Maxillofacial Trauma: Managing Potentially Dangerous And Disfiguring Complex Injuries

Table of Contents

 

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Epidemiology And Etiology
6. Pathophysiology
   1. Nasal Bone Fractures
   2. Mandibular Fractures
   3. Orbital Fractures
7. Differential Diagnosis
8. Prehospital Care
9. Emergency Department Evaluation
   1. Initial Stabilization And Key Historical Questions
10. Diagnostic Testing
    1. Laboratory Testing
       1. Cerebrospinal Fluid
    2. Imaging Studies
       1. Facial Radiographs
       2. Computed Tomography
       3. Imaging Of The Nose
       4. Imaging Of The Mandible
       5. Imaging Of The Orbits
       6. Imaging Of The Zygoma
       7. Imaging Of The Maxilla
       8. Imaging Of The Frontal Sinus
11. Treatment
    1. Nasal Fractures
    2. Mandibular Fractures
    3. Orbital Fractures
       1. Orbital Compartment Syndrome
    4. Zygoma Fractures
12. Special Populations
    1. Pediatric Patients
    2. Elderly Patients
13. Controversies And Cutting Edge
    1. Routine Use Of Antibiotics
    2. Transcatheter Arterial Embolization To Control Bleeding
    3. The Use Of Ultrasound In Diagnosis Of Maxillofacial Injuries
14. Disposition
    1. Consultation
    2. Admission
    3. Discharge
15. Summary
16. Risk Management Pitfalls For Maxillofacial Trauma
17. Case Conclusions
18. Clinical Pathway For Management Of Maxillofacial Trauma In The Emergency Department
19. Tables and Figures
    1. Table 1. Key Patient Historical Questions
    2. Table 2. Components Of The Visual Examination
    3. Table 3. Abbrevaited Cranial Nerve Examination
    4. Table 4. Typical Radiographic Views Used During Evaluation Of Facial Fractures
    5. Table 5. Radiographic Signs Consistent With Facial Fractures
    6. Figure 1. Nasal Bone Anatomy
    7. Figure 2. Mandibular Bone Structure, With Location And Frequency Of Area Fractures
    8. Figure 3. Orbital Bones Of Right Eye
    9. Figure 4. Le Fort Fracture Patterns
    10. Figure 5. Waters View (Occipitomental View)
    11. Figure 6. Waters View (Occipitomental)
    12. Figure 7. Caldwell View (Occipitofrontal)
    13. Figure 8. Bolateral Naso-Orbital-Ethmoid Complex Fractures
    14. Figure 9. Panoramic View Of Jaw Fractures
    15. Figure 10. Fractures Of The Right Parasymphysis And The Left Mandibular Ramus
    16. Figure 11. Coronal CT Of A Blowout Fracture
    17. Figure 12. Waters View With The Lines Of Dolan And The Elephants Of Rogers
    18. Figure 13. CT Scan Of Zygomaticomaxillary Complex Fracture, Left Upper Maxilla
    19. Figure 14. Radiograph And Ultrasound Of A Nasal Bone Fracture
20. References

Abstract

Patients with maxillofacial trauma require a careful evaluation due to the anatomical proximity of the maxillofacial region to the head and neck. Facial injuries can range from soft-tissue lacerations and nondisplaced nasal fractures to severe, complex fractures, eye injuries, and possible brain injury. Though the Advanced Trauma Life Support (ATLS) guidelines provide a framework for the management of trauma patients, they do not provide a detailed reference for many subtle or complex facial injuries. This issue adds a more comprehensive and systematic approach to the secondary survey of the maxillofacial area and emergency department management of injuries to the face. In addition to an overall review of maxillofacial trauma pathophysiology, associated injuries, and physical examination, this review will also discuss relevant imaging, treatment, and disposition plans.

Case Presentation

It is Saturday night and your third straight overnight shift. As you step into the trauma bay, your charge nurse approaches. “Doctor, we have a 27-year-old male coming in 5 minutes. He was involved in a high-speed motorcycle accident and EMS says he has quite a bit of facial trauma…” He trails off as you see EMS speeding down the hallway. Your resident looks at you and asks, “How are we going to intubate this patient?”

Your second patient arrives soon after. This patient is clearly inebriated and accompanied by both EMS and security. As the patient is brought closer, you note that he is combative and appears to have extensive facial injuries, with bleeding that you cannot identify as originating from any one location. The patient suddenly becomes minimally responsive, and the EMT repeats the vital signs, revealing a blood pressure of 60/40 mm Hg, heart rate in the 120s, and pulse ox, 88% on room air. You turn to your resident and ask, “What are our initial priorities in management of this patient?”

You are now exhausted and ready for your third cup of coffee when you decide to see your next patient, who was brought in by her friend. The friend states that the patient had been involved in an altercation with another patron at a bar earlier in the night. She was punched in the face several times and has had progressive swelling over the succeeding hours; now her lower face is deformed and she cannot clench her teeth. You wonder if you should begin with plain films of the jaw, a panoramic x-ray, or if you should go straight to CT...

