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Head and Neck / CF > Fractures of the upper 1/3 of face > Flashcards

Fractures of the upper 1/3 of face Flashcards

1
Q

What is hypertelorism and how is it classified?

A

IOD (dacryon to dacryon) >29mm. Tessier classification, by IOD. Mild 30-34, Moderate 35-40 Severe >40

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2
Q

What is telecanthus?

A

ICD (medial canthus to medial canthus) >35mm. Normal ICD 33-35 or 1/5 width of face

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3
Q

What is ophthalmoplegia?

A

Paralysis of one or more EOM

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4
Q

What is pseudoptosis?

A

Excess of upper lid skin but normal lid to pupil distance

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5
Q

Describe the development of the frontal sinus

A

Absent at birth Forms from lining of ant.ethmoid air cells at 2yo Pneumatization begins at 6yo (visualized on radiograph) Completed development at 10-12yo

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6
Q

What is the venous drainage of the FS?

A

1- Diploic veins of Breschet (drain into dural veins) 2- Angular facial veins

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7
Q

What is the mucous drainage of FS?

A

1- into Anterior ethmoid toward middle meatus (75%) 2- into NF duct toward middle ethmoid below the middle meatus (25%) Ostium is in the posteriomedial floor of the FS

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8
Q

Describe the development of the maxillary sinus.

A

Present and pneumatized at birth Develops until puberty

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9
Q

What teeth roots can penetrate into the maxillary sinus?

A

1st & 2nd premolars 3rd molar

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10
Q

What is the mucous drainage of the maxillary sinus?

A

Middle meatus

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11
Q

What are the boundaries of the ethmoid sinuses?

A

1- Lateral: Lamina Paprycea 2- Midline: Ethmoid plate 3- Posterior: Sphenoid

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12
Q

What are the boundaries of the sphenoid sinus?

A

Within the body of the sphenoid

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13
Q

What is the shape of the orbit?

A

Pyramidal The base is lateral and inferior relative to the apex

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14
Q

What bones form each wall of the orbital cavity?

A

Roof: Frontal, Sphenoid lesser wing Lateral: Frontal, Zygoma, Sphenoid Greater wing Medial: Maxilla, Sphenoid Body, Lacrimal, Ethmoid Floor: Maxilla, Zygoma, Palatine

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15
Q

What forms the posterior shelf of the orbital cavity?

A

The palatine bone

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16
Q

What is the conus of the orbit?

A

Musculofascial system containing the EOM and fascia

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17
Q

What is in the intraconal space?

A

NO muscles!!!

Ophthalmic artery

superior orbital vein

CN 2

CN 3

CN 4

CN 6

CN 5 V1 nasociliary br

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18
Q

What is in the extraconal space?

A

Lacrimal gland

Lacrimal sac

Fat

Superior ophthalmic vein (posterior br)

(All contents are between the conus and the orbital cavity)

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19
Q

What are the contents of the infraorbital fissure?

A

CN5 V1 (Zygomaticofacial, Zygomaticomaxillary)

CN5 V2 (Infraorbital)

Infraorbital artery

Inferior ophthalmic vein

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20
Q

What are the contents of the superior orbital fissure?

A

CN 3

CN 6

Intra conal above - Extra conal below

CN 4

CN 5 V1 lacrimal, frontal branches

Parasympathetic nerves to pupil

Superior ophthalmic vein

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21
Q

What are 3 clinical findings of Enophthalmus

A

1- Narrowed palpebral fissure

2- Pseudoptosis

3- Deepened Upper lid sulcus

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22
Q

How can you objectively measure enophthalmus (2)?

A

1- Helter exophthalmometer (measure from lateral orbital rim to anterior cornea)

2- Forward traction test (pull bulbar conjunctiva to try and anteriorly displace globe)

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23
Q

What causes enophthalmus?

A

1- increased orbital volume

2- decreased orbital contents

3- globe retraction

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24
Q

What is clinically significant orbital volume change?

