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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