OMFS- Cranio-Orbital Trauma Flashcards
What is a panfacial fracture?
Forehead, mid face and mandible are all fractured
Why is it important to have a neurosurgeon on hand in event of cranio-orbital trauma?
Due to proximity of these bones to intracranial space
-> they would be required if frank brain damage or injury to linings around brain
When does frontal sinus begin to form? When is it adult sized?
Forms aged 2
-> adult sized by age 15
When can frontal sinus be seen on plain radiographs from?
Age 8
In what percentage of population is frontal sinus absent/unilateral only?
Absent- 4%
Unilateral- 10%
What type of epithelium lines frontal sinus?
Respiratory type
-> drains into middle meatus through fronto-nasal duct/ethmoid air cells
What is checked for in examination phase of cranio-orbital trauma?
Is injury life threatening- advanced trauma life support system (look at airway and cervical spine first, then consider B and C, disability, exposure- correct and reassess)
If stable you can treat
Dents- on forehead or face
Diplopia- which direction
Open fracture- is wound on top of fracture (can wound be utilised to fix bones)
CSF leak- clear and watery fluid going out nose or ears (like a tap)- use B2 transferring test to check fluid
For related NOE fractures
What should be done if suspicious of injury to frontal bone, mid face, NOE complex?
CT scan- no role for plain radiograph
What are the key features to look at on a CT scan following cranio-orbital trauma?
Anterior table/Posterior table (degree of displacement)
Frontonasal duct
Brain injury/ bleed- common if posterior table fracture
What are the different form of cranio-orbital fractures?
Fracture of anterior table (displaced or
undisplaced)
Fracture involving posterior table (displaced or undisplaced)
Fracture involving the floor of the sinus
Fracture involving dural or cerebral damage
What are the reasons for treating cranio-orbital fractures?
Aesthetics
Manage functional issues- vision problems , drainage of mucous issues (can lead to meningitis)
To prevent:
Wound infection
Mucocele formation- ball of mucous builds up in sinus (can cause obstruction)
-> Mucopyocele formation- when mucous is infected
Cavernous sinus thrombosis- life threatening
Encephalitis
Brain abscesses
What are the aims in surgery of cranio-orbital trauma?
Create safe sinus- drains freely and doesn’t collect mucous/infection
Restore facial appearance
How are minimally displaced anterior/posteiror table fractures managed?
No active tx
Observe for signs of sinusitis
Yearly CT scan for signs of sinus disease
What are the indications for surgical treatment of cranio-orbital 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
How may surgical intervention for CSF leak without displacement be avoided?
Lumbar drain
Keep patient upright
Control ICP
What are the steps in surgery for frontal trauma?
Access- coronal flap (keep a nice pericranial flap for repair of dura just in case)
-> Local access sometimes possible
Reduce fractures and reconstruct- Can be done extracoronally
-> Some do this endoscopically!
Micro or mini plating
Can do delayed repair (custom medpore implant, inject Coleman fat)
How is fronto-nasal duct injury diagnosed?
High res CT
Endoscopy
Methylene blue
-> once forehead off, pour dye down actual fronto-nasal duct and see if it comes out nose
What are the steps in surgery of fronto-nasal duct trauma?
AIM- Obliteration of the sinus cavity and obstruction of the duct outflow
* Expose the sinus lining
* Scrape it out
* Remove the inner table (cranialise the sinus)
* Block the duct with bone and tisseal and consider the percranial flap if it’s a big hole (Fat resorbs variably and should be avoided)
* Reconstruct the outer table
What are the types of NOE fractures?
Type 1: big piece, medial canthus attached to bone
Type 2: comminuted (fragmented), medial canthus attached to bone
Type 3: comminuted, medial canthus not attached to anything
What are the features of NOE fractures? (may also be damage to frontal bone)
Difficult to fix- may drift after treatment (relapse- so need to be fixed firmly)
Occurs due to impact straight on bridge of the nose, nose moves backwards into head (tips up increasing NL angle- pushing eyes further apart)
Difficult to access without facial scarring
What is done when assessing NOE trauma?
Confirm with CT
Check for CSF leak
Normal eye assessment
What are the indications to treat NOE trauma?
CSF leak
Deformity
As part of panfacial repair
What is required if medial canthus is detached?
Trans-nasal wiring is required
What flap is used for NOE fractures?
Coronal
-> include peri-cranial flap to be used to seal anterior
fossa if CSF leaks after disimpaction
Why may a bone graft be required in NOE trauma surgery?
To augment nasal dorsum
What are the ideal features of the fixation plating required for NOE trauma repair?
Must be strong to prevent relapse
Plates must be low profile due to position in face
