Maxillofacial Trauma Flashcards
What GCS score would necessitate intubation?
GCS 8
What are the stages of hemorrhagic shock?
-Stage I: 750 mL blood loss, slightly anxious
-Stage 2: 750-1500 mL blood loss, anxious, slightly tachycardic
-Stage 3: 1500-2000 mL blood loss, confused, tachycardic, hypotensive, 5-15 mL urine output
-Stage 4: 2000 mL+ bloss loss, lethargic, hypotensive, scarce urine output
Describe the Glasgow Coma Scale
-Eyes 1-4: No response, pain only, verbal stimuli, spontaneous
-Verbal 1-5: No response, incomprrehensible, inappropriate, confused, oriented
-Motor 1-6: No response, extension, flexion, withdraws from pain, purposeful, obeys command
How are head injuries classified?
-Severe: GCS 8 or less
-Moderate: GCS 9-12
-Mild: GCS 13-15
-T indicates intubated patient
What are the zones of the neck for penetrating trauma?
-Zone 1: Thoracic inlet to cricoid cartilage
-Zone 2: Cricoid cartilage to angle of mandible
-Zone 3: Angle of mandible to the base of skull
What is the definition of rigid fixation and semi-rigid fixation?
-Rigid fixation: Fixation that prevents interfragmentary movement when a load is applied
-Semi-rigid fixation: Fixation that is not sufficient strength to prevent interfragmentary movement during loading but is adequate to allow union of bone
What is the difference between load bearing and load sharing?
-Load Bearing: Hardware is sufficient strength to bear the entire load. Need at least 3 screws at each segment
-Load sharing: Hardware does not bear entire load but shares with surrounding bone. Use of miniplates and monocortical screws
What are the ideal lines of osteosynthesis?
-Described by Champy
-Line around mandible where plating the tension and compression forces are balanced, offers the best biomechanical advantage for positioning plates/screws
What is the difference between locking and non-locking plates/screws?
-Non-locking: Plate must be adapted intimately to the bone. Compression of the plate onto the bone may cause bone resorption
-Locking: Screw locks in to the plate while being tightened. Does not require perfect adaptation
Describe primary vs secondary bone healing.
-Primary bone healing: Heals by haversian remodeling directly across fracture site. No gap between segments. If gap, deposition of lamellar bone if small gap exists. Requires absolute rigid fixation with minimal gap
-Secondary bone healing: Bony callus forms across fracture site to aid in stability and immobilization. Occurs when there is mobility. Secondary bone healing involves formation of granulation tissue and then thin layer of membranous ossification. Hyaline cartilage is deposited and replaced by woven bone and matures to lamellar bone
What are important aspects of the HPI in a trauma patient?
-Mechanism of injury
-LOC
-Confirm ATLS/PALS
-Ensure proper consultations
-Ensure C-spine evaluated
What is battle’s sign indicative of?
-Base of skull fracture
Describe the nomenclature in mandibular trauma: simple, compound, comminuted, greenstick, pathologic.
-Simple: Not open to external environment
-Compound: Open to external environment
-Comminuted: Splintered/crushed
-Greenstick: Only one cortex fractured
-Pathologic: Pre-existing disease of bone leads to fracture
Describe vertically/horizontal favorable.
-Vertically favorable: Medial pull of muscle reduces fracture
-Horizontally favorable: Vertical pull of muscle reduces fracture
For an edentulous mandible, where is the blood supply mostly from?
-Dependent on periosteal blood flow
-Decreased inferior alveolar artery blood flow
What are the classifications of mandibular condyle fractures?
Wassmud Scheme
-I: Minimal displacement of head
-II: Fracture with tearing of medial joint capsule, bone still contacting
-III: Bone fragments not contacting, condylar head outside capsule medially and anteriorly displaced
-IV: Head is anterior to the articular eminence
-V: Vertical or oblique fracture through condylar head
AO Classification: Use sigmoid notch, lateral pole of condyle, high vs low condylar neck
What are the goals of condylar fracture repair?
-Pain free opening over 40 mm
-Good excursive ROM
-Preinjury occlusion
-Stable TMJ
-Facial/jaw symmetry
What are the criteria for absolute and relative indications of condylar repair?
