Cranio-Maxillary-Facial Injuries

- Facial Fractures and Upper Airway Injuries:
    - in pts with major frxs of the mandible and maxilla (Lefort III) in whom massive edema has yet to occur, oral intubation is preferred, and if 
           required is usually easily accomplished;
    - blind nasal intubation following major facial injury is discouraged because of the hazard of potential false passages into nasal sinuses and cranial vault;
    - injuries of the Larynx may cause rapid respiratory obstruction and require immediate tracheostomy;
          - in less urgen situation, a history of trauma to the head and neck, stridor, hoarseness, and crepitus in the neck are all suggestive or laryngeal injury;

- Lefort Fractures:
    - type I:
          - transverse frx thru maxillary sinus and pterygoid plates;
          - complications: loss of teeth, infection, malocclusion;
    - type II:
          - separation thru frontal process, lacrimal bones, floor of orbits, zygomaticomaxillary suture line, lateral wall of maxillary sinus and pterygoid plates;
          - complications nonunion, malunion, lacrimal system obstruction, infraorbital nerve anesthesia, diplopia, malocclusion;
    - type III:
          - separation of mid third of face at zygomaticotemporal, and naso-frontal sutures, and across the orbital floors;
          - complications include nonunion, malunion, malocclusion, lengthening of mid facee, and lacrimal system obstruction;

- Basilar Skull Frx:
    - complications: meningitis (ATB have not proven efficacious)
    - periorbital ecchymoses (racoon eyes) are indications of intraorbital bleeding from fractures of the floor of the frontal fossa;
    - blood in the external canal indicates a basilar skull fracture thru the lateral portion of the temporal bone;
    - temporal bone fracture medial to the tympanic membrane results in a hemotympanum;
    - ecchymosis overlying the mastoid (Battle's sign)
         - this is usually delayed for 12-24 hrs following injury;
    - damage to the seventh or eighth cranial nerves may accompany temporal bone fractures;
         - facial palsy of immediate onset represents direct facial nerve injury at the site of temporal bone fracture and require early diagnostic 
                  evaluation and possible early surgical repair

- Nasal Frx:
   - r/o septal hematoma, which if present must be evacuated thru a vertical mucosal incision

- Naso-orbital Frx:
    - CT scan for dx:
         - disruption of interorbital space and comminution of nasal pyramid;
    - severe blows to the nasal bridge may result in a communition of the supporting bony structure of the intercanthal region;
    - may be associated neurological damage from telescoping of the nasal pyramid posteriorly and superiorly thru the cribiform plate;
    - CSF rhinorrhea is a common finding;
    - if neurosurgical emergency exists on presentation, a definative, combined intracranial and extracranial approach is effected;
         - otherwise, the pt is stabilized and the surgical repair is performed at a convenent time when the swelling has subsided;
    - complications:
         - "dish face" deformity, frontal sinus mucocele, mucopyocele, and dacryocystitis

- Tripod Frx:
    - CT scan for dx:
         - clouding, air/fluid level maxillary sinus, separation of zygo-matico-maxillary, zygomaticofrontal and zygomaticotemporal suture lines;
    - complications: enophthalmos, diplopia, infraorbital nerve anesthesia, and chronic maxillary sinusitis

- Mandibular Frx:
    - if open (or involves teeth), give Cleocin 300 mg/100 ml NS q6;
    - complications of frx:
            - ankylosis of TMJ, & chronic TMJ, nonunion, malunion, osteomyelitis and residual maloclusion;
    - unlike fractures of other facial bones, the mandibular fracture must be held in reduction by stronger methods of fixation and for longer 
            periods of time;
    - arch bars alone do not afford sufficient stabilization for frxs of the mandibular body or symphyseal region

- Parotid Injuries:
    - transection of Stenson's duct requires surgical intervention to avoid salivary fistula

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Friday, September 9, 2011 11:29 am