one of the vast and difficult topic to present for an mbbs student, so this is a brief presentation regarding otorhinolaryngology aspects of facial trauma

3.  Traffic accidents
 Interpersonel violence
 Sports accidents
 Home accidents
 Occupational accidents
 Shot-gun injuries

4.  Maintenance of airway
 Cleaning of blood, vomit
 Aspiration of blood, saliva, and gastric contents ,FB
 Secured by Early Intubation or Tracheostomy
 Hemorrhage- Direct pressure n ligation of vessels
 Associated injuries- asso with injuries of head,
chest, abdomen,neck,larynx,cervical spines or limbs should
b attended

5.  Facial lacerations- wound is thoroughly cleaned of
any dirt,grease,foreign matter and closed by
approximation of each layer.
 Parotid gland and duct-if exposed ,repaired by
suturing.
 Facial nerve-exposed by superficial parotidectomy
and cut ends are approximated with 8-0 or10-0 silk
under magnification.

6.  Upper third-above the level of supraorbital
ridge.
 Middle third-between supraorbital ridge and
upper teeth.
 Lower third-mandible and lower teeth.

7.  FRONTAL SINUS-
 Anterior wall #-depressed or communited,mainly
cosmetic.
-Sinus is approached through a wound in the skin if present
or through brow incision.Interior of the sinus is inspected
 Posterior wall #-may b accompanied by dural tears, brain
injury and csf rhinorrhea.
 Injury to nasofrontal duct-causes obstruction make
large communication b/w sinus and nose.

8.  SUPRAORBITAL RIDGE-
-cause periorbital ecchymosis ,flattening of the eyebrow,
proptosis or downward displacement of eye..
-Requires open reduction through an incision in the brow
or transverse skin line of forehead.
 #OF FRONTAL BONE-
-depressed/linear, with/without separation.
-Often extends into orbit.
-Assoc with brain injury and cerebral edema-
neurosurgical correction.

9.  Nasal Bones And Septum-
 TYPES-
 DEPRESSED-due to frontal blow.
-causes open book fractures.
-septum is collapsed and nasal bones is splayed out.
 ANGULATED-lateral blow.
-U/L depression of nasal bone on the same side or both
and septum with deviation of nasal bridge

11.  CLINICAL FEATURES-
-Swelling of the nose
-Periorbital ecchymosis
-Tenderness
-Nasal deformity
-Crepitus and mobility of #ed fragments
-Epistaxis
-Nasal obstruction
-Laceration of nasal skin
 DIAGNOSIS-
-Best made on physical examination.
-Xrays may not show #
-should include water’s view,right and left lateral views
and occlusal view

12.  TREATMENT-
-Simple #-no treatment.
-Others-closed or open reduction.edema interferes with
accurate reduction so done before appearance or after
subsiding(5-7 days).
 Closed Reduction-
-# reduced by straight, blunt elevator guided by digital
manipulation from outside,
- Laterally displaced-digital pressure in opp side.
- impacted fragments - disimpaction with walsham or
asch’s forceps before realignment.
 Open Reduction-when closed method fails.

13.  Direct force over the nasion
 Nasal bones, perpendicular plate of ethmoid, ethmoidal air
cells, medial orbital wall are fractured and displaced
posteriorly
 Clinical features
-telecanthus
-pug nose
-periorbital ecchymoses
-orbital hematoma
-CSF leakage
-Displacement of eyeball

15.  Diagnosis- Xray, CT scans(more usefull
 Treatment-
Closed reduction-
• # is reduced with Asch’s forceps and stabilized by a wire
passed thru fractured bony fragments and septum n then tied
over the lead plates
- intranasal packing
- splinting kept for 10 days

16.  Open reduction-
• required in cases of extensive comminution of nasal n
orbital bones and complicated by injury to lacrimal
apparatus , medial canthal ligaments frontal sinus
-H type incision
-nasal bones n orbital walls can b reduced
-medial canthal ligaments avulsed-restored with a thru
n thru wire

17.  2nd most frequently fractured bone
 Direct trauma
 Zygoma is separated from its processes
 Clinical features
-Flattening of malar prominence
-step deformity
-anesthesia in distri of infraorbital N
-Trismus
-Oblique palpebral fissure
-Restricted ocular movements
-periorbital emphysema