Zide Absolute:
-Middle cranial fossa involvement
-Inability to achieve occlusion with CR
-Invasion of joint space by a foreign body
-Lateral capsule violation and displacement
Zide Relative:
-Bilateral condylar where vertical height needs to be restored
-Associated injuries requiring early or immediate function
-Medical conditions that indicate open
-Delayed treatment with misalignment of segments
What is a non-union (including time-frame)?
-Arrested healing after appropriate time has passed
-Mobility after 4 weeks without treatment or 8 weeks with surgical management
How is bleeding during Lefort fracture managed?
-If from pterygoid muscles: Pack with surgicel/fibrin
-If from pterygoid plexus: Tread with LA packing
-If from descending palatine, PSA, or sphenopalatine treat with vessel clips
-Consider embolization if bleeding can’t be controlled with above measures
What are the classifications of Lefort fracutres?
Lefort I: Horizontal (above root apicies)
Lefort II: Pyramidal (extends to nasofrontal region, inferior orbit)
Lefort II: Complete craniofacial disjunction (zygomaticofrontal suture, orbital lateral walls)
What are the classifications of ZMC fractures?
Knight and North
-Group 1: Nondisplaced
-Group 2: Arch fractures
-Group 3: Unrotated
-Group 4: Medially rotated
-Group 5: Lateral rotation outward
-Group 6: Complex fracture
Zingg
-Type A1: Isolated arch, A2: Isolated lateral wall, A3: Isolated inferior orbital rim
-Type B: Monogragment of all 4 buttresses
-Type C: Comminution of zygomatic bone
How can you confirm intra-op reduction of the zygomatic arch?
-Submentovertex view radiograph
What is the sequencing of fixation for a ZMC fracture?
-ZF (restore facial height)
-ZM (Facial projection)
-Fixate orbital rim
-Orbital floor last
ZS good indicator of 3D position of zygoma
How is a post-op asymmetry/malunion treated s/p ZMC reduction?
-Can be managed with osteotomies, onlay graft, alloplastic implants
What is the average volume of the globe?
-30 mL
What bones make up the orbit?
-Roof: Frontal/lesser wing of sphenoid
-Lateral: Greater wing of sphenoid, zygoma
-Floor: Maxilla, zygoma, palatine
-Medial: maxilla, ethmoid, lacrimal and sphenoid
Where is the infraorbital groove?
2.5-3 cm posterior to the orbital rim (infraorbital nerve runs through and exits 5 mm below the infraorbital rim)
What structures are in the superior orbital fissure?
-CN III, IV, V1, VI, sympathetic fibers
-Superior opthalmic vein
-Recurrent/middle meningial artery
What structures are in the inferior orbital fissure?
-V2, parasmpathetic branch of pterygopalatine ganglion
-Inferior opthalmic vein
What structures are in the optic canal?
-Optic nerve, opthalmic artery, sympathetic fibers
Where is Whitnall’s tubercle and what attaches to it?
-10 mm below ZF suture, 3-4 mm insite lateral orbital rim
-Lateral horn of levator aponeurosis, lateral canthal tendon, lockwood’s ligament, check ligaments (all these are lateral retinaculum)
What is the annulus of Zinn?
-Tendonous ring of fibrous tissue at apex of the orbit surrounding the nerve that is the origin of the rectus muscles of eye
What are the safe distances of the orbit?
-From intact anterior lacrimal crest:
-Anterior ethmoid foramen 24 mm
-Posterior ethmoid foramen 36 mm
-Optic foramen 42 mm
What are the layers of the eyelid?
-Skin
-Subcutaneous tissue
-Orbicularis oculi
-Septum
-Tarsal plate
-Conjunctiva
What is the orbital septum?
-Dense CT arising from orbital periosteum; forms anterior boundry of the orbit
-1-2 mm below infraorbital rim it fuses with thickened periosteum to form arcus marginalis
What are normal tonometry values?
10-20 mmHg
Where does the nasolacrimal duct open?
-10 mm behind nasal aperture (into inferior meatus), Hasner’s valve
What is a white eyed blowoutfracture?
-Intact orbital rim but blow-out orbital floor fracture. Typically in pediatric population with restrictive strabismus
What are the indications for orbital repair?
-Larger fractures: 50% orbital floor, enophthalmos 2 mm, diplopia in primary gaze
-Muscle incarceration is a true emergency
What is the technique for a tranconjunctival orbital repair?