A

3.5cc volume change = 3mm displacement

13% volume change = 3mm displacement

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25
Q

How do you manage enophthalmus?

A

1- Restore VOLUME (reconstruction with alloplast/autologous)

2- Release RETRACTING tissues

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26
Q

Why do we recommend no noseblowing post-op facial fractures involving orbit?

A

Tension Pneumo-orbit = Orbital compartment syndrome

= compression of CROA

*air enters via maxillary sinus (floor) and anterior ethmoid (medial wall)

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27
Q

Describe anatomy of medial canthal tendon

A

3 limbs

  • anterior: attaches to anterior lacrimal crest
  • Posterior: attaches to posterior lacrimal crest
  • superior: attaches at frontomaxillary juncture

MCT is continuous with tarsus LCT

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28
Q

Describe anatomy of lateral canthal tendon.

A

2 limbs

  • deep STRONG limb: inserts into whitnall’s tubercle (posterior along orbital rim)
  • superficial weak limb: inserts onto orbital rim
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29
Q

What is red saturation test

A

Sensitive test for visual acuity. Show bright red object to each eye and see if different brightness of red

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30
Q

What are signs of globe rupture?

A
  • pupil shape abnormality (tear drop, cat eye)
  • Fat herniation from globe
  • subconjunctival hemorrhage
  • hyphema
  • flat anterior chamber
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31
Q

What determines pupil shape?

A

Sympathetics CN5- pupil constriction

Parasympathetics CN3 - pupil dilation

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32
Q

What is normal IOP?

A

10-20mmHg

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33
Q

What are principles of corneal protection?

A

INDICATIONS FOR PROTECTION

  • CN7 dysfx
  • Chemosis
  • lid injury

TREATMENT

  • tobramycin or garamycin ointment and occlusive dressing
  • tarsorrhaphy
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34
Q

How do you manage a suspected globe rupture

A

Assessment

  • ophtho
  • shield eye
  • NPO
  • do no dilate eye, do not measure IOP
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35
Q

What is a complication of globe rupture?

A

SYMPATHETIC OPHTHALMIA = BILATERAL GRANULOMATOUS UVEITIS

  • purulent uveitis 2’ immune reaction to choroid antigens, leads to immune reaction to contralateral eye => bilateral blindness
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36
Q

What is Traumatic Optic nuropathy (TON)

A

Loss of visual acuity secondary to trauma

  • no evidence of external injury and normal initial ophtho asx.
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37
Q

What are causes of TRaumatic optic neuropathy (TON)

A

1- Trauma to CN2 (shear force, compression, iatrogenic)

2- Ischemia of CN2 (edema, hemorrhage)

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38
Q

How do you manage Traumatic optic neuropathy?

A

Methylprednisolone x48hrs

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39
Q

What are indications for operative Tx of TON (with decompression of optic canal)?

A

1- Drop in VA over 48hrs and <20/800??

2- CN2 sheath hematoma

3- compression of CN2 with bone fragment

4- Post-op TON

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40
Q

What is superior Orbital fissure syndrome?

A

Compression of contents of SOFissure

CN3 + parasympathetics, CN4, CN6, Cn 5 branches (lacrimal frontal)

Superior orbital vein

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41
Q

Where is the superior orbital fissure?

A

Sphenoid bone

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42
Q

Where is orbital canal

A

Sphenoid

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43
Q

What are clinical features of SOFS?

A
  • ophthalmoplegia
  • ptosis
  • dilatation of pupil
  • loss of corneal sensation
  • loss of forehead sensation
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44
Q

How do you manage SOFS?

