Facial Trauma - OMF - Mandible Flashcards
During the application of rigid fixation in a 9-year-old child who has sustained a Le Fort I fracture, which of the following permanent tooth buds is at greatest risk for injury?
(A) Canine
(B) Central incisor
(C) First molar
(D) First premolar
(E) Lateral incisor
The correct response is Option A.
A 9-year-old child has mixed dentition; deciduous (primary) and permanent (secondary) teeth are present within the oral cavity simultaneously. This commonly occurs between ages 8 and 10 years. As a result, it is imperative for the surgeon to be aware of the potential for injury to the tooth buds when applying rigid fixation for management of pediatric maxillofacial fractures. The permanent canine teeth, or cuspids, erupt between ages 10 and 11 years. Therefore, the tooth buds can be injured during the application of rigid fixation in the region of the nasomaxillary buttress.
The central and lateral incisors erupt between ages 6 and 8 years. The permanent first molars erupt between ages 6 and 7 years, and the first premolars erupt between ages 8 and 9 years. Therefore, in a 9-year-old child, all of these teeth should have already begun erupting into the oral cavity, and the risk for injury to the tooth bud will be minimal.
A 65-year-old man develops a hemorrhagic stroke requiring decompressive craniotomy. The bone is found to be unusable and a customized polyetheretherketone prosthesis is planned. Which of the following is the most common complication of using this material?
A) Cerebrospinal fluid leak
B) Contour deformity
C) Dehiscence
D) Hematoma
E) Infection
The correct response is Option E.
Reports on using polyetheretherketone (PEEK) as an alloplast for cranial reconstruction vary in terms of outcomes and complications. The larger studies conclude that it is a reliable material compared with other alloplastic alternatives and has the advantage of being custom made for a variety of craniofacial defects. However, infection remains the most common complication, and choosing this material should be weighed against the risk for microorganism seeding through, wound dehiscence, hematogenous spread, or indolent colonization of the wound bed.
A 41-year-old man was punched in the eye two days ago and now has numbness in his cheek and double vision. Physical examination shows paresthesias in the V2 distribution, edema of the eyelids, and proptosis. Diplopia occurs at 40 degrees of upward gaze, but there are no definite signs of entrapment. A coronal CT is shown. Which of the following is the absolute indication for repair of the orbital floor fracture in this patient?
A ) Diplopia on upward gaze
B ) Extent of orbital floor loss
C ) Medial maxillary sinus wall fracture
D ) Medial orbital wall fracture
E ) Paresthesia between the lower eyelid and upper lip
The correct response is Option B.
The absolute indication for repair of the orbital floor fracture in the patient described is the CT finding of loss of greater than 50% of the orbital floor. Without repair, this patient is prone to enophthalmos and long-term diplopia.
Diplopia, without evidence of entrapment, is not an absolute indication for operative repair of orbital floor fractures, especially when not within 20 to 30 degrees of primary gaze. Diplopia in extreme gazes is not particularly dysfunctional; therefore, it is only a relative indication for surgery. Definite entrapment noted on examination would be an indication for surgery, but it was not demonstrated in the patient described. Note on the CT the round shape (relative to the left side) of the inferior rectus muscle in coronal section. This shape is indicative of edema in the muscle, which is the likely cause of the diplopia in extreme upward gaze.
Concomitant medial maxillary sinus wall fracture is not an indication for operative repair of the orbital floor. Further, the patient described does not demonstrate such a fracture on the CT.
A fracture of the medial orbital wall is not present on the CT image. When present, a fracture of the medial orbital wall may make enophthalmos more likely. Enophthalmos would be an indication for surgery but also was not demonstrated.
Numbness between the lower eyelid and upper lip indicates injury to the infraorbital nerve, which is present in nearly all orbital floor fractures. It is usually a neurapraxic injury, which improves to some degree with time. It is not improved by surgery, and therefore this finding is not an indication for surgery.
An 18-year-old man presents with right periorbital edema and ecchymosis after an all-terrain vehicle collision. Physical examination shows enophthalmos, diplopia, and pain with eye movements. When asked to look upward from forward gaze, there is upward gaze restriction. A photograph is shown. Which of the following locations is most likely fractured?
A) Greater wing of sphenoid bone
B) Lamina papyracea of ethmoid bone
C) Orbital plate of frontal bone
D) Orbital process of maxillary bone
E) Posterior crest of lacrimal bone
The correct response is Option D.
Limitation with vertical gaze, as described in the vignette, is indicative of extraocular muscle (EOM) entrapment.
The lamina papyracea of the ethmoid bone contributes to the medial orbital wall. Fractures of the medial wall may result in medial rectus entrapment and restriction with lateral gaze. Such injuries can involve the ethmoidal/sphenoidal sinuses.
The greater wing of the sphenoid bone contributes to the lateral orbital wall. Fractures of the lateral wall are less common due to its increased strength, but at the wings of the sphenoid, bone can have serious effects on contents of the superior orbital fissure and may even involve the intraorbital portion of the optic (II) nerve.
The orbital plate of the frontal bone contributes to the superior orbital roof. Fractures of the superior roof may result in superior rectus and/or oblique entrapment. Such injuries can involve the frontal sinus, frontal lobe, supraorbital nerve, and/or supratrochlear nerve (resulting in loss of sensation of the forehead and upper eyelid).
The orbital process of the maxillary bone contributes to the inferior orbital floor. Fractures of the inferior floor may result in inferior rectus/oblique entrapment and restriction with upward gaze. Such injuries can involve the maxillary sinus and/or infraorbital nerve (resulting in malar and superior alveolar numbness).
The posterior crest of the lacrimal bone contributes to the medial orbital wall. Fractures of the medial wall may result in medial rectus entrapment and restriction with lateral gaze. Such injuries can involve the ethmoidal/sphenoidal sinuses.
A 23-year-old man is brought to the emergency department 30 minutes after sustaining a self-inflicted shotgun wound to the face. Physical examination shows loss of soft tissue of the mid face with exposed mandible and maxilla, sonorous respiration, and periods of apnea. Heart rate is 100 bpm and blood pressure is 65/30 mmHg. Which of the following is the most appropriate course of management?
A) Assess and establish airway, control bleeding, perform secondary survey, stabilize cervical spine
B) Assess and establish airway, stabilize cervical spine, control bleeding, perform secondary survey
C) Assess and establish airway, stabilize cervical spine, perform secondary survey, control bleeding
D) Stabilize cervical spine, control bleeding, assess and establish airway, perform secondary survey
E) Take the patient to the operating room for debridement of facial wound with reconstruction
The correct response is Option B.
The appropriate management sequence in this patient is to assess and establish the airway, stabilize the cervical spine, control bleeding, and perform a secondary survey. Only after the patient’s condition has been stabilized using standard Advanced Trauma Life Support (ATLS) protocol would he be taken to the operating room for debridement and eventual facial reconstruction. While the deformity is obvious, and will require near-immediate attention in the operating theater, it can easily distract the evaluator from executing the ATLS management protocol.
The ATLS protocol was developed by the American College of Surgeons (ACS) Committee on Trauma (COT) in 1980 and is the standard of care for all trauma patients. The steps of the primary survey are remembered by the mnemonic ABCDE (Airway, Breathing, Circulation, Disability, Environment/exposure). The airway is the first priority and is assessed by determining the ability of air to pass unobstructed into the lungs. Treatment may require endotracheal intubation or establishment of a surgical airway. Breathing should then be evaluated to determine the patient’s ability to ventilate and oxygenate. Circulation is evaluated by identifying hypovolemia and external sources of hemorrhage. Disability is determined by performing gross mental status and motor examinations. The final step includes patient exposure and control of the immediate environment. The secondary survey should only be completed after following the fundamental steps of the ATLS protocol.
Cervical spine injury should be assumed in all trauma patients and should be managed as such until it can be definitively excluded. This patient with a gunshot wound to the face should have the cervical spine stabilized immediately and strict cervical spine precautions should be maintained during the assessment of the patient’s airway and breathing. During assessment of the airway, the cervical spine should not be flexed, extended, or rotated. If the external neck support must be removed, a member of the trauma team should maintain control of the head and neck using the in-line immobilization technique.
A 70-year-old woman is brought to the emergency department after a fall. Examination shows periocular ecchymosis, epistaxis, and a bluish bulge of the septal mucosa. No other serious injuries are noted. CT shows fracture of the nasal septum. Which of the following is the most appropriate next step in management?
(A) Administration of intranasal oxymetazoline (Afrin)
(B) Drainage of hematomas and resection of septal cartilage
(C) Evacuation of hematomas through a direct incision
(D) Nasal packing only
(E) Needle aspiration of hematomas
The correct response is Option C.
Hematomas can develop between the septal mucoperichondrium and the cartilage in fractures and dislocations of the septum. Untreated septal hematomas may lead to septal perforation or fibrosis with eventual septal distortion, abscess, or complete septal necrosis with development of a saddle nose deformity. Prompt diagnosis and treatment of septal hematomas are essential to prevent such sequelae. Septal hematomas should be treated promptly with an L-shaped incision over the hematoma with thorough evacuation using suction and irrigation. This can be followed by loose repair of the incision to allow drainage and quilting sutures to prevent reaccumulation. It should be followed by internal nasal packing, systemic antibiotic coverage, and close follow €‘up to ensure absence of reaccumulation. Generally, although septal hematomas tend to be bilateral, they should not be incised on both sides because through €‘and €‘through septal perforation may occur. If the entire hematoma cannot be evacuated with a unilateral approach, the incisions on each side should be made at different levels.
Observation and administration of intranasal oxymetazoline (Afrin) spray are not appropriate treatment options because a persistent hematoma can result in significant morbidity. Resection of septal cartilage at the time of drainage should be avoided because septal perforation may occur. Needle aspiration can be used for small hematomas. However, it is not the treatment of choice and may require multiple attempts and extremely close follow €‘up to ensure resolution. Resection of septal cartilage at the time of drainage should be avoided because septal perforation may occur.
A 72-year-old man is brought to the emergency department after he sustained injuries in a high-speed motor vehicle collision as an unrestrained backseat passenger. He has chronic obstructive pulmonary disease and a 40-pack-year history of smoking. The following measurements are obtained:
Heart rate 88 bpm
Respirations 18/min
Blood pressure 115/70 mmHg
Oxygen saturation 98% on 6 L by face mask
Physical examination shows severe swelling in the face. He is coughing blood and mucus from his mouth and nose. Gross malocclusion is noted, but full dentition is present with no dental caries. CT scan shows a naso-orbital-ethmoid fracture, Le Fort III fracture, palatal fracture, and comminuted mandibular body and angle fractures. Which of the following is the most appropriate method of airway management during surgical repair of this patient’s fractures?
A) Cricothyroidotomy
B) Nasotracheal intubation
C) Placement of an orotracheal tube
D) Tracheostomy
E) Use of a laryngeal mask airway
The correct response is Option D.
The method of airway management in patients with facial fractures can be controversial and should be individualized. The patient described has complex facial fractures involving both the midface and the lower face. He also has a significant history of smoking. This particular patient is likely to have continued respiratory issues postoperatively, making pulmonary management challenging. The placement of a tracheostomy at the time of surgery will allow the surgical team full access to all of the patient’s facial fractures and will facilitate the patient’s pulmonary care postoperatively.
Cricothyroidotomy is indicated occasionally as an emergency procedure when there is concern for acute control of the patient’s airway. The patient described is hemodynamically stable and is not in respiratory distress.
Nasotracheal intubation is contraindicated in a patient with a naso-orbital-ethmoid fracture because the presence of a tube can complicate fracture reduction.
Generally, placement of an orotracheal tube is feasible and successful in most facial fracture patients. However, given the complex nature of fractures in the scenario described, the patient will need to be placed into mandibular-maxillary fixation during surgery to obtain normal occlusion and possibly for an indefinite period of time after surgery. Although the tube can occasionally be placed behind the last molar or through a gap where there is a missing tooth, an orotracheal tube can make it difficult to obtain normal occlusion. It is not as beneficial as tracheostomy in providing the postoperative pulmonary care that will likely be required in the patient described. A laryngeal mask airway does not provide as secure an airway as either orotracheal intubation or tracheostomy. During a complex facial fracture surgery, the head may need to be manipulated or turned, which could potentially dislodge a laryngeal mask airway.
Isolated orbital fractures most commonly occur in which of the following bones?
A) Ethmoid
B) Frontal
C) Lacrimal
D) Maxillary
E) Zygomatic
The correct response is Option D.
Most isolated orbital fractures involve the orbital floor, a majority of which is made up of the maxillary bone. The maxillary bone is quite thin behind the infraorbital rim, and is perforated by the infraorbital nerve passing in a canal below it. Most pure blowout fractures involve the orbital floor.
Long-term epidemiologic data regarding the natural history of orbital bone fractures are important for the evaluation of existing preventive measures and for the development of new methods of injury prevention and treatment.
A patient underwent open reduction and internal fixation of naso-orbital-ethmoid fractures 12 months ago, and epiphora was noted on follow-up examination. After 6 months of observation and persistent epiphora, which of the following is the most appropriate next step to evaluate the function of the patient’s nasolacrimal system?
A) Conjunctivorhinostomy tube placement
B) Continued observation, as function is likely to return
C) Jones tests
D) Lacrimal system flushing
E) Schirmer tests
The correct response is Option C.
The Jones test is used to evaluate lacrimal drainage. Divided into two parts, the Jones I test investigates lacrimal outflow under normal physiologic conditions. A drop of sterile 2% fluorescein solution or a moistened fluorescein strip is placed into the conjunctival fornix and a cotton-tipped wire applicator is placed into the inferior nasal meatus in the region of the ostium of the nasolacrimal duct at 2 and 5 minutes to check for fluorescein. As this test occasionally yields abnormal results in normal patients, it is not uniformly performed. The Jones II test determines the presence or absence of fluorescein when the residual fluorescein is flushed from the conjunctival sac with clear saline to determine whether there is reflux of fluorescein.
Naso-orbital-ethmoid (NOE) fractures can be challenging fractures, and either through direct instrumentation with transcanthal wiring or from the fractures themselves, the lacrimal drainage system can be affected. Postoperative epiphora can be very common and is present in at least 50% of patients who have undergone open reduction and internal fixation (ORIF) of an NOE fracture. After 3 to 6 months approximately half of this epiphora resolves, with the other half of patients (25%) requiring consideration for other investigations to evaluate lacrimal drainage. Schirmer test is used to evaluate dry eyes and is not appropriate in this patient.
