9.1 Craniomaxillofacial Trauma
For ear and temporal bone trauma, see Chapter 3.1.2. For laryngeal fractures, see Chapter 5.1.2. For neck trauma, see Chapter 6.1.4.
9.1.1 Nasal Fractures
Key Features
Nasal fractures are the most common head and neck fracture.
They have aesthetic and functional implications.
Septal hematoma should be recognized early and managed immediately.
Closed reduction may reduce the need for delayed treatment.
Open reduction may be necessary.
Even if no surgical intervention is initially planned, the patient should be reevaluated in 1 to 2 weeks after any traumatic swelling has resolved.
Cartilaginous injury, persistent deformity, or persistent nasal obstruction may require delayed functional septorhinoplasty.
The clinical presentation of a nasal fracture may include a history of nasal trauma with associated pain, edema, epistaxis, change in external nasal appearance, nasal airway obstruction, and infraorbital ecchymosis. Imaging is not necessary to diagnose a nasal fracture but may be indicated to rule out other injuries. Deformities that are not immediately identified may become obvious as edema resolves. Treatment may be immediate or delayed based on history, exam, and patient desires. Even if immediate intervention is performed, appropriate follow-up is necessary to identify persistent deformities or nasal obstruction.
Epidemiology
Nasal fractures are cited as the most common type of facial fracture, accounting for approximately half of all facial fractures. These injuries occur largely in the younger, physically active segments of the population and predominantly in males. The most common mechanism is blunt trauma (e.g., accidents, assault, sports), although these fractures also occur via penetrating and high-energy injuries. Nasal fractures occur not only in isolation but also frequently in conjunction with more extensive facial fractures.
Evaluation
A detailed history on mechanism of injury, patient symptoms, associated complaints, premorbid status of the nose, and a general health history should be obtained.
Physical examination is critical in the diagnosis of nasal fractures and may be facilitated if the nose is decongested. Visual inspection, manual palpation, and anterior rhinoscopy are essential. Nasal endoscopy may be performed to increase the acquisition of meaningful clinical data when necessary ( Fig. 9.1 ).
After a focused facial trauma exam to rule out associated injuries, the nose should be examined. The integrity of the nasal skin should be assessed. Often, nasal edema limits visual examination. Palpation of the nose is critical to making the correct diagnosis. All aspects of the nose should be evaluated. Globally, the examiner should determine whether the nose is straight, whether there is a deviation, or whether other dorsal deformities exist (e.g., C-shaped deformity, saddle deformity, etc.). Palpation of the nasal bones will identify fracture of the bony pyramid as a segment versus more complex comminuted injuries. The examiner should assess rotation, projection, and tip and sidewall support. Anterior rhinoscopy must be performed to assess the status of the septum. Determining the status of the septum is frequently underemphasized; however, appropriate appreciation and management of septal injuries is essential to the restoration of optimal nasal function and appearance. The examiner should look for and document the presence or absence of a septal hematoma. If present, it should be expeditiously and appropriately managed.
Photographs should be taken, similar to the views obtained for rhinoplasty evaluation. Planar radiographs and computed tomography (CT) rarely add more valuable data than those obtained through the physical examination and medical history unless an associated injury is suspected based on exam (e.g., telecanthus, dystopia).
Treatment Options
Observation
If minimal displacement of the nasal bones, minimal soft tissue injury, and minimal compromise of the nasal airway exists, observation is appropriate. Patients should be followed within 1 to 2 weeks once edema has resolved to confirm that no posttraumatic deformity exists.
Closed Manipulation
In the case of obvious bony deviation or more severe nasal bone or septal injuries, a closed reduction, with or without splinting, may be warranted. This may be performed under local or general anesthesia, based on patient and surgeon preference. Manipulation is typically performed within 2 to 3 days of injury prior to bony healing of the fracture. During closed reduction, the patient′s fractured nasal bones and septum are mobilized and reduced digitally. This may be aided with the use of blunt instruments such as the Boies elevator or Ashe forceps. Traditional closed manipulation is best applied in patients who have actual subluxation or displacement of the nasal bones without comminution of the nasal bones themselves. However, closed reduction may be attempted in the latter case with the use of intranasal and extranasal stabilization.
Modified Open Reduction with Osteotomies
The modified open technique is a limited version of an open technique in which intranasal incisions are made for the introduction of osteotomes. Such patients frequently benefit from manipulation of the nasal bones into position after undergoing bilateral micro-osteotomies. As with closed manipulation, the position of the septum may impede the success of this technique. A secondary procedure may then be necessary or other treatment offered.