-Corneal shield
-Local
-15 blade for incision through lateral canthus (tip of iris scissor placed insite palpebral fissure, extending laterally to the depth of the underlying lateral orbital rim. Scissors used to cut horizontally through the lateral palpebral fissure (skin, orbicularis muscle, orbital septum, lateral canthal tendon and conjunctiva
-Using lateral orbital rim as a stop, inferior cantholysis is performed by turning the orientation of scissors vertically to incise inferior canthal ligament
-Using blunt tipped pointed scissors, dissection through the conjunctiva, stay 3 mm away from caruncle
-Use scissors to incise conjunctiva below curvature of the tarsal plate (may use 5/0 nylon traction sutures)
-Palpate bony orbit, blunt dissection to orbital rim
-Periosteal elevator to dissect and visaulize floor. Use broad maleable to protect orbit
-Reconstruct with medpore titan
-Foreced duction
-4/0 vicryl to reattach lower limb of lateral canthus
-6/0 skin suture along horizontal lateral canthotomy
-6/0 fast gut for conjunctiva
How is an orbital implant infection managed s/p ORIF orbital floor?
-Implant removal, culture, start antibiotics
How is post-op implant migration managed s/p ORIF orbital floor?
-Early: Reposition with additional fixation
-Late: Implant removal
How is post-op ectropion or entropion managed s/p ORIF orbital floor?
-Ectropion: Shortening of anterior lamellae. May require tarsal strip
-Entropion: Due to shortening of the posterior lamellae. May require suturing (passing a gut suture through the inferior fornix anteriorly towards to lashes). May require grafting (oral mucosa, contralateral eyelid, ear)
What is sympathetic ophthalmia and how is it treated?
-Injury induced autoantibodies to uveal tissue, 80% occur within 3 months
-Enucleation: Removal of globe without rupture
-Evisceration: Leave the sclera/cornea
-Exenteration: Remove entire contents of the orbit
How is a post-op retrobulbar hemorrhage treated s/p ORIF orbital floor?
-1% incedence
-Pain, proptosis, decreased visual acuity
-Manage medically with IV infusion of mannitol 2g/kg to shrink vitreous humor, possibly acetazolamide or steroids
-Manage surgically with lateral canthotomy with cantholysis
How is a nasolacrimal duct injury tested for?
-Jones I: Few drops of fluorescene or propoful in lower conjunctival sac, observe if drains in nose. If not go to Jones II
-Jones II: Irrigate the punctum and inject into puncta/canaliculi. If drainage seen then issue with lacrimal sac. If nothing seen then injury more distal
Describe primary and secondary repair of the nasolacrimal duct.
-Primary repair: Dilate with bowman probe, place stent (crawfor tube or jackson tube) through puncta and duct. Suture both ends with 8/0 PDS and leave for 3 months
-Secondary repair: Dacryocystorhinostomy. Create a bony window between the lacrimal sac and nose
How is a corneal abrasion treated?
-Pain, tearing, photophobia, foreign body sensation
-Treat with topical antibiotics
What is hyphema (including grading)?
-Bleeding from a torn vessel at the root of the iris in the anterior chamber. Blurred vision and photophobia
-Grade 1: 1/4 of anterior chamber
-Grade 2: 1/2 of anterior chamber
-Grade 3: 3/4 of anterior chamber
-Grade 4: Complete blockage (blackball)
How is hyphema managed?
-Atropine 1% ophthalmicd drops BID/QID
-Timolol BID or acetazolamide
-Steroids
-Bed rest with HOB elevated
-3-38% rebleeding most common 2-5 days after injury, glaucoma after one year, corneal staining in 5%
What is an afferent pupillary defect?
-Marcus Gunn pupil
-Swinging flashlight test
-Light in the affected eye produces mild to no consensual light reflex
-Switching to normal eye produces equal constriction
-Swing back to affected eye produces dilation
What is traumatic optic neuropathy and how is it treated?
-Decreased vision in the affected eye; ipsilateral afferent pupillary defect
-Treat with large dose steroids (methylprednisone 30 mg/kg loading and 5.4 mg/kg/hr x24 hours)
What is traumatic mydriasis and how is it treated?