A

Same as TON

Methylprednisone x48hrs

Operative indications

  • post-op
  • bone fragment causing compression
  • hematoma as cause
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45
Q

What is orbital apex syndrome

A

SOFS with CN2 involvement:

+ decreased visual acuity

+ RAPD

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46
Q

How to you surgically treat retrobulbar hematoma

A

1- release sutures

2- lateral cantholysis

3- lateral inferior canthotomy

4- Drainge of hematoma from upper and lower lid sutures

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47
Q

How do you treat post-op RB hematoma compared to post traumatic RB hematoma

A

Post-op RM hemetoma:

  • cantholysis/canthotomy, to OR for decompression

Post- trauma (F#) RB hematoma

  • treatment aims to reduc IOP - less likely to benefit because injury has already occured
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48
Q

What is oculocardiac reflex>

A

ANS drive symptoms secondary to orbital injury and compression of V1

  • bradycardia
  • syncope
  • nausea
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49
Q

How to do treat OCR in kids?

A

Atropine (block parasympathetics

Urgent orbital exploration and reduction

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50
Q

How to you classify diplopia?

A

By CAUSE

1- Mechanical

  • entrapment of IO/IR, Tenon, Lockwood
  • Change in EOM shape/length (enopthalmus/dystopia)

2- NON-MECHANICAL

  • nerve injury
  • muscle injury
  • preexisting phoria
51
Q

How do you manage diplopia

A

1- Non-op: prisms corrective wear

2- Operative: strabismus surgery: 6-9m post surgery. resection/recession/transposition

52
Q

What is progrosis of diplopia if untreated?

A

50% resolved

25% resolve delayed at 6wks

25% unresolved

53
Q

How to you manage hyphema

A
  • shield eye!!!!!!!!!!!!!!!!!! (hurts to accomodate pupil)
  • HOB up
  • bed rest
54
Q

Where is the canaliculis?

A

2mm vertical and 8mm horizontal from punctum

55
Q

How do you treat canaliculi injury?

A

If both injured, repair one w crawford tube to stent it open

Dacrocystorhinostomy to restore flow from sac to inferior meatus

56
Q

What are clinical features of Frontal sinus F#?

A
  • post-nasal drip
  • forehead pain, swelling, bruising
  • periorbital swelling, bruising, subconj hemorrhage
  • paresthesias V1
57
Q

How do you classify FSF#?

A

1- Location : anterior or posterior table

2- Displacement: displaced by >1width of table, comminution

3- CSF leak: presence of absence

4- NFD involvement: yes or no

58
Q

WHat are indictions for operative treatment of Frontal sinus F#

A

1- NFD injury (usually associated with NOE)

2- Persistent CSF leak >72hrs

3- Displacement of posterior table

4- Displacement of anterior table and contour deformity

5- Open F#

59
Q

What are indications for non-operative tx of frontal sinus F#?

A

1- medically unfit

2- anterior and posterior table displaced but no csf leak

3- minimally displaced anterior table

4- Option for secondary recon for contour

60
Q

What are the operative treatment options for FSF# if NFD is involved vs. not?

A

1- FSF with no NF duct involved - ORIF frontal bone

2- FSF with NF duct involved - obliteration of FS (mucosal exenteration, NFD obliteration) and ORIF frontal bone

61
Q

What are indications for cranialization?

A

FS# with CSF leak 2’ posterior wall involvement

62
Q

Describe the steps of cranialization

A

1- Neurosurgery consult and OR presence

2- ORIF anterior table

3- FS obliteration (mucuosal exenteration, NFD ostium obliteration)

4- Removal of posterior table and repair of dural tears

63
Q

What materials can be used for obliteration of NFD ostium?

A

1- Autgenous:

Vascularized: pericranial flap

Graft: fat, fascia(TPF), cancellous bone ,muscle (temporalis)

2- Alloplastic

Bone cement, PMMA with titanium mesh?

64
Q

What are complications of a FSF#?

A

EARLY

  • BONE: contour deformity, lose hardware, resorption)
  • INFECTION: OM, encephalo/meningitis, sinusitis, wound infection
  • NERVE: injury to SON, anosmia
  • CSF leak

LATE

  • INFECTION: mucocele (closed mucosa), mucopyrocele (infected), chronic frontal sinusitis, frontal OM (potts puffy tumor)
65
Q

What is management of a mucopyrocele

A

Emergent Evacuation

Antibiotics

removal of hardware

Reconstruction to seperate nasal cavity and orbital cavity/crnaial cavity

66
Q

Why is mucopyrocele an emergency?

