Faciomaxillary Injuries

2. Faciomaxillary Injuries
Dr Asmatullah Achakzai
Associate Professor ENT Department

3. MAXILLOFACIAL FRACTURES
 Fractures of the facial skeleton including the nose,
mandible, zygoma and orbit are most commonly due
to: •
 Accidental trauma
 Physical combat
 Sports injuries.
Maxillofacial fractures, besides causing cosmetic deformity,
loss of function and brain damage can also result in
endangerment to the airway.

5. Care of Patient in Emergency
The first priority Is securing the airway and controlling bleeding when the
patient presents in the emergency. For this, the following factors for care of
patient In emergency include:
 Airway is to be maintained by alignment of neck and endotracheal intubation
is undertaken in unconscious patient.
 Breathing—to assess and establish breathing to ensure adequate
ventilation.
 Circulation—to maintain and improve blood circulation and to control blood
loss by anterior nasal packing (ANP), suction, suture or arterial ligation.
 Dysfunction—to assess levels of consciousness and neurological deficit.
 To carefully expose the patient to identify all other injuries. Clinical
examination Includes that of eyes, nose, maxilla, mandible, mucosa and
dentition. Any lacerations should be cleaned and sutured. The fractured
fragments should be accurately reduced, immobilized and maintained free
by infection by antibiotics and anti-inflammatory drugs.

6. CLASSIFICATION
 The Faciomaxillary injuries can be divided into:
 Fracture of upper third of face.
 Fracture of middle third of face—central/lateral
 Fracture of lower third of face.

7. FRACTURES OF UPPER THIRD OF FACE
 The upper third of face includes the region of face
above the supraorbital ridge. In this region, there can
be trauma to frontal sinus, supraorbital ridge and
fracture of frontal bone.
 Main Features
 They are as follows:
 If frontal sinus is involved:
 Dural tears/brain injury
 Cosmetic deformity on forehead
 Cerebrospinal fluid (CSF) rhinorrhea.
 If supraorbital ridge is fractured, it results in:
 Periorbital ecchymosis.
 Proptosis/downward displacement of eye.

8. Management
 Reduction of fracture through an open wound/bow,
incision/turnovers skin line on forehead.
 If Dural tears present, these can be covered by
temporalis fascia.
 Neurosurgical consultation fot brain injury and/or
cerebral edema.

9. FRACTURES OF MIDDLE THIRD OF FACE
 Middle third of face includes region between
supraorbital ridge and upper teeth
 Depending on the site of involvement, fractures of
middle third of face can be:
 Central (nasomaxillary) includes fracture nasal bones/
naso-orbital fracture
 Lateral (malar-maxillary).

10. Central (Naso-maxillary) Fractures
 Clinical features
 Epistaxis is the common symptom. It may be temporary or
continuous.
 External nasal deformity due to dislocated bony fragments and
edema of tissues due to trauma or hematoma.
 Nasal obstruction is present due to blood clots, septal
hematoma or septal deformity.
 Palpation over the nasal bridge will elicit tenderness and bony
crepitations.
 Edema usually sets in within 4 to 6 hours of injury. So fracture
can be best assessed within 2 to 4 hours of trauma or after 6 to
8 days when edema subsides.
 Watery nasal discharge is indicative of CSF leak due to fracture
of cribriform plate in the roof of nose.

11. Investigations
 Anterior rhinoscopy should be carried out to
ascertain nasal patency and to remove any blood
clot. Any septal dislocation/septal hematoma can be
noted.
 X-ray lateral view and anteroposterior (AP) view of
nasal bones demonstrate the fracture line.
 X-ray skull and computed tomography (CT) scan are
done to detect associated head injury, if suspected..
 Examination of eyes to rule out subconjunctival
hemorrhage.

12. Classification of fracture nasal bones
 Class 1 Fracture
 Fracture Fractures involving nasal bones and septal
cartilage. (Chevallet fracture).
 Class II Fracture
 It causes significant cosmetic deformity. (Jarjavay
fracture).
 Class III Fracture
 Fracture The fractures extend to include the ethmoidal
labyrinth. It is currently known as naso-orbitoethmoid
(NOE) fracture.