-Pupillary dilation due to interruption of the parasympathetic innervation
-Results in anisocoria
-Treat with 2% prilocaine. May resolve over several days or weeks
What is traumatic iritis and how is it treated?
-Inflammation of the anterior chamber of the eye within 3 days of trauma
-Dull pain, tearing and photophobia
-Treat with cycloplegic agents: Scopolamine 0.25 or cyclopentolate 2%
What is horner’s syndrome and how is it diagnosed?
-Injury to sympathetic nerves supplying globe
-Miosis (constricted pupils)
-Eyelid ptosis (muller’s muscle tone)
-Anhidrosis (sweat glands)
-Diagnosed with 4% cocaine drops to the affected eye fails to dilate (compared to the unaffected pupil)
What is superior orbital fissure syndrome and how is it managed?
-Ophthalmoplegia (CN III, IV, VI)
-Lid ptosis (CN III)
-Mydriasis, loss of direct pupillary light reflex (CN III parasympathetic fibers)
-Treat etiology. Retrobulbar hematoma (lateral canthotomy/inferior cantholysis), surgery if fracture constricting fissure, IR if carotid-cavernous fistula
-Optho and neuro should be consulted as intracranial approach may be needed in posterior orbit if necessary
What is orbital apex syndrome and how is it treated?
-Same as superior orbital fissure syndrome + injury to CN II (Loss of vision and direct/consensual pupillary light reflex)
-Same treatment as superior orbital fissure syndrome. (canthotomy, fix fractures, IR, ophtho/neuro consult)
Which bones make up the NOE complex?
-Nasal bones
-Frontal process of maxilla
-Nasal process of frontal bone
-Medial orbital wall (lacrimal bone/ethmoid bones)
What are the classification of NOE fractures?
-Manson/Markowitz
-Type I: No comminution of central fragment, tendon intact
-Type II: Comminution of central fragment, tendon intact
-Type III: Severe comminution and tendon avulsed
What are the ranges of intercanthal distance?
-28-35 normal
->35 suggestive of medial canthus involvement
->40 suggestive of traumatic telecanthus
How is a CSF leak diagnosed?
-Test for beta-2 transferrin (takes a long time)
-Send sample for glucose/chloride as well as normal serum.
-If CSF leak: Chloride greater and glucose less than serum
How is the medial canthus treated in type I-III NOE fractures treated?
Type I and II: Secure main fragment in anatomically reduced position
Type III: Canthopexy with a posterior superior vector
How is nasal dorsal augmentation/reconstruction treated in NOE fractures?
-Seen as a saddle nose deformity with/without flattening of nasal dorsum
-Outer cortext of calvarium used and stabalized with bone plate
-Bone graft should reach region of lower lateral cartilages for nasal tip support
How is an avulsed medial canthal tendon treated via canthopexy in NOE fractures?
-Transnasal wiring (vector posterior and superior to the lacrimal fossa)
-Suture tendon to miniplate in the NOW region with non-resorbable suture (posteiror and superior to lacrimal fossa)
-Mitek anchoring (posteiror/superior vector
What is dacryocystitis and how is it treated s/p NOE repair?
-Infection of lacrimal sac due to obstruction
-Treat with antibiotics (PCN)
What is epiphora and how is it treated s/p NOE repair?
-Excessive tearing
-Try lower lid massage, if no improvement dacryocystorhinostomy should be considered
How is a dacrocystorhinostomy completed?
-Incision 6 mm from medial canthal angle carried to lacrimal sac
-H incision made in the nasal soft tissue and lacrimal sac
-Posterior flaps sutured together
-Puncta intubated with a crawford tube and passed through the openings of the nose
-Ends of crawford tubes are tied and anterior flaps of nasal mucosa and lacrimal sac are sutured together
-Orbicularis muscle and skin closed
-Stent left in place x3-6 momths
What is the most commonly fractured bone in adults?
-Nasal bones
What makes up the Kisslebach’s plexus and where is it located?
-Confluence of anterior ethmoid, posterior ethmoid, nasopalatine, and septal branch of labial artery (most common site of epistaxis)
-Located along the anterior aspect of the septum
Why does a septal hematoma need to be drained immediately?
-Septum is a major source of support for the nasal complex. If not evacuated no blood can get to the septum resulting in cartilage necrosis
-Can result in saddle nose deformity
How long do you leave internal packings s/p nasal repair?
