Jonathan S. Ilgen
CLINICAL FEATURES
After maxillofacial trauma has been identified during the primary survey, the clinician should first consider the potential need for endotracheal intubation, as mechanical disruption or massive hemorrhage can rapidly lead to airway compromise. Severe facial injuries are associated with injuries to the brain, orbits, cervical spine, and lungs.
Table 164-1 lists the important history and physical examination issues in facial trauma.
TABLE 164-1 Important Clinical Issues in Facial Trauma
DIAGNOSIS AND DIFFERENTIAL
Maxillofacial injuries can be diagnosed clinically as described above and with radiographs.
Plain radiographs are helpful when computed tomography (CT) is not available or to screen for injuries in low-risk patients.
Maxillofacial CT is frequently required to make definitive diagnoses and guide surgical management.
EMERGENCY DEPARTMENT CARE AND DISPOSITION
Focus initial management on airway control. A chin lift or jaw thrust without neck extension often restores airway patency.
While rapid sequence intubation is the preferred method of airway management in trauma, always plan for a difficult airway in patients with facial injuries. To prevent a “can’t intubate, can’t oxygenate” scenario, do not administer paralytics unless a patient can be hand ventilated effectively or alternative airway plans (such as airway adjuncts or cricothyroidotomy) are in place.
Awake intubation with sedation and local airway anesthesia may allow the emergency physician to assess the feasibility of orotracheal intubation while preserving the patient’s airway reflexes.
When endotracheal intubation is required, the oral route is preferred because of concern for nasocra-nial intubation or severe epistaxis with nasotracheal intubation.
In severe mandible fractures, loss of bony support may result in posterior displacement of the tongue. To prevent airway obstruction, pull the tongue forward with a gauze pad, towel clips, or a suture passed through the tip.
Hemorrhage may be controlled with direct pressure. Avoid blind clamping because of the risk of damaging the facial nerve or parotid duct.
Reduction of significantly displaced nasal fractures and Le Fort injuries is rarely needed to stop arterial bleeding. If bleeding persists, either operative ligation or arterial embolization may be necessary.
Severe epistaxis requires direct pressure or nasal packing. Posterior epistaxis can be controlled with nasal tampons, dual balloon devices, or Foley catheter placement, again being careful to avoid intracranial placement in the setting of severe midface fractures.
All patients with sinus fractures should receive oral or intravenous antibiotics, such as second-generation cephalosporins, clindamycin, or amoxicillin-clavulanate.
Frontal sinus fractures are uncommon and increase the immediate risk of traumatic brain injury, additional facial fractures, and cervical spine injury. Fractures that involve both the anterior and posterior tables for the frontal sinus require operative intervention to prevent pneumocephalus, cerebrospinal fluid (CSF) leak, and infection. Depressed fractures also require operative repair.
Patients with isolated fractures of the anterior wall of the frontal sinus may be treated on an outpatient basis.
Naso-orbito-ethmoid fractures often have associated injury to the lacrimal duct, dural tears, and traumatic brain injury. These fractures require consultation with facial surgery and neurosurgery.
Blowout fractures are the most common orbital fracture and occur when a blunt object strikes the globe, fracturing the medial or inferior orbital wall. Suggestive physical examination findings include enophthalmos, infraorbital anesthesia, diplopia on upward gaze, and a step-off deformity on palpation of the infraorbital rim.
The oculomotor and ophthalmic divisions of the trigeminal nerve course through the superior orbital fissure. An orbital fracture involving this canal leads to the superior orbital fissure syndrome, characterized by paralysis of extraocular motions, ptosis, and peri-orbital anesthesia. When the orbital apex is involved, the patient may develop these symptoms and blindness. The swinging light test and visual acuity determination are crucial in making this diagnosis.
Orbital blowout fractures require surgery if they result in extraocular muscle or oculomotor nerve entrapment, or significant enophthalmos. Patients with superior orbital fissure syndrome or orbital apex injuries also require emergent ophthalmologic consultation. The remainder of isolated orbital fractures can be managed on an outpatient basis with oral antibiotics, decongestants, and instructions to avoid nose blowing until the defect has healed or has been repaired.
Zygoma fractures occur in two major patterns: tripod fractures and isolated zygomatic arch fractures.
Tripod fractures cause disruption of the infraorbital rim, diastasis of the zygomaticofrontal suture, and disruption of the zygomaticotemporal junction. These fractures require admission for open reduction and internal fixation.
Patients with isolated fractures of the zygomatic arch can have elective outpatient repair.
Midface fractures are high-energy injuries and are often seen in victims of multisystem trauma. Patients frequently require endotracheal intubation for airway control.
Visual acuity should be tested, especially with Le Fort III fractures, where the incidence of blindness is high.
Both Le Fort II and III injuries can result in CSF leaks.
Le Fort injuries require admission for the management of significant associated injuries, IV antibiotics, and surgical repair.
Mandible fractures are often diagnosed in the setting of malocclusion or pain with attempted movement. A careful intraoral examination is important to exclude small breaks in the mucosa seen with open fractures, sublingual hematomas, and dental or alveolar ridge fractures.
Patients with open mandible fractures require admission and IV antibiotics.
Many patients with closed fractures may be managed on an outpatient basis. A Barton bandage—an elastic bandage wrapped around the jaw and head—may be worn for comfort.
For further reading in Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th ed., see Chapter 256, “Trauma to the Face,” by John Bailitz.