Points and Pearls Digest | Maxillofacial Trauma
0
My ContentLog In
Browse Topics Take CME Tests About Contact Emergency Physicians PAs & NPs Residents Groups & Hospitals
SubscribeEmergency Medicine
Practice Pediatric Emergency
Medicine Practice EM Practice &
Pediatric EM
Practice Bundle LLSA Study Guides Stroke CME Trauma CME View All Courses
Emergency Medicine Practice Pediatric Emergency Medicine Practice EM Practice & Pediatric EM Practice Bundle LLSA Study Guides Stroke CME Trauma CME View All Products
COVID-19 Boosters & More
0Log In Subscribe
COVID-19 Boosters & More
TOC Will Appear Here
2,247 views

Maxillofacial Trauma: Managing Potentially Dangerous And Disfiguring Complex Injuries

2,247 views
Download PDF
Take CME Test
Table of Contents
 
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

Table 1. Key Patient Historical Questions

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.

  1. Kaul RP, Sagar S, Singhal M, et al. Burden of maxillofacial trauma at level 1 trauma center. Craniomaxillofac Trauma Reconstr. 2014;7(2):126-130. (Retrospective review; 542 patients)
  2. Arslan ED, Solakoglu AG, Komut E, et al. Assessment of maxillofacial trauma in emergency department. World J Emerg Surg. 2014;9(1):13. (Retrospective review; 754 patients)
  3. * Perry M. Advanced Trauma Life Support (ATLS) and facial trauma: can one size fit all? Part 1: dilemmas in the management of the multiply injured patient with coexisting facial injuries. Int J Oral Maxillofac Surg. 2008;37(3):209-214. (Review article)
  4. Doerr TD. Evidence-based facial fracture management. Facial Plast Surg Clin North Am. 2015;23(3):335-345. (Review article)
  5. Septa D, Newaskar VP, Agrawal D, et al. Etiology, incidence and patterns of mid-face fractures and associated ocular injuries. J Maxillofac Oral Surg. 2014;13(2):115-119. (Prospective study; 200 patients with confirmed mid-face fractures)
  6. Allareddy V, Allareddy V, Nalliah RP. Epidemiology of facial fracture injuries. J Oral Maxillofac Surg. 2011;69(10):2613-2618. (Retrospective review - database mining; 407,167 patients)
  7. Naveen Shankar A, Naveen Shankar V, Hegde N, et al. The pattern of the maxillofacial fractures - a multicentre retrospective study. J Craniomaxillofac Surg. 2012;40(8):675-679. (Retrospective review; 2027 patients)
  8. Rajendra PB, Mathew TP, Agrawal A, et al. Characteristics of associated craniofacial trauma in patients with head injuries: an experience with 100 cases. J Emerg Trauma Shock. 2009;2(2):89-94. (Retrospective review; 100 patients)
  9. Gassner R, Tuli T, Hachl O, et al. Cranio-maxillofacial trauma: a 10 year review of 9,543 cases with 21,067 injuries. J Craniomaxillofac Surg. 2003;31(1):51-61. (Retrospective; 10-year review; 9543 patients)
  10. Erol B, Tanrikulu R, Gorgun B. Maxillofacial fractures. Analysis of demographic distribution and treatment in 2901 patients (25-year experience). J Craniomaxillofac Surg. 2004;32(5):308-313. (Retrospective 25-year review; 2901 patients)
  11. Scheyerer MJ, Doring R, Fuchs N, et al. Maxillofacial injuries in severely injured patients. J Trauma Manag Outcomes. 2015;9:4. (Prospective study; 67 patients)
  12. Iida S, Kogo M, Sugiura T, et al. Retrospective analysis of 1502 patients with facial fractures. Int J Oral Maxillofac Surg. 2001;30(4):286-290. (Retrospective review; 1502 patients)
  13. Laverick S, Patel N, Jones DC. Maxillofacial trauma and the role of alcohol. Br J Oral Maxillofac Surg. 2008;46(7):542-546. (Retrospective review; 2-year dataset)
  14. Gassner R, Tuli T, Hachl O, et al. Craniomaxillofacial trauma in children: a review of 3,385 cases with 6,060 injuries in 10 years. J Oral Maxillofac Surg. 2004;62(4):399-407. (Retrospective 10-year study; 6060 patients)
  15. Eggensperger Wymann NM, Holzle A, Zachariou Z, et al. Pediatric craniofacial trauma. J Oral Maxillofac Surg. 2008;66(1):58-64. (Retrospective review; 291 patients)
  16. Iida S, Matsuya T. Paediatric maxillofacial fractures: their aetiological characters and fracture patterns. J Craniomaxillofac Surg. 2002;30(4):237-241. (Retrospective review; 174 patients)