A 12-year-old girl is brought to the emergency department after she sustained injuries in a motor vehicle collision. Physical examination shows extensive lacerations of the right medial orbit and forehead (shown) with complete transection of the medial canthal tendon (MCT). For effective reattachment of the MCT with transnasal wiring, which of the following is the most appropriate direction of resuspension of the tendon in relation to the anterior lacrimal crest?
A) Anterior and inferior
B) Anterior and superior
C) Directly horizontal
D) Posterior and inferior
E) Posterior and superior
The medial canthal tendon (MCT) consists of three limbs: 1) a prominent anterior limb that inserts medially on the anterior lacrimal crest, 2) a thinner posterior limb that attaches to the posterior lacrimal crest, and 3) a vertical limb of fascia that inserts on the medial orbital rim inferior to the nasal frontal suture. The resultant vectors of these attachments suggest that resuspension of the entire complex of the MCT following disruption should be posterior and superior to the anterior lacrimal crest.
A 10-year-old boy is brought to the physician after sustaining a nondisplaced fracture of the mandibular body in a fall. Soft diet is recommended. Two days later, he is brought back to the office and reports pain in the right mandibular lateral incisor when drinking cold liquid. The base of the defect appears yellow and is tender when probed. Examination shows a lingual fracture of the tooth crown. On the basis of these findings, which of the following is the deepest layer of exposed tooth?
A) Cementum
B) Dentin
C) Enamel
D) Pulp cavity
E) Root canal
The correct response is Option B.
This patient has a fracture of the tooth crown that extends through the dental enamel into the deeper parts of the tooth. This is evidenced by the sensitivity to touch and cold, a finding not characteristic of a fracture limited to the enamel. The yellow color to the base of the fracture indicates exposed dentin, which resides just under the hard outer enamel layer of the tooth. If the fracture had extended deeper into the pulp cavity, the area where the vessels and nerves reside, the base of the fracture would appear as a blood-filled cavity. These injuries often challenge the viability of the tooth and often require drilling and packing of the pulp space (root canal). The fracture described is of the crown and there is no indication that it involves the root of the tooth or the surrounding structures. Cementum is a bone-like covering of the tooth root and would not be affected by this injury.
The Ellis classification provides a useful system of categorizing these injuries. There are 9 categories:
Ellis I: enamel fracture. The tooth is non tender and treatment is smoothing of the rough surfaces and, possibly, application of a filling or amalgam.
Ellis II: fracture of the enamel and dentin. Tooth is tender to air, cold, and probing and the base of the defect often appears yellow.
Ellis III: involves the enamel, dentin, and the pulp space. The tooth is sensitive as in Ellis II, but the base of the defect appears red or bloody.
Ellis IV: a nonviable tooth.
Ellis V: luxation of the tooth.
Ellis VI: tooth avulsion.
Ellis VII: displacement without fracture.
Ellis VIII: fracture of entire crown.
Ellis IX: fracture of deciduous teeth.
A 12-year-old boy is brought to the emergency department because of double vision six hours after sustaining a blow to the eye with an elbow while jumping on a trampoline. He has had pain since the incident but has not had loss of consciousness. He had one episode of nausea and vomiting before arrival. Pulse rate is 45 bpm, respirations are 18/min, and blood pressure is 110/80 mmHg. Examination shows photophobia, periorbital ecchymosis, and restriction of extraocular motion. CT of the head shows a fracture of the orbital floor. Which of the following is the most appropriate time for surgical repair of the fracture?
(A) Emergently
(B) 1 to 3 Days
(C) 4 to 7 Days
(D) 8 to 14 Days
The correct response is Option A.
Observation alone is not indicated for entrapment with nausea, vomiting, and oculocardiac reflex. Recent publications in the ophthalmologic literature emphasize the importance of urgent surgical intervention to prevent ocular muscle damage, improve postoperative function, and decrease the need for additional surgery.
A 22-year-old man comes to the office because of a history of nasal trauma with resultant nasal deformity, C-shaped septal fracture, and nasal obstruction. Two weeks after injury, he undergoes closed reduction of the nasal fractures, but significant nasal obstruction persists. Which of the following is the most likely reason for his residual nasal deformity and nasal obstruction?
A) Inadequate time of nasal casting
B) Nonunion of the nasal bones
C) Presence of a septal fracture
D) Turbinate hypertrophy
E) Unidentified septal hematoma
The correct response is Option C.
One of the most important causes of failure of closed reduction to address the nasal fracture is simultaneous nasoseptal fracture. Murray, et al. found 30 to 40% residual nasal deformity after closed reduction. The cadaver study showed failure consistently associated with a C-shaped nasoseptal deviation and fracture when the external nose deviated at least 1/2 of the nasal bridge width. The theory is that the interlocking of the septal fracture creates tension causing the nasal bone to displace.
Untreated septal hematoma results in thickening of the cartilage and nasal obstruction, but not with inadequate reduction. Nasal casting for 7 to 10 days is sufficient to allow the reduction to set. Nonunion is a rare cause of inadequate reduction, usually in comminuted or open nasal fractures. Turbinate hypertrophy can cause nasal obstruction but does not interfere with nasal bone reduction.
A 24-year-old man has moderate ectropion three weeks after undergoing open reduction and internal fixation of a malar complex fracture through subciliary and intraoral incisions. Operative exploration of the orbital floor was performed to confirm fracture reduction.
Which of the following anatomic sites is the most likely origin of this patient’s ectropion?
(A) Lateral canthal ligament
(B) Orbicularis oculi
(C) Orbital septum
(D) Skin
(E) Tarsus
The correct response is Option C.
This patient has ectropion that has most likely been caused by edema and scar contracture of the orbital septum. Incision into the first eyelid crease is recommended to prevent the development of this complication. This incision has the lowest associated incidence of ectropion because it preserves the innervation of the pretarsal portion of the orbicularis oculi; therefore, normal eyelid tone is maintained. Although there is no true skin shortage seen in this patient, longstanding ectropion can lead to further untoward complications.
The lateral canthal ligament and tarsus would not be affected by this incisional approach. Cutaneous deficiencies should not occur because skin should not be resected.
A 24 year old woman is brought to the emergency department after being involved in a motor vehicle collision. Physical examination shows multiple minor abrasions of the face. Clear rhinorrhea is noted. CT of the head shows a nondisplaced fracture of the posterior table of the frontal sinus. No other serious injuries are noted. The patient is admitted to the hospital, and antibiotic therapy is initiated. Which of the following is the most appropriate next step in management?
(A) Bed rest, head elevation, and observation
(B) Cranialization of the frontal sinus
(C) Craniotomy and repair of the dural tear
(D) Lumbar puncture and drainage of spinal fluid
(E) Obliteration of the frontal sinus
The correct response is Option A.
The patient described has a nondisplaced fracture of the posterior table of the frontal sinus with a cerebrospinal fluid (CSF) leak and should be treated with antibiotic coverage and maneuvers to facilitate spontaneous resolution of the leak. These include bed rest and head elevation greater than 30 degrees. If the CSF leak persists for more than four days, spinal drainage is recommended. Prolonged CSF leakage for longer than seven to 10 days requires craniotomy, repair of the dural laceration, and either obliteration of the sinus or cranialization.
In treating frontal sinus fractures, the involvement of the anterior sinus wall, posterior sinus wall, dural lining, and frontonasal duct are the major determinants of the type and extent of treatment.
Isolated anterior wall fractures without depression do not require surgical treatment. However, some authors recommend treatment with antibiotics for one week. In patients with isolated depressed anterior wall fractures, surgical correction to restore aesthetic contour is indicated. If there is frontonasal duct injury, the sinus mucosa is removed and the cavity is obliterated. During sinus obliteration, the mucosa usually is removed and the sinus is curettaged with a sharp periosteal elevator or a high-speed burr. The frontonasal duct can then be occluded with a pericranial flap or a bone graft and the sinus obliterated with autogenous fat, dermal fat, muscle, cartilage, bone, pericranial graft, Surgicel, bone wax, or other material.
Posterior table fractures without displacement, CSF leakage, or frontonasal duct involvement do not require surgical intervention but do require antibiotic treatment.
Posterior table fractures without displacement, but with CSF leakage, are initially treated conservatively as described above. Should the leakage persist for longer than 10 days despite measures to resolve spontaneously, a craniotomy with dural repair is required. This procedure is usually done in conjunction with neurosurgical colleagues. Displaced posterior wall fractures require exploration with repair of any dural tears and either sinus obliteration or cranialization. Cranialization involves removal of the entire posterior table, plugging of the frontonasal duct, repair of any dural lacerations, and separation of the intracranial cavity from the aerodigestive tract. The frontal lobe is then expected to fall into and fill the previous sinus cavity.
Although the specifics of treatment of frontal sinus fractures remain controversial, the illustration below shows a simple algorithm for treating these fractures.
Long-term follow-up with annual CT is required for all frontal sinus fractures.
In adults, which of the following bones is most commonly fractured in isolated orbital floor fractures?
A) Ethmoid
B) Frontal
C) Lacrimal
D) Maxillary
E) Zygomatic
The correct response is Option D.
Most isolated orbital fractures involve the orbital floor made up of the maxillary bone. The maxillary bone is quite thin behind the infraorbital rim and is perforated by the infraorbital nerve passing in a canal below it. Most pure blow-out fractures involve the orbital floor with the maxillary bone making the majority of the orbital floor.
A retrospective study by Hwang et al. evaluated 391 patients with orbital bone fractures from a variety of accidents that were treated at the department of Plastic and Reconstructive Surgery, Inha University Hospital, Incheon, South Korea, between February 1996 and April 2008. The medical records of these patients were reviewed and analyzed to determine the clinical characteristics and treatment of the orbital bone fractures. The following results were obtained. The mean age of the patients was 31.1 years, and the age range was 4 to 78 years. The most common age group was the third decade of life (32.5%). There was a significant male predominance in all age groups, with a ratio of 4.43:1. The most common etiology was violent (assault) or nonviolent traumatic injury (57.5%) followed by traffic accidents (15.6%) and sports injuries (10.7%). The most common isolated orbital bone fracture site was the orbital floor (26.9%). The largest group of complex fractures included the inferior region of the orbital floor and zygomaticomaxilla (18.9%). Open reduction was performed in 63.2% of the cases, and the most common fracture reconstruction material was MEDPOR (56.4%) followed by a resorbable sheet (41.1%). The postoperative complication rate was 17.9%, and there were no statistically significant differences among the reconstruction materials with regard to complications. During follow-up, diplopia, hypoesthesia, and enophthalmos occurred as complications; however, there was no significant difference between porous polyethylene sheet (MEDPOR) and resorbable sheet groups.
Long-term epidemiologic data regarding the natural history of orbital bone fractures are important for the evaluation of existing preventative measures and for the development of new methods of injury prevention and treatment.
A 25-year-old man comes to the office for evaluation of unilateral proptosis, visual impairment, and limitation of ocular movements. History includes basilar skull fractures and repair of panfacial fractures 4 weeks ago. On physical examination, the left eye appears to be pulsating. Which of the following is the most appropriate next step?
A) Beta-2 transferrin assay
B) Carotid duplex
C) Cerebral angiography
D) Craniotomy
E) Noncontrast CT scan
The correct response is Option C.
This case described represents the classic presentation of a posttraumatic carotid-cavernous fistula (CCF). Symptoms include pulsatile proptosis, ocular and orbital erythema, chemosis, diplopia, headaches, and visual loss. This pathology occurs through abnormal connections between the internal carotid artery and the cavernous sinus, and, on rare occasions, may appear between the internal carotid or branches of the external carotid artery and the venous plexus of the skull. Traumatic CCF can lead to blindness as the disorder progresses and, in rare cases, can result in paralysis, unconsciousness, and even death. It is important that clinicians operating on the craniofacial region, and especially those who manage craniofacial trauma, have a thorough understanding of this potentially lethal entity. Although CCF occurs rarely after craniofacial trauma, this disorder is thought to occur relatively frequently in patients with basilar skull fractures. Once there is a suspicion, a prompt evaluation of the arterial vasculature around the cavernous sinus is required. Most commonly, a cerebral angiogram is used to make the diagnosis and, using related techniques, a variety of curative measures (e.g., embolization) can then be enacted. A craniotomy-type modality would be relegated to only the most refractory of cases and would be for cure and not diagnosis. A noncontrasted CT scan would only show posttraumatic bony derangements. Beta-2 transferrin assay could be used if there is an accompaniment of clear rhinorrhea to rule out a craniospinal fluid leak. CCF can be mistaken for other pathologies such as an orbital apex syndrome or even stroke. The latter suspicion may lead to the ordering of a carotid duplex, which would be expected to be normal.
A 33-year-old man is brought to the emergency department after sustaining injuries to the face during a snowmobile collision. Axial CT scan is shown. Which of the following is the most appropriate management?
A ) Ablation of the frontal sinus
B ) Cranialization and reconstruction of the anterior frontal sinus wall
C ) Obliteration of the frontal sinus
D ) Observation with x-ray studies monthly
E ) Reconstruction of the nasofrontal duct and anterior and posterior frontal sinus walls
The correct response is Option B.
A comminuted fracture of the frontal sinus is shown in the CT scan, with significant displacement of fragments involving both the anterior and posterior frontal sinus walls and the region of the nasofrontal duct. The most appropriate treatment is cranialization and reconstruction of the anterior wall to restore normal forehead contour and protect the brain. Cranialization involves removing the posterior frontal sinus wall to make the sinus part of the intracranial space and blocking the nasofrontal duct, typically with bone or a pericranial flap so that sinus mucosa is excluded from the intracranial space. The anterior frontal sinus wall is also reconstructed as part of this procedure to restore normal forehead contour and to protect the brain.
Ablation (or exenteration) involves removing the anterior frontal sinus wall and allowing the skin to collapse in on the posterior wall, if it is intact, or on the dura if the posterior wall requires removal as well (as it would in this scenario). While this may lead to a stable, healed wound in the patient described, it is not the most appropriate management as it would leave the patient with a significant deformity that would be difficult to reconstruct. It would also leave the underlying brain unprotected by bone. Ablation is appropriate only in extreme cases of acute infection that require open drainage and removal of infected bone.
