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Facial Plastics & Trauma > Trauma - ZMC, Orbit, NOE > Flashcards

Trauma - ZMC, Orbit, NOE Flashcards

1
Q

Describe the anatomy of the zygomaticomaxillary complex (ZMC). What are ZMC fractures typically called?

A

4 attachments of the zygoma bone:
1. Zygomatico-frontal
2. Zygomatico-maxillary
3. Zygomatico-temporal
4. Zygomatico-Sphenoid

ZMC fractures known as tripod or tetrapod fractures (tetrapod due to 4 attachments above)

Orange is Zygoma, Zygomatic process/arch from the temporal bone: https://abbottcenter.com/bostonpaintherapy/wp-content/uploads/2009/09/facial-bones2.jpg

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2
Q

Discuss the classification of zygomaticomaxillary complex fractures

A

ZINGG CLASSIFICATION:

  1. Type A: Incomplete Zygomatic fracture
    - A1: Isolated zygomatic arch fracture
    - A2: Isolated lateral orbital wall fracture
    - A3: Isolated infraorbital rim fracture
  2. Type B: Tetrapod fracture
  3. Type C: Multi-fragment ZMC fracture

Kevan Trauma Page 10

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3
Q

Discuss the different options for incisions to zygomaticomaxillary complex fractures? Name 7.
What are the exposure, advantages, and disadvantages of each?

A

A. Upper Gingivobuccal Sulcus incision
- Exposure: ZM buttress and infraorbital rim
- Advantages: No visible scar
- Disadvantages: Contamination with oral flora

B. LOWER EYELID APPROACHES
1. Subciliary incision
2. Transconjunctival incision
3. Subtarsal incision
- Exposure: Infraorbital rim, ZM suture, orbital floor
- Advantages: Only access option for the orbital floor
- Disadvantages: Ectropion, scleral show

C. UPPER EYELID APPROACHES
1. Lateral brow incision
2. Upper blepharoplasty incision
- Exposure: ZF and ZS suture
- Advantages: No cantholysis needed to access ZF suture (compared to the lower eyelid approach)
- Disadvantages: Visible scar

D. Coronal incision
- Exposure: ZF suture and ZS suture
- Advantages: Excellent exposure of lateral orbit
- Disadvantages: Scar, facial nerve injury, temporal hollowing

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4
Q

What are the principles of repair for zygomaticomaxillary complex fractures? What to do if it’s non displaced vs displaced fracture?

A
  1. ZS suture is the best place to assess the accuracy of reduction
  2. ZM and ZF sutures are the best to fixate due to thick bone

Principles of surgery:

A. Non- or Minimally displaced fractures can be observed
- Soft diet, close follow up
- If there is progressive displacement due to masseter action (originates on zygomatic arch and inserts along mandible), these should be repaired

B. Displaced fractures are repaired
- Small studies suggest ORIF > closed reduction in most cases
- 3 or more articulations should be EXPOSED
- At least 2 articulations should be PLATED
- Procedures usually delayed 5-7 days to allow resolution of edema, after 10 days masseter begins to shorten/fibrose

Approaches:
1. Multiple fractures and displacement = Coronal approach
2. Isolated zygomatic arch fracture = Gillies or Keen
3. Anything other than pure anterior maxillary wall fracture = ORIF in the OR

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5
Q

Discuss the typical surgical approach and steps to zygomaticomaxillary complex fractures

A
  1. Start with a transoral gingivobuccal incision - this accesses ZM suture and infraorbital rim
  2. Reduction can be attempted with an elevator under the body of the zygoma; a single plate can then be placed here
  3. A second incision is then made (usually) if there is inadequate reduction - usually lower or upper lid incisions, to allow for further access to ZF suture, infraorbital rim, and ZS suture
    - Lower lid incisions: Transconjunctival, subciliary, subtarsal
    - Upper lid incisions: Upper blepharoplasty, direct brow
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6
Q

What are the indications for orbital floor exploration when there is a zygomaticomaxillary complex fracture? 6

A
  1. Signs of soft tissue entrapment
  2. Herniation of soft tissue into maxillary sinus
  3. 2cm^2 or more of orbital floor disruption
  4. Non-resolving oculocardiac reflex
  5. Primary diplopia
  6. Enopthalmos

canada is 2 RED EH
2 - 2cm2 or more of orbital floor disruption
R - Reflex - Oculocardiac reflex persistent
E - Entrapment evidence of soft tissues
D - Diplopia
E - Enopthalmia
H - Herniation of soft tissues into maxillary sinus

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7
Q

What are the options for reducing a zygomaticomaxillary complex fracture?

