midface trauma/cranio-orbital trauma Flashcards
What is involved in pre-assessment of trauma cases?
A - airway and C-spine control
B - breathing
C - circulation and haemorrhage control
D - disability (head injuries, GCS)
What is needed for midface trauma diagnosis and what are the key features seen in this?
CT scan
Anterior table
Posterior table
Frontonasal duct
Degree of displacement
Brain injury/bleed
Name 6 reasons for treating fractures
Any from:
- aesthetics
- prevent wound infection
- chronic sinusitis (up to 60% chance)
- meningitis (6%)
- mucocele/mucopyocele
- cavernous sinus thrombosis
- encaphalitis
- brain abscess
What are the aims of midface trauma treatment?
Create a safe sinus
Restore appearance
What are the 4 indications for surgery in midface trauma?
Anterior table displacement with significant forehead deformity
Frontonasal duct involvement/obstruction
Displacement of posterior table with underlying neurological injury
Early non-surgical intervention for CSF leak to mitigate the need for surgical intervention
How is surgery in midface trauma carried out?
Access through a coronal flap - local access sometimes possible
Micro or mini plating
Reduce fractures and reconstruct - can be done extracorporeally (outside of the body)
Sometimes done endoscopically
Can do a delayed repair
What is needed for a frontonasal-nasal duct injury?
High resolution CT
Endoscopy
Methylene blue on table
Describe surgery when there is a duct injury with a cosmetic defect
Obliteration of the sinus cavity and obstruction of the duct outflow are the aims
Expose the sinus lining and scrape it out
Remove the inner table (cranialise the sinus)
Block the duct with bone and tissue and consider a pericranial flap if its a big hole
Reconstruct the outer table
Name 4 signs of a mandible fracture
Any from:
- sublingual haematoma
- 2 point mobility vertically
- abnormal sensation contralateral to the side of the injury
- pain contralateral to the side of the injury
- numbness that can’t be explained by direct injury to the nerve
What is needed for a mandible fracture?
2 X-rays - OPT and PA mandible
How can a GDP treat facial trauma?
Be fast
Analgesia
Antiobiotics for open fractures
Liquid diet
Immediate discussion with oral maxillofacial surgery (OMFS) team
Name 8 signs of midface and zygoma fractures
Any from:
- epistaxis without a blow to the nose (nosebleed)
- CNV2 numbness without a direct blow to the nerve
- subconjunctival bleed
- midface mobility
- malocclusion
- surgical emphysema around the eye (air inside)
- swelling after nose blowing
- diplopia
- change of appearance
- CSF
How are naso ethmoidal cranial fractures classified according to the Markowitz classification?
Type 1 - big piece, medial canthus attached
Type 2 - comminuted, medial canthus attached to bone
Type 3 - communities, medial canthus not attached to anything
Name 4 signs of cranio-orbital trauma
Blow to bridge of nose
Nasal bridge pushed in
Nose tipped up
Increased naso-labial angle
What should be assessed in cranio-orbital trauma?
Assess for telecanthus (lateral displacement of medial canthi)
Confirm with CT
Check for CSF leak
Eye assessment as usual
What are 3 indications to treat cranio-orbital trauma?
CSF leak
Deformity
As part of a facial repair
What is a class I LeFort fracture?
Horizontal separation of the maxilla from the rest of the facial skeleton
What is a class II LeFort fracture?
Pyramidal fracture - triangular shaped separation of the central face from the rest of the skull
What is a class III LeFort fracture?
Most severe - complete separation of the midface from the base of the skull
What instructions should a GDP give to pts with zygomatic fracture?
No need for antibiotics
Call OMFS - will be followed up 7-10 days
No nose blowing
Soft diet for comfort
Give warning re-retrobulbar bleed
How should maxilla fractures be managed as a GDP?
Be fast
Antibiotics
Must discuss with OMFS
Liquid diet
No nose bleeding
Most will need assessed on the day
What is the referral route for OMFS?
Contact QEUH OMFS DCT on call
Have pt details ready
Keep pt fasted
Need to call before the pt goes
Describe the embryology of the frontal sinus
Begins to form at 2 years
Adult sized by 15 years
Seen on plain x-rays by 8 years
Highly variable - unilateral in 10%, absent in 4%
Where does the frontal sinus drain?
Into the middle meatus through the fronto-nasal duct and ethmoid air cells
What epithelium is found in the frontal sinus?
Respiratory epithelium
