UG online theory class on Trauma to Face

1. TRAUMA TO FACE
Dr.R.Malarvizhi MS(ENT), DLO
Senior Resident
Department of Otorhinolaryngology

2. Trauma to Face
 Involves
 Soft tissues, bones or both
 Cause
 Automobile accidents (RTA)
 Sports, physical assaults, accidents etc
 Management
 General, Soft tissue and bone

3.  GENERAL
 Airway , Breathing , Circulation
 Associated injuries
 SOFT TISSUE
 Facial laceration
 Parotid gland and duct
 Facial nerve
 BONE ( upper, middle and lower 3rd of face)

4. Face

5. Upper third Face
1. Frontal sinus
 Anterior wall fractures
 Depressed/ communitted
 Cosmetic deformity
 Interior inspected to rule out posterior wall fractures
 Posterior wall fractures
 Associated with dural tears, brain injury & CSF rhinorrhoea
 Injury to nasofrontal duct
 Causes obstruction to frontal sinus drainage leading to sinusitis and
mucocele

8. 2. Supraorbital ridge
 Cause periorbital ecchymosis, flattening of eyebrow, proptosis,
 Bone fragments may be pushed into orbit
3. Fractures of Frontal bone
 Depressed/ linear with or without separation
 Extend into orbit
 Associated with brain injury and/ or cerebral oedema

9. Middle third Face
1. Nasal bone and septum
2. Naso-orbital fractures
3. Fractures of Zygoma
4. Fractures of Zygomatic arch
5. Fractures of Orbital floor
6. Fractures of Maxilla

10. Fractures of Nasal bone and Septum
 Most common
 Magnitude of force will determine depth of injury
 Types
 Depressed: due to frontal blow. Lower thinner part gives away. If force
greater- open book type can occur (nasal septum collapses and nasal
bones are splayed)
 Angulated : due to lateral blow

14.  Clinical features
 Swelling
 Periorbital echymosis
 Tenderness & crepitus
 Nasal deformity
 Epistaxis
 Nasal obstruction
 Lacerations of nasal skin

15.  Diagnosis
 PHYSICAL examination
 Xray – lateral views and Water’s view
 CT PNS with 3D reconstruction of facial bones

16.  Treatement
- SIMPLE # without displacement – NO intervention
- If displaced and presenting within 6 hours easy to reduce
- Best time to reduce – before edema sets in (i.e, within 6 hours of injury)
and 5-7 days later (i.e, after edema reduces)
- Difficult to reduce after 14 days

17.  Closed
 Depressed type- elevated by blunt forceps / septal elevator, guided by
digital manipulation
 Walsham and Asch forceps
 Septal hematoma- if present must be drained and nasal packing must be
done to prevent re-collection
 Open
 When closed methods fail
 Grossly deformed nose
 Rhinoplasty or septorhinoplasty

20. NASO-Orbital #
 Direct force over the nasion
 Injured- perpendicular plate of ethmoid, ethmoidal aircells &
medial orbital wall
 Clinical features
 Telecanthus, pug nose, periorbital ecchymosis, orbital hematoma, csf
leakage, displacement of eyeball
 Diagnosis
 CT PNS and facial bones
 Treatment
 Closed reduction in uncomplicated cases
 Open reduction- ‘H’ incision, intranasal packing must

23. TRIPOD #
 Fractures of zygoma/ Tripod
#
 2nd most commonly injured
 Direct trauma
 Lower segment of zygoma
pushed medially and
posteriorly – leading to
flattening of malar
prominence and step-
deformity
 Clinical features
 Flattening, step deformity
 Anaesthesia of infraorbital nerve
area
 Trismus
 Obliquity of palperal fissure
 Restricted EOM
 Periorbital emphysema
 Diagnosis- CT, Water’s &
exaggerated Water’s
 Treatment
 ORIF

26. # Zygomatic Arch
 Depressed
 3 fractures lines- one at each end and third at centre
 Clinical features
 Depressed zygoma, pain during talking and chewing, & trismus
 Diagnosis- Water’s view, CT PNS
 Treatment- vertical incision behind hairline, elevator passed
deep to temporal fascia and depressed fragments are
elevated. No fixation required

28. Orbital floor #
 Accompanied by Lefort II and zygoma #s
 Includes ‘Blow out fractures’ ( isolated fractures of orbital floor
when large object strikes the globe- orbital contents herniate
into maxillary antrum- “tear drop sign”)
 Clinical features
 Ecchymosis, enophthalmos, diplopia, hypoasethesia and anaesthesia of
cheek

29.  Diagnosis
 CT PNS, Water’s
 Traction test- nerve entrapment
 Treatment
 Indication – enophthalmos & persistent diplopia
 Transantal approach
 Infraorbital approach
 Reforcement of orbital floor

32. TEAR DROP SIGN

34. Maxilla #
 3 types
 Lefort

37.  Clinical features
 Malocclusion of teeth, elongation of midface, mobility of maxilla, csf
rhinorrhoea( II & III)
 Diagnosis
 CT PNS, Water’s , postero-anterior, lateral
 Treatment
 Immediate
 Airway
 Hemorrhage- maxillary artery br
 Fixation (interdental wiring, intermaxillary wiring- arch bars, Open
reduction with intraosseous wiring & wire slings)

38. Fractures of lower third
 MANDIBULAR fractures
 Classified based on location
 CONDYLE> angle> body> symphysis
 Uncommon – ramus, coronoid and alveolar processes
 Multiple – more common
 Direct trauma
 Displacement determined by
 Pull of muscles attached to fragments
 Direction of # line
 Bevel of #

41.  Clinical features- tenderness and crepitus at the fracture site
 Condyle
 Pain, trismus (when not displaced)
 When displaced associated with malocclusion of teeth and deviation of jaw to
opp side on opening mouth
 Angle, body & symphysis
 intra- & extra- oral palpation
 Step deformity, malocclusion of teeth, ecchymoss of mucosa,

42.  Diagnosis
 OPG, Water’s , CT PNS with 3D reconstruction of facial bones
 Treatment
 Closed: interdental wiring, intermaxillary fixation. External pin fixation
 Open : # site exposed and direct wiring ( figure of 8) aided with
compression plates
 CAUTION- Immobilasation beyond 3 weeks causes ankylosis. Therefore
jaw exercises are started as soon as wires are removed after a week.

45. OROANTRAL FISTULA
 Communication between maxillary antrum and oral cavity
 Aetio
 Dental extraction
 Failure of sublabial incision to close
 Carcinoma
 Fractures of maxilla
 Osteitis – syphilis, malignant granuloma

46.  Clinical features
 Food regurgitation- into nose
 Antral discharge- foul smelling from infected antral mucosa
 Inability to build positive or negative pressure in the mouth ( holding air
within mouth or drinking from straw)

48.  Diagnosis
 Probe test
 CT PNS
 Treatment
 Recent – if no infection – suturing of margins and antibiotics
 Chronic – palatal or buccal flap, dental obturators, removing fistulous
tract
 CALDWELL LUC surgery is both the cause and treatment of oroantral
fistula