A

Can lead to abscess of brain/subdural/epidural/meningeal

67
Q

What are signs and symptoms of CSF rhinorrhea

A
  • clear leak when SITTING FORWARD
  • POSTURAL HEADACHE
  • ANOSMIA
68
Q

what are investigations for determining presence of CSF leak?

A
  • positive Beta trasnferrin
  • halo sign (blood centrally and clear fluid ring around)
69
Q

How do you manage CSF leak?

A

Non-operative

Conservative for 72hrs

  • HOB at 30’, prevent nausea, hypertension

If no resolution at 3-5days, lumbar drain

Operative

  • dural patch
70
Q

Indications for operative repair of CSF leak

A
  • failure conservative management
  • large displaced fragment of bone. penetrating injury
  • large pneumocephalus
  • meningitis despite abx
71
Q
A
72
Q

What is the pathophysiology of orbital compartment syndrome?

A

1- SOL (retrobulbar hematoma) or other lesion (abscess) increasing pressure in closed spcae (orbital septum and canthal tendons)

2- compensatory proptosis

3- RESULT - CRA compression

73
Q

What are clinical features of orbital compartment syndrome?

A
  • PAIN
  • proptosis
  • decrease function of CN2 (VA, visual field, APD)
  • IOP>30mmHg
74
Q

Managmeent of a RB hematoma

A

Acetazolimide 500mg IV x1 then 250mg IV q6h

Timilol 0.5% 1gtt affected eye BID

Methylprednisone 1000mg IV x1

Mannitol 1-2g/kg IV over 30-60mins

analgesics

+/- canthotomy

75
Q

What are operative indications for RB hematoma?

A
  • in awake patient: acute VA loss
  • if not awake: proptosis, IOP>40mmHg +/- RAPD
76
Q

How do you classify obital floor f#

A

Blow out: pure (rim intact) vs impure (rim injured)

Blow in

77
Q

Why do all orbital F# require ophtho consult?

A

30% or orbital fracture have ocluar injury

78
Q

Describe OR sequence for Orbital floor f# repair

A

1- optho pre-op consult

2- forced duction pre-post

3- temp tarsorrhaphy then confirmer

4- release and elevation of periorbital tissue

5- ORIF rim

6- Recon orbital cavity

79
Q

What are options for recon of orbital floor

A

Alloplastic

  • titanium mesh
  • pmma
  • MEDPOR TITAN (high density porous polyethylene with titanium mesh - malleable, visible on imaging, minimal ingrowth on superior surface given density)
  • polygalactin (absorbable)

Autogenous

  • bone graft
80
Q

What are surgical approaches to the lower lid?

A
  • transconjunctiva (retroseptal, preseptal)
  • subciliary
  • midlid
81
Q

Describe subciliary approach and compx

A
  • 2mm below lash line
  • Sq dissection above tarsus until past tarsus
  • cut through O.ocli and septum to rim

+/- lateral extension

Complications

  • 20% rate of compx, 14% ectropion
82
Q

Describe mild lid approach and compx

A
  • in lower crease below tarsus
  • thgough subq and O.oculi
  • dissect along septum to rim and through arcus marginalis

Complication 10%

83
Q

Describe transconjunctival

A
  • below tarsus but above arcade
  • trhough lower lid retractors

preseptal - thgouth septum, trace along deep surface of o.oculi to rim

retroseptal - alonf fat to rim - avoid septum and CPF confluence disruption.

complication - ectropion 1.5%

84
Q

What is white-eyed blow-out?

A

Trapdoor f# in child

entrapment with restricted EOM

Nausea/vomiting

No periorb ecchymosis (white eye)

85
Q

What are clinical features of an orbital fracture?

