S21C256 - Trauma to the Face

Question 1

facial trauma, immediate management

Answer 1

• 44% of pts will require intubation if airway impeded or massive hemorrhage present
• ABCs, deal with life-threatening injuries, then deal with the facial trauma
• up to 6% of pts with maxillofacial trauma will have vision loss
• do a complete eye exam

Question 2

Facial clinical exam

Answer 2

• check for numbness
• ask about bite, do teeth fit together?
• pain near ear may indicate mandibular condyle injury
• palpate orbital rim for tenderness and step-off deformities and for crepitus
• palpate all bones of face
• examine eyes: VA, EOM, PEARL
• inspect for nasal septal hematoma
• check ears
• check teeth, tongue blade test
• battle sign/racoon sign, hemotympanum

Question 3

Ocular exam in facial trauma

Answer 3

• binocular double vision suggest entrapement of extraocular muscles
• monocular double vision suggests lens dislocation
• limited upwards gaze occurs with # to inferior and medial orbital wall
• teardrop pupil indicates globe injury
• loss of vision indicates optic nerve or globe injury
• distance b/w the medial canthi is normally the width of the pt’s globe, if greater this may indicate naso-orbito-ethmoid injuries
• widening of interpupillary distance indicates a ‘blow-out’ injury to the orbits - blindness
• swinging light test for marcus gun pupil - if present it indicates injury to optic nerve or retina
• fundoscopy, slit lamp, fluorescein exam, IOP

Question 4

Nasal Exam

Answer 4

• check for deformity, tenderness, crepitus, septal hematoma, CSF, rhinorrhea
• septal hematoma needs to be I+D to prevent destruction of cartilage and saddle nose deformity

Question 5

Jaw exam

Answer 5

• malocclusion suggests: mandibular #, le fort #, zygomatic #
• check teeth
• check for sublingual hematomas and breaks in oral mucosa
• tongue blade test - 85% sensitive for jaw #

Question 6

Imaging

Answer 6

• xr of facial bones (water’s view) good for midface #
• CT head is 90% sensitive for excluding injury to facial bones, can be used in pts with low suspicion for facial #
• if high suspicion of # then do dedicated coronal and axial section
• panorex for mandibular fractures (70-86% sensitive vs CT which is 92-100%), misses mandibular condyle #

Question 7

Frontal bone #

Answer 7

• oral Abx (1st gen cephalosporin or amox-clav) recommeneded for any sinus #
• uncommon injury, high-energy MOI
• depressed#: admission, IV Abx, operative repair

Question 8

Orbital #

Answer 8

• ‘blow out’ #: small diameter object strikes globe, force transmitted through globe and results in a # of the inferior/medial orbital walls. adipose tissue or inferior rectus/oblique muscle then herniate and become entrapped w/in the maxillary or ethmoid sinus
• trauam to nasal brige can cause a naso-orbital ethmoid # that may be associated with injury to the lacrimal duct, dural tears and TBI
• look for enophthalmos - occurs with herniation of globe contents before significant deformity or crepitus
• infraorbital anesthesia occurs with # of the orbital floor
• diploplia on upward gaze assoc with entrapment of the inferior rectus, inferior oblique, orbital fat, or injury to oculomotor nerve
• naso-orbito-ethmoid # cause pain with EOM, traumatic telecanthus, epiphora (tears spilling over lower lid), CSF leak

-tx for orbital #: amox-clav, avoid blowing nose

Question 9

Ocular Compartment Syndrome

Answer 9

• can occur from retrobulbar hematoma or malignant orbital emphysema
• causes an acute ischemic optic neuropathy
• exophalmos, decreased visual acuity, increased intraocular pressure

-tx: emergent lateral canthotomy

Question 10

Zygoma #

Answer 10

• common, mostly zygoma arch #
• tripod # can occur: zygomaticomaxillary #, high-energy, deceleratio injury (orbital and sinus #)

-signs/Sx: swelling, eye may tilt, subconjunctival hemorrhage, trismus, diplopia, infraorbital anesthesia, crepitus

Question 11

Midfacial #

Answer 11

• Le Fort I: transverse # separating body of maxilla from pterygoid plate and nasal septum, only teeth and hard palate move with rocking motion
• Le Fort II: pyramidal through the cetnral maxilla and hard palate, movement of hard palate and nose occurs but not eyes
• Le fort III: entire face is separated from the skull, # of frontozygomatic suture line, across orbit, through base of th enose and ethmoids
• Le fort IV: is a III with involvement of the frontal bone
• often require intubation, nasal packing, and fluid resusc
• IV Abx and surgery

Question 12

Mandibule #

Answer 12

• ring structure, so if one # present go looking for the second
• presume # is open until thorough oral exam can be performed
• examine ears for tympanic membrane perforation, hemotympanum, condyle displacement
• give Pen G IV or clindamycin for open #

Question 13

Pediatric facial trauma

Answer 13

• think abuse

- cricothyrotomy is contraindicated if