Facial Trauma

Impacted 2
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Diagnosis and reasoning

This young man has presented following significant trauma. As per ATLS guidelines, we should begin with a primary survey to ensure no immediate threats to life. In this case, there are none. We may now take a detailed history and perform a comprehensive assessment. The first priority is to rule out the most dangerous possibilities - particularly intra-cerebral hemorrhage. Our patient's history is reassuring in this regard; he denies headache, vomiting or loss of consciousness. We also need to exclude injury to the cervical spine; as per the Canadian C-Spine rules, this cannot be performed clinically, given the high-force mechanism of injury. We must therefore immobilize the spine and arrange for an X-ray, which is fortunately normal. Closer examination reveals multiple cuts and blunt trauma to the midface. The cuts should be examined for depth and any retained material, but as they appear to be superficial, our main concern is the blunt trauma, which could be associated with deeper damage. Trauma to the midface can lead to fractures of the temporal bone; these are particularly concerning as they can damage the middle or inner ear. Thus, it is important to enquire about any bleeding from the ear, as well as hearing issues and vertigo. However, our patient denies any problems of this nature. We then move on to check for signs of a basilar skull fracture, as this can tear the meninges and predispose the patient to meningitis. In this patient's case, note the periocular ecchymosis (often referred to as 'panda eyes'), which may indicate a basal skull fracture. We should also consider orbital fractures, given the mechanism of injury. Notably our patient is complaining of pain and double vision with upgaze, suggestive of orbital pathology and meriting a careful examination of all the cranial nerves, with particular attention to the eyes. Examination finds that his eye movements are indeed abnormal, with restricted movement in the right eye causing vertical diplopia on upgaze. We now need to determine if the restricted upgaze is neurological or muscular in origin and locate the site of the damage. Further examination of the cranial nerves reveals a clue: paresthesia over the right side of the nose, cheek and upper lip. This represents the distribution of the infraorbital nerve (a branch of the trigeminal nerve) and is clinically significant, as the course of the infraorbital nerve carries it through the infraorbital part of the maxilla, where it is frequently damaged by orbital floor fractures. The possibility of an orbital floor fracture is further supported upon a more detailed examination of the orbit. This reveals orbital emphysema, which is usually secondary to a fracture of the medial or inferior orbit (which creates a passage through which air can enter from the sinuses). Enophthalmos is also noted, suggesting a loss of orbital integrity. Given the high likelihood of an orbital fracture, and possibility of a basilar skull fracture, CT imaging is a must; this shows a right-sided fracture of the orbital floor with a small amount of herniated tissue (often referred to as the "teardrop sign"). This herniated tissue is the inferior rectus muscle, which is entrapped in the orbital floor, thus restricting the patient's upgaze. Note that the teardrop sign is often visible on a plain skull X-ray, but plain films are generally less sensitive than CT and less useful in planning surgical repair. His initial management should include a short course of antibiotics to prevent infection and further damage to the tissues. Advising the patient to avoid blowing their nose is also important, as this may force air and nasal bacteria into the orbit. Steroids are also helpful in reducing edema. The presence of symptomatic diplopia, infraorbital anesthesia and enophthalmos suggest that this patient will benefit from surgical reconstruction of the orbit and release of the herniated tissue. Watchful waiting would only be appropriate for patients with minimal or no symptoms.