A
  1. Elevator via gingivobuccal sulcus incision
  2. Percutaneous hook (e.g. via Gillies incision)
  3. Carol-Girard Screw (can be applied transcutaneously)
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8
Q

What is the difference between the Gilies incision vs. Keene incision?

A

Gillies: Temporal hair line incision - elevator superficial to the surface of the temporalis muscle under the deep temporal fascia and sliding the elevator under the arch to lift it into reduction

Keene: Intraoral incision in the maxillary vestibule to lift the zygomatic fracture

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9
Q

Discuss the surgical approach to fixation of ZMC fractures based on the Zingg Classification

A
  1. Type A1: Gillies or Keen reduction
  2. Type A2: ORIF via lateral brown incision or upper blepharoplasty incision
  3. Type A3: ORIF via lower eyelid approach (transconjunctival or subtarsal)
  4. Type B: Usually requires at least 2 points of fixation as above
  5. Type C: Absolute indication for ORIF. Treatment similar to a type B fracture
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10
Q

What are the different types of transcutaneous lower lid incisions to access the orbital cavity? 3

A
  1. Subciliary = lower blepharoplasty
  2. Subtarsal = mid-eyelid
  3. Infraorbital = inferior orbital rim

Kevan Trauma Pg 12

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11
Q

Discuss 2 management options for the isolated zygomatic arch fracture

A
  1. Transcutaneous = Gillies approach
  2. Transoral = Keen approach

Kevan Trauma Pg 12

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12
Q

What is the general approach to ORIF of midface fractures?

A
  1. Expose all fracture sites
  2. Reduce all dislocated parts
  3. Place in MMF to restore occlusion
  4. Plate sutures/buttresses
  5. Remove MMF and test occlusion/movement (replace MMF if extra stability is required)
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13
Q

What eye deformity may result from a ZMC fracture?

A

Enopthalmos (eye sinks deeper into orbit)

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14
Q

How much orbital floor fracture involvement results in enopthalmos?

A
  1. 2cm^2 (hence one indication for reconstruction); or
  2. Greater than 50% of the orbital floor
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15
Q

What are the pitfalls of midfacial degloving? 4

A
  1. Injury to infraorbital foramen/nerve
  2. Inadequate mucosa for closure
  3. Nostril stenosis
  4. Epiphora / nasolacrimal duct stenosis
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16
Q

What is the oculocardiac reflex? Draw out the reflex pathway

A

Decrease in heart rate by greater than 20% following globe pressure or traction of the extraocular muscles

Reflex pathway:
Afferent limb: Globe –> Short ciliary nerve –> ciliary ganglion –> long ciliiary nerve –> ophthalmic division CNV –> sensory nucleus of trigeminal nuclei –> Motor nucleus of vagus nerve

Efferent limb:
Motor nucleus of vagus nerve –> Vagus nerve –> SA node and stomach

Kevan Trauma Pg 14

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17
Q

What is the tear drop sign?

A

Herniation of orbital soft tissue into the maxillary sinus, seen on AP imaging, due to orbital floor disruption

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18
Q

What are the bones of the orbit?

A
  1. Frontal
  2. Maxillary
  3. Ethmoid
  4. Zygomatic
  5. Sphenoid
  6. Lacrimal
  7. Palatine
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19
Q

What is the definition of an orbital blowout fracture?

A

Blowout fracture = INTACT orbital rims + fracture of one or more walls of the orbit

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20
Q

What are the signs and symptoms of orbital blowout fractures? 7

A
  1. Diplopia
  2. Enopthalmos
  3. Decreased visual acuity
  4. Inferior rectus entrapment
  5. Periorbital bruising
  6. Periorbital emphysema
  7. Numbness in the V2 distribution

“BE A DIME”
B - Bruising periorbital
E - Emphysema periorbital
A - Acuity of vision decreased
D - Diplopia
I - Inferior rectus entrapement
M - Maxillary V2 distribution numbness
E - Enopthlamos

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21
Q

What are the 2 theoried mechanisms for an orbital blowout fracture?

A
  1. Bone conduction Theory (or Buckling Theory)
    - A force applied directly to the thicker orbital rim is transmitted onto the thinner bone of the floor, leading to buckling and subsequent fracture of the orbital wall, with preservation of the orbital rim
    - The orbital floor and medial wall are thinnest, and thus most likely to fracture
  2. Hydraulic Theory
    - A force applied to the globe increases intraorbital pressure, which causes a decompressing fracture into the adjacent sinus
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22
Q

What are ways to assess for entrapment with orbital or facial fractures?