  17. Deliverska EG, Rubiev M. Facial fractures and related injuries in department of maxillo-facial surgery, University Hospital “St. Anna,” Sofia, Bulgaria. J IMAB - Annual Proceeding (Scientific Papers). 2013;19(2):289-291. (Retrospective review; 276 patients)
  18. * Kucik CJ, Clenney T, Phelan J. Management of acute nasal fractures. Am Fam Physician. 2004;70(7):1315-1320. (Review article)
  19. Morrison AD, Gregoire CE. Management of fractures of the nasofrontal complex. Oral Maxillofac Surg Clin North Am. 2013;25(4):637-648. (Review article)
  20. Chan J, Most SP. Diagnosis and management of nasal fractures. Oper Tech Otolaryngol Neck Surg.19(4):263-266. (Review article)
  21. * Tuckett JW, Lynham A, Lee GA, et al. Maxillofacial trauma in the emergency department: a review. Surgeon. 2014;12(2):106-114. (Review article)
  22. Morrow BT, Samson TD, Schubert W, et al. Evidence-based medicine: mandible fractures. Plast Reconstr Surg. 2014;134(6):1381-1390.
  23. * Ceallaigh PÓ, Ekanaykaee K, Beirne CJ, et al. Diagnosis and management of common maxillofacial injuries in the emergency department. Part 5: dentoalveolar injuries. Emerg Med J. 2007;24(6):429-430. (Review article)
  24. Mundinger GS, Borsuk DE, Okhah Z, et al. Antibiotics and facial fractures: evidence-based recommendations compared with experience-based practice. Craniomaxillofac Trauma Reconstr. 2015;8(1):64-78. (Review article)
  25. Boyette JR, Pemberton JD, Bonilla-Velez J. Management of orbital fractures: challenges and solutions. Clin Ophthalmol. 2015;9:2127-2137. (Review article)
  26. Brady SM, McMann MA, Mazzoli RA, et al. The diagnosis and management of orbital blowout fractures: update 2001. Am J Emerg Med. 2001;19(2):147-154. (Review article)
  27. Winterton JV, Patel K, Mizen KD. Review of management options for a retrobulbar hemorrhage. J Oral Maxillofac Surg. 2007;65(2):296-299. (Review article)
  28. Lima V, Burt B, Leibovitch I, et al. Orbital compartment syndrome: the ophthalmic surgical emergency. Surv Ophthalmol. 2009;54(4):441-449. (Review article)
  29. Adam AA, Zhi L, Bing LZ, et al. Evaluation of treatment of zygomatic bone and zygomatic arch fractures: a retrospective study of 10 years. J Maxillofac Oral Surg. 2012;11(2):171-176. (Retrospective 10-year review; 310 patients)
  30. * Ceallaigh PÓ, Ekanaykaee K, Beirne CJ, et al. Diagnosis and management of common maxillofacial injuries in the emergency department. Part 1: advanced trauma life support. Emerg Med J. 2006;23(10):796-797. (Review article)
  31. Hopper RA, Salemy S, Sze RW. Diagnosis of midface fractures with CT: what the surgeon needs to know. Radiographics. 2006;26(3):783-793. (Review article)
  32. Waldhart E, Rothler G, Norer B, et al. Management of mid-facial fractures. Mund Kiefer Gesichtschir. 2000;4 Suppl 1:S118-S125. (Review article)
  33. Strong EB, Pahlavan N, Saito D. Frontal sinus fractures: a 28-year retrospective review. Otolaryngol Head Neck Surg. 2006;135(5):774-779. (Retrospective 28-year review; 202 patients)
  34. Bell RB, Dierks EJ, Brar P, et al. A protocol for the management of frontal sinus fractures emphasizing sinus preservation. J Oral Maxillofac Surg. 2007;65(5):825-839. (Review article)
  35. * Perry M, Dancey A, Mireskandari K, et al. Emergency care in facial trauma--a maxillofacial and ophthalmic perspective. Injury. 2005;36(8):875-896. (Review article)
  36. Nielsen M. ABC of major trauma. BMJ. 1984;289(Sept):595-599. (Review article)
  37. Perry M, Morris C. Advanced trauma life support (ATLS) and facial trauma: can one size fit all? Part 2: ATLS, maxillofacial injuries and airway management dilemmas. Int J Oral Maxillofac Surg. 2008;37(4):309-320. (Review article)
  38. * Perry M, O'Hare J, Porter G. Advanced Trauma Life Support (ATLS) and facial trauma: can one size fit all? Part 3: Hypovolaemia and facial injuries in the multiply injured patient. Int J Oral Maxillofac Surg. 2008;37(5):405-414. (Review article)
