This presentation deals with the management of Facial trauma with the main emphasis on Nasal bone fracture.

1. NASAL AND FACIAL
FRACTURES
CONSULTANT : DR VIKAS MALHOTRA
MODERATOR : DR KARISHMA
PRESENTOR : DR AVINAV

2. NASAL FRACTURES
• 25-75 lb/in2 force is required.
• Refracture rate – 5%
• 15-30 years
• Causes : assaults, contact sports,
adventurous leisure
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

3. CLASSIFICATION :
1. Nature of injury
2. Extent of injury
3. Pattern of the fracture
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

4.  NATURE OF INJURY :
 Laterally applied force injuries – 66%  Frontal injuries – 13%
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

5. EXTENT OF DEFORMITY :
 Grade 0 : bones perfectly straight
 Grade 1 : <½ of width of bridge of nose
 Grade 2 : ½ to 1 width of bridge of nose
 Grade 3 :> 1 width of bridge of nose
 Grade 4 : almost touching the cheek
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

6.  PATTERN OF FRACTURE :
 Simplest form : Depressed nasal bone,
nasal septum not involved
 Severe form : both nasal bone and
septum involved
 Clinically : depressed nasal bone with
tenderness and crepitus
1. CLASS 1 FRACTURES : CHEVALLET FRACTURE
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

7. 2. CLASS 2 FRACTURE : JARJAVAY FRACTURE
 Associated with cosmetic deformity
 Involves the # of frontal process of maxilla and
septal structures
 Ethmoidal labyrinth and adjacent orbital
structures remain intact
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

8. 3. CLASS 3 FRACTURES : NASO ORBITO
ETHMOID FRACTURE
 High velocity trauma
 Pig like appearance
 Two categories –
i. Type 1 : anterior skull base, posterior
wall of frontal sinus, optic canal remain
intact
ii. Type 2 : disruption of posterior frontal
sinus wall, multiple fracture of roof of
etmoid and orbit.
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

9. CLINICAL PRESENTATION :
• History
 How ? When ?
 Nasal obstruction
 Change in appearance
 Epistaxis
 Orbital trauma signs
 Dental injury
 Skull base damage
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

10. • Examination :
 Any deformity ?
 Mobility/crepitus/tenderness
 Generalised swelling
 Laceration
 Fracture/haematoma/abscess/
perforation
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

11. INVESTIGATION :
• XRAYS
• CT scan
• Csf leak :
TREATMENT :
 80% no active treatment
 topical vasoconsrtictor drops
 Surgical intervention – significant cosmetic deformity or nasal obstruction
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

12. METHODS OF REDUCTION :
• CLOSED REDUCTION :
 U/L or B/L # of nasal bones
 # of nasal septum with deviation <1/2 of width of nasal
bridge
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set
(a) Howarth’s elevator;
(b) Ashe’s forceps
(septum);
(c) Walsham’s forceps
(nasal bones)

13. Determining depth of insertion of
instrument into nasal cavity.
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

14. • OPEN REDUCTION (Verwoerd)
 B/L # with dislocation of nasal dorsum and septal deformity
 Infraction of nasal dorsum
 # of cartilaginous pyramid + dislocation of upper laterals
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

15. COMPLICATIONS :
• Poor cosmetic result
• Nasal obstruction
• Epistaxis
• Septal complication– haematoma, abscess, perforation
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

16. FACIAL FRACTURES :
• 10% of all A/E are related to facial injuries
• Immediate airway assessment is required
• RTA, attempt suicide, sport injuries, physical violence
• mechanism of injury provides insight on possible degree and
extent of injury.
• PRIMARY CARE :
 Airway
 Breathing
 Circulation
 Disability
 Exposure
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

17. MANDIBULAR FRACTURES :
• SURGICAL ANATOMY :
 # occurs where the bone is relatively thin –
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

18. • Signs and symptoms :
# of body, angle and symphysis
oBony step deformity
oDeranged occlusion
oPain
oSublingual haematoma
oMobile teeth in fracture line
oAnesthesia in lower lip
otrismus
 # of condylar neck :
o TM joint tenderness
o Trismus
o Lateral open bite
o Anterior open bite
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

19. • CLOSED REDUCTION TECHNIQUES
 Intact dental arch : leonard button
 Incomplete dental arch :
oArch bars o Intermaxillary bone pins
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

20. • EXTERNAL FIXATION
Cast silver splint Gunning splint
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

21. • INTERNAL FIXATION
 Intra oral incision :
 Extra oral incision :
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set
• CONDYLAR NECK FRACTURES
 Functional adaptation
 Neuromuscular rehabilitation
 Altered condylar mechanics

22. FRACTURES OF MAXILLA :
• INTRODUCTION :
 Midfacial # - lateral (zygomatic)
central (maxillary,
nasal, nasorbitoethmoid)
• SURGICAL ANATOMY :
 low energy injuries : Le Fort Classification
 High energy injuries :
Source: Cummings Otolaryngology - Head and Neck Surgery, 3-Volume Set: Expert Consult:

23. Kim, Hak & Kim, Seong & Lee, Hyun. (2017). Management of Le Fort I fracture. Archives of Craniofacial
Surgery. 18. 5. 10.7181/acfs.2017.18.1.5.