A

Forced Duction Testing:
- Topical anesthesia applied to the eye
- Sclera is grasped with fine-toothed ophthalmic forceps and globe is rotated to assess for resistance

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23
Q

What are the indications for repair of orbital blowout fractures? 6
4 reasons to delay repair by 5-7 days?

A

Indications for immediate repair:
1. Oculocardiac reflex
2. Inferior rectus entrapment
3. Significant enopthalmos

Indications for delayed repair (within 2 weeks)
1. Enopthalmos > 2mm at 10-14 days post-trauma
2. Ocular motility dysfunction
3. Persistent diplopia after swelling decreased
4. Progressive V2 hypesthesia
5. Abnormal forced duction testing

OVERALL INDICATIONS FOR REPAIR: “Orbital DEFECT”
1. Oculocardiac reflex
2. Defect > 2cm2 or 50%
2. Enopthalmos or hypoglobus > 2mm (persistent at 10-14days post)
3. Forced duction test positive
4. Entrapped muscle evident on radiography
5. Comminution
6. Two vision (diplopia) > 7 days

Fractures that need immediate repair but should delay 5-7 days if:
1. Globe rupture (repair globe first)
2. Only seeing eye
3. Significant edema (post-orbital hematoma drainage)
4. Hyphema (blood in anterior chamber/iris)
“GOSH”

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24
Q

What are the contraindications for orbital fracture repair?

A

Relative contraindications:
1. Critically ill patients
2. Co-existent globe rupture (globe repair takes precendence)
3. Only seeing eye (intervention should be weighed against the potential for blindness)

Note: Ophtho should be consulted to rule out globe injury prior to planned periorbital surgery

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25
Q

Discuss the surgical approaches to the orbit depending on their location. Name 2 for each location

A

A. ORBITAL FLOOR
1. Lower lid approaches
- Trancutaneous (Subciliary, subtarsal, infraorbital)
- Transconjunctival (Preseptal preferred, postseptal)

  1. Transmaxillary/transnasal approaches
    - Endoscopic transmaxillary (via Caldwell luc)
    - Endoscopic Transnasal (via LARGE maxillary antrostomy ie. transantral)

B. LATERAL ORBITAL WALL
1. Upper lid approaches
- Upper blepharoplasty
- Lateral brow incision

  1. Lower lid approaches (these usually require lateral canthotomy and cantholysis for sufficient access)
    - Extended subciliary incision
    - Extended transconjunctival

C. ORBITAL ROOF
- Lynch incision (external ethmoidectomy)
- Coronal incision

D. MEDIAL ORBITAL WALL
- Lynch incision
- Transcaruncular (through the lacrimal caruncle, which contains skin, hair follicles, sebaceous glands, accessory lacrimal tissue, etc.)
- Transnasal endoscopic

Kevan Trauma Pg 15

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26
Q

Discuss the complications of orbital fracture repair 10

A
  1. Diplopia
  2. Enopthalmos
  3. Exopthalmos
  4. Vision loss
  5. Preseptal hematoma
  6. Retrobulbar hematoma
  7. Hypertrophic/keloid scar
  8. V2 Hypesthesia
  9. Ectropion (eyelid droops outward)
  10. Entropion (eyelid droops inward irritating cornea)
  11. Hardware infection, displacement, or extrusion
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27
Q

A child gets hit in the head. He has vertical diplopia with NO fracture seen on x-ray. What is the diagnosis? List 2 possibilities

A

Trapdoor fracture:
- Pure orbital-floor fracture, linear in form and hinged medially, allows herniation of orbital content through the fracture and traps them
- Almost exclusive to children and teens
- Frequently no fracture site is seen on radiology
- Symptoms: vertical diplopia, and abnormal eye movement

Other possibilities:
- 4th nerve palsy

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28
Q

What are the orbital anatomy considerations in facial trauma?

A
  1. No true medial rim
  2. Maximum diameter ~15mm posterior to inferior orbital rim
  3. Maximum height of orbital root convexity ~5mm
  4. Maximum height of infraorbital floor concavity ~3mm
29
Q

What is Enopthalmos?
What are the symptoms? 4
What amount of orbital injury will cause enopthlamos?

