[ENT] Maxillofacial

• Maxillofacial fractures


  Physical trauma to the face resulting in laceration, bruises, and fractures of the facial bones

  
• Facial buttresses


  • Maintain the height, width and projection of the face
• Clinical findings of nasal bone fracture


  • Bleeding (epistaxis)
  • Nasal swelling
  • Periorbital ecchymosis
  • Deviation of the nasal pyramid
  • Medial collapse of the nasal bones or upper lateral cartilage
  • Broadening of the nasal dorsum
  • Collapse of the nasal profile
  • Loss of nasal length
  • Deviation of the columella with narrowing of the external nasal valve
  • Crepitus on palpation

  
• Diagnosis of nasal bone fracture

  • Radiograph (lateral and sinus projection)
  • CT-scan (severe trauma & evidence of other facial fractures)

  
• Timing of reduction for nasal bone fracture

  • Ideally before 10 days after trauma (to avoid development of fibrous connective tissue within the fracture line)
  • Re-examine the patient 2-3 days later after swelling has decreased
• Management of nasal bone fracture

  • Observation (for non displaced fractures)
  • Closed reduction (for simple unilateral with medial displacement)
  • Open reduction (for severe bilateral, depressed fracture with septal and cartilagenous involvement)

  
• Lateral midface fracture


  Fracture caused by blunt trauma to the lateral side of the face, affecting the maxillary sinus, bony orbit, zygoma or zygomatic arch

  
• Blow-out fracture


  Isolated fracture of the orbital floor with partial herniation of the orbital contents into the maxillary sinus
• Symptoms of lateral midface fracture


  • Facial asymmetry (fracture of the zygoma)
  • Limited mouth opening (depression of the zygomatic arch)
  • Diplopia (orbital floor fracture)
  • Sensory disturbances (cheek, ipsilateral upper lip, lateral nasal wall, infraorbital nerve affected)

  
• Diagnosis of lateral midface fracture

  • Inspection
  • Palpation
  • Ophthalmologic exam
  • Radiograph (defines extent of discontinuity or displacement)
  • CT-scan
• Maxillofacial fractures


  Physical trauma to the face resulting in laceration, bruises, and fractures of the facial bones

  
• Types of maxillofacial fractures


  • Nasal fracture
  • Zygoma & Malar fracture
  • Frontobasal fracture
  • Orbital fracture
  • Mandibular fracture

  
• Facial buttresses


  • Maintain the height, width and projection of the face
• Nasal bone fracture


  Fracture of the nasal bones

  
• Clinical findings of nasal bone fracture


  • Bleeding (epistaxis)
  • Nasal swelling
  • Periorbital ecchymosis
  • Deviation of the nasal pyramid
  • Medial collapse of the nasal bones or upper lateral cartilage
  • Broadening of the nasal dorsum
  • Collapse of the nasal profile (lateral view inspection)
  • Loss of nasal length (due to telescoping)
  • Deviation of the columella with narrowing of the external nasal valve
  • Crepitus on palpation

  
• Diagnosis of nasal bone fracture


  • Radiograph (lateral and sinus projection)
  • CT-scan (severe trauma & evidence of other facial fractures)

  
• Nasal bone fracture


  • Normal
  • Plain radiograph
  • CT-scan

  
• Management of nasal bone fracture


  1. Assessment of ABC

  2. Topical decongestants

  3. Cold packs

  4. Anterior bleeding (cauterization using silver nitrate)

  5. Anterior nasal packing

  
• Timing of reduction


  • Re-examine the patient 2-3 days later after swelling has decreased
  • Ideally, reduction is done before 10 days after trauma
  • After 10 days (development of fibrous connective tissue within the fracture line)
• Reduction techniques


  • Observation (for non displaced fractures)
  • Closed (simple injuries, unilateral with medial displacement)
  • Open (severe injuries, bilateral, depressed fracture with septal and cartilagenous involvement)
• Lateral midface fracture


  Fracture caused by blunt trauma to the lateral side of the face, affecting the maxillary sinus, bony orbit, zygoma or zygomatic arch
• Blow-out fracture


  Isolated fracture of the orbital floor with partial herniation of the orbital contents into the maxillary sinus
• Symptoms of lateral midface fracture