A

diplopia

enophthalmus

infraorbital nerve paresthesia

86
Q

What is best imaging for orbital fractures

A

CT coronal - to view size of floor defect and for rounding of IR

CT sagittal to view floor inclination

3D recon for orbital volume

87
Q

Indicaitions for non-operative treatment of orbital f#

A

no defect/displacement

monocular patient

medically unstable

* need to review patient in 5-7days to re-examine for enophthamus, diplopia, ocular injury

88
Q

Indiciations for operative treatment of orbital f#

A

entrapment

enophthalmus

(only two according to JF)

relative:

RB hematoma

hypoglobus

defect >1cm2

diplopia in functional fields of gaze unresolved in two weeks

89
Q

What are early complications post-op of orbital fracture ORIF?

A
  • worse/new diplopia
  • retrobulbar hematoma 3%
  • optic nerve injury w visual loss 1%
  • compression to parasympathetic nerve w pupil dilatation
  • SOFS, OAS
  • V2 numbness
90
Q

What are late complications of orbital f# ORIF

A

ENOPHTHALMUS 20%

DIPLOPIA

Ectropion 10%

Damage of canaliculi, lacrimal system, lid elevator

Sinusitis

91
Q

How do you classify orbital roof f#? (sullivan)

A

undisplaced

displaced with orbit involvement

displaced with brain involvement

92
Q

What are operative indications for orbital roof f#

A

Need for decompression of SOF contents of optic canal

Repair of associated injuries (dural tear)

Prevent herniation of cranial contents into orbit

93
Q

What is an NOE fracture

A

Fracture of lower /3 of medial orbital rim allowing for segment displacing the MCT

94
Q

What defines an NOE fracture

A

Fracture of four regions

1- orbital rim

2- medial orbital wall

3- superior nasomaxillary buttress (maxilla at jx w frontal bone)

4- inferior nasomaxillary buttress (at piriform)

95
Q

What are clinical features of NOE

A
  • telecanthus >35mm
  • short palpebral fissure
  • epiphora (in 100% of cases)
  • epistaxis/CSF rhinorrhea
  • loss of nasal projection, height
96
Q

How do you classify NOE fracture

A

Manson - Markowitz classification

Type 1 - single central fragment bearing MCT

Type 2 - Comminuted central fragment external to insertion of MCT

Type 3- Comminuted central fragment extending into MCT (avulsion in 5% only)

97
Q

Indications for NOn-operative tx of NOE

A

no displcaement on CT or physical exam

98
Q

Indication for opeative tx of NOE

A

Displaced fragment

Mobility of canthal bearing segment

CSF leak with extended cranial fractures

epiphora NOT ADDRESSED at 1’ surgery

99
Q

Treatment of NOE fractures according to type

A

Type 1: ORIF with plates and screws

Type 2: ORIF with plates, screws adn trasnasal wires

Type 3: ORIF with 1’ BG, ORIF plates and screws and trasnansal wires

100
Q
A
101
Q

What is a normal medial wall distance?

A

25mm

102
Q

Describe transnasal wiring

A
  • place wire posterosuperior to lacrimal fossa, just below NFsuture. if too anterior, get rotation of segment posterirly which actually causes telecanthus

ALL NOE neeed MANSON splint

103
Q

What is the resulting deformity of untreated Lefot 1?

A

Malocclusion

Anterior open bite

elongated posterior midface

104
Q

What is the resulting deformity of untreated zygoma?

A

enophthalmus, increased facial width, decreased projection

105
Q

What is the resulting deformity of untreated NOE?

A

Telecanthus

canthal dystopia

106
Q

Why is timing 2wks for facial fractures?

A

b/ soft tissue contracts, fracture heals

107
Q
A
108
Q

Scarring in each lamella of the lower eyelid will cause what deformity

A
109
Q

what and where is the carumcle

A

confluence of periosteum, deep tarsal fascia and CPF. Need to be infront of lacrimal fossa (at caruncle) and dissect behind lacrimal crest, leaving the sac down, dissecting above or superficial to lacrimal sac. Limited by mct

110
Q

Describe steps of ORIF zygoma

A

Need 3 pts of fixation per f# sgement, but not all three if low evergy.