Open Nasal/Septal Repair
The open nasal/septal repair refers to an aggressive approach to the acute management of complicated injuries using existing lacerations or external and intranasal incisions. With this approach the surgeon can reduce, graft, and fixate fractured anatomic components under direct visualization.
Formal Septorhinoplasty
Formal septorhinoplasty after nasal fracture is employed in two general clinical situations. Septorhinoplasty may be used as a delayed primary treatment for late patient presentation or persistent deformity and/or obstruction after a period of fracture observation. It may also be used as a secondary procedure after initial acute management with persistent deformity or obstruction. Precise treatment plan is selected based on anatomic diagnosis of persistent deformities and may include osteotomies and repositioning of the bony pyramid, septoplasty, and grafting.
Outcome and Follow-Up
Up to half of untreated nasal fractures require delayed surgical intervention. Immediate closed manipulation reduces the need for delayed intervention in appropriate cases. After nasal bone reduction, externally stabilizing dressings should be applied similarly to standard rhinoplasty care, and the patient should avoid activities that may lead to nasal trauma for 4 to 6 weeks. When there have been significant septal injuries, internal soft Silastic splints may provide stabilization and aid in the prevention of synechiae. Nasal bones may be supported by intranasal supports placed under the nasal bones. Packing is rarely necessary. Patients should be followed until healing is complete with satisfactory functional and aesthetic results.
9.1.2 Naso-Orbito-Ethmoid Fractures
Key Features
A naso-orbito-ethmoid fracture is a severe injury involving depression of nasal bones into ethmoids with associated medial orbital wall fracture.
It is secondary to a high-energy mechanism; often associated with intracranial and other severe injuries.
Treatment requires open reduction with internal fixation (ORIF).
Naso-orbito-ethmoid (NOE) fractures result from a high-energy injury, such as a motor vehicle accident. Accordingly, multiple serious injuries are often present, requiring neurosurgery, ophthalmology, and otolaryngology, and/or facial plastic surgery care. Treatment is directed at minimizing complications and achieving adequate functional and cosmetic repair.
Epidemiology
NOE fractures result from severe trauma to the frontal and midface region. The most common mechanism is a motor vehicle accident with an unrestrained driver. Seatbelt and airbag use has reduced its incidence in recent decades to approximately 5% of all facial fractures in adults and around 15% in children.
Clinical
Signs and Symptoms
Often, patients with NOE fractures have other life-threatening injuries due to the high-energy mechanism and require initial trauma evaluation and stabilization. These fractures rarely occur in isolation, and the most common concomitant facial injuries include frontal sinus fractures and LeFort pattern midface fractures. Eye and brain injuries are common. Concurrent ocular injury, such as globe rupture, lens dislocation, retinal detachment, or vitreous hemorrhage, occurs in ~ 30% of patients. Patients may have cerebrospinal fluid (CSF) leakage due to disruption of the anterior skull base. Typical associated signs and symptoms include severe epistaxis, CSF rhinorrhea, diplopia, epiphora, facial lacerations and severe facial pain. The typical facial deformity resulting from disruption of the ethmoids and medial canthal tendon attachments includes flattening of the nasal dorsum, upward tip rotation with loss of projection, and increased interpupillary distance (traumatic telecanthus).
Differential Diagnosis
It is important to differentiate NOE fractures from isolated nasal fractures (see Chapter 9.1.1), orbital fractures (see Chapter 9.1.3), and fractures that involve only the ethmoid air cells. Computed tomography (CT) imaging allows rapid, definitive diagnosis.
Evaluation
History
The mechanism of injury will help determine possible injuries and severity. Often, the patient may be unable to provide history because of loss of consciousness, altered mental status, or intubation/sedation.
Physical Exam
Exam, as with all traumas, begins with ABCs (airway, breathing, circulation). Care must be taken to protect the cervical spine until it has been cleared. Head and face are inspected and palpated for ecchymoses, soft tissue injuries, skeletal stability, and bony step-offs. Telecanthus results from NOE fractures. The average intercanthal distance ranges from 25 to 35 mm; this is usually 50% of interpupillary distance. A distance of ≥ 40 mm is considered diagnostic of telecanthus ( Fig. 9.2 ).
The medial canthal tendon attachment is easily evaluated with the “bowstring” test ( Fig. 9.3 ). While palpating the tendon insertion at the lacrimal crest, the examiner retracts the lower lid laterally. If the tendon insertion is intact, the examiner will feel it tighten like a bowstring. Ideally, the nose should be decongested to allow for an intranasal exam. With use of a headlight and speculum, clots and blood are suctioned and mucosal tears, position of the septum, and possible hematomas are noted. Clear fluid may represent a CSF leak. A drop of this fluid on gauze may reveal a “halo sign” indicative of CSF and suggesting concomitant anterior skull base disruption. As globe injuries are common, a thorough ophthalmologic evaluation should be performed.
