Summary

Nasal and paranasal sinus trauma is generally considered within the broad topics of facial trauma and craniomaxillofacial (CMF) trauma. However, these broader topics include soft tissue and visceral injuries, which are not included in nasal and paranasal sinus trauma.

Trauma to the CMF region may involve soft tissue, visceral structures, and the underlying, supportive bony structures. Repair of these injuries is important not only for normal function of the various components, especially vision, smell, communication, eating, and breathing, but also for proper facial appearance (i.e., cosmesis). Reestablishment of a normal and “acceptable” appearance is critically important, as facial appearance is the doorway to human interaction.

In this section, the focus is primarily on the underlying skeletal structure. Classification of injuries is discussed, as this provides the framework for planning repairs; it is also important for documentation of cases and communication among health care professionals. Next, the general epidemiology of these injuries is briefly addressed. With classification understood, it is then important to know how to define the injuries so that they can fit into the classification system, so diagnostic testing and evaluation are discussed. In this regard, it is critically important to remember to assess patients for associated injuries, particularly the cervical spine, as the presence of an unrecognized cervical spine injury could have grave implications if an iatrogenic injury to the spinal cord is created during intubation and management of facial injuries. Management of these injuries is then discussed, followed by a discussion of outcomes.

Classification of Nasal and Paranasal Sinus Trauma

To understand and discuss sinus trauma, we need to have some definitions and categories that will help clarify the injuries involved and allow communication among surgeons. The Le Fort classification system is based on work done by Renee Le Fort that was originally published in 1901.1 Le Fort inflicted trauma on human cadaver heads and looked at the resultant patterns of skeletal injury that predominated. He defined three basic patterns of fracture that have come to be known as the Le Fort I, II, and III fractures (see discussion below). Note that, although most facial fractures are often more complicated than those represented in the Le Fort classification system, the categories that he defined still provide an excellent framework for the basic patterns of fractures that occur. More importantly, the Le Fort definitions are commonly understood by most specialists/surgeons who treat maxillofacial fractures. This system therefore provides an excellent basis for communication among providers who care for these patients.

One of the many complexities of the facial skeleton is the presence of appendages in the bone, specifically the dentition. The presence of teeth makes fracture repair more difficult, as it decreases the tolerance in the system for imperfections in fracture reduction. Patients may be quite sensitive to minor discrepancies in tooth position, and, of course, significant discrepancies translate into malocclusions that often lead to functional impairment and temporomandibular joint problems. Other potential pitfalls result from the presence of multiple visceral structures that are placed at risk from both the injuries and the repairs, including the eyes, the brain, salivary glands and ducts, and multiple sensory and motor nerve branches, as well as skin and muscle problems that may cause cosmetic and functional problems.

Midface

Maxilla (Upper Jaw)

Le Fort I

The Le Fort I type fracture is a maxillary fracture that traverses the maxilla horizontally, usually bilaterally, completely separating the tooth-bearing maxillary alveoli from the remainder of the CMF skeleton ( Fig. 29.1 ). It crosses the nasal septum and is completed posteriorly by fracturing through the pterygoid plates (an important component of all true Le Fort fractures). Obviously, the fracture involves the maxillary sinuses, though it generally avoids the ostia of the sinuses and therefore should not be expected to alter sinus function.

Palate

Palatal fractures typically occur together with Le Fort fractures. Splitting of the palate usually occurs in a parasagittal or sagittal plane, though, depending on the force applied, any direction and degree of complexity is possible. When combined with a Le Fort fracture, it makes reestablishing the occlusion more difficult and therefore adds to the complexity of the repair. It also allows for the occurrence of a unilateral Le Fort fracture, seen most commonly at the Le Fort I level. Palatal fractures almost invariably include a laceration of the palatal mucosa.