  39. Ardekian L, Rosen D, Klein Y, et al. Life-threatening complications and irreversible damage following maxillofacial trauma. Injury. 1998;29(4):253-256. (Review article)
  40. Mantur M, Lukaszewicz-Zajac M, Mroczko B, et al. Cerebrospinal fluid leakage--reliable diagnostic methods. Clin Chim Acta. 2011;412(11-12):837-840. (Review article)
  41. Sunder R, Tyler K. Basal skull fracture and the halo sign. CMAJ. 2013;185(5):416-416. (Review article)
  42. Yellinek S, Cohen A, Merkin V, et al. Clinical significance of skull base fracture in patients after traumatic brain injury. J Clin Neurosci. 2016;25:111-115. (Review article)
  43. Hasheminia D, Kalantar Motamedi MR, Hashemzehi H, et al. A 7-year study of 1,278 patients with maxillofacial trauma and cerebrospinal fluid leak. J Maxillofac Oral Surg. 2015;14(2):258-262. (Retrospective cross-sectional study; 1278 patients)
  44. Malhotra R, Dunning J. The utility of the tongue blade test for the diagnosis of mandibular fracture. Emerg Med J. 2003;20(6):552-553. (Review article)
  45. Alonso LL, Purcell TB. Accuracy of the tongue blade test in patients with suspected mandibular fracture. J Emerg Med. 1995;13(3):297-304. (Prospective study; 110 patients)
  46. Bhatoe HS. Trauma to the cranial nerves. Indian J Neurotrauma.4(2):89-100. (Review article)
  47. Nandapalan V, Watson ID, Swift AC. Beta-2-transferrin and cerebrospinal fluid rhinorrhoea. Clin Otolaryngol Allied Sci. 1996;21(3):259-264. (Prospective observational study; 25 patients with suspected CSF leakage)
  48. Hogg K, Maloba M. Which facial views for facial trauma? Emerg Med J. 2004;21(6):709-710. (Retrospective database review)
  49. Hodgkinson DW, Lloyd RE, Driscoll PA, et al. ABC of emergency radiology. Maxillofacial radiographs. BMJ. 1994;308(6920):46-51. (Review article)
  50. * Dolan KD, Jacoby CG, Smoker WRK. The radiology of facial fractures. Radiographics. 1984;4(4):577-663. (Review article)
  51. Avery LL, Susarla SM, Novelline RA. Multidetector and three-dimensional CT evaluation of the patient with maxillofacial injury. Radiol Clin North Am. 2011;49(1):183-203. (Review article)
  52. Myga-Porosilo J, Skrzelewski S, Sraga W, et al. CT Imaging of facial trauma. Role of different types of reconstruction. Part I - bones. Pol J Radiol. 2011;76(1):41-51. (Review article)
  53. Stacey DH, Doyle JF, Mount DL, et al. Management of mandible fractures. Plast Reconstr Surg. 2006;117(3):48e-60e. (Review article)
  54. Wilson IF, Lokeh A, Benjamin CI, et al. Prospective comparison of panoramic tomography (zonography) and helical computed tomography in the diagnosis and operative management of mandibular fractures. Plast Reconstr Surg. 2001;107(6):1369-1375. (Prospective cross-sectional study; 73 mandibular fractures in 42 patients)
  55. Pathria MN, Blaser SI. Diagnostic imaging of craniofacial fractures. Radiol Clin North Am. 1989;27(5):839-853. (Review article)
  56. Ceallaigh PÓ, Ekanaykaee K, Beirne CJ, et al. Diagnosis and management of common maxillofacial injuries in the emergency department. Part 4: orbital floor and midface fractures. Emerg Med J. 2007;24(4):292-293. (Review article)
  57. Chirico PA, Mirvis SE, Kelman SE, et al. Orbital "blow-in" fractures: clinical and CT features. J Comput Assist Tomogr. 1989;13(6):1017-1022. (Review article)
  58. Ceallaigh PÓ, Ekanaykaee K, Beirne CJ, et al. Diagnosis and management of common maxillofacial injuries in the emergency department. Part 3: orbitozygomatic complex and zygomatic arch fractures. Emerg Med J. 2007;24(2):120-122. (Review article)
  59. Manson PN, Markowitz B, Mirvis S, et al. Toward CT-based facial fracture treatment. Plast Reconstr Surg. 1990;85(2):202-212. (Review article)
  60. Metzinger SE, Metzinger RC. Complications of frontal sinus fractures. Craniomaxillofac Trauma Reconstr. 2009;2(1):27-34. (Review article)
  61. Alvarez H, Osorio J, De Diego JI, et al. Sequelae after nasal septum injuries in children. Auris Nasus Larynx. 2000;27(4):339-342.