Imaging
Thin-cut multiplanar CT is the most useful imaging study. Fractures of the facial and nasal bones are readily visualized, with excellent detail of the medial orbital walls and lacrimal region. The integrity of the skull base may be assessed, as well as the presence of pneumocephalus or other intracranial injury. NOE fractures can be categorized according to the degree of comminution at the medial canthal tendon insertion:
Type I: Large central fragment
Type II: Comminution of central fragment but not involving the tendon
Type III: Comminution involving lacrimal fossa and tendon attachment site with tendon laceration
Labs
Lab studies may be indicated, including complete blood count (CBC), prothrombin time (PT), partial thromboplastin time (PTT), serum electrolytes, β-2-transferrin analysis of clear nasal drainage, and a toxicology screen.
Treatment Options
Treatment of an NOE fracture typically requires ORIF once the patient is stabilized. For relatively limited fractures, an external ethmoidectomy incision may afford adequate exposure. Often the surgeon may take advantage of large lacerations for bony exposure. However, a coronal incision is generally used and affords excellent exposure to the NOE region and allows treatment of upper facial skeleton (frontal bone or frontal sinus) injuries. Stabilization of the central fracture fragment, to which the medial canthal tendon is attached, is achieved with plating to stable bone, especially in type I and II injuries. Transnasal wiring is often necessary to achieve an adequate result, especially in type III injuries, in which severe comminution is present with detachment of the medial canthal tendon. Many surgeons advocate slight initial overcorrection. Bone grafting may be necessary.
Outcome and Follow-Up
Patients are often admitted secondary to their severe concomitant injuries for multidisciplinary treatment. The need for perioperative antibiotics is controversial. Frequent vision examinations are performed following repair of orbital fractures, and neurologic checks are performed for concomitant skull base and intracranial injuries. Infection, hematoma, or vision change requires prompt attention to correct underlying issues. Possible complications of NOE fractures and their treatment include persistent telecanthus, nasal deformity, CSF leak, intracranial infection, standard postoperative complications, and unrecognized concomitant frontal sinus outflow tract injury with chronic frontal sinusitis or mucocele. Some authors recommend annual evaluation with CT scan to rule out the latter.
9.1.3 Zygomaticomaxillary and Orbital Fractures
Key Features
Zygomaticomaxillary complex (ZMC) fractures are the most common facial fractures after nasal bone fractures.
ZMC fractures involve disruption of the maxillofacial buttresses.
Features of an orbital floor blowout fracture may include enophthalmos, V2 numbness, diplopia, and an orbital rim fracture.
The fractured ZMC is most often displaced posteriorly and inferiorly.
Midface fractures require high force and may lead to aesthetic and functional deficits. Zygomaticomaxillary complex (ZMC) fractures are considered tetrapod fractures if they involve the zygomaticomaxillary, frontozygomatic, zygomaticotemporal, and zygomaticosphenoid sutures. Undiagnosed orbital or ZMC fractures may lead to delayed functional and aesthetic deficiencies. Treatment often requires surgical intervention with open reduction and internal fixation.
Epidemiology
ZMC fractures often occur in conjunction with orbital fractures. Zygoma fractures are most common in men (in the third decade) and are most commonly caused by blunt force trauma from sports injuries, motor vehicle accidents, or assault. Up to 30% of midface and periorbital fractures have a concomitant orbital injury.
Clinical
Signs and Symptoms
Patients suffering ZMC or orbital fractures typically present with a history of blunt trauma with development of periorbital edema or ecchymosis, lacerations, pain, vision changes, trismus, facial deformity. Numbness of the ipsilateral upper lip, gum, nostril, and cheek is common due to fractures through the infraorbital foramen because of injury to cranial nerve (CN) V2 (the maxillary nerve). Orbital signs include chemosis, subconjunctival hemorrhage, proptosis, enophthalmos, and diplopia. Entrapment of the inferior rectus muscle in an orbital floor fracture results in diplopia due to impaired extraocular muscle function. Palpation of the zygoma may show stepoffs, mobility, or crepitus. Malocclusion may result from either a mobile midface (Le Fort) fracture or a concomitant mandible fracture. A depressed zygoma fracture may cause trismus by compressing the coronoid.
