- 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