OMFS- Cranio-Orbital Trauma

Question 1

What is a panfacial fracture?

Answer 1

Forehead, mid face and mandible are all fractured

Question 2

Why is it important to have a neurosurgeon on hand in event of cranio-orbital trauma?

Answer 2

Due to proximity of these bones to intracranial space
-> they would be required if frank brain damage or injury to linings around brain

Question 3

When does frontal sinus begin to form? When is it adult sized?

Answer 3

Forms aged 2
-> adult sized by age 15

Question 4

When can frontal sinus be seen on plain radiographs from?

Answer 4

Age 8

Question 5

In what percentage of population is frontal sinus absent/unilateral only?

Answer 5

Absent- 4%

Unilateral- 10%

Question 6

What type of epithelium lines frontal sinus?

Answer 6

Respiratory type
-> drains into middle meatus through fronto-nasal duct/ethmoid air cells

Question 7

What is checked for in examination phase of cranio-orbital trauma?

Answer 7

 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

Question 8

What should be done if suspicious of injury to frontal bone, mid face, NOE complex?

Answer 8

CT scan- no role for plain radiograph

Question 9

What are the key features to look at on a CT scan following cranio-orbital trauma?

Answer 9

Anterior table/Posterior table (degree of displacement)

Frontonasal duct

Brain injury/ bleed- common if posterior table fracture

Question 10

What are the different form of cranio-orbital fractures?

Answer 10

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

Question 11

What are the reasons for treating cranio-orbital fractures?

Answer 11

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

Question 12

What are the aims in surgery of cranio-orbital trauma?

Answer 12

Create safe sinus- drains freely and doesn’t collect mucous/infection

Restore facial appearance

Question 13

How are minimally displaced anterior/posteiror table fractures managed?

Answer 13

No active tx

Observe for signs of sinusitis

Yearly CT scan for signs of sinus disease

Question 14

What are the indications for surgical treatment of cranio-orbital trauma?

Answer 14

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

Question 15

How may surgical intervention for CSF leak without displacement be avoided?

Answer 15

Lumbar drain

Keep patient upright

Control ICP

Question 16

What are the steps in surgery for frontal trauma?

Answer 16

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)

Question 17

How is fronto-nasal duct injury diagnosed?

Answer 17

High res CT

Endoscopy

Methylene blue
-> once forehead off, pour dye down actual fronto-nasal duct and see if it comes out nose

Question 18

What are the steps in surgery of fronto-nasal duct trauma?

Answer 18

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

Question 19

What are the types of NOE fractures?

Answer 19

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

Question 20

What are the features of NOE fractures? (may also be damage to frontal bone)

Answer 20

 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

Question 21

What is done when assessing NOE trauma?

Answer 21

Confirm with CT

Check for CSF leak

Normal eye assessment

Question 22

What are the indications to treat NOE trauma?

Answer 22

CSF leak

Deformity

As part of panfacial repair

Question 23

What is required if medial canthus is detached?

Answer 23

Trans-nasal wiring is required

Question 24

What flap is used for NOE fractures?

Answer 24

Coronal
-> include peri-cranial flap to be used to seal anterior
fossa if CSF leaks after disimpaction

Question 25

Why may a bone graft be required in NOE trauma surgery?

Answer 25

To augment nasal dorsum

Question 26

What are the ideal features of the fixation plating required for NOE trauma repair?

Answer 26

Must be strong to prevent relapse

Plates must be low profile due to position in face