  • Facial asymmetry (fracture of the zygoma)
  • Limited mouth opening (depression of the zygomatic arch)
  • Diplopia (orbital floor fracture)
  • Sensory disturbances (cheek, ipsilateral upper lip, lateral nasal wall, infraorbital nerve affected)

  
• Diagnosis of lateral midface fracture


  • Inspection
  • Palpation
  • Ophthalmologic exam
  • Radiograph (defines extent of discontinuity or displacement)
  • Plain radiograph
  • CT-scan
  • CT-scan facial 3D reconstruction
• Treatment of lateral midface fracture


  • Observe (undisplaced, asymptomatic fracture)
  • Surgery (reduction and fixation using miniplates, intraosseous wiring or both) (displaced, symptomatic fracture)
• Central midface fractures


  Le Fort fractures - types of facial fractures involving the maxillary bone and surrounding structures

  
• Types of Le Fort fractures

  • Le Fort I (Guerin) - extends from the pyriform aperture through the lateral maxillary and lateral nasal walls to the posterior region
  • Le Fort II (Pyramidal) - extends from the pterygoid region, zygomaticomaxillary buttress, medial portion on the infraorbital rim, lacrimal bone, medial wall of the orbit towards the dorsum
  • Le Fort III (Craniofacial Dysjunction) - entire mass of the facial bones is separated from the cranial base

  
• Symptoms of central midface fractures


  • Le Fort I: Swelling of the upper lip, malocclusion, mobile palate
  • Le Fort II: Edema of the midface, epistaxis, CSF rhinorrhea, diplopia, dish face deformity, bilateral subconjuctival hemorrhage
  • Le Fort III: Tenderness on the fronto-zygomatic suture, lengthening of the face, depression of ocular levels, enopthalmos, diplopia
• Diagnosis of central midface fractures


  • Physical examination (otoscopy, rhinoscopy & endoscopy, palpation of facial bones, oral cavity exam, ophthalmologic exam)
  • Imaging studies (plain radiograph, PNS CT scan with 3D reconstruction)
  • Other tests (glucose test, beta 2 transferrin test, olfactory testing, hearing and balance tests)
• Treatment of central midface fractures


  • Stabilize the patient
  • Fixation of unstable fracture segments to stable structure
  • Surgery
• Complications of central midface fractures


  • Scarring
  • Lower lid ectropion
  • Nerve injury
  • Injury to tooth roots
  • Osteomyelitis
  • Malocclusion
• Anterior skull base fracture


  Injuries to the anterior skull base and adjacent paranasal sinuses (frontal and sphenoid sinuses, ethmoid labyrinth)

  
• Types of anterior skull base fractures (Escher classification)

  • High fracture
  • Central fracture
  • Low fracture
  • Latero-orbital fracture

  
• Symptoms of anterior skull base fracture


  • Dish face
  • Cerebrospinal fluid rhinorrhea (associated with dural injury)
  • Vision loss (ocular destruction or optic nerve injury)
  • Diplopia (oculomotor palsy)
  • Damage to III, IV or VI cranial nerves
  • Cerebral prolapse
  • Anosmia

  
• Diagnosis of anterior skull base fracture


  • Palpation of facial bones
  • Inspection of nasal cavity (anterior rhinoscopy or endoscopy)
  • Otoscopy
  • Cranial CT-scan
  • High resolution CT-scan (bone window) of paranasal sinuses (axial and coronal)
  • Glucose test or beta 2 transferrin test
  • Tests for hearing and balance, olfactory testing

  
• Treatment of anterior skull base fracture


  • Stabilize patient
  • Surgery
  • Patient advised not to blow the nose

  
• Complications of anterior skull base fracture


  • Meningitis
  • Brain abscess
• Orbital fracture (blow-out fracture)


  Fracture of the orbital floor, medial, lateral or superior wall, with trap-door rotation of bone fragments involving the central area of a wall
• Types of orbital fractures


  • Pure blow-out fracture
  • Impure blow-out fracture (associated with other fractures)
• Symptoms of orbital fracture


  • Periorbital hematoma
  • Subconjuctival hematoma
  • Diplopia
  • Enophthalmos
  • Hypophthalmos