Obliteration of the frontal sinus involves removing the sinus mucosa and burring the bony walls to remove mucosal invaginations, plugging the nasofrontal duct, and filling the sinus cavity with fat, muscle, bone, or alloplasts. A variation of this is osteoneogenesis, where the cavity is not filled but allowed to fill spontaneously with bone or scar over time. This would not be feasible in the patient described because of the extreme comminution and displacement of the posterior wall fracture fragments.
Observation is appropriate for minimally or nondisplaced fractures of the frontal sinus that do not involve the nasofrontal duct or do not acutely obstruct the nasofrontal duct. Regular plain x-ray studies should be obtained for several months afterward to monitor for development of a frontal sinus mucocele, which requires surgical treatment.
Reconstruction involves preserving sinus mucosa and reducing fractures of the nasofrontal duct and sinus walls. There are currently no data to support this technique, and in the patient described it could to lead to mucocele development as the nasofrontal duct became scarred and obstructed postoperatively.
Which of the following best represents the likelihood that a patient with a frontal sinus fracture would have a concurrent intracranial injury?
A) 1%
B) 15%
C) 30%
D) 55%
E) 90%
The correct response is Option D.
In an acute trauma setting, the recognition of mild traumatic brain injury (mTBI) is a diagnostic challenge as there are often competing diagnoses that take immediate priority. Furthermore, within this cohort, patients with craniofacial fractures have been shown to be at risk for delayed or missed diagnosis for all degrees of TBI, although with a higher likelihood of missed or delayed diagnosis for mTBI compared with moderate to severe TBI. Previously, it was hypothesized that facial fractures buffered the forces transmitted during blunt head trauma, thereby protecting intracranial structures. This conceptual framework has since been questioned as evidence has mounted that individuals with facial fractures are at increased risk for head injury. The biomechanics resulting in different types of facial fractures and the amount of force required to fracture the different components of the facial bony structure have been well described. The nasal bone has the lowest tolerance for fracture at 25 to 75 lbs, while the frontal bone has the highest tolerance at 800 to 1600 lbs. Recent studies have proposed that craniofacial fractures can serve as clinical markers for brain injury and Mulligan et al. suggest that the prevalence of overall head and cervical spine injuries in the setting of facial fractures is high enough to warrant a change in current protocols. In this context, the prevalence of mTBI and moderate to severe TBI in patients with isolated facial fractures in the National Trauma Databank (NTDB) was evaluated, and further characterized the association of isolated facial fractures with different degrees of TBI in patients with mild, moderate, and severe TBI. Facial fractures can serve as objective clinical markers for the potential presence of mTBI and moderate to severe TBI in trauma patients. As mTBI patients have been shown to benefit from simple, easy-to-administer educational interventions, trauma patients with facial fractures may benefit from automatically receiving education about mTBI and TBI recovery, given the clinically meaningful prevalence of mTBI and TBI in this population. As one moves up the craniofacial skeleton, the forces are transmitted more reliably to the intracranial space. Therefore, a frontal sinus fracture is at extremely high risk (usually a 45 to 65% chance) of having an associated intracranial injury.
A 35-year-old woman sustains blunt trauma to the preauricular region during a field hockey game. Radiographs show a fracture of the condylar neck with medial displacement of the proximal fracture fragment. Which of the following muscles most likely contributes to the fracture displacement?
(A) Buccinator
(B) Lateral pterygoid
(C) Masseter
(D) Medial pterygoid
(E) Temporalis
The correct response is Option B.
In this patient who has a fracture of the condylar neck, displacement of the proximal fracture fragment is most likely caused by the action of the lateral pterygoid muscle. This muscle, which has two heads, is the only muscle that inserts directly on the mandibular condyle, on its anterior portion. The inferior head of the lateral pterygoid muscle arises from the lateral pterygoid plate and inserts into the anterior surface of the neck of the condyle; it acts to open the mandible. The superior head arises from the infratemporal crest, infratemporal surface of the greater wing of the sphenoid bone, and a portion of the squamous part of the temporal bone and inserts into the capsule and articular disk of the TMJ; it contributes to the motion of the articular disk. In patients with condylar fractures, the unopposed force of the lateral pterygoid muscle pulls the condylar head medially.
The buccinator muscle lines the oral cavity and has no attachments within the TMJ. The masseter muscle has its bony attachments at the zygomatic arch and along the inferior border of the lateral portion of the mandibular angle and body. The medial pterygoid muscle arises within the pterygoid fossa and inserts into the medial surface of the mandibular angle and ramus. The temporalis muscle originates at the insertion of the infratemporal fossa of the temporal bone and the coronoid process. This muscle does not attach to the TMJ.
In a patient who has sustained a fracture of the zygomaticomaxillary complex (tripod fracture), accurate reduction of the fracture components is most likely to be accomplished with the use of which of the following anatomic structures?
(A) Inferior orbital rim
(B) Lateral orbital wall
(C) Orbital floor
(D) Zygomatic arch
(E) Zygomaticomaxillary plane
The correct response is Option B.
Appropriate reduction of a fracture of the zygomaticomaxillary complex involves a three-dimensional process. In order to obtain the most accurate reduction, the lateral orbital wall and sphenoid wing should be visualized from inside the orbit. This will allow for visualization of the relatively flat plane of the orbital portion of the zygoma and the relatively flat portion of the sphenoid wing; accurate reduction is obtained when these two areas are aligned completely.
Although the inferior orbital rim, orbital floor, zygomatic arch, and zygomaticomaxillary plane are helpful sites for alignment individually, use of any of the sites as a landmark for accurate fracture reduction can result in significant rotational malalignment at the other sites.
A 24-year-old man is brought to the emergency department after being struck in the face. CT scan of the face shows an orbital blow-out fracture. Which of the following findings is an indication for operative intervention?
(A) Blood in the maxillary sinus
(B) Diplopia on primary gaze
(C) Hypesthesia in the infraorbital nerve distribution
(D) Orbital floor defect greater than 2 cm
(E) Subconjunctival hematoma
The correct response is Option D.
In a patient who has sustained an orbital blow-out fracture, indications for surgical exploration include an orbital floor defect of greater than 2 cm, abnormally low vertical height of the globe, and the presence of other fractures. Operative exploration should be performed in patients who have symptomatic diplopia in association with positive findings on forced duction testing. Patients who have symptoms of extraocular muscle entrapment that do not resolve in one week or indications of muscle entrapment on radiographs obtained one week after surgery should undergo additional exploration.
Diplopia on primary gaze typically improves within the first two weeks after surgery. The presence of blood in the maxillary sinus and hypesthesia in the distribution of the infraorbital nerve is common in patients with minor orbital fractures, and surgical intervention is not required. Likewise, subconjunctival hematoma is not an indication for operative intervention
Which of the following concomitant fractures is most likely to affect the perceived reduction when performing open reduction and internal fixation of a zygomaticomaxillary complex fracture?
A) Anterior maxillary wall comminution with loss of bone.
B) Articular tubercle of the zygomatic arch.
C) Le Fort I fracture.
D) Naso-orbito-ethmoid fracture.
E) Orbital floor blowout fracture.
When surgically reducing a zygomaticomaxillary complex (ZMC) fracture (tripod fracture), the surgeon uses multiple landmarks to confirm adequate reduction. The lateral orbital sidewall is the most reliable landmark as it is a three-dimensional landmark (junction of frontal bone, sphenoid, and zygoma). Other landmarks include the zygomaticofrontal suture, the zygomaticomaxillary lateral buttress, the orbital rim, and the zygomatic arch. Because the orbital rim is easily visualized, surgeons may rely heavily on this landmark for alignment. Sometimes due to orbital swelling or poor visualization, the lateral orbital wall is not easy to assess for adequate reduction of the fracture. If the orbital rim appears to be reduced (well aligned) but the ZMC fracture is not well reduced, then an ipsilateral unreduced naso-orbito-ethmoid (NOE) fracture is the most likely reason. It is important to reduce the NOE fracture before aligning the orbital rim for the ZMC fracture reduction. Postoperative deformity will ensue if the NOE fracture is not reduced and the ZMC is plated in position based on the orbital rim alignment. The deformity will lead to enlarged orbital volume and facial widening, loss of malar projection, and enophthalmos. Proper reduction and initial management are important, as secondary corrections are more difficult and have more morbidity.
Isolated orbital fractures most commonly occur in which of the following bones?
A) Ethmoid.
B) Frontal.
C) Lacrimal.
D) Maxillary.
E) Zygomatic.
Most isolated orbital fractures involve the orbital floor, a majority of which is made up of the maxillary bone. The maxillary bone is quite thin behind the infraorbital rim, and is perforated by the infraorbital nerve passing in a canal below it. Most pure blowout fractures involve the orbital floor. Long-term epidemiologic data regarding the natural history of orbital bone fractures are important for the evaluation of existing preventive measures and for the development of new methods of injury prevention and treatment.
A 24-year-old woman undergoes Le Fort I osteotomy with maxillary impaction and bilateral sagittal split osteotomy with mandibular advancement. Following release of intermaxillary fixation six weeks later, the patient has an anterior open bite. Which of the following is the most likely cause of this finding?
A) Improper intraoperative seating of the condyles in the glenoid fossae
B) Improper presurgical orthodontic treatment
C) Loosening of all plates of the rigid internal fixation
D) Parafunctional habits, such as tongue thrusting
E) Progressive resorption of the condyles
This patient’s anterior open bite, seen six weeks after surgery, is most likely a result of improper intraoperative seating of the condyles in the glenoid fossae. Once the osteotomy has been completed, it is important to release the patient from intemaxillary fixation in order to ensure that the condyles are properly seated within the fossae. The occlusion and path of the opening of the mandible are examined at this time.
Improper presurgical orthodontic treatment would result in a late recurrence of malocclusion. It is unlikely that all of the plates of the rigid internal fixation would loosen over the six-week fixation period. Parafunctional habits, such as tongue thrusting, are a late cause of anterior open bite. Progressive condylar resorption, which manifests as condylar shortening, decreased height of the posterior face, and clockwise rotation of the mandible, is a late cause of open bite occurring primarily in young women. The cause of this condition is unknown.
A 21-year-old man undergoes repair of the parotid gland and Stensen duct after sustaining an injury while being assaulted with a glass bottle. Ten days later, salivary leakage from the wound is noted. Which of the following is the most appropriate next step in management?
A) Pressure dressings and limited oral intake
B) Radiation therapy
C) Re-exploration of the wound and repair of the duct injury
D) Tympanic neurectomy
E) Observation only
The correct response is Option A.
Sialocele and cutaneous fistula may occur as a complication of a major salivary gland injury or after attempted parotid gland or duct repair. Prior to intervention, the surgeon should confirm the presence of salivary fluid in the aspirate by evaluating for amylase (>1000 U/L). This helps to rule out hematoma vs. infection. At this time, the accepted initial treatment of sialocele and cutaneous fistula is conservative management. This includes pressure dressings, repeated aspirations, limited intake by mouth, and the use of antisialagogues to decrease salivary flow. Most studies have shown that most sialoceles and fistulas will resolve within 2 to 3 weeks with this approach.
Secondary repair of the duct is generally difficult because of granulation and scar tissue. This runs the risk for delayed or poor wound healing as well as facial nerve injury. Radiation therapy has been used in the past but has been found to have a high failure rate in ductal injuries. More than 6 weeks is needed for gland atrophy to occur after radiation. There is also the risk of inducing malignancy, which has led to the abandonment of radiation for the treatment of sialoceles and cutaneous fistulas. Antisialagogues primarily have a role as an adjunct therapy to decrease salivary flow. Alone, they have had mixed reviews in the literature and have been found generally ineffective in major salivary duct injuries. Tympanic neurectomy has a high failure rate and does not speed recovery. Internalization of salivary flow could be considered for failures of conservative management. It has lower surgical risk than wound exploration and duct repair.
The CT scans shown above are from a 25-year-old man who sustained facial injuries in a motor vehicle collision. In this patient, rigid fixation at which of the following points is most likely to result in stable reduction of the fractures?
(A) Nasomaxillary buttress, inferior orbital rim, and zygomaticomaxillary buttress
(B) Zygomatic arch, central fragment, and nasomaxillary buttress
(C) Zygomatic arch, inferior orbital rim, and zygomaticomaxillary buttress
(D) Zygomaticofrontal suture, inferior orbital rim, and zygomaticomaxillary buttress
(E) Zygomaticofrontal suture, orbital floor, and zygomaticomaxillary buttress
The correct response is Option D.
This patient has sustained a fracture of the zygomaticomaxillary complex, also known as a zygoma fracture. To ensure stable reduction of the fracture, rigid fixation is applied at the zygomaticofrontal suture, inferior orbital rim, and zygomaticomaxillary buttress. Partial relapse may occur without this three-point rigid fixation.
Central fragments are associated with naso-orbitoethmoid fractures, not zygomaticomaxillary complex fractures. This fragment is comprised of the ascending frontal process of the maxilla and the descending internal angular process of the frontal bone. It provides the bony support for the medial canthus.
The nasomaxillary buttress is comprised of the piriform rim and is osteotomized routinely during elective Le Fort I maxillary advancement procedures. This structure is typically involved in midface fractures and not in fractures of the zygomaticomaxillary complex.
The orbital floor is often involved in zygomaticomaxillary complex fractures but not in simple fractures of the zygoma. Therefore, open reduction and internal fixation of the orbital floor may not be necessary to ensure correction of the zygomaticomaxillary fracture.
The zygomatic arch is contained within a periosteal sleeve and is often reduced and fixed adequately with adequate reduction and fixation of the zygomaticomaxillary complex. Open reduction and internal fixation through a coronal approach may be required if the zygomatic arch is comminuted significantly, but this is rare.
A patient underwent open reduction and internal fixation of naso-orbital-ethmoid fractures 12 months ago, and epiphora was noted on follow-up examination. After 6 months of observation and persistent epiphora, which of the following is the most appropriate next step in management of the patient’s nasolacrimal system?
A) Conjunctivorhinostomy tube placement
B) Continued observation
C) Dacryocystorhinostomy
D) Jones tests
E) Lacrimal system flushing
The correct response is Option D.