Dental Arches (Alveoli)

Fractures through the dental arches may occur independently or together with other fractures. When they occur in isolation, they are usually managed by either dentists or oral/maxillary surgeons. When they occur together with Le Fort fractures, their presence makes the repair more difficult, as the dental occlusion may move independently of the maxillary bones, making it more difficult to identify the proper relationship of the bone fragments.

Le Fort II (Includes Nose/Nasal Root)

This is often called the “pyramidal fracture” of the midface, because of the shape of the mobile fragment when viewed straight on ( Fig. 29.1 ). Like the Le Fort I, the fracture crosses the maxillary sinuses, nasal septum, and pterygoid plates. However, instead of a reasonably horizontal orientation, the fracture extends from the lateral maxillary sinus in a more superior direction through the inferior orbital rim into the orbit, involving the orbital floor. It then extends across the medial orbital wall and involves the nasal bones, classically separating them from the frontal bones at the nasal root. (Note that this fracture may cross the nasal bones bilaterally, having the same ultimate effect of creating a pyramidal-shaped midfacial segment.)

Nose

Nasal Bones

Various classifications have been proposed for nasal bone fractures, although few surgeons use them. Most discussions of nasal fractures are therefore descriptive, rather than based on classification. In analyzing nasal injuries, once issues of bleeding and infection have been addressed, the key concerns are appearance and function. It is important to determine as best as possible the status of the patient′s nose before the injury in this regard. The presence of a preexisting deformity, cosmetic and functional, will influence the decision of whether or not to consider an attempt at acute repair and by what means. Pre-injury photos should be acquired, if available.

Although the sense of smell can be adversely affected by nasal fractures, most functional complaints relate to nasal airway obstruction.

Nasal Septum

The nasal septum is frequently fractured and/or dislocated as a result of nasal trauma. It is difficult to estimate the frequency of this injury, as most people probably do not even seek treatment for minor nasal traumas. However, if a patient presents with nasal trauma, it is most important to examine the nasal septum to rule out the presence of a septal hematoma, as failure to identify and manage this problem can lead to long-term sequelae. A septal hematoma develops in the plane between the perichondrium and the septal cartilage. Because the cartilage derives its blood supply from the perichondrium, failure to identify and manage the hematoma can lead to cartilage necrosis and/or abscess formation, which can lead to both airway problems and cosmetic (saddle nose) deformity or worse.

Orbits

Orbital Floor (Roof of the Maxillary Sinus)

The floor of the orbit is the roof of the maxillary sinus. Fractures are categorized as blowout fractures, which are fractures of the orbital floor that occur in association with an intact orbital rim, and other orbital floor fractures, which occur in association with rim fractures, along with maxillary and zygomaticomaxillary fractures.

The mechanism of occurrence of pure blowout fractures is controversial. Some experts argue that certain traumas to the rim will cause it to buckle without fracturing, leaving a blowout fracture of the orbital floor. Others believe that direct trauma to the globe results in transmission of force to the orbital floor, causing it to fracture.2–5 Recent work suggests that both mechanisms can explain the occurrence of these fractures.

Medial Wall (Lateral Wall of the Ethmoids)

Medial orbital wall fractures can occur in isolation or in combination with other fractures. Like the orbital floor, the medial wall is thin and can fracture in response to direct blunt trauma to the globe. It is not uncommon for both medial and floor blowout fractures to occur in response to the same blunt trauma.

Naso-orbital Ethmoid or Nasoethmoid Complex

Trauma directly to the solid bone of the nasal root results in transmission of force through the solid nasal root into the thin bone behind it. In most cases, the solid glabellar bone remains intact, though not always. The bone behind it generally fractures and accordions posteriorly, shattering the medial wall of the orbit, which is the lateral wall of the ethmoid sinuses, frequently bilaterally. The nasal bone telescopes inward, thus creating the so-called naso-orbital ethmoid fracture. The descriptive term naso-orbitonasal ethmoid fracture replaces the older, somewhat less descriptive term nasoethmoid complex fracture, although both are still used.