A

Enopthalmos = posterior displacement of the eye due to volume relative to contents
- Often occurs when disruption of orbital floor > 2cm^2

Symptoms:
- Palpebral opening decreases
- Pseudoptosis (false perception of ptosis)
- Decrease canthal angles
- Increased supratarsal fold

Orbital injury:
- Bony volume changes > 1.5cm^3 (ie. 5% of orbital volume) = 1-1.5mm enopthalmos
- Considerable fat and soft tissue displacement (teardrop sign)
- Enopthalmos > 2mm relative to contralateral eye creates an observable cosmetic deformity, and = >3cm^3 change in bony volume (10%)
- Every 1.5cm^3 is ~1mm of enopthalmos which is ~5% orbital volume change

30
Q

What are the contents of the orbital apex?

A

Inferior orbital fissure:
1. Zygomatic nerve (CNV2)
2. Ganglionic branches from pterygopalatine ganglion to maxillary nerve
3. Infraorbital nerve (CNV2)
3. Inferior ophthalmic vein
4. Infraorbital artery
5. Infraorbital vein

Superior orbital fissure:
1. CN III, IV, VI
2. Ophthalmic branch of CNV and branches (Lacrimal nerve, frontal nerve, nasociliary nerve)
3. Superior opthalmic vein
4. Inferior ophthalmic vein

Optic canal:
1. Optic nerve
2. Ophthalmic artery

Annulus of Zinn (encompasses Superior orbital fissure and optic canal)
1. Optic canal contents - optic nerve (CNII) and opthalmic artery)
2. CNIII (superior and inferior division), CNVI
3. Nasociliary nerve of V1

Kevan Trauma Pg 16

31
Q

What are the innervations of CNIII?

A
  1. Superior rectus, inferior rectus, medial rectus, and inferior oblique muscles
  2. innervation of the pupil and lens (parasympathetic - constriction)
  3. Innervation of upper eyelid (somatic - levator palpebrae superioris; open lid)
32
Q

Differentiate orbital apex syndrome vs. Superior orbital fissure syndrome.

What are the clinical presentation/symptoms?
What is the possible etiologies?

A

ORBITAL APEX SYNDROME (SOF + optic canal):
- Aka Jacod Syndrome
- Pathologic involvement of OPTIC NERVE as well as any other structures of the SUPERIOR ORBITAL FISSURE
- ie. CNII, CNIII, CNIV, CNVI, CNV1 frontal/lacrimal/nasociliary, and ophthalmic veins

SUPERIOR ORBITAL FISSURE SYNDROME (SOF only):
- Aka. Rochon-Duvigneaud’s syndrome
- Identical to orbital apex syndrome, WITHOUT vision changes (ie. does not include the optic canal)

Involvement of the optic canal differentiates the two syndromes

CLINICAL PRESENTATION:
1. Decreased visual acuity (CNII - orbital apex syndrome only)
2. Ophthalmoplegia, ptosis (III, IV, VI)
3. Pupillary dilatation (parasympathetic of CNIII)
4. Decreased sensation in V1 distribution

ETIOLOGY:
1. Inflammatory: Sarcoidosis, SLE, eGPA, GPA, IgG4-related disease
2. Infectious: Invasive fungal sinusitis, orbital cellulitis
3. Neoplasms: NPC, meningioma
4. Iatrogenic/traumatic: Post-FESS or craniofacial surgery, post-trauma
5. Vascular: Cavernous sinus thrombosis, cavernous aneurysm, or fistula
6. Other: Mucocele, fibrous dysplasia, neurofibromatosis

33
Q

What is an RAPD? Sign of?

A

Relative Afferent Pupillary Defect:
- Reflects a relative weakness of the optic nerve from one side to the other
- sign of optic nerve ischemia or compression

Clinical test: swinging flashlight test
- Normally, direct light results in pupil constriction
- If the optic nerve is weak, direct light pupil dilatation occurs because weak nerve doesn’t transmit light
- Pupil is dilated because the contralateral pupil has less light and is therefore sending “dilation” signals to the weak eye (working nerve has a stronger signal than weakened nerve)

34
Q

Describe methods of upper eyelid laceration repair based on the size of the laceration

A

A. 1/3 OF LID OR LESS
1. Primary closure
- Key: Extending a pentagonal wedge excision beyond the tarsus prevents lid notching or kinking
- A superior lateral cantholysis can be done to improve horizontal mobility

B. 1/3 TO 1/2 OF LID
1. Sliding Tarsoconjunctival flap
- Tarsoconjunctival flap is rotated over to cover the defect, which is then covered with a skin graft

  1. Tenzel Semicircular flap
    - Rotation flap with rotation from the lateral canthus to mobilize tissue to fill the upper lid defect