Naso-orbital-ethmoid (NOE) fractures can be challenging fractures, and either through direct instrumentation with transcanthal wiring or from the fractures themselves, the lacrimal drainage system can be affected. Postoperative epiphora can be very common and is present in at least 50% of patients who have undergone open reduction and internal fixation (ORIF) of an NOE fracture. After 3 to 6 months approximately half of this epiphora resolves, with the other half of patients (25%) requiring consideration for other investigations to evaluate lacrimal drainage.
A 25-year-old man comes to the office for a follow-up examination because he has had intraoral drainage and pain and swelling over the right mandible for the past 24 hours. Ten days ago, he underwent maxillomandibular fixation followed by rigid internal fixation. CT scan of the head shows a soft-tissue collection along the right mandibular body; there is no evidence of osteomyelitis, and the rigid fixation is stable. Which of the following is the most appropriate management?
A) Incision and drainage
B) Incision and drainage, removal of hardware, and external fixation
C) Incision and drainage, removal of hardware, and maxillomandibular fixation
D) Incision and drainage, removal of hardware, and vascularization of fibula flap transfer
E) No additional intervention is needed
The correct response is Option A.
Postoperative infections are the most common complication after mandibular fracture repair, with an incidence ranging from 0.4 to 32%. Management of these infections requires adequate incision and drainage as well as intravenous antibiotics and mouth care. If the source of infection is an exposed infected tooth root, it should be removed. It is important that rigid internal fixation be maintained until the bone fracture segments have ossified because nonrigid fixation, such as external fixation or maxillomandibular fixation, can lead to worsening of infection.
Removal of the internal hardware is rarely necessary unless the hardware is actively infected and loosened because of bone involvement (osteomyelitis).
Repair with vascularized fibula flap transfer is also not indicated because there is no evidence for osteomyelitis or extensive bone loss.
A 30-year-old man sustains an injury to the left side of the face in a fistfight. Radiographs show an isolated fracture of the zygomatic arch; surgical reduction of the fracture is planned. Following incision in the temporal region, the instrument should be passed immediately beneath which of the following layers of the scalp?
(A) Hair follicles
(B) Subcutaneous fat of the scalp
(C) Superficial temporal fascia
(D) Deep temporal fascia
(E) Temporalis muscle
The correct response is Option D.
In the temporal (Gillies) approach, a technique used for operative fixation of zygomatic fractures, the initial scalp incision extends down through skin, subcutaneous tissue, and the superficial and deep temporal fascia. An elevating device is then inserted to raise the fractured arch in order to facilitate effective reduction. This instrument is passed immediately beneath the deep layer of the deep temporal fascia, which lies just beneath the arch. Guiding the instrument beneath the deep layer of the deep temporal fascia allows for careful elevation of the fractured bone.
Because the hair follicles, subcutaneous fat, and superficial temporal fascia are all positioned superficial to the zygomatic arch, passing the elevating device beneath any of these structures will not allow for elevation of the zygoma and may instead result in damage to the frontal branch of the facial nerve. Guiding the elevating device beneath the temporalis muscle is a less optimal approach; if the surgeon passes the instrument too deeply, it will also pass beneath the coronoid process and make elevation of the zygomatic arch more difficult.
A 21-year-old woman comes to the emergency department because she has had ocular pain and decreased vision since she was struck in the face with a bottle 2 hours ago. On examination in a dark room, both pupils constrict when a light is shone in the right or left sides directly. When the light is shifted from the right to the left, the pupils dilate. Which of the following is the most likely pathologic condition in this patient?
A) Central retinal artery occlusion
B) Oculomotor (III) nerve injury
C) Preexisting cataract
D) Symmetrical acute glaucoma
E) Vitreous hemorrhage
The correct response is Option A.
A Marcus Gunn pupil is a relative afferent pupillary defect caused by a lesion of the optic nerve (between the retina and the optic chiasm) or severe retinal disease. It is observed during the swinging-flashlight test whereupon the patient’s pupils constrict less (therefore appearing to dilate) when a bright light is swung in front of the unaffected eye to the affected eye. The affected eye still senses the light and produces pupillary sphincter constriction to some degree, albeit reduced. Conditions that do not cause a Marcus Gunn pupil include cataracts, vitreous hemorrhage, injury to the oculomotor nerve (cranial nerve III), or symmetrical acute glaucoma.
A 25-year-old man is brought to the emergency department after sustaining injury during a roll-over motor vehicle collision. CT scan shows multiple facial fractures and systemic injuries. Which of the following is a CONTRAINDICATION to nasotracheal intubation in a trauma patient?
A) Base of skull fracture
B) Bilateral mandibular condyle fractures
C) Cervical spine fracture
D) Depressed mental status
E) Fracture of the maxilla
The correct response is Option A.
Of the options listed, base of skull fracture is the only contraindication to nasal intubation. In these patients, there is a risk of the nasotracheal tube passing through the cribriform plate into the frontal lobes of the brain. Other absolute contraindications include mid face instability, suspected epiglottitis, coagulopathy, or apnea/impending respiratory arrest. Relative contraindications to nasotracheal intubation include nasal polyps, suspected nasal foreign bodies, recent nasal surgery, upper-neck hematoma or infection, and a history of frequent epistaxis. Depressed mental status, suspected cervical spine fracture, hypotension, and bilateral mandibular condyle fractures are not contraindications to nasotracheal intubation.
The options for intubating a trauma patient include nasal, oral, and surgical airways. The indications for nasotracheal intubation include intraoral and oropharyngeal surgery, complex intraoral procedures involving the mandible (e.g., segmental mandibulectomy, osteotomy, mandibular reconstructive procedures), and dental surgery.
The advantages of nasotracheal intubation include uninhibited access to the mouth as well as an enlarged surgical field. Despite these advantages, one must be cognizant of the contraindications and when in doubt (e.g., during initial advanced trauma life support management), the airway should be secured using either oral intubation or tracheostomy. Other drawbacks to nasotracheal intubation are that it often requires multiple attempts, there can be an abrupt rise in intracranial pressure, and it is difficult to attempt in an uncooperative patient.
In the presence of an isolated maxillary fracture nasal intubation may be preferred so that premorbid occlusion can be established.
The method of insertion of a nasotracheal tube includes using a well-lubricated tube with the cuff fully deflated. The tube should be inserted into either naris at a right angle to the face. Once the tube is beyond the nasopharynx, a laryngoscope is placed in the oral cavity and the tube is advanced under direct vision.
A 42-year-old woman is brought to the emergency department after sustaining traumatic fractures of the right orbit and zygoma in a motor vehicle collision. Physical examination shows localized edema. Which of the following indications is most likely for immediate ophthalmologic consultation?
A) Corneal abrasion
B)Diplopia
C) Eyelid ptosis
D) Hyphema
E) Subconjunctival hemorrhage
The correct response is Option D.
Hyphema is defined as blood within the anterior chamber of the eye. It is caused by tearing of the vessels within the iris as a result of trauma. Subconjunctival hemorrhage, on the other hand, stains the bulbar conjunctiva with blood from the site of a nearby fracture. Blood within the eye is worrisome because clotting can interfere with fluid egress from the anterior chamber, leading to the development of glaucoma. Immediate ophthalmology consultation, urgent intraocular pressure measurement, and slit-lamp examination should be performed to determine the extent of hemorrhage. Blindness, blurred vision, eye pain, globe rupture, or retrobulbar hematoma also warrant ophthalmology consultation. Patients with painful corneal abrasions have epithelial defects diagnosed by urgent (but not emergent) slit-lamp examination with topical fluorescein. Diplopia, or double vision, may be present in one or several directions of gaze following blunt trauma to the face. Neither diplopia nor traumatic ptosis warrants emergent consultation.
A 42-year-old man is brought to the emergency department 30 minutes after sustaining trauma to the face in a motor vehicle collision. Physical examination shows periorbital ecchymoses on the right, malar flattening, and enophthalmos. Neurologic examination shows numbness on the upper right lip. Radiographs show a displaced zygomaticomaxillary complex fracture. Anatomic reduction of each of the following is required in this patient EXCEPT:
A) greater wing of the sphenoid
B) inferior orbital rim
C) nasomaxillary buttress
D) zygomaticofrontal suture
E) zygomaticomaxillary buttress
Approximately 15% to 22% of patients with orbital fractures develop enophthalmos because of increased bony intraorbital volume. This is most frequently associated with a zygomaticomaxillary complex fracture that has not been reduced adequately. It is critical that an anatomic reduction be obtained to prevent the development of this difficult late complication. It is also critical that appropriate anatomic reduction of the greater wing of the sphenoid and lateral wall of the orbit is obtained after reduction of a fracture of the zygomaticomaxillary complex. Correct reduction of the inferior orbital rim, zygomaticofrontal suture, and zygomaticomaxillary buttress is also important but does not ensure the reduction of the lateral wall. The surgeon must therefore verify that the complete reduction of all structures has been performed. Reduction of the nasomaxillary buttress is not typically involved in this type of fracture pattern.
A 5-year-old boy is evaluated because of downward and lateral displacement of the left globe and diplopia that has increased steadily for the past 18 months. History includes open reduction and internal fixation of a frontal bone fracture at 2 years of age. An image is shown. This deformity was most likely caused by which of the following at the time of repair?
A ) Failure to obliterate the frontal sinus
B ) Failure to recognize dural injury and insufficiency
C ) Failure to repair periorbital lacerations
D ) Poorly aligned bony fixation
E ) Use of absorbable plates
The correct response is Option B.
Head injuries in infants and young children accompanied with skull fracture often contain dural laceration. Although rare in occurrence, when these dural tears are not recognized (especially when extensive), a growing skull fracture (GSF) can occur. Repair of these dural tears acutely prevents the development of GSF and the potential for secondary cortical injury. The frontal sinus, unlike the maxillary and ethmoid sinuses, is not present at birth and only starts to develop at age 2 years, which, in this case, was when the original repair was performed. Thus, obliteration of the sinus was not warranted. Lacerations of the periorbita, poor bone fixation, and the use of absorbable plates are not linked to GSF.
A 22-year-old man is evaluated for multiple facial fractures after he was assaulted. Which of the following fractures is most likely associated with an increased risk of temporomandibular joint dysfunction?
A) Bilateral parasymphyseal mandible
B) Comminuted unilateral condylar mandible
C) Complete Le Fort I maxillary
D) Displaced unilateral subcondylar mandible
E) Unilateral zygomaticomaxillary
The correct response is Option B.
Temporomandibular joint (TMJ) dysfunction symptoms are serious, often overlooked complications of facial fractures and their treatments. They can range from clicking and pain to locking, malocclusion, and trismus. Overt ankylosis can occur in rare circumstances. Fractures that result in significant disruption of the condylar/glenoid apparatus are more likely to result in TMJ dysfunction symptoms than more anatomically remote fractures. Condylar fractures are most susceptible to post-fracture TMJ dysfunction. This is especially true in comminuted condylar head fractures. One recent study demonstrated an increase in TMJ dysfunction symptoms in patients with condylar fractures and concomitant contralateral mandibular body/angle fractures. Le Fort I and zygomaticomaxillary complex (ZMC) fractures are unlikely to be associated with TMJ symptoms.
A 20-year-old man comes to the office with severe malocclusion 8 weeks after sustaining injuries during a motor vehicle collision. Physical examination shows healing lacerations, loss of sensation in the infraorbital nerve distribution on the affected side, and no orbital rim step-off deformity. CT scan shows a unilateral orbital blowout fracture with a mid face fracture. No mandibular fracture is identified. Which of the following is the most appropriate initial step in management?
A) Le Fort I osteotomy with fixation
B) Maxillomandibular fixation
C) Open reduction and internal fixation of the fracture
D) Open reduction and reconstruction of the orbital floor fracture
The correct response is Option A.
Because the patient is 8 weeks out from the injury, the fracture lines are immobile and a Le Fort I osteotomy and maxillomandibular fixation would be required to correct the malocclusion. Maxillomandibular fixation alone would not get the patient into normal occlusion at this late date. Open reduction and internal fixation of the zygomaticomaxillary complex fracture is not indicated at this time because the bone is solid and minimally displaced. While correction of the orbital floor fracture would be indicated if there were entrapment or increased orbital volume, this management would not address the malocclusion.
A 33-year-old man is brought to the emergency department after he is struck in the forehead with a baseball bat. The patient is awake and alert. Examination shows an obvious deformity in the frontal region. Emergency CT scan shows a displaced and comminuted fracture of the anterior wall of the frontal sinus and a nondisplaced fracture of the posterior wall. The frontonasal duct is patent. Which of the following is the most appropriate treatment?
A) Cranialization of the sinus
B) Craniotomy
C) Obliteration of the sinus and fat grafting
D) Observation and intravenous administration of antibiotics
E) Open reduction and internal fixation of the anterior wall of the frontal sinus
The correct response is Option E.
Frontal sinus fractures can be assessed by patency of the nasofrontal duct and by whether the fracture involves the anterior wall of the sinus, the posterior wall, or both. In this case, CT scanning shows significant damage to the anterior wall and a minimal fracture in the posterior wall. The normal nasofrontal duct would allow salvage of the sinus with minimal risk of a mucocele or an infection. The underlying brain is uninvolved, so craniotomy is unnecessary. The obvious deformity indicates open reduction and fixation, and because the posterior wall is minimally involved, repair of the anterior wall without craniotomy could be performed.
In patients without loss of posterior vertical height, which of the following is the most appropriate duration of maxillomandibular fixation (MMF) for treatment of minimally displaced bilateral subcondylar fractures of the mandible?
A) 1 week
B) 4 weeks
C) 8 weeks
D) None; stabilize mandible with gunning splint for 8 weeks
E) None; treat patient with soft diet
The correct response is Option B.
Closed reduction has historically been the standard treatment for subcondylar fractures of the mandible. Its widespread use is attributed to the idea that closed reduction results in fewer complications with similar functional and aesthetic outcomes compared with open reduction and internal fixation (ORIF). For instance, complications such as facial nerve damage and excessive scarring are significantly decreased because of the noninvasive nature of this approach. However, as highlighted by ongoing debate, a consensus regarding outcomes between open and closed reduction is not evident in the literature. In short, some studies conclude that both approaches produce roughly similar results, while other studies have associated an array of unfavorable outcomes with closed reduction. These outcomes include facial asymmetry, deviation upon mouth opening, skeletal malocclusion, and chronic pain of the temporomandibular joint (TMJ). The fact that many of these parameters lack standardization in the duration of the treatment further obscures the debate. Larger studies with consistent parameters are needed to reassess outcomes with the surgical techniques and technology present today. However, it is unlikely that a large enough trial will deliver granular evidence to conclusively quell this debate.