Will expose orb floor w midlid if high energy and expect injury

If low E, start w UBS and lateral wall

111
Q

When do you need a coronal for zygoma?

A

so comminuted there is no bony continuity

112
Q

Where is the optic canal, and what are its contents?

A
  • within lesser sphenoid
  • 45-55mm superomedial from oribtial rim
  • optic nerve & ophthalmic artery
113
Q

where is the superior orbital fissure and what are it’s contents

A
  • superior orbital fissue is between the greater and lesser sphenoid bone
  • contents include:
    • CN III, IV, VI
    • CN V1 - lacrimal, nasociliary, frontal
    • parasympathetic nerve to pupil (v1)
    • superior ophthalmic vein
114
Q

what is the inferior orbital fissure bounded by, and what are its contents?

A
  • Bounded by:
    • superiorly: greater wing of sphenoid
    • inferiorly: maxilla and orbital process of palatine bone
    • laterally: zyoma
  • CN V2: infraorbital, zygomaticofacial, nasofrontal
  • inferior orbital artery, inferior ophthalmic vein
115
Q

what are the components of the medial canthus

A
  • medial canthal ligament
  • medial check rein ligament (fascial extension of medial rectus)
  • Whitnall & Lockwood ligament
  • Levator superioris aponeurosis
  • septum
  • deep head of pretarsal OO
116
Q

what are the insertion points of the medial canthal ligament?

A
  • 3:
    • anterior to lacrimal fossa (maxilla)
    • posterior to lacrimal fossa (lacrimal bone)
    • superiorly near NF suture
117
Q

what comprises the lateral canthus?

A

4L’s

  • lateral canthal ligament
  • lockwood (and whitnall) ligament
  • lateral rectus check rein ligament
  • levator aponeurosis
118
Q

what are clinical features associated w/ globe rupture

A
  • extruding eye contects
  • subconj hemorrhage
  • oblonge / cat eye pupil
  • hyphema
119
Q

what is sympathetic ophthalmia?

A
  • autoimmune reaction that can occur after a globe rupture
  • mechanism: globe rupture +/- subsequent necrotic globe releases choroidal pigment systemically
  • this induces an autoimmune response to uvea and can result in ipsilateral purulent uveitis
  • bc systemic, a contralateral purulent uveitis autoimmune reaction can occur, causing bilateral blindness
120
Q

what are bad prognostic features of traumatic optic neuropathy?

A
  • associated orbital fracture
  • sudden onset
  • no light perception at presentation
  • penetrating injury

(not, good prognostic features are exact opposite of above)

121
Q

A patient has post-operative hypertension and vomiting after orbital floor repair. This is followed by extreme pain of ipsilateral globe, proptosis, diminished EOM.

What is your suspected diagnosis?

What will you do immediately?

What will you plan urgently within 2 hours?

Will anything be different if there is a sudden change to visual acuity,

A
  • Post-operative retrobulbar hematoma
  • Immediately will put patient on 95% O2 and elevate HOB
  • Call ophthalmology for stat assessment +/- bedside tonometer to measure IOP
  • Initiate medical treatment w IV mannitol, diamox (CA inhibitor) +/- oral steroid +/- topical beta-blocker
  • Consider stat CT scan
  • with a sudden change to VA consider adding
    • suture removal
    • lateral canthotomy / cantholysis
    • urgent (WI 2 hrs) trip back to the OR for exploration / evacuation of hematoma (consider interval imaging after cantholysis)
122
Q
A
123
Q

why would a patient have diplopia after orbital floor fracture?

A
  • mechanical causes
    • entrapment of periorbital tissue
      • muscle
      • fat
      • suspensory ligamentous strutures
    • enopthalmos
    • dystopia
  • non-mechanical causes
    • nerve injury
    • muscle injury: acute - hematoma; late - fibrosis
    • CNS injury
    • pre-existing phoria or tropia

Head and Neck / CF (27 decks)

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