C. MORE THAN 1/2 OF LID
1. Cutler-beard Technique (See video)
- Useful for large central defects of the upper lid
- Full thickness segment of the lower lid is passed underneath an intact bridge of eyelid skin (the margin)
- This is then sutured into the upper lid defect
- 2-stage technique, requires delayed separation

  1. Tarsoconjunctival graft from contralateral lid
    - Described by Bengoa-Gonzalez
    - A tarsoconjunctival graft is harvested from the contralateral upper lid and is used to fill the defect
    - A soft tissue rotation flap is used to reconstruct the anterior lamella

Kevan Trauma Pg 17

Cutler Beard: https://www.youtube.com/watch?v=nSc8JD05xBU

35
Q

Describe methods of lower eyelid laceration repair

A

A. 1/3 OR LESS OF LID
1. Primary closure
- Key: extending a pentagonal wedge excision beyond the tarsus prevents lid notching or kinking

B. 1/3 TO 1/2 OF LID
1. Sliding Tarsoconjunctival Flap
- Tarsoconjunctival flap is rotated over to cover the defect, which is then covered with a skin graft

  1. Tenzel Semicircular Flap
    - Same as with upper lid except with rotated soft tissue oriented in the opposite direction

C. MORE THAN 1/2 OF LID
1. Modified Hughes Technique (Tarsoconjunctival bridge flap from the upper lid)
- Unlike the cutler-beard technique, this is NOT full thickness
- A tarsoconjunctival flap is harvested from within the upper lid, and is flipped down to cover the lower lid defect
- This is then covered with a FTSG
- At least 4mm of tarsus must be left for upper lid stability and to prevent entropion
- Hughes originally described a technique involving the lid margin but that’s no longer used, hence “modified hughes”

  1. Tarsoconjunctival graft from contralateral lid
    - A tarsoconjunctival graft is harvested from the contralateral upper lid and is used to fill the defect (similar to upper lid)

D. 100% OF LID
1. Mustarde Cheek rotation flap
- Soft tissue rotation flap from the cheek
- Posterior lamella can be separately constructed with a free tarsoconjunctival graft, a nasal chondromucosal graft, or with mucous membrane

Kevan Trauma Pg 18

36
Q

What are the components of tears?

A
  1. Lipid layer (outer) - from Meibomian glands
  2. Aqueous layer (middle) - from lacrimal glands
  3. Mucin (inner) - from goblet cells

Corneal epithelial layer under that

Kevan Trauma Pg 20

37
Q

What is normal interpupillary distance?
What is normal intercanthal distance?

A

Normal IPD = 60-70mm

Normal intercanthal distance = 1/2 IPD (~30-35mm)

38
Q

Define the following terms:
1. Telecanthus
2. Hypertelorism
3. Pseudohypertelorism
4. Dystopia Canthorum

A
  1. Telecanthus: Widened intercanthal distance (> 45mm), usually traumatic
  2. Hypertelorism: Widened interpupillary distance, usually congenital (due to overgrowth of sphenoid)
  3. Pseudohypertelorism: Apparent widening of the interpupillary distance due to medial canthal disruption
  4. Dystopia Canthorum: Widened intercanthal distance with a normal interpupillary distance, associated with many conditions, especially Waardenburg (WS1 has dystopia canthorum, WS2 doesn’t)

Pseudohypertelorism and Dystopia Canthorum are both considered telecanthus

Kevan Trauma Pg 20

39
Q

What are 5 signs of medial canthal ligament disruption?

A
  1. Telecanthus
  2. Rounded medial canthus
  3. Narrowed and blunted palpebral fissure (area between open eyelids)
  4. Epiphora
  5. Bowstring sign: Lateral movement of the nasal bone with lateral pull of the skin in the medial canthal area

“BRENT” like brent trull in plastics
Bowstring sign
Rounded medial canthus
Epiphora
Narrowed blunted palpebral fissures
Telecanthus

40
Q

What is the naso-orbital-ethmoidal complex? 6 components

A

Naso-orbital ethmoid (NOE) complex is comprised of the nasal bone, the nasal processes of the frontal bone, the frontal processes of the maxillae, the lacrimal bones, the laminae papyraceae of the ethmoid bone, and the sphenoid bone.

41
Q

What is the anatomy of the orbital suspensory ligaments?