Another controversial point regarding closed reduction is the length of time a patient should spend in maxillomandibular fixation (MMF). Many surgeons choose to apply fixation for a very short period (i.e., 2 weeks) to avoid ankylosis of the TMJ secondary to forced immobilization during MMF. While the etiology of ankylosis is not completely understood, it is hypothesized that trauma leading to intracapsular hematoma results in fibrosis and excessive bone formation, ultimately causing hypomobility of the affected side.
Given the current hypothesis, ankylosis of the TMJ is most likely a manifestation of direct injury within the joint capsule or condylar head itself. It is imperative to point out that as a result, there should be a lower risk of ankylosis in subcondylar fractures compared with fractures of the condylar head. Therefore, the position of the fracture line relative to the joint capsule should be closely examined, and a longer period of MMF should be employed if there is no involvement of the condylar head, disc, or capsule. A longer period of MMF commonly results in better union of the fractured segments with no increase in the incidence of ankylosis. In a nondisplaced fracture or minimally displaced fracture with a functional occlusion, 4 to 6 weeks of MMF is recommended, followed by 2 to 3 weeks of guiding elastics. The same treatment applies in the case of a nondisplaced bilateral fracture. However, this scenario is less common because the force parameters to cause the bilateral fracture are often greater and tend to displace the fracture fragments significantly, necessitating ORIF. The patient will most likely develop shortening of the masseter muscle and stiffness with prolonged immobilization during 8 to 10 weeks. With bilateral instability, the fracture pattern is unstable and soft diet alone would likely lead to malocclusion. A gunning splint is often used in edentulous mandible only and is not functional MMF.
Avulsions occur most commonly at which of the following layers of the scalp?
A) Aponeurotic layer
B) Loose areolar layer
C) Pericranium
D) Skin
E) Subcutaneous layer
The correct response is Option B.
The layers of the scalp can be remembered by the mnemonic SCALP: skin, subcutaneous tissue, aponeurotic layer (also called the galea), loose areolar tissue, and pericranium. The skin, subcutaneous tissue, and galea are intimately fused and move as a unit. These layers are separated from the pericranium by a layer of areolar tissue. This layer allows easy movement of the scalp and provides a space for fluid accumulation. It is through this layer that separation most easily occurs in the setting of trauma to or surgical reflection of the scalp. Emissary veins cross this space as they drain the scalp into the intracranial venous sinuses. Because of the potential for accumulation of fluid in the loose areolar tissue, an infection or abscess in this layer may lead to meningitis or septic venous sinus thrombosis. However, the incidence of such events is low.
The galeal aponeurosis is considered the strength layer of the scalp and is contiguous with the frontalis and occipitalis muscles and the temporoparietal fascia laterally. The pericranium is tightly adherent to the skull. It derives its blood supply from the diploic circulation via a multitude of perforating blood vessels and can serve as a vascularized bed for accepting skin grafts. The subcutaneous tissue contains the vessels, lymphatics, and nerves that supply the scalp.
Which of the following is a late complication following frontal sinus fracture?
(A) Cerebrospinal fluid leak
(B) Epistaxis
(C) Meningitis
(D) Mucocele
(E) Sinusitis
The correct response is Option D.
Patients with frontal sinus fractures, especially those involving the posterior table, can develop complications secondary to nasofrontal duct obstruction, dural injury, or entrapment of the sinus mucosa. Acute complications within the first few hours after injury can include epistaxis, cerebrospinal fluid leak, meningitis, and intracranial injury. The most common subacute complications occurring within the first few weeks following fracture are frontal sinusitis, mucocele, and meningitis. Long-term complications, such as osteomyelitis, mucocele, and chronic intracranial or orbital abscesses, can occur as late as several years after injury. Cosmetic deformities may also be seen late.
Because most complications occur in patients with fractures of the posterior table, appropriate reduction of all posterior fragments and repair of all dural tears are recommended. Reconstruction with pericranial flaps can decrease the risk for development of complications by distancing the brain tissue from the fracture site. Cranialization, which involves removal of mucosa and plugging of the nasofrontal ducts, can also be used to minimize complications. In patients who have nonfunctioning nasofrontal ducts, obliteration of the frontal sinus may be considered.
A 27-year-old man has malocclusion and tenderness around the orbits and bridge of the nose after sustaining facial injuries in a motor vehicle collision. A photograph and CT scan are shown above. The patient is to undergo open reduction and internal fixation of the fractures.
Which of the following is the most appropriate management of the lacrimal system?
(A) Observation
(B) Exploration of the lacrimal duct
(C) Placement of a silicone stent
(D) Immediate dacryocystorhinostomy
(E) Primary repair followed by dacryocystorhinostomy in three months
The correct response is Option A.
In this patient who has sustained a naso-orbitoethmoid fracture, the most appropriate management of the lacrimal system is observation. The incidence of injury to the nasolacrimal duct in patients who undergo open reduction and internal fixation of naso-orbitoethmoid fractures but have no overlying lacerations is fairly low. Although swelling or fracture may contribute to blockage of the duct at the time of the initial injury, approximately 90% of patients will experience improvement of symptoms with resolution of the swelling and reduction of the fracture.
Exploration and/or manipulation of the duct are not recommended if there is no obvious injury to the duct. These procedures may only result in further damage because of the edema and friability of the tissues. Immediate dacryocystorhinostomy is not warranted for the same reason.
Patients who have persistent epiphora after resolution of swelling should undergo further evaluation. Dacryocystography can be performed for assessment of possible nasolacrimal duct occlusion. If occlusion is present, dacryocystorhinostomy is indicated.
For each patient, select the most appropriate management.
(A) Cranialization of the frontal sinus
(B) Obliteration of the sinus and nasofrontal ducts
(C) Observation for one week
(D) Rigid fixation with preservation of the frontal sinus
(E) Serial CT scans
48 A 22-year-old woman sustains a comminuted fracture of the posterior table of the frontal sinus
49 A 17-year-old boy who sustained a nondisplaced fracture of the frontal sinus has a cerebrospinal fluid leak
50 Five years after sustaining a displaced fracture of the anterior table of the frontal sinus that was not treated operatively, a 43-year-old man has a mucocele
The correct response for Item 48 is Option A, for Item 49 is Option C, and for Item 50 is Option B.
In patients who have comminuted fractures of the posterior table of the frontal sinus, rigid fixation cannot be achieved, and management involves cranialization, whereby the sinus is eliminated and thus converted to a portion of the intracranial cavity. This procedure requires neurosurgical exposure.
No operative intervention is required for nondisplaced fractures of the posterior wall of the frontal sinus as long as there is no evidence of cerebrospinal fluid leak. In patients with nondisplaced or minimally displaced fractures of the posterior wall of the frontal sinus who exhibit cerebrospinal fluid leak, the most appropriate initial management is observation for spontaneous resolution for five to seven days. If the cerebrospinal fluid leak continues beyond this point, cranialization of the frontal sinus and repair of the dural laceration are warranted.
Mucocele is a rare, late complication of untreated frontal sinus injury. Symptoms include headache and frontal sinus and orbital pain. Because mucoceles can erode the bony boundaries of the frontal sinus, appropriate management involves exenteration of the mucosa and obliteration of the sinus and nasofrontal ducts.
Serial CT scans are not indicated in the management of fractures of the frontal sinus.
An 83-year-old man undergoes radiation therapy and surgical resection and coverage with a cranial bone graft to treat meningioma. The graft becomes infected and is removed 6 weeks after the procedure. One year later, the patient is scheduled to undergo reconstruction of the resulting 23-cm2 defect in the skull. Which of the following is a relative contraindication for the subsequent use of hydroxyapatite in this patient?
A ) Age of patient
B ) History of infection
C ) History of radiation
D ) Location of defect
E ) Size of defect
The correct response is Option C.
Hydroxyapatite cement is widely used in cranioplasty. In one study, the complication rate of the use of hydroxyapatite in patients who have received irradiation to the scalp was 100%. Therefore, its use is not recommended in this population.
Use of hydroxyapatite is not recommended in large, full-thickness defects in the pediatric population because it is largely nonresorbable and may be deleterious to the rapidly growing skull.
Reduction in the incidence of infection has been shown when a period of 1 year has elapsed between the initial injury or infection and the reconstruction with hydroxyapatite.
Use of hydroxyapatite in frontal areas causes twice the incidence of infection than in its use in all other areas.
Hydroxyapatite is approved by the FDA for reconstruction of bony defects up to 25 cm2 in size.
In patients without loss of posterior vertical height, which of the following is the most appropriate duration of maxillomandibular fixation (MMF) for treatment of minimally displaced bilateral subcondylar fractures of the mandible?
A) 1 week.
B) 4 weeks.
C) 8 weeks.
D) None; stabilize mandible with gunning splint for 8 weeks.
E) None; treat patient with soft diet.
Closed reduction has historically been the standard treatment for subcondylar fractures of the mandible. Its widespread use is attributed to the idea that closed reduction results in fewer complications with similar functional and aesthetic outcomes compared with open reduction and internal fixation (ORIF). For instance, complications such as facial nerve damage and excessive scarring are significantly decreased because of the noninvasive nature of this approach. However, as highlighted by ongoing debate, a consensus regarding outcomes between open and closed reduction is not evident in the literature. In short, some studies conclude that both approaches produce roughly similar results, while other studies have associated an array of unfavorable outcomes with closed reduction. These outcomes include facial asymmetry, deviation upon mouth opening, skeletal malocclusion, and chronic pain of the temporomandibular joint (TMJ). The fact that many of these parameters lack standardization in the duration of the treatment further obscures the debate. Larger studies with consistent parameters are needed to reassess outcomes with the surgical techniques and technology present today. However, it is unlikely that a large enough trial will deliver granular evidence to conclusively quell this debate. Another controversial point regarding closed reduction is the length of time a patient should spend in maxillomandibular fixation (MMF). Many surgeons choose to apply fixation for a very short period (i.e., 2 weeks) to avoid ankylosis of the TMJ secondary to forced immobilization during MMF. While the etiology of ankylosis is not completely understood, it is hypothesized that trauma leading to intracapsular hematoma results in fibrosis and excessive bone formation, ultimately causing hypomobility of the affected side. Given the current hypothesis, ankylosis of the TMJ is most likely a manifestation of direct injury within the joint capsule or condylar head itself. It is imperative to point out that as a result, there should be a lower risk of ankylosis in subcondylar fractures compared with fractures of the condylar head. Therefore, the position of the fracture line relative to the joint capsule should be closely examined, and a longer period of MMF should be employed if there is no involvement of the condylar head, disc, or capsule. A longer period of MMF commonly results in better union of the fractured segments with no increase in the incidence of ankylosis. In a nondisplaced fracture or minimally displaced fracture with a functional occlusion, 4 to 6 weeks of MMF is recommended, followed by 2 to 3 weeks of guiding elastics. The same treatment applies in the case of a nondisplaced bilateral fracture. However, this scenario is less common because the force parameters to cause the bilateral fracture are often greater and tend to displace the fracture fragments significantly, necessitating ORIF. The patient will most likely develop shortening of the masseter muscle and stiffness with prolonged immobilization during 8 to 10 weeks. With bilateral instability, the fracture pattern is unstable and soft diet alone would likely lead to malocclusion. A gunning splint is often used in edentulous mandible only and is not functional MMF.
A 37-year-old woman is brought to the emergency department two hours after she sustained injuries to the face in a motor vehicle collision. Radiographs show an orbital zygomatic fracture on the left side. On ophthalmologic examination, the left pupil fails to constrict when direct light is shined in the eye; consensual pupillary constriction is normal. Color perception is diminished in the left eye. Findings in the right eye are normal. Which of the following is the most likely cause of these findings?
(A) Detachment of the retina
(B) Extension of the fracture through the optic canal
(C) Impingement of bone fragments on the optic (II) nerve
(D) Shear force injury to the optic (II) nerve
(E) Thrombosis of the retinal artery
The correct response is Option D.
Physical examination of the patient with an orbital zygomatic fracture includes an ophthalmologic assessment. Along with evaluation for motility disturbances of the globe and diplopia, a direct visual assessment is performed. The finding of traumatic optic neuropathy has been reported in 2% to 5% of patients with severe facial trauma. In its most severe form, traumatic optic neuropathy results in visual loss; however, findings may be more subtle, such as diminished color perception. It is also possible to find an afferent pupillary defect in the affected eye (if the pupil fails to constrict with direct light stimulation but constricts normally in a consensual response when light is directed to the contralateral eye). Injury to the optic (II) nerve can result from either mechanical or ischemic insults. The most likely mechanism of injury is shear force to the optic (II) nerve. The dural sheath is firmly attached to the optic nerve at its entrance into the optic foramen. Rapid deceleration injuries of the head can generate forces that are concentrated at the optic foramen. An optic nerve injury can also result from fracture fragments directly damaging the optic nerve or globe, thrombosis of the retinal artery, or retinal detachment; however, these are less common than injury resulting from shear force.
Which of the following is the most common cause of posttraumatic enophthalmos?
(A) Fat atrophy
(B) Increased volume of the bony orbit
(C) Ligament disruption
(D) Orbital roof defect
(E) Soft-tissue contracture
The correct response is Option B.
Enophthalmos, or posterior displacement of the globe within the bony orbit, is most frequently caused by an increase in bony orbital volume. Because the positioning of the globe is determined by the bony orbit, ligamentous system, and orbital fat, changes in any of these contributing factors occurring as a result of trauma can lead to a change in globe position. However, volumetric studies have pointed to enlargement of orbital volume as the predominant cause of enophthalmos. As such, surgical correction of facial fractures should always include the confirmation and/or re-establishment of normal bony orbital volume. This involves confirmation of the correct positioning of the medial and lateral orbital floors.
