Maxillofacial Flashcards
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 27-year-old man sustained multiple facial fractures when he was involved in a motorcycle collision. On arrival to the emergency department, blood pressure is 80/50 mmHg and heart rate is 150 bpm. Significant retropharyngeal bleeding is noted. Trauma workup reveals no other injuries. CT angiography shows active bleeding from the right maxillary artery. Angioembolization is planned and massive transfusion protocol is initiated. Which of the following is the most appropriate intravenous resuscitation in this patient?
A) Fresh frozen plasma (FFP) and packed red blood cells (pRBC) in a 1:1 ratio; discontinuation of crystalloids
B) FFP and pRBC in a 1:1 ratio; crystalloids via rapid transfuser (max rate)
C) FFP and pRBC in a 1:4 ratio; crystalloids at 125 cc/h
D) FFP and pRBC in a 1:4 ratio; discontinuation of crystalloids
E) FFP and pRBC in a 4:1 ratio; crystalloids via rapid transfuser (max rate)
The correct response is Option A.
For initiation of a massive transfusion protocol, transfusing fresh frozen plasma (FFP) and packed red blood cells (pRBC) at a 1:1 ratio and discontinuing intravenous crystalloids is the most appropriate next step in patient management.
Massive Transfusion Protocol guidelines have been set forth by the American College of Surgeons through its Trauma Quality Improvement Program (TQIP). Recommendations for initiating a massive transfusion protocol include:
Beginning universal blood product infusion rather than crystalloid or colloid solutions,
Transfusing universal pRBC and FFP in a ratio between 1:1 and 1:2 (FFP:pRBC),
Transfusing one single donor apheresis or random donor platelet pool for each six units of pRBC.
It is also suggested to deliver PRBC and FFP by a rapid transfuser and through a blood warmer, and that the initial rate of transfusion should restore perfusion while allowing for “permissive hypotension” until the operation or angioembolization to stop the bleeding begins.
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 32-year-old man comes to the emergency department after being hit in the right eye. Examination shows enophthalmos, hyphema, and numbness over the cheek. There is no diplopia. CT scan shows a large orbital floor fracture with herniation of contents into the maxillary sinus. Which of the following findings requires urgent management?
A) Cheek numbness
B) Enophthalmos
C) Hyphema
D) Maxillary sinusitis
E) Orbital floor fracture
The correct response is Option C.
Hyphema is marked by presence of blood in the anterior chamber and is an emergent concern. It can lead to permanent damage to the vision. All the other options are urgent concerns but can be addressed after the hyphema is treated.
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.
In a patient undergoing reconstructive cranioplasty, an increased rate of complications is most likely if which of the following is present?
A) Frontal location
B) Occipital location
C) Parietal location
D) Sphenoidal location
E) Temporal location
The correct response is Option A.
Early decompressive craniectomy is a life-saving maneuver for certain traumatic brain injuries and can be performed far forward in the theater of war. Patients treated with decompressive craniectomy for combat injuries are a unique understudied population. Outcome of treatment of this patient cohort has been previously reported using a standardized cranial defect treatment protocol using custom alloplast implants. Two subgroups of patients (large endocranial dead space and frontal orbital bar injuries) were identified as often having higher rates of complications than other cranial reconstruction cohorts.
A 28-year-old man is brought to the emergency department after sustaining injury during a motor vehicle collision. Cranialization of the frontal sinus is planned. Which of the following best describes the components of cranialization?
A) Removal of the anterior table, reconstruction of the posterior table with a titanium plate, and closure of the dura
B) Removal of the posterior table, sinus mucosa, and closure of the sinonasal tract
C) Repair of both the posterior and anterior tables with bioabsorbable plates, and obliteration of the frontal sinus
D) Repair of the anterior table and obliteration of the frontal sinus
E) Repair of the posterior table with bioabsorbable plates, removal of the sinus mucosa, and closure of the dura
The correct response is Option B.
Cranialization involves removal of the posterior table (not repair), closure of the dura, sinonasal tract, and obliteration of the sinus mucosa. Management of the anterior table is as indicated.
Surgical repair of the anterior table is indicated if there is nasofrontal duct involvement, or, in the absence of nasofrontal duct involvement (such as a minimally displaced anterior table), patient desire for a better aesthetic outcome. If there is nasofrontal duct involvement, the nasofrontal duct and frontal sinus can be obliterated (repair of the anterior table and obliteration of the frontal sinus).
Bioabsorbable or titanium plates can be used to fixate the fractured anterior table. It is not used for the posterior table.
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 40-year-old man and his 80-year-old father are assaulted. They both have facial fractures. The older victim is more likely to have which of the following?
A) Decreased chance of noncraniofacial injuries
B) Higher mortality
C) Less severe injuries
D) Mandibular body fracture
E) Shorter hospital stay
The correct response is Option B.
In recent years many publications focused on craniofacial injury in the elderly as not only the mode of trauma differs compared with the younger population, but also the associated injuries and morbidities. In general, most related comorbidities in patients older than 60 to 65 (depending on the study) versus those younger are worse, including: longer hospital stays, need for assistance upon discharge, more severe injuries, likely to have noncraniofacial injuries like limb and spine fractures, and, of greatest concern, a much higher death rate. In a recent article though, Mundinger et al, showed that panfacial and mandible fractures were more common in the nongeriatric population, whereas mid face, orbital, and condylar fractures were more common in those older than 60 years of age.
A 20-year-old man desires correction of a depressed, retracted, post-tracheostomy scar. Which of the following is the best recommendation for improving the scar?
A) Perform autologous fat grafting and laser resurfacing
B) Reconstruction tracheal ring and detach adhesions
C) Scar excision and interposition of acellular dermal matrix
D) Scar excision and reapproximation of strap muscles
E) Scar revision
The correct response is Option D.
After decannulation, the tracheostomy site heals by secondary intention. Often the patient is left with a soft, small asymptomatic scar. On occasion, the scar is painful and the skin has adhesions to tissue deep to the strap muscles. This may lead to pulling and retraction with swallowing as well as a scar that is not aesthetically pleasing to the patient. The depressed retracted tracheostomy scar requires reapproximation of platysma and approximation of the sternothyroid and sternohyoid for correction. Fat grafting is unlikely to address retraction or fully correct the depression. Laser resurfacing and fat grafting will have minimal improvement of retraction. Several studies support use of cadaver materials or fascia to support the coverage of the strap muscles when tissue is missing or heavily damaged. The tracheal ring does not need to be reconstructed for routine tracheostomy scar revision. Care must be taken when working around the trachea. Communication with anesthesia about oxygen content and fire risk is important for surgical safety.