Differential Diagnosis
The spectrum of fractures in the zygoma, maxilla, and orbital bones can range from isolated to complicated, from severely displaced to greenstick, and from simple to comminuted. Classification should begin with assessing for midface instability, which would indicate a Le Fort fracture (see Chapter 9.1.5). Assessment of the seven bones that constitute the orbit (lacrimal, palatine, frontal, ethmoid, zygomatic, maxillary, and sphenoid) most often reveals fractures at the weakest bones: the lamina papyracea (ethmoid) and orbital floor (maxilla). Imaging is critical for appropriate diagnosis.
Evaluation
Physical Exam
As with any trauma patient, establishing the ABCs and obtaining cervical spine clearance should be the first priority. The full head and neck examination must include cranial nerve testing, an ophthalmologic evaluation, and a maxillofacial skeletal assessment. Le Fort fractures have palatal mobility, which can be examined by grasping the upper teeth and pulling the maxillary arch forward and inferiorly. Finger palpation for step-off deformities of the orbital rims, zygoma, nasal bones, and frontozygomatic suture can help determine the site of fractures, although edema may make this difficult. The dermatome of CN V2 should be tested and documented. Extraocular movement and vision testing may demonstrate diplopia or an entrapped inferior rectus muscle.
Forced duction testing may be performed by topically anesthetizing the conjunctiva with tetracaine drops, grasping the episcleral tissue in the fornix (near the inferior oblique insertion) with fine forceps, and testing the mobility of the globe for restriction that could indicate an impinged inferior oblique muscle in an orbital floor fracture. Facial nerve function should be assessed, especially when overlying lacerations are present. An ophthalmologic consult is often performed prior to fracture repair. Retinal detachment or retrobulbar hematoma may preclude immediate surgery or require orbital decompression, respectively.
Imaging
Fine-cut multiplanar maxillofacial computed tomography (CT) scan is the gold standard. Three-dimensional reconstruction, if available, enables an easy assessment of any displacement of the ZMC. Additionally, sagittal or parasagittal cuts improve evaluation of the orbital floor in conjunction with the coronal views. The pterygoid plates and zygomatic arches are best seen on axial films; the orbital rims, floor, and cribriform plate require coronal cuts. Subcutaneous air or intraconal air is often seen with both ZMC and orbital fractures. Foreign bodies or bone fragments near the optic nerve should be identified on CT to prevent damage during fracture reduction. For orbital floor fractures, bone and periorbital disruption should be assessed. The degree of floor disruption, amount of soft tissue herniation, and signs of entrapment should be evaluated. For zygoma fractures, imaging will enable more specific classification of the ZMC fracture, determine the severity of the fracture pattern, and assess the degree and direction of displacement.
Treatment Options
Minimally displaced fractures can be managed with observation. Patients should be followed until full resolution of edema to confirm the absence of functional or aesthetic deficiencies. Isolated zygomatic arch fractures may be treated with a transoral (Keen), temporal (Gilles), percutaneous, or, rarely, coronal approach (comminuted fractures).
Displaced ZMC fractures should be repaired with open reduction and internal fixation. Approaches often include a combination of transoral (to address the maxillary buttress), lower eyelid (orbital rim and floor), and upper eyelid (frontozygomatic) approaches. Additionally, lacerations may be used to assess the fractured segments. Severe fractures may require a coronal approach for repair. Typically two- to four-point fixation with wires or miniplates to stabilize the ZMC is required.
Significant controversy exists regarding the need for operative repair of orbital floor fractures. In general, large fractures with significant soft tissue herniation, immediate enophthalmos, muscle entrapment, or a persistent oculocardiac reflex are indications for surgery. Transconjunctival, transcutaneous lower lid, and transantral/endoscopic approaches may be used based on surgeon experience and fracture characteristics. Basic tenets are to reduce herniated soft tissue and to restore normal orbital volume by reconstructing the orbital floor. Many types of implant materials are available for floor and wall reconstruction.
Complications
Increased intraocular pressure from an orbital hemorrhage can cause vision loss from the injury itself or as a complication of repair. Prompt treatment includes immediate lateral canthotomy and cantholysis, intravenous (IV) steroids (methylprednisolone), ophthalmology consult, and an urgent CT scan. Orbital decompression may be necessary. The most common complications of orbital floor repair are inadequate fracture reduction with subsequent enophthalmos or diplopia, eyelid malposition, corneal abrasion, chronic lower eyelid edema, and chemosis. Complications after ZMC repair include poor reduction with cosmetic deformity and flattening of the malar eminence, intraoral wound dehiscence, and hardware complications (loosening, palpability, exposure).
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