A

Medial canthal ligament:
- Anterior horizontal component = anterior lacrimal crest, strongest
- Anterior vertical component = superior to the horizontal component
- Posterior horizontal component = posterior lacrimal crest (weakest)

Lateral canthal ligament
- Attaches to Whitnall’s tubercle (bony spur at lateral orbital rim)

Suspensory ligament of lockwood
- Suspensory ligament below the eye, enclosing the inferior rectus and inferior oblique

42
Q

What are the signs of a Naso-orbital-Ethmoidal (NOE) fracture? 6

A
  1. Any signs of medial canthal disruption (telecanthus, roudned medial canthus, blunted palpebral fissure, positive bowstring sign, epiphora)
  2. Pig-Nose deformity (loss of nasal dorsal height and increased tip rotation)
  3. Diplaced nasal bones
  4. Periorbital ecchymoses and edema
  5. Epistaxis
  6. CSF rhinorrhea
43
Q

Name and describe the Classification of Naso-orbital-ethmoidal fractures

A

MARKOWITZ AND MANSON CLASSIFICATION

  1. Type I
    - Single large fracture fragment
    - Attachment site of the medial canthal ligament is intact
    - Repair with miniplates
  2. Type II
    - Comminuted NOE fracture
    - However, attachment site of the medial canthal ligament remains intact (attached to a single bone fragment)
    - Repair with miniplates and transnasal wiring
  3. Type III
    - Comminuted NOE fracture with disruption of the medial canthal ligament attachment site
    - Resultant tendon avulsion
    - Repair with miniplates + transnasal wiring + fixation of the MCL + bone grafts

Kevan Trauma 21

44
Q

Where must you place transnasal wiring when repairing an NOE fracture, and why?

A
  • Posterior to the posterior lacrimal crest
  • Otherwise the repair will be unstable and is more likely to fail

See Kevan Trauma 22

Kevan Trauma 22
Lacrimal crest: https://upload.wikimedia.org/wikipedia/commons/9/95/Lacrimal_bone.jpg

45
Q

Where does the lateral canthal tendon attach?

A

Whitnall’s tubercle of the lateral orbital rim

https://www.aao.org/image.axd?id=1840d3e1-8d1a-473b-bab1-c9965c954d72&t=637442506359302203

46
Q

Describe how to repair an NOE fracture, the steps and how to reconstruct the medial canthal tendon? 4 general

A
  1. First stabilize all the segments with transnasal wiring
  2. Repair the medial orbital wall first
  3. Then repair the medial canthal ligament
  4. Lastly, repair the lacrimal apparatus. Either DCR or conjunctivoDCR, which can also be done at a later date
47
Q

List the possible complications of an orbital floor repair?

A
  1. Blindness
  2. Ectropion/entropion
  3. Persistent symptoms: Diplopia, enopthalmos
  4. Orbital hematoma
  5. Infection of hardware/graft
48
Q

What is the approach for visual loss after trauma? 3

A
  1. Urgent ophthalmology consultation
  2. If no light perception, decompression is controversial
  3. If progressive loss, very high dose steroids 24-48 hours, if no effect, then decompression via intracranial, subcranial, or endoscopic approaches
49
Q

Describe the technique for harvesting outer table of calvarial bone for graftings

A
  1. Expose parietal skull
  2. Outline the area of bone getting stripped of perosteum, 2cm posterior to coronal and 2cm lateral to sagittal sutures
  3. Use cutting burr for monocoritcal cuts (start with 4 corners then join up with side cutting burr
  4. Use a straight osteotomy to elevate the outer table from the diploic space
50
Q

What are the goals of nasal fracture repair and reduction? 3

A
  1. Cosmesis
  2. Restore patent airway (decrease obstruction and maintain nasal valve patency)
  3. Avoiding growth center changes

Generally if cannot reduce within 3 hours, then wait 5-7 days for swelling to improve

51
Q

What are the indications for closed reduction of nasal fractures? 2

A
  1. Unilateral or bilateral nasal bone fracture
  2. Nasal pyramid deviation < 50% of nasal bridge width

Can use Ashe forceps or boise elevator

52
Q

What are the indications for open reduction of a nasal fracture? 8

A
  1. Extensive fractures
  2. Deviation of nasal pyramid > 50% of width of the nasal bridge
  3. Displace fracture of the caudal septum
  4. Open septal fracture
  5. Persistent deformity after closed reduction
  6. Displaced fracture of the anterior spine
  7. Septal hematoma
  8. Combined septal and alar cartilage deformities

Note: avoid plates, use iterosseous wires and bone grafts if needed

“SHIT NOSE”
Spine fracture (displaced)
Hematoma (septal)
Inability to fix with closed reduction
Together the septal and alar cartilages are deformed
Nasal pyramid deviation > 50% of bridge
Open septal fracture
Septal caudal dislocation
Extensive fracture/dislocation

53
Q

Name and Describe the classification of nasal fractures

A

Ondik et al.