Classification of this fracture is typically based on the status of the bone fragment that bears the medial canthal ligament, rather than the status of the other fractured bones. In the classification system proposed by Markowitz et al,6 a type I fracture leaves the ligament-bearing fragment intact and attached to a large central fragment, and a type II results in a small ligament-bearing fragment that requires control of the ligament for proper repair. In type III fractures, the central fragment is shattered, and the ligament is completely disarticulated ( Fig. 29.2 ).

Zygoma

Fractures of the zygoma are often called tripod or tetrapod fractures. The solid malar eminence usually remains fairly intact, whereas the thinner connections that stabilize the eminence in space usually break. These include the thin zygomatic arch, which articulates with the temporal bone and the thicker lateral orbital rim. Fracture of these bony attachments allows the eminence to rotate, usually medially and inferiorly, although it can rotate laterally as well, and sometimes directly inward. The third and fourth attachments are continuous, explaining the terms tripod and tetrapod, and the solid attachments are the inferior orbital rim and the lateral buttress between the zygoma and the maxilla. The fracture traverses the generally thin anterior maxillary bone and the thin orbital floor and inferolateral wall.

Le Fort III

This is often called the complete “craniofacial separation,” as it completely disarticulates the facial skeleton from the skull. The classical pattern crosses the orbit above the infraorbital rim, fracturing across both the medial and lateral orbital rims and walls, while also crossing the upper nasal bones or nasal root. The craniofacial separation is completed by disarticulating the zygoma from the temporal bone via fractures through the zygomatic arches (see Fig. 29.1 ). Like the Le Fort I and II fractures, the pterygoid plates are fractured as well.

Skull Base/Frontal Bone/Frontal Sinuses

The orbits, nose, ethmoid, sphenoid, and frontal sinuses contribute to the floor of the anterior cranial fossa. Fractures through the cribriform plate (roof of the nose), the ethmoid sinus roof, the roof of the sphenoid sinus, and the back wall of the frontal sinus result in communication between the sterile intracranial space and the contaminated nasal and sinus areas. Management of these fractures therefore poses additional concerns due to the need to definitively segregate these spaces. Unlike the other fractures discussed here, reduction and repositioning of the fractured fragments are generally inadequate to ensure protection of the meninges and brain, mandating additional intervention. Fractures through the orbital roof also violate the floor of the anterior fossa, but because the orbit is usually protected from the outside environment, these generally do not pose an additional concern.

Epidemiology of Nasal and Paranasal Sinus Trauma

There are many articles and book chapters that describe the occurrence and distribution of CMF traumas, but these tend to vary significantly by the country, city, and hospital type (e.g., a primary hospital in a rural setting will see a very different distribution of injuries than a tertiary referral hospital in a major metropolitan area), so such listings are not particularly helpful. However, it is often noted that the nasal bones are the most frequently fractured bones, probably due to their prominent and protruding position on the face. Patterns of fractures also vary as technology changes, with the number of severe, high- impact panfacial fractures decreasing in areas where airbag use has become typical in the majority of automobiles driven. Although this is a welcome change, it does pose problems for hospitals and universities trying to provide adequate training to residents and may ultimately result in fractures being repaired by surgeons who are less experienced in the management of these complex and often difficult-to-treat injuries. The changing implements of war (e.g., improvised explosive devices) are also yielding a new variety of facial injuries that were not previously seen by most surgeons.

