This document discusses trauma to the face, including causes such as automobile accidents and sports injuries. It describes the management of soft tissue injuries, bone fractures, and other conditions affecting the upper, middle, and lower thirds of the face. Specific fractures discussed include the nasal bone, orbital floor, zygoma, maxilla, and mandible. Diagnosis involves physical examination, x-rays, and CT scans. Treatment depends on the location and severity of the injury, and may involve closed or open reduction of fractures as well as fixation with wiring or plates.

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