16. Naso-orbitoethmoid fracture—subtypes
 In this type, anterior skull base, posterior wall of
frontal sinus and optic canal remain Intact. The
ethmoidal labyrinth collapses or telescopes on itself
causing a classical pig-like appearance to the face
with foreshortening of nose and increased space
between the eyes (telecanthus).
 In this type, there is disruption of posterior frontal
sinus wall, multiple fractures of roof of ethmoid and
orbit extending as far back as sphenoid and
parasellar region. It may result in dural tears, CSF
leakage and cerebral herniation.

17. Management of nasal fractures
 In case of head injury or vehicular accidents, maintain the
vital parameters of the patient
 Epistaxis, if present, is treated by anterior nasal packing
 Any open wounds are to be cleaned and sutured
 Antibiotics and anti-inflammatory analgesics to be given
to the patient
 If the patient is seen within 1 to 2 hours of trauma, the
fracture can be reduced under LA using Asche's or
Walsham's forcep
 If edema has already set in, it is better to wait for 7 to 8
days to allow the edema to subside and then to reduce
the fracture under general anesthesia (GA)
 If there is septal deformity, septal hematoma, it is to be
treated at the same time as fracture reduction.

19. Asche’s Septal Forcep
Walsham’s Forcep

20. Fractures of orbit floor
 Result from direct trauma to the orbit, usually occur
when a large blunt object strikes the globe resulting
in blow out fractures. In this, the orbital contents may
herniate into the antrum.
 Clinical features
 Ecchymosis of lid, conjunctiva and sclera, epiphora,
subconjunctival hemorrhage and diplopia.

21. Fracture of the Maxillary Sinus
 There is step deformity of infraorbital margin due to
fracture, edema of soft tissues and anesthesia or
numbness over cheek due to involvement of infraorbital
nerve.
 It is based on the extent of bone involvement (Figures
27.2A and B). LeFort I (Transverse) In this, there is
transverse fracture of maxilla involving the palate only,
running above floor of nasal cavity through the nasal
septum and maxillary sinus. LeFort ll (Pyramidal) Runs
from floor of mwdllary sin uses superiorly to the
infraorbital margin, through the zygomati-comaxillary
suture and through the orbit. The infraorbital nerve is
often damaged in this.

22. LeFort's classification for central fractures
 It is based on the extent of bone involvement.
 LeFort I (Transverse)
 LeFort ll (Pyramidal)
 LeFort lll (Craniofacial dysotosis)

24. Lateral Fracture of the Middle Third (Malar
Maxillary)
 These are due to blow from side
of face. Direct trauma causes
lower segment of zygoma to be
pushed medially and posteriorly
causing flattening of malar
prominence and step defomity of
infraorbital margin. Fracture line
passes through
zygomaticofrontal suture, orbital
floor, Infraorblial in gin And
anterior wall of maxillary sinus.

26. Continued..
 Clinical Features
 They include flattening of malar prominence, 11-knit's,
anesthesia in distribution of infraorbital nerve, step deformity of
infraorbital margin and diplopia. Diagnosed by X-ray PNS
(Water's view) and in case of CSF rhinorrhea. Cr might also be
undertaken to show site of leakage.
 Treatment
 Fracture is reduced under GA and the fractured fragments are
kept in contact with the help of steel wires, splints and rods
using various techniques of external or internal fixation.

27. FRACTURES OF LOWER THIRD OF FACE
 These include fractures of mandible. Subcondylar region
fractures are the most common (35%) followed by those
of angle, body and symphysis. Most fractures are caused
by indirect trauma to chin.
 Clinical Features
 If undisplaced fracture, pain and trismus are mainly observed
and there is tenderness at the site of fracture
 Displaced fragments of mandible result in malocclusion of teeth
and deviation of jaw to opposite side
 Diagnosis is by X-ray skull (poster anterior [PA] view) and X-ray
right and left oblique view of mandible. Management is by
interdentally wiring, intermaxillary fixation, transosseous wiring
and bone plates by both open or closed reduction techniques.

28. ANY QUESTIONS

29. THANK YOU