Face And Neck

Question 1

What is the defining feature of a Le Fort fracture

Answer 1

Fracture through the pterygoid plates leading to pterygomaxillary separation

Question 2

Where does Le Fort type 1 extend

Answer 2

Lateral margin of nasal opening
Maxillary sinus
Upper alveolar ridge

Question 3

How does Le Fort type 1 present

Answer 3

Ecchymosis over greater palatine vessels
Teeth mobility
Cracked pot sound on percussing upper teeth
Airway obstruction

Question 4

Why do you get airway obstruction in Le Fort type 1

Answer 4

Medial pterygoid muscles pull the jaw back and down

Question 5

Describe the fracture of Le Fort type 2

Answer 5

Lacrimal bones
Inferior orbital floor and rim
Maxillary sinus

Question 6

How would a Le Fort type 2 present

Answer 6

Step deforming at infra-orbital margin
Mobile midface
Cheek parasthesia (infraorbital nerve)

Question 7

Describe the fracture of Le Fort type 3

Answer 7

Nasal bone
Frontal process of maxilla
Medial, floor and lateral wall of orbit
Zygomatic arch

Question 8

How does a Le Fort type 3 present

Answer 8

Profuse CSF rhinorrhoea (ethmoid air cells very thin)
Lengthened face
Enophthalmus
Temporalis muscle impingement

Question 9

What are some signs common to all types of Le Fort

Answer 9

Epistaxis
Gross oedema 
Circumorbital ecchymosis 
Diplopia 
Subconjunctival haemorrhage

Question 10

What is the source of bleeding in Le Fort type 2 and 3

Answer 10

Maxillary

Question 11

What is the prehospital management of facial fractures

Answer 11

Airway intubation 
Insert epistats
Dental bite blocks
Collar
Inflate epistats

Question 12

What do the posterior and anterior balloons of the epistats compress

Answer 12

Posterior - sphenopalatine

Anterior - Keisselbachs

Question 13

Why is a wound to the external jugular vein help open and what are the consequences

Answer 13

Tightly adhered to thick fascia

Means air can enter

Question 14

Fractures through the sphenoid sinuses can cause what

Answer 14

Torrential epistaxis from the ICA draining through the sinus then nasal cavity
Monocular blindness due to optic nerve ischaemia (ophthalmic artery is first branch of ICA)

Question 15

What nerve is damaged and hence what is the consequence of a zygomatic arch fracture

Answer 15

Infraorbital nerve

Impaired sensation to cheek, nasal vestibule and upper lip

Question 16

Where is a blow out fracture most common and what muscles prolapse where

Answer 16

Inferior wall - inferior rectus prolapse into maxillary sinus
Medial wall - medial rectus prolapse into ethmoid air cells

Question 17

What is the defining feature of a blow out fracture

Answer 17

Fractured wall but with intact orbital rim

Question 18

How would a blow out fracture present

Answer 18

Diplopia due to extraocular muscle involvement
Emphysema due to communication with sinus
Malar numbness due to infraorbital nerve involvement

Question 19

Describe the pathophysiology of a retrobulbar haematoma

Answer 19

Bleeding from the ophthalmic artery or vein leads to RIOP, ischaemic of the optic nerve and sight loss

Question 20

How does a retrobulbar haematoma present

Answer 20

Severe pain
Proptosis
Ophthalmoplegia

Question 21

How is a retrobulbar haematoma managed

Answer 21

Clinical diagnosis so immediate lateral canthotomy and drainage of the retrobulbar space

Question 22

What are the borders used to define penetrating neck trauma

Answer 22

3 - base of skull to angle of mandible
2 - angle of mandible to cricoid cartilage
1 - cricoid cartilage to clavicle

Question 23

What may be injured in zone 3,2, and 1 neck traumas

Answer 23

3 - vertebral artery, internal/external carotid
2 - larynx, common carotid, IJV
1 - lung apex, brachial plexus, common carotid, IJV, EJV, sympathetic chain

Question 24

What is the stepwise management of penetrating neck trauma

Answer 24

External compression —> Foley catheter balloon tamponade —> immediate surgical exploration

Question 25

What investigations are required following neck trauma

Answer 25

CTA (possibility of carotid artery dissection)

CT to include the chest (possibility of pneumothorax)

Question 26

How does Horners syndrome present?

Answer 26

Miosis
Partial ptosis
Anhidrosis

Question 27

When would you not get anhidrosis in Horners syndrome

Answer 27

Post-ganglionic as sympathetics to face sweat glands have already come off
ICE aneurysm or dissection
Cavernous sinus pathologies

Question 28

What could indicate a difficult airway

Answer 28

Obesity
Neck stiffness
Malampati (type 4 being the worst)
332 rule

Question 29

What are the indications or RSI

Answer 29

Compromised airway
Ventilatory failure
Unconscious 
Humanitarian reasons 
Severe agitation

Question 30

What is the procedure for RSI

Answer 30

Preparation 
Pre-oxygenation (100% for 3 minutes)
Fentanyl - pretreatment 
Ketamine - induction agent
Rocuronium - paralytic
Apply cricoid pressure
Place the ET tube directly between the cords
Confirm its placement with ETCO2

Question 31

What are the 30 second drills following failed intubation

Answer 31

Adjust position of patient and you
Suction
Backward,upward,rightward pressure
Change laryngoscope

Question 32

When is a surgical airway done (cricothyroidotomy)

Answer 32

Failed intubation, failed ventilation

Question 33

What is the procedure for a surgical airway

Answer 33

Vertical incision through the skin then horizontal through the cricothyroid membrane. Insert a gloved finger to keep the hole open, place a bougie and insert ET tube over it (Seldinger technique). Remove the bougie. Confirm position with ETCO2 monitor

Question 34

When would you use an OP

Answer 34

Unconscious patient with no gag reflex at risk of airway obstruction