  1. Type I: Simple Straight
    - Unilateral or bilateral displaced fracture WITHOUT midline deviation
  2. Type II: Simple deviated
    - Unilateral or bilateral displaced fracture WITH midline deviation
  3. Type III: Comminution of nasal bones
    - Comminuted fracture but with preservation of midline septal support
    - Septum does not interfere with bony reduction
  4. Type IV: Severely deviated nasal AND septal fractures
    - Includes severe disruption of nasal midline either due to severe septal fracture or dislocation
  5. Type V: Complex nasal and septal fractures
    - Includes open fractures, saddle nose deformity, soft tissue avulsion
54
Q

Describe the treatment algorithm for nasal fractures based on type

A
  • Type I-III, mobile: Closed reduction
  • Type I-III, immobile: Modified open repair with osteotomies
  • Type IV, mild septal deviation: Modified open repair with osteotomies
  • Type IV, severe septal deviation, or Type V: Open nasal septal repair

If residual deformity or septal deviation after open repair, recommendation is to proceed with septorhinoplasty

Algorithm Kevan Trauma Pg 22

55
Q

Discuss the 6 early and 7 late complications of nasal fractures

A

EARLY:
1. Epistaxis
2. Wound infection
3. Septal hematoma
4. Septal abscess
5. CSF leak
6. Edema

LATE:
1. Nasal airway obstruction
2. Synechiae
3. Septal perforation
4. Adverse cosmesis
5. Saddle nose deformity
6. CSF leak
7. Vision impairment

Emergency: CSF leak, vision impairment, severe epistaxis, hematoma in a child, nasal obstruction in a newborn

56
Q

Discuss the classification of frontal sinus fractures according to fracture site and fracture type

A

FRACTURE SITE:
1. Anterior wall
2. Posterior wall
3. Floor
4. Corner
5. Through and Through
6. Frontonasal duct

FRACTURE TYPE:
1. Linear
2. Displaced
3. Compound
4. Comminuted

57
Q

Discuss the Gonty classification of frontal sinus fractures

A
  1. Type 1: Anterior table fracture
    - A: Isolated to anterior table
    - B: Accompanied by supraorbital rim fractures
    - C: Accompanied by nasoethmoidal complex fractures
  2. Type 2: Anterior and posterior table fracture
    - A: Linear Fractures
    - Ai: Transverse linear
    - Aii: Vertical linear
    - B: Comminuted fractures
    - Bi: Involving both tables
    - Bii: Accompanied by NOE complex fractures
  3. Type 3: Posterior table fracture only
  4. Type 4: Through and Through frontal sinus fracture (with skin)
58
Q

What is the clinical presentation of patients with frontal sinus fractures? 5

A
  1. Depressed forehead
  2. Forehead bruising, ecchymosis
  3. Decreased sensation
  4. CSF rhinorrhea
  5. Conjunctival ecchymosis

Note: in high velocity impact, the smaller the sinus, the more likely posterior table will be fractured

59
Q

Discuss the general management approach to frontal sinus fractures

A
  1. Antibiotics: Ceftriaxone + Flagyl (good brain coverage) - for two weeks (prevent intracranial sepsis via veins in foramina of Breschet)
  2. Tetanus
  3. Rule out other injuries
  4. CT Face/neck
  5. Consult ophtho/neurosurgery
  6. Surgery: Important to repair displaced fractures due to late risks of mucocele, abscess, ostemyelitis
60
Q

Discuss the approach to management of Anterior table fractures of the frontal sinus.

A
  1. Nondisplaced = No intervention
  2. Displaced = Open reduction
61
Q

Discuss the approach to management of Posterior table fractures of the frontal sinus.

A
  1. Linear fracture = Observation
  2. Displaced fracture = Frontal sinus exploration

If there is a CSF leak:
1. Remove surrounding bone and repair dura
2. Reinforce with a patch of tensor fascia lata or temporalis fascia

  • If >2cm bone removed, perform frontal sinus cranialization (drill away all bone and sinus mucosa, brain and dura are permitted to rest against the repaired anterior wall and sinus floor)
  • If < 2cm bone removed, perform frontal sinus obliteration + fat grafting (Key is to drill out all the bone of the frontal sinus to remove any remnants of mucosal lining, followed by obliteration with an abdominal wall fat graft)
62
Q

Discuss the approach to management of Frontonasal duct fractures of the frontal sinus.