Disruption of the orbital ligaments can also result in posttraumatic enophthalmos, especially in relation to increased bony orbital volume. In certain patients who have increased orbital volume, intact ligaments can function to maintain the globe in its normal position. However, if the ligaments are disrupted, the soft tissues can contract, resulting in a change in both orbital shape and volume. If this is not corrected, the globe will be positioned abnormally following healing, and the enophthalmos will then be difficult to correct.
Defects in the orbital roof are not commonly cited as a cause of enophthalmos because superior displacement of the globe into the anterior cranial fossa is rare.
A 23-year-old man sustains a severe right orbital floor fracture in a physical altercation. Reconstruction with a pre-bent orbital floor plate and intraoperative CT scanning is planned. Which of the following is the most likely to be optimized using this imaging modality intraoperatively?
A) Operative time
B) Plate positioning
C) Rate of corneal abrasion
D) Rate of plate extrusion
E) Risk for lid malposition
The correct response is Option B.
Use of intraoperative computed tomography has been gaining traction in maxillofacial trauma. Stated benefits include decreased re-operation rate, improved accuracy of plate positioning, and decreased postoperative enophthalmos. Although the use of intraoperative CT scans may increase time in the operating room, it has no effect on rates of corneal abrasion, lid malposition, or plate extrusion.
In a 32-year-old man who sustained a panfacial fracture in a high-speed motor vehicle collision, what is the approximate risk for concomitant cervical spine injury?
(A) 5%
(B) 10%
(C) 15%
(D) 20%
(E) 25%
The correct response is Option B.
Patients who are involved in high-speed motor vehicle collisions have a risk for concomitant cervical spine injury that is closest to 10%. The incidence of associated cervical spine injury is greatly increased in these patients. Therefore, a patient who has sustained a facial fracture in a high-speed collision should be evaluated for a potential cervical spine injury prior to treatment of the facial fracture.
A 24-year-old woman undergoes Le Fort I osteotomy with maxillary impaction and bilateral sagittal split osteotomy with mandibular advancement. Following release of intermaxillary fixation six weeks later, the patient has an anterior open bite. Which of the following is the most likely cause of this finding?
(A) Improper intraoperative seating of the condyles in the glenoid fossae
(B) Improper presurgical orthodontic treatment
(C) Loosening of all plates of the rigid internal fixation
(D) Parafunctional habits, such as tongue thrusting
(E) Progressive resorption of the condyles
The correct response is Option A.
This patient’s anterior open bite, seen six weeks after surgery, is most likely a result of improper intraoperative seating of the condyles in the glenoid fossae. Once the osteotomy has been completed, it is important to release the patient from intemaxillary fixation in order to ensure that the condyles are properly seated within the fossae. The occlusion and path of the opening of the mandible are examined at this time.
Improper presurgical orthodontic treatment would result in a late recurrence of malocclusion. It is unlikely that all of the plates of the rigid internal fixation would loosen over the six-week fixation period. Parafunctional habits, such as tongue thrusting, are a late cause of anterior open bite. Progressive condylar resorption, which manifests as condylar shortening, decreased height of the posterior face, and clockwise rotation of the mandible, is a late cause of open bite occurring primarily in young women. The cause of this condition is unknown.
Which of the following is the most common cause of posttraumatic enophthalmos?
A) Fat atrophy
B) Increased volume of the bony orbit
C) Ligament disruption
D) Orbital roof defect
E) Soft-tissue contracture
Enophthalmos, or posterior displacement of the globe within the bony orbit, is most frequently caused by an increase in bony orbital volume. Because the positioning of the globe is determined by the bony orbit, ligamentous system, and orbital fat, changes in any of these contributing factors occurring as a result of trauma can lead to a change in globe position. However, volumetric studies have pointed to enlargement of orbital volume as the predominant cause of enophthalmos. As such, surgical correction of facial fractures should always include the confirmation and/or re-establishment of normal bony orbital volume. This involves confirmation of the correct positioning of the medial and lateral orbital floors.
Disruption of the orbital ligaments can also result in posttraumatic enophthalmos, especially in relation to increased bony orbital volume. In certain patients who have increased orbital volume, intact ligaments can function to maintain the globe in its normal position. However, if the ligaments are disrupted, the soft tissues can contract, resulting in a change in both orbital shape and volume. If this is not corrected, the globe will be positioned abnormally following healing, and the enophthalmos will then be difficult to correct.
Defects in the orbital roof are not commonly cited as a cause of enophthalmos because superior displacement of the globe into the anterior cranial fossa is rare.
In a patient undergoing surgical management of a Le Fort I fracture, rigid fixation is applied using metal plates and screws. When maxillomandibular fixation is removed to confirm the occlusal relationship, a unilateral posterior open bite is noted.
Which of the following is the most appropriate next step in management?
(A) Fixation with elastic banding on the side of the open bite for four weeks
(B) Re-establishment of maxillomandibular fixation for six weeks
(C) Removal of all rigid fixation and disimpaction of the maxillary fracture
(D) Removal of all rigid fixation followed by wire fixation of the fracture sites
(E) Replacement of the metal plates with absorbable (Lactasorb) plates on the side of the open bite
The correct response is Option C.
The most important management principal in this patient who has a Le Fort I fracture involves re-establishing the pretraumatic maxillomandibular orientation. Erich arch bars can be used to re-establish occlusion in patients with
If the maxilla has been impacted into the pterygoid plates, the occlusion will be angled superiorly toward the side of impaction. Therefore, if rigid fixation is applied before the fracture site is disimpacted, the patient will have an open bite on removal of maxillomandibular fixation. In order to prevent this, the impacted segments should be mobilized prior to the application of rigid maxillomandibular fixation, and an even plane should be established to correct the open bite.
Wires, elastic bands, and absorbable plates (Lactasorb) can be used to re-establish maxillomandibular fixation but will not correct the open bite.
A patient has an infection at the surgical site one week after undergoing open reduction and internal fixation of a fracture of the mandibular body using an inferior border reconstruction plate and a tension band. Occlusion is normal. The infection site is surgically drained; intraoperative exploration shows that the plates and screws are stable with no evidence of loosening. Which of the following is the most appropriate management of the hardware?
A) Maintenance of current stabilization without removal of the hardware
B) Removal of all plates and immediate application of intermaxillary fixation
C) Removal of all plates and immediate application of two miniplates
D) Removal of all plates and immediate placement of an external fixator
E) Removal of all plates and placement of new plates when the infection has subsided
Infections following open reduction and internal fixation of mandibular fractures typically result from failure of fixation devices, for example, loosening of the screws. In addition to operative drainage of the infection and antibiotic therapy, appropriate management in the majority of these situations includes removal and replacement of the hardware with intermaxillary or external fixation for stabilization of the fracture.
In this patient, the plates continue to provide stable fixation of the fracture. Because of this, the current stabilization should be maintained without removal of the hardware, and the patient should undergo operative drainage of the infection and administration of antibiotics.
A 22-year-old man is brought to the emergency department after sustaining injuries to the head during a high-speed motor vehicle collision. Examination shows fluid draining from the nostrils. Beta-2 transferrin test on the fluid is positive. CT scan shows a frontal sinus fracture. The anterior and posterior tables are nondisplaced. Which of the following is the most appropriate next step?
A) Cranialization of the frontal sinus
B) Dural repair
C) Obliteration of the frontal sinus
D) Reduction and fixation of the anterior-table frontal sinus
E) Observation
The correct response is Option E.
A positive beta-2 transferrin test result indicates a cerebrospinal fluid (CSF) rhinorrhea. The first priority is to seal the leak. The patient should be observed before proceeding. The head of the bed should be elevated, and consideration should be given to placement of a lumbar CSF drain. If the leak does not resolve, surgical intervention should be planned.
Once the CSF rhinorrhea has resolved, operative repair of the facial fractures can begin. After the premorbid occlusion is established, the mandible fractures are plated sequentially.
Cranialization is reserved for displaced posterior table frontal sinus fractures. Dural repair is not needed at this stage as the CSF leak will probably seal on its own. Obliteration of the frontal sinus may be required if the CSF rhinorrhea fails to respond to conservative treatment.
A 30-year-old woman presents with the dental findings shown in the diagram. Which of the following best describes the dental relationship?
A) Angle class I
B) Angle class II
C) Angle class III
D) Negative overjet
E) Overbite
The correct response is Option B.
The images show an Angle class II relationship. The Angle classification system describes the relative positions between the mesial buccal cusp of the maxillary first molar and the buccal groove of the mandibular first molar. Angle class I molar relationship implies that the mesiobuccal cusp is in line with the buccal groove. In an Angle class II molar relationship, the maxillary mesiobuccal cusp is anterior to the mandibular buccal groove. Class II is subdivided into two divisions. In class II, division 1, patients have minimal crowding of the maxillary teeth and proclination of the upper central incisors, and a significantly increased overjet. In a class II, division 2 relationship, the central incisors are retroclined. An Angle class III molar relationship exists when the maxillary mesiobuccal cusp lies posterior to the mandibular buccal groove.
A 42 year old man is brought to the emergency department 30 minutes after sustaining trauma to the face in a motor vehicle collision. Physical examination shows periorbital ecchymoses on the right, malar flattening, and enophthalmos. Neurologic examination shows numbness on the upper right lip. Radiographs show a displaced zygomaticomaxillary complex fracture. Anatomic reduction of each of the following is required in this patient EXCEPT
(A) greater wing of the sphenoid
(B) inferior orbital rim
(C) nasomaxillary buttress
(D) zygomaticofrontal suture
(E) zygomaticomaxillary buttress
The correct response is Option C.
Approximately 15% to 22% of patients with orbital fractures develop enophthalmos because of increased bony intraorbital volume. This is most frequently associated with a zygomaticomaxillary complex fracture that has not been reduced adequately. It is critical that an anatomic reduction be obtained to prevent the development of this difficult late complication. It is also critical that appropriate anatomic reduction of the greater wing of the sphenoid and lateral wall of the orbit is obtained after reduction of a fracture of the zygomaticomaxillary complex. Correct reduction of the inferior orbital rim, zygomaticofrontal suture, and zygomaticomaxillary buttress is also important but does not ensure the reduction of the lateral wall. The surgeon must therefore verify that the complete reduction of all structures has been performed. Reduction of the nasomaxillary buttress is not typically involved in this type of fracture pattern.
In a patient with fracture of the frontal sinus, laboratory analysis of which of the following is most reliable to confirm cerebrospinal rhinorrhea?
(A) Albumin
(B) Beta-2 transferrin
(C) Glucose
(D) Glutamine
(E) Lactic acid
The correct response is Option B.
Initially described for the detection of cerebrospinal fluid (CSF) in 1979, beta-2 transferrin is currently accepted as the most reliable method of laboratory testing in determining the presence of CSF in rhinorrhea and otorrhea. It has been reported to have a sensitivity near 100% and a specificity near 95%. Beta-2 transferrin is a carbohydrate €‘free (desialylated) isoform of transferrin that is almost exclusively found in CSF. It is also found in perilymph in the cochlea and the aqueous and vitreous humor of the eye, but in lower concentrations. It is not present in blood, nasal mucus, tears, or mucosal discharge. Its presence is identified using immunofixation electrophoreses. Glucose testing of rhinorrhea or otorrhea was commonly used in the past, but interpretation of the studies was confounded by contamination of glucose containing fluid (tears, nasal mucus, blood in nasal mucus) or low CSF glucose levels (as seen in meningitis). Glucose testing of CSF has been found to have an unacceptably high rate of false-positive results.
A 24-year-old man presents following a motor vehicle collision. There is a 16-cm vertical laceration extending from the right cheek to the temporal region. The wound is explored surgically. The frontal branch of the facial nerve should be intact provided that the wound does not extend deep into which of the following structures?
a. Deep temporal fascia
b. Pericranium
c. Temporalis muscle
d. Temporoparietal fascia
e. Zygoma
The correct response is Option D.
Knowledge of the course of the frontal branch of the facial nerve is important in craniofacial and neurosurgery, repair of traumatic lacerations, and facial rejuvenation surgery. The frontal branch of the facial nerve emerges from the anterior-superior border of the parotid gland and travels roughly along a line starting from a point 0.5 cm below the tragus, a point 1.5 cm above the lateral extremity of the eyebrow (Pitanguy’s line). The structures of the temporal region from superficial to deep include: skin and subcutaneous fat, temporoparietal fascia (also known as superficial temporal fascia), a loose areolar plane (also known as the innominate fascia), deep temporal fascia (which comprises a superficial and a deep layer that envelop the superficial temporal fat pad above the arch of the zygoma), temporalis muscle, pericranium, and calvarium. There is some controversy as to whether the frontal branch of the facial nerve travels within or deep to the temporoparietal fascia within the innominate fascia. Nevertheless, if the wound described does not penetrate the temporoparietal fascia, the frontal branch should be intact.
Reference(s)
- Agarwal CA, Mendenhall SD 3rd, Foreman KB, Owsley JQ. The course of the frontal branch of the facial nerve in relation to fascial planes: an anatomic study. Plast Reconstr Surg. 2010 Feb;125(2):532-7.
- Hwang K. Surgical anatomy of the facial nerve relating to facial rejuvenation surgery. J Craniofac Surg. 2014 Jul;25(4):1476-81.1.
- O’Brien JX, Ashton MW. Relationship of the temporofrontal rami of the facial nerve to the fascial layers of the temporal regions. Ann Plast Surg. 2012 Jun;68(6):547-8.
A 7-year-old boy is brought to the emergency department after sustaining trauma to the face. He has nausea and vomiting but is alert and oriented to time and place. Pulse rate is 48/min. Physical examination shows right periorbital ecchymosis, diplopia, and limited vertical gaze. Visual acuity is within normal limits. Which of the following is the most likely finding on CT scan of the head and craniofacial skeleton?
(A) Compression of the optic nerve
(B) Displaced fracture of the zygoma
(C) Large (greater than 3 cm) displaced fracture of the orbital floor
(D) Minimally displaced fracture of the orbital floor
The correct response is Option D.
Based on the patient €™s age, signs, and symptoms, a CT scan is most likely to show a minimally displaced fracture of the orbital floor, suggesting a trapdoor fracture of the orbital floor. This type of fracture allows herniation of the orbital contents, which are then entrapped. It most commonly occurs in children, possibly because of the relative elasticity of their bones, which allows them to snap back into position after tissue herniates through the fracture. As in this patient, a trapdoor fracture of the orbital floor can cause an oculocardiac reflex, which produces bradycardia, nausea, and syncope.