Paranasal Sinuses as a Protective Crumple Zone

A unique aspect of the pathophysiology of paranasal sinus trauma is the presence of strong, solid, trauma-resistant areas (sometimes referred to as the “pillars of the facial skeleton”7), which are surrounded by areas of weak, thin bone that breaks easily (recently referred to as “crumple zones”).8,9 It has been proposed by the author that these “crumple zones” may in fact provide a survival advantage, as they serve to protect the eyes and the brain from many commonly seen facial impacts. This survival advantage would provide a possible explanation for the evolutionary persistence (if not the development) of the paranasal sinuses in the human organism. According to this theory, the thin walls of the paranasal sinuses allow for these areas to “crumple” in response to direct and indirect trauma, thereby providing some protection for the globes, optic nerves, and brain. In a recent experimental study, direct trauma to the globe typically resulted in fracture of the orbital floor rather than globe rupture, whereas obliteration of the sinuses with cement resulted in globe rupture as a result of similar or lesser trauma.9 In Table 29.1, the possible crumple zones provided by the paranasal sinuses and the structures they may protect are listed.

Clinical Features

Clinical Examination

Although the majority of facial and sinus fractures will be diagnosed on computed tomography (CT) scans, the physical exam is nonetheless extremely important, particularly if surgery is going to be a consideration. It also serves to direct what consultations and scans will be necessary for proper management.

It is important to be sure that the ABC′s (airway, breathing, and circulation) have been properly addressed. A second C in CMF/sinus is the cervical spine. For traumas serious enough to fracture the sinuses, it is generally believed that though low, the risk of associated cervical spine injury is not trivial. It is therefore important to be sure that the cervical spine has been properly evaluated, particularly if the patient will need surgery, as intubation can pose a significant hazard if proper precautions are not observed.

Tips and Tricks

Always check the ABCCs:

A: Airway

B: Breathing

C: Circulation

C: Cervical spine

With nasal and sinus fractures, evaluation should include looking for any evidence of cerebrospinal fluid (CSF) leak (rhinorrhea). The presence of a thin, watery fluid discharge or serosanguinous fluid should at least raise the level of suspicion, and suspicion warrants further assessment.

In patients with Le Fort and maxillary alveolar fractures, assessment of the occlusion is mandatory. Some malocclusions are apparent and will themselves point to the diagnosis of certain fractures. It is particularly important to see if the maxillary alveoli are mobile; if they are, then it must be determined whether the entire dental arch moves as a unit, or whether there are multiple fractures and/or loose teeth. Any empty sockets should be examined to see if the tooth loss is recent; if it is, then it is necessary to account for missing teeth or check that they were not aspirated.

Palpation of bones for mobility and step-offs will not only help direct the surgeon who will be evaluating the CT scans, but also help with the assessment of the severity of the injury and in determining whether surgery is indicated.

For any fracture that traverses the orbit, a proper eye evaluation is essential, and many surgeons will obtain an ophthalmology consultation. At a minimum, the visual acuity should be checked, and the extraocular movement of the eyes should be assessed. Evaluation for retinal injury and traumatic optic neuropathy is important. It is also essential to evaluate the eye position, as orbital fractures can result in either enophthalmos or exophthalmos, and neither of these globe malpositions should be missed. Hyperophthalmos and hypophthalmos describe the vertical position of the globe and also should not be missed.

Note

For fractures traversing the orbit, proper eye evaluation is essential. It is very important to evaluate the position and attachment of the medial canthal ligaments, as orbitonasal ethmoid fractures can result in significant malposition of this structure, which, if undiagnosed (and therefore unrepaired), will result in a significant and often cosmetically disturbing deformity that typically is extremely difficult to repair secondarily. When the ligament loses its bony attachment, it tends to move laterally, inferiorly, and anteriorly ( Fig. 29.3 ). Blunting of the caruncle may be seen as well. If suspected, direct assessment using a small forceps allows the surgeon to check the attachment of the ligament to the bone. Bimanual manipulation of the bone to which the ligament is attached by placement of an instrument inside the nose and directly assessing mobility has been described as well.10

Neurologic assessment is critically important, both from the standpoint of brain injury and from the status of the cranial nerves. Identifying nerve injuries in the area of trauma becomes even more important when surgical intervention is planned, as undocumented sensory and motor loss that is identified later is likely to be blamed on the surgery rather than the injury.

Diagnostic Studies

Management

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