closed # zygoma
III: open # mandible Le Forte III compound # with <20% blood loss
IV: >20% blood loss
History: vision, epistaxis, teeth fit, numb, diplopia
Examination: airway (44% with severe maxfax trauma need ETT)
Face: inspect from top, front, sides; facial scalloping, bony steps, crepitus; mobilty of midface / teeth; racoon eyes, Battle sign
Dental: jaw movement, malocclusion, mental nerve
Nasal: septal haematoma, nasal obstruction, deviation, epistaxis
Nerve: facial nerve, IO nerve
Eye: enopthalmos (blow out #), exopthalmos (retrobulbar haematoma), proptosis, hypoglobus, monocular diplopia (lens dislocation), binocular
diplopia (entrapment of muscle), hyphema, RAPD (ON inj or other inj to visual pathway), VA (6% vision loss), ROM (decr upward gaze = entrapment of
IR/IO muscle, OM nerve), pupil response, telecanthus (widening of distance with normal interpupillary distance), lacrimal apparatus, hypertelorism
(widening of interpupillary distance (blow out #)
Ear: auricular haematoma, CSF, haemotympanum
Other: HI, C spine
Facial views: Waters (occipitomental; for midface, maxilla, infraorbital, zygoma), Caldwell (PA; for frontal, paranasal sinus), skyline (submental; for
zygoma, base of skull), Towne’s (for mandibular rami and condyles), mandibular and TMJ, lateral
OPG: mandibular
CT: do if CT head indicated, ?orbital blow out, gas in orbit, clinically obvious facial deformity, # maxilla / orbit / frontal sinus on XR, high degree of
suspicion despite normal XR
Bloods: do coag if major facial haemorrhage (DIC common)
Fractures
Naso-orbito-ethmoid complex fracture: across nasal bridge and ethmoids; avulses medial canthal
ligament from lacrimal bone  short, laterally displaced medial palpebral fissure; incr intercanthal
distance (telecanthus, >1/2 interpupillary distance, >4cm); trt with surgical repair
Le Fort:
I: # through lower 1/3 maxilla, palate, pterygoid plate body of maxilla
separate from base of skull at level of nasal floor / above level of palate /
below level of zygomatic arch  movement of upper dental arch,
malocclusion with premature premolar contact
II: # through maxilla towards medial infraorbital rims, into ethmoid sinus,
cross bridge of nose  movement of nose and upper dental arch,
donkey face on frontal; most common midface #; assoc with epistaxis,
CSF leak
III: # through fronto-zygomatic suture (or zygomatic arch), med and lat
walls of orbits, base of nose  movement of entire maxilla and zygoma,
cranio-facial dysfunction, dish face on lateral, donkey face on frontal
Tripod #: separation at zygomatico-frontal / zygomatico-maxillary suture / infraorbital rim  flat
cheek, asymmetrical ocular level, infraorbital nerve numbness, diplopia, subconjunctival haem,
unilateral epistaxis, decr mandibular movement; penicillin; reduction and internal fixation if complex /
deformity / open
Nasal trauma
Treatment
Mandibular: body (30-40%, esp 1st and 2nd molar region); angle (25%); condyle (20%, cause malocclusion); symphysis (10%, lower incisors displaced
laterally); alveolar (<5%); may need IVF; penicillin; ADT; most need internal fixation; if dislocated, press down with thumbs, upward pressure with
fingers on one side
TMJ dislocation: mandibular head goes forward and superior; caused by trauma, drugs, epilepsy, prolonged dental procedure; mouth open and unable
to close
Zygomatic arch: mandibular opening may be limited by masseter muscle entrapment; OT if entrapment / cosmetic probs
Maxillary, alveolar: most common # of maxilla; avulsion of teeth; trt with wiring
Maxillary, orbital floor blow out #: # orbital floor without # orbital margin; usually med / inf floor; can trap IR, IO; occurs from direct blow to orbit;
diplopia in 85%, decr upward gaze (due to IR / IO entrapment), enopthalmos, hypertelorism, corneal abrasion, hyphema, subC emphysema, IO
anaesthesia; teardrop on Caldwell; augmentin, decongestants, no nose blowing, OT if diplopia in 1Y position, Sx persist, cosmetic
Septal haematoma – between septal cartilage and mucoperichondrium  cartilage necrosis, infection, abscess, cartilage destruction in 24hrs
General principles: attend to airway and life threatening inj first; if airway compromise, pull maxilla forward, lift tongue and mandible; ensure C spine
OK; allow patient to sit when C spine cleared; beware ETT, may be hard to BVM, have back up plan, use etomidate/ketamine to maintain resp  if
good view, paralyse and intubate; early shock usually due to bleeding elsewhere; immediate reduction of Le Forte # if bleeding / airway compromise;
catheter tamponade of epistaxis; gauze packing of oropharynx, nasopharynx, around ETT; inject bleeding sites with adrenaline; consider early OT /
embolisation; ADT
Nasal trauma: review at 5/7; reduce at 5-10/7 if indicated; delayed septoplasty if cartilage inj; drain septal haematoma and cover with anti-staph Abx
(review at 24hrs)
Indications for reduction: cosmetic deformity due to #, nasal obstruction
Antibiotics if: extensive ST inj (contaminated wound, open #, # communicating with intranasal/oral/spinous space, bites, exposed cartilage,
immunological compromise; penicillin 1/52 for all # involving maxillary antrum
Lateral canthotomy: decompress orbit; indicated if IO p > retinal artery p (vision threatening if >2hrs) = visual loss, RAPD, proptosis, hard globe on
palpation; incise skin over lateral canthus towards bony orbit  retract lower lid  divide inf lat canthal lig  divide sup if p not dropped enough
Notes from: Dunn, Cameron