A CT scan is not likely to show compression of the optic nerve because the patient does not have a relative afferent pupillary defect. A CT scan also is unlikely to show a displaced fracture of the zygoma because this type of fracture usually occurs in older patients. This study should not disclose a large displaced fracture of the orbital floor because this type of fracture does not typically cause oculocardiac reflex. Because the patient €™s mental status is intact, a CT scan is not likely to show a subarachnoid hemorrhage.
In a trapdoor fracture of the orbital floor, the muscles most likely to be entrapped are the inferior rectus and inferior oblique muscles. If entrapment restricts ocular movement, immediate surgery is recommended to prevent irreversible ischemia and fibrosis of the entrapped contents.
A 52-year-old man is evaluated 7 months after sustaining an isolated left-sided orbital blowout fracture for which no surgical intervention was performed. Physical examination shows extraocular movements are intact. He reports gradual and progressive episodes of double vision over the past 3 months. Which of the following physical findings is most likely associated with this condition?
A) Ectropion
B) Muscle entrapment
C) Exophthalmos
D) Vertical dystopia
E) Orbital proptosis
The correct response is Option D.
The physical finding that would most likely be associated with the finding of double vision 7 months after having sustained an orbital blowout fracture is enophthalmos. The position of the globe is altered in enophthalmos. Because of increased orbital volume, the globe is situated deeper or more inferiorly, such that the direct line of vision of the affected eye no longer matches that of the unaffected eye. The two eyes no longer track appropriately, causing double vision or diplopia by virtue of not having the same visual field.
Orbital fractures frequently occur in conjunction with other facial fractures, most commonly the zygomaticomaxillary complex fracture. Often the orbital floor or sidewall can be fractured without concomitant fractures. This occurs from a direct blow to the orbit/eye, most often by a punch or elbow/ball in sports. The absolute indication for operative repair acutely is the presence of entrapment, most often of the inferior rectus muscle. The belly of the muscle herniates into and remains within the fracture site in the orbital floor. The finding of diplopia on upward, lateral gaze with the affected eye having reduced movement in that upward direction indicates entrapment. The forced duction test further documents this condition. Surgical repair is indicated acutely to avoid permanent damage and fibrosis to the inferior rectus muscle and consequent visual difficulties.
In the absence of entrapment or orbital hematoma, surgical repair is a judgment call based on the location and extent of the fractures. If the fracture is deemed sizable enough to increase the orbital volume, then the risk of subsequent enophthalmos and diplopia is considered high and surgical repair is indicated. The repair involves reduction of orbital contents and restoration of the orbital floor, most often with titanium mesh. Large fractures may require primary bone grafting.
The conventional means of correcting post-traumatic enophthalmos is bone grafting. However, it is often difficult to accurately judge the correction needed due to multimodal increase in orbital volume from the combination of increase orbital volume and potential reduction in periorbital fat from traumatic atrophy. New techniques of alloplastic floor restoration and periorbital fat grafting have shown encouraging results.
Exophthalmos, ectropion, and proptosis are not conditions typically associated with isolated orbital blowout fractures. Furthermore, these conditions frequently occur without diplopia.
Entrapment of the periorbital muscles, most usually the inferior oblique, can cause entrapment by limiting proper movement of the involved globe. However, this is usually an acute symptom and would not present initially several months after the trauma.
A 30-year-old man sustains significant mid face injuries following a motor vehicle collision, and has a large laceration in the vicinity of the medial canthal region. Canalicular injuryis confirmed intra-operatively. Which of the following is the most appropriate method for repairing this patient’s canalicular injury?
a. Delayed dacryocystorhinostomy
b. Direct microsurgical suture repair
c. Healing by secondary intention
d. Immediate dacryocystorhinostomy
e. Placement of silicone canalicular stents
The correct response is Option E.
When canalicular injury is suspected, the lacrimal system should be investigated for patency. Typically, this involves performing a Jones I and II test to determine if fluorescein navigates from the lower lid fornix into the nose. If canalicular interruption is suspected and identified, the proximal and distal stumps of the canaliculus are joined by placing a silicone stent and leaving this in place for 3 to 6 months to allow for healing.
Direct microsurgical suturing is not preferred because of the high likelihood of cicatricial obstruction.
Dacryocystorhinostomy is generally reserved as a “salvage” procedure for patients who have lacrimal obstruction after being treated with a stent. Healing by secondary intention is incorrect since it would likely result in canalicular obstruction.
Reference(s)
- Lipke KJ, Gümbel HOC. Management of Injuries of the Eye and its Adnexa. Facial Plast Surg. 2013 Aug;29(4):310-5. Epub 2013 Jul 24.
- Eo S, Park J, Cho S, Azari KK. Microsurgical Reconstruction for Canalicular Laceration Using Monostent and Mini-Monoka. Ann Plast Surg. 2010 Apr;64(4):421-7.
A 23-year-old man is undergoing evaluation one week after sustaining a nasal fracture. Each of the following is appropriate management of this patient’s injuries EXCEPT
(A) closed realignment of the nasal fracture with forceps
(B) drainage of septal hematomas
(C) intranasal packing
(D) osteotomy and realignment of the nasal fracture
(E) use of a dorsal nasal splint
The correct response is Option D.
Complications associated with fracture of the nasal bones include hemorrhage and hematoma. Bleeding is common with nasal trauma because of the rich blood supply of the mucoperichondrium. Fracture of the nasal septum can lead to hematoma, which frequently occurs bilaterally, as septal fractures communicate between both sides of the nose. If untreated, a septal hematoma can become thick and fibrotic, obstructing the nasal passage, or can cause pressure necrosis of the nasal mucosa and cartilage, ultimately leading to septal perforation. Therefore, appropriate management involves incision along the base or most inferior portion of the hematoma, which will allow for drainage and prevent blood from refilling the cavity. In addition, closed reduction is appropriate for septal fractures and deviated nasal bones. Intranasal packing and dorsal nasal splints are typically used to aid in maintaining the reduction.
Osteotomy should not be performed in patients with acute fractures because nasal collapse may result. This procedure should be delayed until the fracture has healed significantly.
A 23-year-old man is brought to the emergency department unconscious after a head-on motor vehicle collision. Physical examination shows left periorbital bruising. When a light is shined into the left eye, no pupillary constriction is noted, and thereafter, the light is shined into the right eye, and both pupils constrict. When the light is subsequently shined again into the left eye, the right pupil constricts and the left pupil dilates. Which of the following best explains this finding?
A) Extraocular muscle entrapment
B) Hyphema
C) Inadequate brain perfusion
D) Optic nerve injury
E) Tentorial herniation
The correct response is Option D.
The vignette illustrates findings consistent with a Marcus Gunn pupil. A lesion at the level of the posterior globe (retina) and optic nerve anterior to the chiasm alters the afferent response normally expected from shining a light in the eye. The test is done by shining a light in the pupil of the affected side first, and this will cause little or no constriction on that side, yet there will be a consensual response on the normal side. Then, the light is shined in the normal pupil, resulting in constriction of both pupils (normal ipsilateral and consensual response). The third step is to swing the light back to the injured side, and this typically will cause paradoxical dilatation of the affected pupil. A fracture in the posterior orbit may cause pressure on the optic nerve directly by impingement of a fracture fragment or from hematoma.
Extraocular muscles control the directionality of the globe for the purpose of binocular vision. There is no direct distal anatomical connection to the pupillary sphincter muscle (parasympathetic) or the iris dilator (sympathetic), both of which control pupillary size. However, there is a proximal commonality in that some extraocular muscles (superior/medial/inferior recti, inferior oblique) and the pupillary muscles are supplied by the oculomotor nerve. Most commonly, it is the inferior oblique with or without the inferior rectus muscle that is entrapped in an orbital floor fracture, and thus has no direct bearing on pupillary size. Therefore, pupils should react normally in an isolated orbital floor fracture with muscle entrapment.
Hyphema is the presence of blood in the anterior chamber. It does not cause a Marcus Gunn pupil, or any other abnormal pupillary reaction.
The pupils in a patient with inadequate brain perfusion are usually dilated and fixed, or react sluggishly to light, but always symmetrical.
In tentorial herniation, due to a laterally expanding intracranial hematoma, the oculomotor nerve is susceptible to compression as it exits the mid brain. The pupillary examination will show one ipsilateral dilated pupil that is fixed or sluggish, and the globe will be laterally displaced due to the unopposed tone generated by cranial nerve VI on the lateral rectus muscle over a paralyzed medial rectus muscle.
Normal pupillary constriction as a reaction to light begins with a light stimulus on the retina that triggers a signal via afferent fibers in the optic (II) nerve. These fibers connect to the pretectal nucleus and both Edinger-Westphal nuclei. A response is generated from there through parasympathetic fibers via the oculomotor (III) nerve, which supplies the sphincter pupillae.
A 23-year-old man sustains multiple fractures to the middle and upper face during a motor vehicle collision. The patient reports disturbances of smell immediately afterwards. Injury to which of the following bones is the most likely reason for this patient’s anosmia?
A) Ethmoid
B) Frontal
C) Nasal
D) Sphenoid
E) Vomer
The correct response is Option A.
The cribriform plate is the horizontal component of the ethmoid bone which supports the olfactory bulb and creates a passageway for the olfactory nerves.
The cribriform plates (right and left) have many foramina that act as passageways for olfactory nerves and are in intimate contact with the meninges. In addition to anosmia (loss of smell), injury to the cribriform plate may cause tearing of the meninges with cerebrospinal fluid leakage. The crista galli is a midline prominence of the ethmoid, immediately above the cribriform plates, which serves as a point of attachment for intracranial soft tissue. Other components of the ethmoid bone are the vertical portion and the lateral masses. The vertical portion is called the perpendicular plate, which forms part of the nasal septum. The lateral masses of the ethmoid bone contain a plate of bone called the lamina papyracea, which forms part of the medial orbital wall and the ethmoid air cells.
While anosmia and taste abnormalities can occur following a variety of facial fracture patterns, including frontal bone, naso-orbital-ethmoid, nasal, Le Fort, and zygoma, the close anatomic relationship of the ethmoid cribriform plate to the olfactory nerve makes it most likely.
A 32-year-old man sustains a fracture of the mandible in a motor vehicle collision. The likelihood of concomitant cervical spine injury in this patient is closest to
(A) 10%
(B) 20%
(C) 30%
(D) 40%
(E) 50%
The correct response is Option A.
In patients who sustain facial fractures in motor vehicle collisions, the incidence of cervical spine injury has been shown to range from 5% to 15%, according to the results of multiple studies. Overall, multiple studies have reported the incidence of concomitant injuries associated with facial fractures sustained during motor vehicle collisions as ranging from 11% to 99%. These injuries are most likely to include closed head injuries, soft-tissue lacerations to the face, head, or other regions, and fractures of the ribs, pelvis, and lower extremities.
Because of the correlation between facial fractures and cervical spine injuries, standard Advanced Trauma Life Support (ATLS) protocols recommend that the cervical spine be immobilized until the absence of cervical spine injury can be documented definitively. These injuries can result in paresis, paraplegia, and even death; therefore, the surgeon must maintain a high index of suspicion in any patient who sustains a mandibular fracture in a motor vehicle collision. Even patients who have mandibular fractures resulting from physical altercations should be evaluated carefully, although the incidence of concomitant cervical spine injury is not as high as in those patients who are involved in motor vehicle collisions.
Patients with mandibular fractures often have other associated injuries, such as lacerations of the face and head and other associated facial fractures. These patients should also be evaluated for potential closed head injury, which is a life-threatening concern associated with high mortality rates.
A 21-year-old man is evaluated because of pain and double vision 2 weeks after being punched in the face. An orbital fracture is suspected. Which of the following characteristics of an orbital floor fracture is the most common indication for surgical repair?
A) Concomitant naso-orbito-ethmoid fracture
B) Contralateral zygomaticomaxillary complex fracture
C) Herniation of orbital contents with diplopia
D) Medial wall fracture without additional symptoms
E) Nondisplacement
The correct response is Option C.
The facial skeleton acts as a buffer and barrier against injury to the brain and deep structures. Reconstruction of the buttress system is integral to reforming the form and function of the facial skeleton.
Zygomaticomaxillary complex (ZMC) fractures, sometimes referred to as tripod fractures, may involve fractures of the following: zygomaticotemporal suture, maxillary sinus, and occasionally sphenoid bone. Correction involves reduction of the fracture, commonly with miniplate fixation or with 2-point wire fixation. These fractures can also involve the orbital floor and maxillary wall.
Symptoms may include numbness in the maxillary nerve (V2 of trigeminal (V) nerve), subconjunctival hemorrhage, diplopia, and enophthalmos. Orbital floor fractures can be isolated, as in a blowout, or involve other structures (e.g., orbital rim, orbital medial/lateral walls, orbital apex). Additional fractures are typically associated with higher-force injury and may require more extensive surgical repair.
Diagnostic study typically includes CT scan of the facial bones to assess the fractures and to delineate the extent of the facial trauma.
There are three main indications to treat isolated orbital fractures:
Entrapment of the extraocular muscles: this may cause injury and permanent dysfunction of the globe if not reduced.
Prevention of globe malposition: malposition of the globe may occur leading to diplopia or enophthalmos. This may not be apparent immediately after the injury because of soft-tissue edema. Reduction is indicated if there are signs of early enophthalmos, displacement of more than 50% of the orbital floor, or significant soft-tissue displacement.
Lateral orbital wall displacement: when the injury is more severe, the lateral orbital bone (sphenoid bone) may impact the orbital apex or even the mid-cranial fossa.
The CT scan should be examined for muscle entrapment, herniation of orbital contents, and associated fractures (naso-orbito-ethmoid, zygomaticomaxillary, Le Fort). Open reduction and internal fixation can be performed emergently or after edema has subsided, and usually after the orbit has been examined by an ophthalmologist for ocular injury.
Repair of the orbital floor can be done using several different types of materials—alloplastic and autologous. This is usually dictated by the surgeon’s preference and the extent of the injury.
A 65-year-old man who wears glasses sustained a massive injury to the left side of the face causing a ruptured globe with total loss of the upper and lower eyelids. Which of the following is the best aesthetic option to recommend?
A) Eye patch
B) Hemifacial prosthesis
C) Ocular prosthesis
D) Orbital prosthesis
The correct response is Option D.