-Removed within first 7 days.
-Keep on systemic antibiotics
What happens if a nasal decongestant is used longer than 48 hours?
-Interfere with normal nasal mucosal thickness
-Rhinitis medicamentosa (rebound nasal congestion)
How long should you wait after CR to consider post-traumatic rhinoplasty?
-12 months
-If full thickness laceration may want to wait 12 months due to compromised vascularity
How does the frontal sinus drain?
-Drains into middle meatus
-Through ostium located on the posteromedial portion of sinus floor
-15% of population have a true nasofrontal duct. Otherwise drains via the hiatus semilunaris through nasofrontal tract
How are frontal sinus fractures classified?
-Gonty’s Classification
-Type 1: Isolated anterior table
-Type 2: Anterior and posterior table fractures
-Type 3: Posterior table fractures
-Type 4: Comminuted fracture
How is a CSF leak managed?
-NSGY consult (posterior table fracture with dural tear)
-Some can be treated conservatively with observation (+/- antibiotics)
-If it does not resolve within 7 days, may need placement of lumbar drain to decrease intracranial pressure or direct repair of dural tear
How is a non-displaced frontal sinus fracture treated?
-Conservative. Dictated by esthetics
-Decongestants to aid in sinus pressure relief
-Repeat 6 week CT to ensure fluid levels dissipated and duct system intact
How is nasofrontal duct inolvement tested?
-Tested intraop with injection of dye with a large bore needle and observation for passage into the nasal sill
-If not patent need to complete obliteration
Describe the steps of frontal sinus obliteration.
-Exposure of sinus
-Complete removal of mucosa to prevent mucocele formation
-Block the outflow tract (fibrin sealants)
-Pack pericranium of dead space
How are posterior table fractures managed?
-May require cranialization
-Frontal craniotomy, repair of dura, debridement of damaged brain segment, repair of dural lacerations, pericranial flap
-Brain allowd to fill into extradural space and anterior table is reconstructed
Describe the coronal approach to a frontal sinus fracture.
-Incision 5 cm behind the hairline (Through skin, subcutaneous tissue and galea between the temporal lines). Place Raney clips
-Dissection in loose areolar plane anteriorly
-At temporal line, switch to subgaleal plane
-Continue 2-3 cm superior to the supraorbital rims. Pericranium incised and dissection can proceed in a subpericranial plane
-Temporalis fascia can be excised at root of zygomatic arch meeting the horizontal incision above the orbital rims at a 45 degree angle. Fascial nerve should be safely located on the undersurface of the temporoparietal fascia
-Layered closure, placement of a drain
What is your follow-up timeline for a frontal sinus fracture?
-Weekly for 1 month
-Every 3 months for first year
-Every year up to 5 years
-CT scan recommended at 1, 2, 5 years or if ever symptomatic
What is meningitis, how is it identified and treated?
-Inflammation of the arachnoid membrane and the pia mater extending throughout the subarachnoid space, brain, spinal cord and ventricles
-Symptoms: Acute fever, headache, stiff neck, confusion. Kernig sign is inability to flex the leg with thigh at a right angle to the trunk. Brudzinski sign is flexion of hips/knees when neck is flexed.
-Diagnosed on CT scan to rule out mass or lesion. BLood culture and CSF examination for protein, glucose, cell count and gram stain
-Start antibiotics empirically until cultures available with NSGY consult
How is a mucocele or mucopyocele treated s/p frontal sinus repair?
-Mucopyocele is an infected mococele
-Antibiotics if mucopyocele.
-Obliteration of sinus
How is an intracranial abscess treated s/p frontal sinus fracture repair?
-Patient appears ill without being toxic, mental status changes or seizures
-Parental antibiotics (3rd generation cephalosporin).
-NSGY consult possible surgical intervention
How is cavernous sinus thrombosis treated s/p frontal sinus repair?
-Clinical signs of headache, ptosis, ophthalmoplegia, paraesthesia
-Obtain MRI or CT head with contrast
-Broad spectrum antibiotics, anticoagulation with heparin, sinus drainage
How is a contour deformity treated s/p frontal sinus repair?