A
  • Difficult to diagnose based on signs/symptoms
  • Must be addressed if persistent fluid after 2 weeks, or if fracture on facial CT
  • Can be re-cannulated either via an open or endoscopic approach

OPEN APPROACHES:
1. Lynch approach + Sewall-Boyden flap
- Lynch incision for access
- Sewall-Boyden flap to line the widely open tract
- Flap is harvested from the nasal septum or lateral nasal wall and is rotated up

  1. Osteoplastic flap with fat obliteration
    - Elevate the anterior wall, drillout the sinus mucosa, and obliterate with fat

ENDOSCOPIC APPROACHES:
1. Draf III approach (more common nowadays)

63
Q

Discuss the approach to management of Through-and-Through frontal sinus fractures

A

CRANIALIZATION PROCEDURE:
- Combined procedure with neurosurgery to address intracranial bleeding, debriding necrotic brain, and dural repair
- Remove entire posterior wall of sinus
- Strip frontal sinus mucosa and drill down bone
- Frontonasal duct eliminated by inverting frontal sinus mucosa, and then obliterating with temporalis muscle

64
Q

What are the possible complications (early and late) of frontal sinus fractures?

A

EARLY:
1. Meningitis
2. CSF leak
3. Forehead numbness
4. Frontal sinusitis

LATE:
1. Forehead deformity
2. Mucocele / Mucopyocele
3. Brain abscess
4. Osteomyelitis
5. Encephalitis
6. Encephalocele

65
Q

How do you assess the patency of the nasolacrimal system after an NOE injury?

A

PRIMARY JONES DYE TEST

Procedure:
1. Instill one drop of fluorescein in the inferior cul-de-sac of the lower eyelid
2. Insert a cotton pledget minimally soaked in topical anesthetic beneath the inferior turbinate
3. Assess for fluorescein after 5 minutes

Interpreting results:
1. Fluorescein present: Patent nasolacrimal system
2. Fluorescein absent: Indicates some type of obstruction; Further testing required to localize obstruction (secondary jones dye test)

SECONDARY JONES DYE TEST

Procedure:
1. Place a clean cotton pledget beneath the inferior turbinate
2. Flush the fluorescein from the cul-de-sac with saline
3. Irrigate the lacrimal sac via the inferior sac via the inferior canaliculus with a special blunt canalicular needle and syringe

Interpreting results:
1. Fluorescein present (on fresh pledget): Suggests a functional obstruction of the nasolacrimal duct - cuz once you irrigate its all there, just sitting in the nasolacrimal duct itself that you’ve flushed out
2. Fluorescein absent but saline observed: Indicates pathology at the lacrimal punctum or canaliculus - once you irrigate if the fluorescein still not there it means its a higher up problem that you bypassed
3. No saline after irrigation: Indicates complete blockage of the nasolacrimal system at some level

https://www.academy.org.uk/tutorials/dilate1.jpg

66
Q

Who should you always consult after shotgun injury to the NOE/frontal sinus?

A

Ophthalmology (rule out shrapnel injury to the globe)

67
Q

What are the pitfalls of coronal incisions? 3

A
  1. Injury to supratrochear and supraorbital nerves (sensation to forehead)
  2. Brow ptosis
  3. Failure to fully close galea
68
Q

What are the complications of maxillary sinus fractures? 10

A

Early:
- Hematoma
- Infection / sinusitis
- Lacrimal obstruction
- CSF rhinorrhea
- Vision changes

Late:
- Cosmetic deformities
- Enopthalmos
- Ectropion
- Non or malunion
- Implant extrusion
- Plate exposure
- Infraorbital paresthesia
- Lip distortion
- Malocclusion
- Deviated dentition
- Altered facial width/height

69
Q

What is the order of approach to complex facial fractures?

A
  1. Establish occlusion first wherever possible

Think: Mandible, Zygoma (/NOE), Palate, Maxilla - from periphery to the centre

  1. Mandible, then top down approach: Frontal bar, NOE/MCL, infraorbital rim and zygoma, orbital floor, then Maxilla Lefort (do maxilla last because it is forgiving)

OR can do a Periphery to central approach:
1. Mandible and skull base (outside)
2. Lateral midface
3. Central midface (leaving last the soft tissue repair, e.g. MCL, lacrimal repair)

Facial Plastics & Trauma (9 decks)

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