Facial Trauma

Question 1

Causes of facial trauma

Answer 1

RTA
Sporting injuries
Intentional trauma

Question 2

Acute management of facial trauma

Answer 2

• Mx with ATLS principles
• Primary survey
• ABCDE
• Exclude life-threatening injuries (Intracranial, C-spine, vision-threatening) first
• Control airway, bleeding, circulation
• Facial and anterior neck injuries can result in airway compromise
  -> Causes:
  1. Soft tissue edema (E.g. tongue)
  2. Blood/secretions
  3. Mandibular # with posterior displacement of tongue
  4. Foreign body
• Airway control measures
  -> Suctioning, chin lift, jaw thrust, oral airway, intubation, tracheostomy or cricothyrotomy
  -> Always think of C-spine injuries when dealing with airway
• Acute measures to control bleeding: packing in nose or mouth
  -> Pack nose 1st, pack mouth also if doesn’t work
  -> Nose: Merocel or ribbon gauze
  -> Mouth: Roller gauze (Very long so can go into airway and still have 1 end sticking out of mouth) or normal gauze
  -> Packing stops bleeding or buys time for angiogram and embolization of specific bleeding vessel
  -> Interventionist uses coils to embolise bleeding vessel –> Lower risk of stroke than carotid artery ligation

Question 3

Most common facial bone fractures

Answer 3

Fractures of nasal bones and nasal septum are the most common of all facial bone fractures due to thin bone structure and prominent location

Question 4

Management of stable patient

Answer 4

Hx: Time of injury, MOI, LOC, vision, hearing problems, facial numbness, pain on biting or chewing to check CN involvement

PE:
- Facial skeleton, ENT, CN exam
- Look for area of bruising
- Palpate facial skeleton for step deformity as palpation is more sensitive in detecting small displacements in face

Ix: CT with 3D reconstruction

Question 5

Anatomy of nose

Answer 5

External nose is pyramidal
- Upper 1⁄3: Two thin rectangular nasal bones
- Lower 1⁄3: Cartilaginous

Nasal septum
- Anterior: Quadrangular cartilage
- Posterior: Two thin bones - vomer, perpendicular plate of the ethmoid

Question 6

Clinical presentation of fractured nose

Answer 6

Pain
External deformity
Epistaxis
Nasal obstruction
CSF leak
Septal hematoma

Question 7

What is septal hematoma?

Answer 7

• Cystic bulge on nasal septum (usually bilateral)
• Collection of blood between septal cartilage and overlying perichondrium
• Soft in consistency (vs deviated nasal septum which is hard in consistency)

Question 8

Infected septal hematoma can lead to

Answer 8

Nasal septal abscess which can destroy nasal septal cartilage

Question 9

What is the next step to take for a patient with nasal septal abscess?

Answer 9

Emergency! Refer to ENT for Incision and Drainage

Question 10

How does septal hematoma form?

Answer 10

• Tearing of capillaries in nasal septal mucosa causing collection of blood that separates perichondrium from underlying cartilage
• Bilateral hematoma lifts up perichondrium and devascularise nasal septal cartilage (receives nutrients and oxygen from perichondrium) -> avascular necrosis -> nasal septal perforation -> nasal septal collapse -> saddle nose deformity

Question 11

In base of skull fracture, what physical finding can be observed?

Answer 11

CSF rhinorrhea

Question 12

What sign indicates presence of CSF rhinorrhea?

Answer 12

Halo sign
- clear outer ring which is CSF, red inner ring which is blood

Question 13

Investigations to send for nasal bone fracture

Answer 13

• Investigate with nasal XRAY*** (medico-legal)
• CT scan of H&N TRO temporal bone/ base of skull (BOS) #

Question 14

Management for nasal bone fracture

Answer 14

0:
Manage complications first (if have) eg septal hematoma

1:
If position is ok and no major deformity, don’t need to fix and can let it heal on its own even if # seen on X-ray

2:
If cosmesis or new nasal obstruction
- Reassess in 3-5 days for need to do M&R and refer to ENT if needed
–> Swelling would have settled so you can tell if there is septal deviation, cosmetic deformity or new nasal obstruction (Tell patients don’t touch their nose at all!!!)

3:
- Golden period for reduction: after 1 week & within 14 days (can’t do after 14 days as bones will be too fixed to push back)
- Counsel patient that it’s unlikely that deformity will be corrected completely with closed reduction and their original looks may not be restored

4:
- M&R can be done under LA or GA
- Comminuted #: need to pack underneath for support
- Non-comminuted #: just elevate nasal bone

5:
- If patient not satisfied or unhappy with residual deformity (usually younger patients), can do septoplasty, rhinoplasty or septorhinoplasty 6-9 months later, so f/u 6-9 months later