In this case the patient has had severe orbital trauma with loss of lids and globe. Natural-looking and functional total-lid reconstruction is challenging. Lids would be needed to support an ocular prosthesis. An orbital prosthesis would likely provide this patient a comfortable and aesthetically satisfactory prosthesis. Eyeglasses can help mask the seam of the prosthesis. The hemifacial prosthesis is larger than necessary for this patient and has unnatural seams. An eye patch would not improve symmetry or be reconstructive.
A 27-year-old man is brought to the emergency department 1 hour after sustaining a knife wound to the left cheek. Physical examination shows a wound just anterior to the left ear that extends intraorally. A photograph is shown. He is able to elevate the brow, close the eyes, smile, and evert the lower lip. The laceration is irrigated thoroughly. Which of the following is the most appropriate next step in management?
A) Application of wet-to-dry dressings
B) Cannulation of Stensen duct
C) Closure of the facial wound and administration of sialogogues
D) Starch-iodine test
E) Testing of the distal branches of the facial nerve with a stimulator
The correct response is Option B.
After ruling out facial nerve injury, the next priority in management of a cheek laceration is to rule out injury to the parotid (Stensen) duct. Failure to repair a parotid duct laceration can result in a salivary fistula or sialocele. A small amount of methylene blue dye injected via an intravenous catheter, introduced through the ductal papilla in the mouth opposite the maxillary second molar, may be effective in identifying lacerations. Whenever possible, it is best to repair lacerations primarily using fine suture (eg, 8-0 nylon) over a stent. If the duct cannot be repaired because of extensive damage, ligation of the duct can be considered.
Wet-to-dry dressing changes and healing by secondary intention are not indicated in an early, uninfected facial wound. If a ductal injury can be ruled out, the wound should be closed primarily. It is not necessary to explore the facial nerve when the patient has clinically intact facial motor function. Such exploration risks inadvertent injury to the nerve. Anticholinergic medications, such as glycopyrrolate, can be administered to limit salivary secretion during healing and to help prevent salivary fistula or sialocele formation from an unrecognized ductal injury or glandular laceration. Sialogogues increase salivary secretion and are not effective in limiting complications. The starch-iodine test is used to assess gustatory sweating thought to occur because of inappropriate sympathetic reinnervation of the facial sweat glands after parotid surgery and is not indicated in the initial management of the patient described.
A 1-month-old infant is brought to the office by her parents for evaluation of a skull deformity. CT scan of the head is shown above. Which of the following cranial dysmorphologies is the most likely diagnosis?
(A) Dolichocephaly
(B) Plagiocephaly
(C) Scaphocephaly
(D) Trigonocephaly
(E) Turricephaly
The correct response is Option D.
The CT scan demonstrates an infant with a narrowed forehead and decreased bitemporal distance. There is also evidence of orbital hypotelorism and an obliterated or fused metopic suture. These findings are consistent with trigonocephaly.
Scaphocephaly is a cranial shape excessive in the anterior-posterior dimension and narrow in the bitemporal dimension. This results in a long and narrow (boat-like) shape of the head. This results from premature fusion of the sagittal suture.
Dolichocephaly is another term for scaphocephaly.
Plagiocephaly or “twisted head” is used to describe anterior or posterior deformities. Plagiocephaly is classified as anterior or posterior as well as synostotic and nonsynostotic or deformational. Anterior synostotic plagiocephaly refers to coronal craniosynostosis and posterior synostotic plagiocephaly refers to lambdoid craniosynostosis. Anterior or posterior nonsynostotic plagiocephaly refers to deformational plagiocephaly or skull molding from a persistent sleep position.
Turricephaly or oxycephaly is used to describe vertically tall head shapes that are usually associated with the brachycephaly (short in the anterior-posterior dimension) of bicoronal syndromic craniosynostosis.
A 35-year-old man has swelling and tenderness of the nose and deviation of the nose to the left after being accidentally struck in the face while playing squash. Intranasal examination shows a localized purple mass on the left side of the septum. A CT scan is shown on page 4. Which of the following is the most appropriate initial management?
(A) Immediate closed reduction and placement of an external splint
(B) Immediate open reduction of the nasal fractures
(C) Immediate incision and drainage of the septal mass
(D) Immediate submucous resection of the septal fracture
The correct response is Option C.
The most appropriate initial step in the management of this patient is immediate incision and drainage of the septal hematoma. If left untreated, septal hematomas cause fibrosis and narrowing of the nasal passages, distortion of the septum, and/or formation of an abscess. They can also cause pressure necrosis of the septum, leading to septal perforation and eventually to complete necrosis with formation of a saddle-nose deformity.
Fracture management is undertaken after the hematoma has been evacuated. In patients who have significant swelling obscuring the nasal structure, fracture reduction is delayed until the swelling resolves, typically within five to 10 days. If swelling is minimal, then reduction can be performed immediately after evacuation.
Although closed reduction is appropriate in most patients with nasal fractures, open reduction may be necessary to obtain anatomic reduction. If lacerations are present, they may be used as incisions for surgical reduction. However, it should be noted that open techniques have been associated with a small incidence of necrosis of the traumatized nasal mucosa. In addition, unsatisfactory results following surgery are likely to lead to severe injury of the nasal septum that may be difficult to correct. Formal rhinoplasty may be performed at a later date to resolve breathing difficulties or improve the aesthetic appearance of the nose.
Proper reduction of a zygomaxillary complex (ZMC) fracture requires reduction and realignment of which of the following?
A) Zygomatic arch, infraorbital rim, alveolus
B) Zygomaticofrontal suture, infraorbital rim, alveolus
C) Zygomaticofrontal suture, zygomaticomaxillary buttress, infraorbital rim
D) Zygomaticofrontal suture, zygomaticomaxillary buttress, orbital floor
E) Zygomaticomaxillary buttress, infraorbital rim, alveolus
The correct response is Option C.
A zygoma fracture involves displacement of the zygoma that articulates with the frontal bone, maxilla, and sphenoid. In order to stabilize the fracture after adequate reduction, the zygomaticofrontal, zygomaticomaxillary buttress, and infraorbital rim need to be fixated. If there is a large (>2 cm2) defect in the orbital floor after reduction, reconstruction of the orbital floor is also necessary to prevent enophthalmos.
While the nasomaxillary buttress is one of the vertical buttresses of the face, the zygoma does not articulate with the nasal bones.
A 51-year-old woman is scheduled to undergo a lower lip reduction. Blockade of the mental nerve is planned for anesthesia. The most appropriate site for injection of the mental foramen blockade is the mucosa below which of the following teeth?
a. Canine
b. Central incisor
c. Lateral incisor
d. Second bicuspid
e. Second molar
The correct response is Option D.
The mental nerve foramen is located near the second bicuspid or first molar along the border of the mandible. This nerve will give sensation to the lower lip. The other answers are too distal or mesial for the mental nerve foramen.
Reference(s)
- Chapter 30: Face and Scalp. In: Standring S. Gray’s Anatomy. Elsevier 2018:475-506.
- Scalp and Face. In: Moses KP, Banks JC, Nava PB, Petersen DK. Atlas of Clinical Gross Anatomy. Elsevier Saunders 2018(4): 26-43.
A 30-year-old man sustains significant mid face injuries following a motor vehicle collision, and has a large laceration in the vicinity of the medial canthal region. Canalicular injury is confirmed intra-operatively. Which of the following is the most appropriate method for repairing this patient’s canalicular injury?
A) Delayed dacryocystorhinostomy
B) Direct microsurgical suture repair
C) Healing by secondary intention
D) Immediate dacryocystorhinostomy
E) Placement of silicone canalicular stents
The correct response is Option E.
When canalicular injury is suspected, the lacrimal system should be investigated for patency. Typically, this involves performing a Jones I and II test to determine if fluorescein navigates from the lower lid fornix into the nose. If canalicular interruption is suspected and identified, the proximal and distal stumps of the canaliculus are joined by placing a silicone stent and leaving this in place for 3 to 6 months to allow for healing.
Direct microsurgical suturing is not preferred because of the high likelihood of cicatricial obstruction.
Dacryocystorhinostomy is generally reserved as a “salvage” procedure for patients who have lacrimal obstruction after being treated with a stent. Healing by secondary intention is incorrect since it would likely result in canalicular obstruction.
A 12-year-old girl is brought to the emergency department after she sustained injuries in a motor vehicle collision. Physical examination shows extensive lacerations of the right medial orbit and forehead (shown) with complete transection of the medial canthal tendon (MCT). For effective reattachment of the MCT with transnasal wiring, which of the following is the most appropriate direction of resuspension of the tendon in relation to the anterior lacrimal crest?
(A) Anterior and inferior
(B) Anterior and superior
(C) Directly horizontal
(D) Posterior and inferior
(E) Posterior and superior
The correct response is Option E.
The medial canthal tendon (MCT) consists of three limbs: 1) a prominent anterior limb that inserts medially on the anterior lacrimal crest, 2) a thinner posterior limb that attaches to the posterior lacrimal crest, and 3) a vertical limb of fascia that inserts on the medial orbital rim inferior to the nasal frontal suture. The resultant vectors of these attachments suggest that resuspension of the entire complex of the MCT following disruption should be posterior and superior to the anterior lacrimal crest.
A 14-year-old boy is brought to the emergency department after a fall. Physical examination shows ocular entrapment. A CT scan is shown. Surgical correction is planned. Which of the following is the most appropriate location for incision in this patient?
A) Bicoronal
B) Lateral brow
C) Orbital rim
D) Subciliary
E) Transcaruncular
The correct response is Option E.
The CT scan shows an isolated medial wall fracture with entrapment of the medial rectus muscle. The transcaruncular approach can be used for isolated medial wall surgery or combined with a retroseptal transconjunctival approach to the orbital floor (with or without a lateral canthotomy).
Although a bicoronal incision will give the necessary exposure to reduce the entrapment and repair the fracture, it has a higher morbidity associated with it, primarily in regards to blood loss and scarring. In this case, it would be excessive in regards to what is needed to expose and treat an isolated medial wall fracture. The bicoronal incision is more appropriate in complex cases where multiple fractures are involved or if access to a naso-orbital-ethmoid or frontal sinus fracture is needed.
In this case, subciliary, orbital rim, or lateral brow incisions would not give adequate exposure to reduce the entrapped muscle and repair the fracture.
The 27 -year -old woman shown above comes to the office for evaluation because she has had diplopia for the past 18 months. Physical examination shows orbital dystopia, enophthalmos, and malar flattening on the right. On the basis of the current findings, this patient €™s prior injury was most likely which of the following fractures?
(A) Le Fort II fracture
(B) Le Fort III fracture
(C) Orbital floor blow €‘out fracture
(D) Orbital roof fracture
(E) Orbitozygomatic complex fracture
The correct response is Option E.
The clinical findings of orbital dystopia, enophthalmos, and malar flattening on the patient €™s right side are typical for orbitozygomatic fractures. With the downward pull of the muscles, the zygoma rotates and the orbital volume is increased. This results in enophthalmos and possible dystopia, depending on the degree of displacement. The rotation of the zygoma causes loss of malar projection. This patient had only her orbital floor repaired with synthetic mesh. This repair was inadequate for her type of fracture, and stresses the importance of correct diagnosis and treatment in order to prevent secondary post €‘traumatic deformities.
Orbital floor or roof fractures would not result in malar flattening. Le Fort II and III fractures would cause a malocclusion, which is not present in this patient.
The CT scan shown demonstrates a fracture of which of the following bones?
(A) Ethmoid
(B) Maxillary
(C) Palatine
(D) Parietal
(E) Sphenoid
The correct response is Option E.
In the CT scan, the lateral orbital wall is fractured. The lateral orbital wall is made up of the zygoma and the greater wing of the sphenoid. The medial orbital wall is made up of the ethmoid and palatine bones, and no fracture of these is demonstrated. The parietal bone largely is a cranial bone, which is not fractured in this CT scan. The maxillary bone, making up the buttresses and walls of the maxillary sinus, a portion of the orbital floor, and the medial aspect of the inferior orbital rim, is not fractured in this CT scan.
A 42-year-old man comes to the office for consultation regarding the appearance of the right eye 10 months after sustaining a fracture of the right orbitozygomatic complex and multiple lacerations in a motor vehicle collision. He was unable to undergo treatment of the fractures because of other injuries. A photograph is shown. Which of the following is the most likely cause of the enophthalmos?
A ) Atrophy of globe fat
B ) Cicatrix of adnexal tissue
C ) Eyelid lacerations
D ) Increased orbital volume
The correct response is Option D.
Posttraumatic enophthalmos is primarily the result of increased bony orbital volume. Atrophy of globe fat and cicatrix of adnexal tissue may also contribute to enophthalmos, but minimally. Eyelid lacerations do not lead to changes in orbital volume. Clinical features of enophthalmos include narrowing of the palpebral fissure and deepening of the supratarsal fold. Enophthalmos is best assessed on submental view to evaluate globe projection. Posttraumatic enophthalmos results from displaced zygoma fractures, medial wall or floor blow-out fractures, and nasoorbito-ethmoidal fractures with disruption of the medial wall resulting in increased orbital volume.
An otherwise healthy 74-year-old man presents with traumatic brain injury from an open comminuted anterior and posterior table frontal sinus fracture sustained in a motor vehicle collision. Persistent clear fluid rhinorrhea is observed when the patient is upright. The patient is initially medically unstable, and surgical intervention is delayed by 5 days. Which of the following factors represents the greatest increase in risk for a central nervous system infection?
A) Cerebrospinal fluid leak
B) More than 48 hours before operative repair
C) Open fracture injury
D) Patient age
E) Presence of traumatic brain injury
The correct response is Option B.
There are many algorithms for treating frontal sinus fractures. Unfortunately, many of these patients have other injuries that may limit their surgical options. Conservative management has been shown to be successful at managing comminuted, displaced fractures, pre-injury comorbidities, or those with cerebrospinal fluid (CSF) leak. Factors that are not associated with an increased risk for serious infection include: preoperative CSF leak, persistent CSF leak, surgical procedure performed, age, gender, and penetrating or open injury. Factors that do impact the risk for serious infection include: greater than 48 hours from injury to operating room intervention, use of CSF catheter diversion, and soft-tissue infection.