24. • SIGNS AND SYMPTOMS :
 Epistaxis
 Circumorbital ecchymosis
 Facial oedema
 Surgical emphysema
 Lengthening of face
 Infraorbital anaesthesia
• MANAGEMENT :
 Emergency treatment
 Reduction
 Fixation : ( IMF, EF, IF )
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

25. Severe multilevel Le Fort
fracture with typical
‘panda eyes’
3D CT reconstruction demonstrating
vertical, horizonal and transverse
disruption to the entire craniofacial
skeleton
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

26. ZYGOMATIC COMPLEX FRACTURES :
• SURGICAL ANATOMY :
1. Frontozygomatic
2. Zygomaticomaxillary buttress
3. Inraorbital rim
4. Zygomatic arch
5. zygomaticosphenoid
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

27. • SIGNS AND SYMPTOMS :
 Subconjunctival haemorrhage, eyelid oedema, restricted eye
movement
 Step deformity of infraorbital margin, tender frontozygomatic suture
 Arch # : palpable depression and limited mouth opening
 Sensation of cheek altered
• IMAGING :
 Occipitomental Xrays
 CT scan
 HESS charting
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

28. • MANAGEMENT :
 Minimally displaced # - conservative
 Displaced # - reduction + fixation
1. Gillies temporal approach –
Medially displaced body #, zygomatic
arch #
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

29. 2. Poswillo Hook –
Posteriorly displaced #
3. Dingman –
Medially displaced body #
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

30. 4. Intra oral or Keen –
medially displaced #,
arch #
5. Coronal –
laterally displaced arch #
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

31. • POST OP CARE :
 First 12 hours : don’t blow nose
 Watch for retrobulbar haemorrhage :
1. Decreased visual acuity
2. Diplopia
3. Opthalmoplegia
4. Proptosis
5. Tense globe
6. Dilated pupil
7. Loss of direct light reflex
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

32. ORBITAL FLOOR FRACTURES :
• Blunt trauma to the globe or adjacent bone
• Signs and symptoms :
1. Enopthalmus
2. Hypoglobus
3. Supratarsal hollowing
4. Hooding of the eye
5. Palpebral fissure narrowing
6. Infraorbital nerve deficit
• Trap door phenomenon
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

33. • Imaging : CT
• Management : exploration and repair
 Grafts used – PDS (polydimethylsiloxane)
Titanum alloplasts
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

34. NASO-ORBITO-ETHMOID COMPLEX #
• Markowitz et al classification :
1. TYPE 1 : single large fragment bearing the
canthal ligament
2. TYPE 2 : fragmentation of the central
fragment, medial canthal
ligaments attached to bone
3. TYPE 3 : communition of the central
ligament with no bone attached
to canthal ligament
Source: Cummings Otolaryngology - Head and Neck Surgery, 3-Volume Set: Expert Consult:

35. • Signs and symptoms :
 Loss of nasal projection and tipping tip of end of
nose
 Splaying of nasal root and telecanthus
 Blunting of canthal angle
• Management :
 Type 1 : miniplates through coronal flap, intra
orally and eyelid incision
 Type 2 and 3 : miniplates through transnasal
canthopexy
Elbarbary, Amir S. and Ahmed Ali Hassan. “Medial canthopexy of old unrepaired naso-orbito-ethmoidal (noe) traumatic telecanthus.” Journal of
cranio-maxillo-facial surgery : official publication of the European Association for Cranio-Maxillo-Facial Surgery 42 2 (2014): 106-12 .

36. ROCHA, J. L. S.; CAVALIERI-PEREIRA, L.; BRANCHER G. Q. B.; ALTAFIN, L.; CEREZETTI, L. & MIRANDOLA, C. Treatment of
naso-orbito-etmoidal Type III fracture in adolescents - Case report. Int. J. Odontostomat., 14(2):167-171, 2020.
Pre op
Post op

37. UPPER FACIAL THIRD # INVOLVING
FRONTAL SINUS :
• Anterior table # -
 no cosmetic deformity - managed conservatively.
 Displaced # - reduction and fixation
• Posterior table # - neurosx opinion, obliterative
procedure, cranialization
• Soft tissue injuries :
 Facial wound – close early
 Meticulous debridement
 Facial nerve
 Chloramphenicol eye oint.
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

38. PAEDIATRIC FACIAL INJURIES
• Soft tissue injuries :
 Resorbable suture
 Cyanoacrylate glue
• Injured anterior teeth :
 # teeth
 Moblie teeth – slint to adjacent teeth
 Exposed pulp – calcium hydroxide paste
 Avulsed - reimplant
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

39. • # of facial bone :
 Reduction and fixation
 Plates with short screw, remove >3-6 months
 Condyle # – conservative
 Medial canthi dissection – acrylic button
Source: Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

40. Reference :
• Links:
• Elbarbary, Amir S. and Ahmed Ali Hassan.
“Medial canthopexy of old unrepaired naso-
orbito-ethmoidal (noe) traumatic
telecanthus.” Journal of cranio-maxillo-facial
surgery : official publication of the European
Association for Cranio-Maxillo-Facial
Surgery 42 2 (2014): 106-12 .
• Kim, Hak & Kim, Seong & Lee, Hyun. (2017).
Management of Le Fort I fracture. Archives of
Craniofacial Surgery. 18. 5.
10.7181/acfs.2017.18.1.5.
• ROCHA, J. L. S.; CAVALIERI-PEREIRA, L.;
BRANCHER G. Q. B.; ALTAFIN, L.; CEREZETTI, L. &
MIRANDOLA, C. Treatment of naso-orbito-
etmoidal Type III fracture in adolescents - Case
report. Int. J. Odontostomat., 14(2):167-171,
2020.
Cummings
Otolaryngology -
Head and Neck
Surgery, 3-Volume
Set: Expert Consult:
Source: Scott-
Brown's Otorhinolary
ngology: Head and
Neck Surgery 7Ed: 3
volume set

41. THANK YOU