Initial Assessment and Evaluation of Traumatic Facial Injuries

Primary Survey in Maxillofacial Trauma

Airway Compromise

• Importance: Ensuring airway patency is critical.
• Intubation Requirement: Up to 42% of severe maxillofacial trauma patients.
• Compromise Causes: Soiling (hemorrhage, emesis), obstruction (displaced tongue, soft tissue injury, swelling, foreign bodies like dislodged teeth).
• Ventilation Difficulty: Distorted facial anatomy, especially with Le Fort II and III fractures.
• Interventions:
  • Suction Catheters: Large-bore DuCanto catheters for soiled airways.
  • Advanced Intubation Methods: Suction Assisted Laryngoscopy and Airway Decontamination (SALAD).
  • Patient Positioning: Sitting up to maintain airway and prevent aspiration, if spinal precautions allow.
• Spinal Precautions: Maintain cervical spinal precautions; incidence of associated cervical spine injury ranges from 0.3 to 24%.

Hemorrhage Control

• Significance: Facial structures have increased vascularity; severe hemorrhage can cause shock.
• Incidence: Up to 11% of maxillofacial trauma cases.
• Common Causes: Midfacial fractures with bleeding from the maxillary artery and its branches.
• Control Measures:
  • Direct pressure and early packing of nasal and oral cavities.
  • Nasal Packing: Use nasal tampons, Foley catheters, double lumen balloon catheters.
  • Severe Hemorrhage: May require arterial ligation or embolization.

Secondary Survey

Focused History

• Screening Questions:
  • Vision issues (blurriness, double vision, floaters, flashes of light, photophobia, foreign body sensation, pain with eye movements).
  • Facial numbness.
  • Normal teeth alignment.
• Medication Use: Ask about anticoagulants or platelet-inhibiting medications.

Inspection and Motor Function

• Facial Inspection:
  • Views: “Bird’s eye view” from above, “worm’s eye view” from below.
  • Asymmetries: Look for subtle facial asymmetries.
• Motor Function:
  • Facial nerve function: Close eyes tightly, raise eyebrows, purse lips, smile, frown.

Sensation, Palpation, and Stability

• Sensory Assessment: Lightly touch forehead, lower eyelid, cheek, upper lip, chin.
• Palpation: Assess for tenderness, step-offs, subcutaneous crepitus.
• Facial Stability: Rock the hard palate while palpating the central face.

Ocular Examination

• Visual Acuity: Check visual acuity and pupillary response.
• Eye Injury Signs:
  • Teardrop-shaped pupils (open globe injury).
  • Exophthalmos, fixed dilated pupils, ophthalmoplegia (retrobulbar hemorrhage, orbital compartment syndrome).
  • Pain with extraocular movements (periorbital fracture).
  • Limited movements (extraocular muscle injury or entrapment).
  • Diplopia: Binocular (entrapment), monocular (lens dislocation, retinal detachment, foreign body).

Ears, Nose, and Oropharynx

• Ears: Auricular hematoma, hemotympanum, CSF leak (basilar skull fracture).
• Nose: Epistaxis, CSF leak, nasal lacerations, septal deviation, nasal septal hematomas.
• Oropharyngeal Cavity: Malocclusion, missing/fractured teeth, oral mucosa breaks, sublingual hematomas, alveolar ridge fractures.
• Tongue Blade Test: Screening for mandibular fractures.

Imaging

• Facial CT: Gold standard for diagnosing facial fractures; high sensitivity, low cost.
• Head and Cervical Spine CT: Due to the mechanism of injury.
• CTA Imaging: Consider for penetrating trauma to the lateral face.

Management and Disposition of Certain Fracture Types

Orbital and Nasoorbitoethmoid Fractures

• Orbit Anatomy: Four-walled structure with a posterior apex.
• Fracture Types:
  • Pure (blowout) fractures: Involves internal orbit, typically maxillary sinus or ethmoid sinus.
  • Nasoorbitoethmoid fractures: Significant force to nasal bridge, often with lacrimal duct injuries, cribiform plate disruption, dural tears, TBI.
• Management:
  • Consult facial surgery for all orbital fractures.
  • Urgent facial surgery and ophthalmology consultation for ocular involvement.
  • Emergent lateral canthotomy for retrobulbar hemorrhage.
  • Admission for nasoorbitoethmoid fractures.
  • Isolated blow-out fractures with normal eye exam: Discharge with facial surgery and ophthalmology follow-up.

Zygoma Fractures

• Anatomy: Forms inferior and lateral borders of the orbit, attaches to maxillary, frontal, temporal bones.
• Fracture Types:
  • Zygomatic arch fracture.
  • Tripartite, tripod, or zygomaticomaxillary fractures.
• Management:
  • Isolated, minimally displaced fractures: Discharge with facial surgery follow-up.
  • Complex fractures: Facial surgery consultation, possible admission for repair, and IV antibiotics.

Nasal Fractures

• Anatomy: Composed of bones and cartilaginous framework.
• Management:
  • Closed, uncomplicated fractures: Reduce in ED if no swelling.
  • Associated septal hematoma: Drain, pack, antibiotics, ENT follow-up.
  • Open fractures: ENT consultation for repair and IV antibiotics.

Maxillary (Le Fort) Fractures

• Classification:
  • Le Fort I: Transverse, separates maxilla from pterygoid plate and nasal septum (“floating palate”).
  • Le Fort II: Pyramidal, extends into orbital floor and rim.
  • Le Fort III: Craniofacial dysjunction, entire face mobility.
  • Le Fort IV: Includes frontal bone involvement.

• Management:
  • Severe epistaxis and oropharyngeal hemorrhage: Airway protection, nasal/oral packing.
  • Early facial surgery consultation, neurosurgery for Le Fort IV.
  • Admission for most patients, IV antibiotics if open.

Mandible Fractures

• Common Sites: Condyle, body, angle.
• Management:
  • Open fractures: Facial surgery consultation, admission for IV antibiotics, operative repair.
  • Closed fractures: Discharge with facial surgery follow-up, Barton’s bandage, soft/liquid diet.

Common Antibiotics for Facial Fractures

Condition	Antibiotics
Open fractures	Ampicillin/sulbactam, penicillin G, clindamycin
Closed fractures with hematoma	Amoxicillin-clavulanate, clindamycin

Sinus Precautions

• Sneeze with mouth open.
• No nose blowing.
• No smoking.
• Avoid using straws.
• Avoid air travel.