-Allow swelling to resolve completely
-May correct with bone grafting, bone cement or custom alloplastic implant
What other injuries are closely associated with panfacial fractures and should be evaluated for prior to repair?
-Spine fractures (20%)
- Intracranial hemorrhage/hematoma
-Get spinal films and CT Head
What buttresses are important in maintaining facial height (vertical buttress)?
-Nasomaxillary
-Zygomaticomaxillary
-Pterygomaxillary (Can’t access surgically)
-Posterior mandibular buttress
What buttresses are important in maintaining facial projection (horizontal buttresses)?
-Mandibular
-Maxillary
-Zygomatic
-Frontal
What are important principals in panfacial fracture repair?
-Airway control (is trach needed, submental intubation?)
-Work from known to unknown (work where anatomic reduction is best accomplished
-Visualize all fractures prior to fixation
Describe the bottom up, inside out method of treatment sequence.
-MMF
-Mandible (prevent splaying of mandible by pressure at angles for facial width), condyle for vertical height
-ZMC complex (ZF first for facial height, ZM next for facial width, next orbital rim, orbital floor last)
-NOE
-Frontal sinus
Describe the top down
-Frontal sinus
-ZMC
-NOE
-Maxillary/lefort
-MMF
-Subcondylar
-Mandible
Describe tetanus in setting of trauma.
-Tetanus is neuromuscular disease from clostridium tetani (spore forming gram positive in soil, intestines and feces)
-Spores form endotoxin tetanospasmin, blocks inhibitory neurons and cause spastic paralysis
-Administer tetanus toxoid if patient has not been vaccinated in over 10 years or if unclean wound nad not vaccinated over 5 years
-Booster dose is 0.5 mL intramuscular
-If unsure, fulll dose is 250 units intramuscular
What types of soft tissue injuries increase susceptibility to infection?
-Crushing injuries
How should dirty wounds be irrigated?
-Pulsatile (high pressure) irrigation of 7 Psi with balanced salt solution or a scrub brush
What is the dose of rabies vaccination for concerning injuries/bites?
-20 IU/kg directly to wound and any remaining intramuscular
-1 mL of human diploid cell vaccine given on days 0, 3, 7, 14, 28
What are the locations of Stenson duct injuries and how are they repaired?
-Buccal branch of facial nerve follows duct, if injury to facial nerve, likely injury to duct as well
-Type A: Most proximal part of duct and is intraglandular. If injury here, closure of parotid capsule as these injuries have a lower complication rate
-Type B: Part superficial to masseter.
-Type C: Anterior to masseter and enters buccinator
-Type B/C: Attemptt o identify stumps for repair
What is a sialocele?
-Formed by leak of saliva into glandular or periglandular tissue
-Can aspirate and check for amylase levels >10,000 u/l
How is a sialocele treated?
-Pressure dressing
-Multiple aspirations
-Antisialogogues (propantheline 15 mg PO QID half an hour prior to meals)
-Secondary duct repair (intraoral fistula creation; dochoplasty)
-Low radiation
-Botox 10-20 unites
-Superficial or total parotidectomy
How is a stensen duct repair completed?
-Use ketamine to encourage salivary flow
-Identify distal end with a 20 gauge silastic tube via opening of duct
-Identify proximal end of duct by parotid massage and encourage salivary flow
-Repair duct with 6/0 nylon
-Stent kept for 5 days to 3 weeks
-Give sialogogues lemon drops
Describe the House Brackmann scale for classifying facial nerve injuries.
-Grade I: Normal, no deficit
-Grade II: Mild, hypokinetic/uncoordinated movement with symmetry at rest
-Grade III: moderate, noticable weakness, symmetry at rest, able to close eye with maximal effort
-Grade IV: Moderate-severe, obvious/noticable weakness. Unable to close eye
-Grade V: Severe, minimal movement, asymmetry at rest
-Grade VI: No movement
What is surgical timing for facial nerve repair and trauma setting, what locations of injuries can be treated?
-Should attempt if injury posterior to line drawn down from lateral canthus
-Repair within 72 h due to Wallerian degeneration
How is the facial nerve repaired?
-Nerve stimulator used to identify distal end
-Proximal end identified by retrograde dissection
-Repair epineurium with 9/0 nylon
-Use 3 sutures to obtain anastomosis
How is a laceration of the submandibular gland done with trauma, how does that differ with pathologic resection?