Discussion

Maxillofacial trauma represents a wide range of injuries to the facial region; it is a leading medical problem in emergency rooms worldwide. In developed countries, assault is the leading cause of facial fractures, followed by motor vehicle accidents, pedestrian collisions, falls, sports and recreation, and finally, occupational accidents. In underdeveloped regions, road traffic accidents account for the majority of these cases, followed by assault and other events, including warfare. Considering the pathophysiology, it is important to appreciate that the maxillofacial region is one of the most prominent and exposed areas of the body, and is thus highly vulnerable to injury. Specific lines of weakness run across the face, and are usually the site of fractures. These include the posteromedial orbital floor, mandibular neck, zygomatic arch and the naso-orbit-ethmoid complex. Thus, the key types of fractures are those of the midface (i.e. the maxilla, nasal bone, and zygoma), mandibular fractures, orbit-zygomatic complex and zygomatic arch fractures, and orbital floor fractures. Clinical findings suggestive of a mandibular fracture include dental malocclusion, reduced mandibular mobility, or a feeling that one's teeth are not in the correct position when the mouth is closed. Inability to bite or chew due to pain, sensory deficits in the distribution of the mental nerve, and the presence of gingival tears are other signs suggestive of this type of fracture. Note also that the feeling of missing one or more teeth even though they are still present may indicate a displaced mandibular fracture. Orbitozygomatic complex and zygomatic arch fractures are almost always associated with ipsilateral infraorbital or upper lip numbness. The affected side may be flattened, although this may be difficult to assess in the presence of swelling. Periorbital edema, lower lid ecchymosis, lateral subconjunctival hemorrhage, a decreased range of mouth opening (less than 30mm), a palpable step-off or deformity of the infraorbital rim or malar buttress are other common signs that indicate a fracture here. Note also that retrobulbar hemorrhage may occur, resulting in blindness secondary to the hemorrhagic pressure effect and ischemic necrosis of the optic nerve. Orbital floor fractures are suspected when there is a history of trauma accompanied by restricted eye movements, diplopia and hypoglobus of the affected eye. New onset floaters are particularly concerning for impending retinal detachment. Raccoon eyes, chemosis, Battle's sign, CSF rhinorrhea or otorrhea, anterior open bite, posterior gagging, ecchymosis of the maxillary vestibule, palatal laceration, palatal split, palpable infraorbital step, a mobile nasal bridge, tenderness over buttresses, and mobility of the maxilla are other signs suggestive of a midface fracture. Where suggestive clinical findings are present, imaging should be performed to confirm the presence of a fracture. Oral panoramic and posterior-anterior mandible radiographs should be obtained in cases of suspected mandibular fractures, while in orbitozygomatic complex and zygomatic arch fractures, occipitomental 15/30 views and a submentovertical view, which is specific for arch fractures, are preferred. Note that when requesting and reviewing radiographs, it is important to remember that non-displaced fractures may not be apparent on plain films until 7 to 10 days have elapsed. Orbital floor fractures should be investigated with CT scanning, as plain films are often inadequate. Visual fields and acuity should also be assessed and documented. Note also that fractures of the midface can be classified as Le Fort I, II and III, depending on the area involved. Le Fort I fractures run horizontally across the maxillary alveolar process; the pterygoid plates are broken, along with the walls of the maxillary sinus of the affected side(s), including a point on the anterolateral margin of the nasal fossa. Le Fort II fractures are pyramidal in shape with the teeth at the base and the nasofrontal suture at the apex. The pterygoid plates are broken along with the posterior and lateral walls of the maxillary sinus, as the fracture travels inferior to the zygoma, traverses across the orbital rim, floor and medial wall of orbit before crossing midline near the nasofrontal suture. A Le Fort III fracture completely separates the bones of the face from the rest of the skull. Apart from the pterygoid plates, the upper posterior margins of maxillary sinuses fracture, as does the zygomatic arch, lateral orbital wall, and lateral orbital rim. These fractures can be identified on radiography; however, spiral CT imaging with axial, coronal and 3D reconstruction is the gold standard. The initial management should follow ATLS principles, with securing and maintaining the airway being of paramount importance, as obstruction is the main cause of death in these patients. Conscious individuals are unlikely to suffer from airway collapse and should be seated upright to allow blood and secretions to drain out of the mouth and increase comfort. As approximately half of these patients have multiple trauma, coordination with otolaryngology, plastic surgery, ophthalmology, and oral/maxillofacial surgery units is often necessary. With respect to the specific management, note that most mandibular fractures are open fractures, and thus at an increased risk of airway compromise due to displacement of the tongue, loss of laryngeal tone or excess secretions. Patients with orbital floor and midface fractures should have their vision monitored regularly, as progressive loss of vision can occur rapidly. Restricted eye movement should prompt immediate referral, as the risk of ocular muscle necrosis due to bony entrapment is high. These patients should also not blow their nose and avoid pressure on the affected side, so as to prevent surgical emphysema, displacement of the bony fragments or optic nerve impingement. Overall complication rates of maxillofacial trauma range from 7% to 29%; as might be expected, they are higher in those with more severe injuries. Mortality is approximately 10%, usually owing to the associated injuries.


Take home messages

  1. Maxillofacial trauma comprises a wide range of injuries including mandibular fractures, orbitozygomatic complex and zygomatic arch fractures, and orbital floor and midface fractures.
  2. The leading cause in developed countries is interpersonal violence, while in developing countries it is motor vehicle accidents.
  3. Clinical features include malocclusion of the teeth, gingival tears, tooth displacement, mandibular mobility, flattening of the affected side and concurrent periorbital injuries.
  4. Patients with maxillofacial trauma should be managed initially according to the ATLS protocol, with subsequent input from specialists in ophthalmology, plastic surgery, neurosurgery and orthopedics.
  5. Mortality is approximately 10% and is usually secondary to associated injuries from the initial trauma.

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