Introduction

Over the past decades, the incidence of maxillofacial trauma has increased worldwide, due to increasing urbanization and industrialization. The etiology of facial injuries varies among different countries, depending on the socioeconomic, cultural, and environmental factors specific to the area.¹

Maxillofacial injuries can be particularly difficult to evaluate, as they can range from simple soft-tissue lacerations to complex facial bone fractures.¹ Failure to recognize and adequately address concomitant injuries in a patient suffering multiple trauma may negatively impact overall morbidity. In one study, 9% of patients with significant maxillofacial trauma had coexisting brain injury.²

The primary goal in managing maxillofacial trauma in the emergency department (ED) is recognizing potential complications and managing a difficult airway, if the need arises. It is also fundamental to perform a full secondary survey that includes evaluating for possible nasal bone, orbital, maxillary, and mandibular fracture patterns. Initial assessment of a patient with maxillofacial injuries should also exclude any potential vision-threatening injury. Life-threatening blood loss from isolated maxillofacial injuries is uncommon; however, hypovolemia may result from concomitant injuries. Early assessment of all trauma patients requires consideration of potential cervical spine injuries, particularly in the unconscious or obtunded patient.

This issue of Emergency Medicine Practice provides a systematic review of the literature and makes best-practice recommendations to aid emergency clinicians in the initial management of patients who present with maxillofacial injuries. Currently, the Advanced Trauma Life Support (ATLS) guidelines are considered the gold standard for initial management of all trauma patients; however, many studies have addressed the shortfall of these guidelines.³ This issue will supplement the ATLS guidelines by providing a more comprehensive discussion of diagnostic and management options for these patients.

Critical Appraisal Of The Literature

A literature search was performed using PubMed and MEDLINE^®, with the search terms maxillofacial trauma, craniofacial trauma, mandibular fracture, maxillary fracture, zygoma fracture, cervical spine injury, nasal fracture, and orbital fracture. The reference section of each article was also reviewed for additional articles. Although the literature on maxillofacial injuries is extensive, most of the articles obtained were retrospective, case studies, or review articles. There are currently few prospective studies on maxillofacial injuries in the ED setting.

There are currently no national practice guidelines for patients presenting with maxillofacial injuries. Additionally, there are no Cochrane studies that directly address maxillofacial injuries. A study by Doerr rationalizes the scarcity of randomized controlled trials in maxillofacial trauma as being due to high costs, ethical constraints, subject recruitment, and variability of facial fractures.⁴

Risk Management Pitfalls For Maxillofacial Trauma

1. “The patient’s injuries seemed isolated to the orbital and nasal region, so I only performed a maxillofacial CT.”

Severe maxillofacial trauma may be associated with head trauma and intracranial pathology. This is especially important in patients who have altered mental status or are unable to give a history. Facial fractures may extend into the base of the skull.

2. “The patient didn’t complain of any neck pain, so I didn’t order a cervical spine CT.”

Even soft-tissue injuries to the maxillofacial region may have associated injuries to the cervical spine. Injuries to the midface are most likely associated with C5-C7 disruption, while injuries to the lower face are likely associated with C1-C4 disruption.⁷⁹

3. “I didn’t notice any obvious injuries in the mouth, so I didn’t think to check for missing teeth.”

Dental injuries occur frequently with maxillofacial trauma. Mandibular fractures and Le Fort fractures are more likely to have associated dental injuries.⁸⁰ If a trauma patient appears to have a newly missing tooth, consider aspiration. Signs of a missing tooth include an empty socket, possibly with bleeding, or remnants of a fractured tooth. Consider a radiograph of the soft-tissue neck and chest to assess for aspirated teeth.

4. “Both of the patient’s eyes were swollen, so I couldn’t assess for extraocular movements.”

In an alert patient, make sure to perform a complete neurological examination. If the patient complains of diplopia, consider further imaging. Diplopia should raise suspicion of entrapment from a blowout fracture. CT of the facial bones will demonstrate whether any of the orbital walls or the orbital floor have been fractured. An abnormal neurological examination should also prompt assessment of the patient for intracranial trauma. Remember that ultrasound may be used to assess for extraocular movements in patients unable to open their eyes due to swelling.

5. “The patient’s nose keeps running. I’m not sure why.”

CSF rhinorrhea should be considered if there is persistent nasal discharge. Once confirmed, a CT of the head and facial bones should be ordered to evaluate how the cranium has been violated. A neurosurgical consultation is required.

6. “I didn’t notice any obvious bleeding or injuries inside the patient’s nose.”

Patients who have had blunt trauma to the nasal area are at risk for developing septal hematomas. A missed septal hematoma may lead to septal necrosis, perforation, or abscess and disfigurement. A septal hematoma should be incised, drained, and packed during evaluation.

7. “The patient keeps bleeding from somewhere inside his mouth, but I’m not sure where it’s coming from.”

The tongue has an extensive blood supply, and deep or complex lacerations may cause enough bleeding to obscure the physician’s view while evaluating the mouth. More importantly, persistent bleeding from the tongue could obscure the oropharynx, possibly complicating airway management.

8. “I did my primary survey. The patient’s airway appears intact.”

Once a patient is stabilized initially and appears to have an intact airway, re-evaluate the patient multiple times to ensure that soft-tissue edema or hematomas have not developed to the point of airway compromise. In a patient who is at high risk for developing airway compromise due to third-spacing, intubation may need to be considered early in ED management.

9. “I placed a nasal catheter to stop the patient’s epistaxis, but now his face looks more swollen.”

While attempting to control intractable epistaxis, especially from posterior sources, inflatable nasal packing is usually utilized. However, in naso-orbital-ethmoid complex fractures or midface fractures, overinflated nasal packing may displace fracture fragments, causing more injury.

10. “The parents’ story seems a little off. They must be very upset and emotional because their child is injured.”

With any trauma, it is exceedingly important to be aware of signs that could point to underlying abuse. Consider abuse when the history of trauma is inconsistent with the injuries.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, random-ized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the ref-erence, where available. The most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

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