-Repair usually not necessary. Fistula will normally form in the floor of mouth
-If submandibular fistula forms, will need to complete serial aspirations withe pressure bandage or possible submandibular gland removal
-Sialodochoplasty done for pathologic resections that include the FOM
How is injury to the lacrimal apparatus managed?
-Anesthetize medial canthus
-Dilate punctum
-Pass silicone intubtion stent (crawford tube)
-Pigtail probe passed through intact punctum and canaliculus to identify transected protion
-Cannulate upper and lower punctum and threat stent into nose (below inferior turbinate).
-Tie a knot and allow to heal for 3 months
-Chronic lacrimal duct obstruction managed with dacrocystorhinostomy
Why should wounds be kept moist in the healing phase?
-Heal faster (keratinocytes migrage sooner, prevent hypoxia, protects against exogenous organisms, retains water and proteolytic enzymes which debride wound)
What is the difference between hypertrophic scars and keloids?
-Hypertrophic scars develop within borders of the wound
-Keloids extend outside of wound borders
How are keloids/hypertrophic scars managed?
-Intralesional steroids (40 mg/mL triamcinolone 0.2 mL0
-Start 1 month post-op and continue every 3 weeks for 3 months
-Aggressive injections can lead to atrophy
What are options for scar revision/management?
-Need to wait 6 months to a year at least
-May consider silicone sheeting, laser, dermabrasion, radiotherapy
What antibiotic is used in ear injuries?
-Fluoroquinolones (cover pseudomonas aeruginosa of cartilage)
-Can’t give to patients under 18 years old
What are techniques to repair a partially avulsed ear?
-De-epithelize amputated auricle
-Perform anatomic cartilage reattachment
-Bury into retroauricular pocket x2 weeks
-After healing cartilage elevation and split thickness graft
How is an auricular hematoma managed?
-Needle evacuation (I&D for late treatment)
-Bolster dressing x7 days
What percentage of upper and lower lip lacerations can be closed primarily?
-Upper lip: 25%
-Lower lip: 30%
-Defects of to 66% treated with Abbe or Estlander flap
-Larger defects Gilles flap
What long term sequelae are associated with pediatric NOE fractures?
-Premature ossification of frontoethmoidal, frontolacrimal, frontomaxillary, nasomaxillary or ethmoidomaxillary bones
-Result in midface hypoplasia
How are frontal-orbital injuries managed in pediatrics?
-If displaced, EOM affected or intracranial injury is confirmed, need to treat open approach via coronal flap
-Usually occur in children under 7 due to large cranium and lack of rudimentary sinuses
How are pediatric orbital floors managed?
-Use resorbable mesh or gelfilm
-If larger defect, a calvarial bone graft may be necessary
How are pediatric ZMC fractures typically managed?
-If displaced require ORIF
-Usually 1 point of fixation is adequate
-Maxillary tooth buds may be present and taken into account when fixating from the maxillary vestibule
How are titanium plates/screws managed in the pediatric population?
-Can be used (beware of tooth buds)
-Remove after 2-3 months
What are disadvantages to biodegradable plates/screws?
-Complex bending, need a heat source
-Higher rate of visability/palpable hardware post-op (greater thickness)
-Foreign body reaction or sterile abscess May occur during biodegradation/absorption
What system of resorbable plates/screws do you use? What is it made up of and how does it resorb?
-KLS Sonic Weld system
-PDLLA, PLLA-PGA (Poly-D, L-Lactic Acid. Poly-L-Lactic Acid and 15% Poly glycolic acid)
-Last 8-10 weeks
-Polymer chains absorb the water contents of surrounding body fluids through hydrolysis. The stored water initiates the degradation process by breaking down the polymer chains and converting to CO2 and water
What are the classifications of tooth fractures?
Ellis I-IV
Ellis I: Enamel
Ellis II: Enamel and dentin
Elis III: Enamel, dentin and pulp
Elis IV: Root fracture
How is an avulsed tooth treated?
-Splinted 7-10 days (semi-rigid)
How is an alveolar fracture managed?
-Reduce into proper position
-Stabilize x4 weeks (splint or arch bar)
-Eval for endodontic treatment
What is a PEEK implant?
-Polyether ether ketone
-Biocompatible thermoplastic material