18.  Diagnosis- Water’s view shows # n displacement best,
CT
 Treatment
-Only displaced # requires treatment
-open reduction n internal wire fixation – best results
- fracture is exposed at frontozygomatic suture through laterlal
brow incision n reduced by passing an elevator behind the
zygoma
-Wire fixation is done at frontozygomatic suture n infraorbital
margin(incision at lower lid)

19.  Generally breaks into 2 fragments which get depressed
 3 fracture lines- one at each end n 3rd in centre of arch
 Clinical features
-depression in the area of arch
-local pain- aggravated by talking chewing
-Trismus or limitation of movements of mandible due to
impingement of fragments on the condyles or coronoid
process

20.  Diagnosis-
best seen on submentovertical view of skull
 Treatment
-vertical incision on hair bearing area above or infront of the
ear, cutting through temporal fascia
-an elevator passed deep to temporal fascia and carried under
the depressed bony fragments which r then reduced
- fixation not required as fragments remain stable

21. Axial CT scan
isolated depressed left zygomatic arch
fracture.

22.  Accompanied with zygomatic n Le Fort II fracture
 Isolated- large blunt objects, Orbital blowout fracture
 Clinical Features
-Ecchymosis of lid, conjuntiva,
and sclera
-Enophthalmos with inferior
displacement of the eyeball
-Diplopia
-Hypothesia or anesthesia of cheek
and upper lip( infraorbital N

23. A- small orbital blow-out fracture is confined t
the orbital floor
B- larger blow-out fracture extends to involve
to the lower medial orbit as well as orbital floo
Coronal CT

24.  Diagnosis- Waters’ view shows a convex opacity bulging in to
the antrum from above(tear drop opacity)
- CT confirms the diagnosis
Treatment
-Indications for surgery- enophthalmos n persistent diplopia
-by transantral approach
-Infraorbital approach alone or in combination with transantral
approach
-a pack can b kept in the antrum to support fragments
-Badly comminuted fractures can be repaired by bone graft from iliac
crest, nasal septum or antr wall of antrum
-silicon and teflon sheets have also been used to reconstruct the
orbital floor

25.  1. Le Fort I(transeverse) fractures runs above and
parallel to the palate
-It crosses lower part of nasal septum, maxillary antra n
pterygoid plates
 2. Le Fort II(pyramidal) –passes though the root of
nose , lacrimal bone,floor of orbit, upper part of maxillary
sinus and pterygoid plates
 3. Le fort III(craniofacial dysjunction)
complete seperation of facial bones from the cranial bones.
Fracture line passes through root of nose, ethmofrontal
junction,superior orbital fissure, lateral wall of orbit,
frontozygmatic and temporozygomatic sutures and the upper
part of pterygoid plates

27.  Clinical features
- Malocclusion of teeth with antr open bite
- Elongation of midface
- mobility in the maxilla
-CSF rhinorrhoea (cribriform plate injured in II n III)
 Diagnosis
-Xray- water’s view, posteroanterior view lateral view
-CT
Coronal CT

28.  Treatment
-immediate attention- to restore airway n stop haemorrhage
-fixation achieved by
a. Interdental wiring
b.Intermaxillary wiring using arch bars
c. open reduction and interosseous wiring
d. wire slings from frontal bone,zygoma or infraorbital rim to
teeth or arch bars

29.  Classified according to
the location
 CABS
 Displacement of fractures
determined by
- direction of pull of muscles
attached
-direction of fracture line
-bevel of fracture

30.  Clinical features
• in # of condyles-
-if fragments not displaced- pain and trismus , tenderness
can be elicited
-if displaced- also malocclusion of teeth and deviation of jaw
to the opp side on opening the mouth
• Fractures of angle, body n symphysis – diagnosed by
intraoral n extraoral palpation
• -step deformity, malocclusion of teeth, ecchymosis of oral
mucosa, tenderness at site of fracture

31.  Treatment
-closed methods- interdental wiring and intermaxillary fixation
-open methods- fracture site is exposed and fragments fixed by
direct interosseous wiring (further strengthened by by a wire
tied in shape of 8)
-Now compression plates are available- prolonged
immobilisation n intermaxillary fixation can b avoided
-immobilisation of mandible beyond 3 weeks in condylar
fractures- ankylosis of TMJ
- therefore wires r removed n jaw exercises started
-if occlusion is still disturbing- wires r reapplied for another
week n process repeated until bite n jaw movements r
normal