  62. Newton E, Lasso A, Petrcich W, et al. An outcomes analysis of anterior epistaxis management in the emergency department. J Otolaryngol Head Neck Surg. 2016;45(1):1-5. (Retrospective review; 353 patients with anterior epistaxis)
  63. Jacobson JA, Kasworm EM. Toxic shock syndrome after nasal surgery. Case reports and analysis of risk factors. Arch Otolaryngol Head Neck Surg. 1986;112(3):329-332. (Retrospective review of patients with TSS after nasal surgery)
  64. Viducich RA, Blanda MP, Gerson LW. Posterior epistaxis: clinical features and acute complications. Ann Emerg Med. 1995;25(5):592-596. (Retrospective chart review; 81 patients with posterior epistaxis)
  65. * Kellman RM, Tatum SA. Pediatric craniomaxillofacial trauma. Facial Plast Surg Clin North Am. 2014;22(4):559-572. (Review article)
  66. van As AB, van Loghem AJ, Biermans BF, et al. Causes and distribution of facial fractures in a group of South African children and the value of computed tomography in their assessment. Int J Oral Maxillofac Surg. 2006;35(10):903-906. (Retrospective case reports; 107 patients)
  67. Fasola AO, Obiechina AE, Arotiba JT. Incidence and pattern of maxillofacial fractures in the elderly. Int J Oral Maxillofac Surg. 2003;32(2):206-208. (Retrospective database review)
  68. Velayutham L, Sivanandarajasingam A, O'Meara C, et al. Elderly patients with maxillofacial trauma: the effect of an ageing population on a maxillofacial unit's workload. Br J Oral Maxillofac Surg. 2013;51(2):128-132. (Prospective cross-sectional study; 470 patients)
  69. Sidal T, Curtis DA. Fractures of the mandible in the aging population. Spec Care Dentist. 2006;26(4):145-149. (Review article)
  70. Chole RA, Yee J. Antibiotic prophylaxis for facial fractures. A prospective, randomized clinical trial. Arch Otolaryngol Head Neck Surg. 1987;113(10):1055-1057. (Prospective, randomized clinical trial; 101 patients)
  71. Brooke SM, Goyal N, Michelotti BF, et al. A multidisciplinary evaluation of prescribing practices for prophylactic antibiotics in operative and nonoperative facial fractures. J Craniofac Surg. 2015;26(8):2299-2303. (Survey research; 205 respondents)
  72. Liu WH, Chen YH, Hsieh CT, et al. Transarterial embolization in the management of life-threatening hemorrhage after maxillofacial trauma: a case report and review of literature. Am J Emerg Med. 2008;26(4):516.e513-e515. (Case report and literature review)
  73. Chen YF, Tzeng IH, Li YH, et al. Transcatheter arterial embolization in the treatment of maxillofacial trauma induced life-threatening hemorrhages. J Trauma. 2009;66(5):1425-1430. (Prospective observational study; 8 patients)
  74. Bynoe RP, Kerwin AJ, Parker HH 3rd, et al. Maxillofacial injuries and life-threatening hemorrhage: treatment with transcatheter arterial embolization. J Trauma. 2003;55(1):74-79. (Retrospective chart review; 7562 patients)
  75. Adeyemo WL, Akadiri OA. A systematic review of the diagnostic role of ultrasonography in maxillofacial fractures. Int J Oral Maxillofac Surg. 2011;40(7):655-661. (Retrospective database review; 17 articles)
  76. McCann PJ, Brocklebank LM, Ayoub AF. Assessment of zygomatico-orbital complex fractures using ultrasonography. Br J Oral Maxillofac Surg. 2000;38(5):525-529. (Prospective observational study; 22 patients)
  77. Ogunmuyiwa SA, Fatusi OA, Ugboko VI, et al. The validity of ultrasonography in the diagnosis of zygomaticomaxillary complex fractures. Int J Oral Maxillofac Surg. 2012;41(4):500-505. (Prospective observational study; 21 patients)
  78. Friedrich RE, Heiland M, Bartel-Friedrich S. Potentials of ultrasound in the diagnosis of midfacial fractures. Clin Oral Investig. 2003;7(4):226-229. (Prospective observational study; 81 patients)
  79. Lalani Z, Bonanthaya KM. Cervical spine injury in maxillofacial trauma. Br J Oral Maxillofac Surg. 1997;35(4):243-245. (Retrospective study; 536 patients)
  80. Murray JM. Mandible fractures and dental trauma. Emerg Med Clin North Am. 2013;31(2):553-573. (Review article)

Welcome back to another episode of EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. This month, we’ll be talking “Maxillofacial Trauma in the Emergency Department.”

This episode’s content was curated by Drs. Devjani Das, MD, RDMS, FACEP, and Lea Salazar, MD. Both of Hofstra Northwell School of Medicine, Northwell Health-Staten Island University Hospital, Staten Island, NY. Don’t miss it!

Topics:

  • Overview on Maxillofacial Trauma
  • Epidemiology of Maxillofacial Trauma
  • Fracture Types:
    • Nasal bone fractures
    • Mandibular fractures
    • Orbital fractures
    • Zygomatic fractures
    • Maxillary fractures or Le Fort fractures
      • Le Fort 1 fractures or horizontal fractures
      • Le fort 2 fractures or pyramidal fractures
      • Le Fort 3 fractures or transverse fractures
    • Frontal bone fractures
  • Prehospital Care
  • Initial ED Evaluation and Management
  • 10 Steps of the Physical Exam
  • Diagnostic Testing, Treatment, and Disposition
  • Imaging Specific to Each Injury
  • Management of Each Injury
  • Special Populations
  • Controversies and Cutting-Edge A
  • Disposition
  • Quick Rundown of the Key Take-Home Points

Links and Resources:

Maxillofacial Trauma: Managing Potentially Dangerous and Disfiguring Complex Injuries - https://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=538

Hofstra Northwell School of Medicine - http://medicine.hofstra.edu/

Northwell Health-Staten Island University - https://www.northwell.edu/find-care/locations/staten-island-university-hospital

Clinical Decision Making in Emergency Medicine - http://www.clinicaldecisionmaking.com/

EMplify Twitter Account - @ebmedicine

Email: emplify@ebmedicine.net

To Read The Companion Article:
Log in
Purchase
Subscribe
To Read The Companion Article:
Log in
Purchase
Subscribe
To Read The Companion Article:
Log in
Purchase
Subscribe
Already purchased this course?
Log in to read.
Purchase a subscription

Price: $449/year

140+ Credits!

More information

Get a Sample Issue

Purchase Issue & CME Test

Price: $49

+4 Credits!

Buy Now
Money-back Guarantee
Publication Information
Authors

Devjani Das, MD, RDMS, FACEP; Lea Salazar, MD

Publication Date

April 1, 2017

CME Expiration Date

April 30, 2020

Get Permission

CME Information

Related Articles

Cervical Spinal Injury In Pediatric Blunt Trauma Patients: Management In The Emergency Department (Trauma CME)

Ocular Injuries: New Strategies In Emergency Department Management (Trauma CME)

Get A Sample Issue Of Emergency Medicine Practice
Enter your email to get your copy today! Plus receive updates on EB Medicine every month.
Please provide a valid email address.

Call Us

1-678-366-7933

Email Us

ebm@ebmedicine.net

Connect With Us

Company

Contact Us
About Us
Testimonials
Group Subscriptions
CME Joint Providership
Partners
Terms & Conditions

Who We Serve

Emergency Physicians
PAs & NPs
Residents
Groups & Hospitals

Products

Emergency Medicine Practice
Pediatric Emergency Medicine Practice
EM Practice & Pediatric EM Practice Bundle
LLSA Study Guides
Stroke CME
Trauma CME
View All Products

Accredited By

ACCME AAP AOA ACEP AMA

Our Partners

Last Modified: 01/19/2022 © EB Medicine. All rights reserved.