MAXILLOFACIAL INJURIES

Published on 10/03/2015 by admin

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CHAPTER 27 MAXILLOFACIAL INJURIES

Guy J. Cappuccino, Samuel T. Rhee, Mark S. Granick

While facial injuries may be dramatic in appearance, they are infrequently life threatening, and often not the most critical injuries the patient has sustained. Developing a systematic approach to the examination of patients with multiple wounds and prioritizing treatment is of paramount importance.

When craniofacial injuries occur in the setting of multiple injuries, the Advanced Trauma Life ® guidelines should be followed beginning with a primary survey. The primary survey is called “the ABCs” because it stabilizes airway, breathing, and circulation. The application of these fundamental principles as they apply to facial trauma deserves special attention.

AIRWAY AND BREATHING

Early death as a result of airway obstruction most often occurs in the setting of multiple mandibular fractures or the combination of nasal, maxillary, and mandibular fractures. Since the tongue is suspended in the mouth by the mandible, fracture can cause the tongue to fall unsupported into the posterior oropharynx causing airway obstruction. In addition, surrounding tissue edema and hematoma can significantly narrow the airway. Fractured or avulsed teeth, broken dentures, blood, vomitus, or foreign bodies can also cause obstruction and need to be evacuated. If the patient exhibits signs of impending respiratory obstruction, including stridor, cyanosis, or drooling, or is unable to protect the airway with an effective gag reflex, endotracheal intubation or a surgical airway is indicated. Nasotracheal and nasogastric intubation may be contraindicated with midface instability due to the risk of passing the tube through the fractured cranial base into the brain. Early tracheostomy or cricothyroidotomy should be considered for the setting of pan-facial fractures, profuse nasal bleeding, severe soft-tissue edema surrounding the airway, comatose patients requiring intermaxillary fixation, severe facial burns, high spinal cord injuries, and concerns about difficult reintubation or prolonged intubation.

All trauma patients should be considered to have cervical spine instability and kept in a cervical collar until it can be cleared by physical or radiographic examination.

CIRCULATION AND CONTROL OF HEMORRHAGE

The head and neck receive 20% of the cardiac output; however, hemorrhage from facial wounds alone rarely cause systemic shock. Veins of the head and neck have no valves, and this can increase venous bleeding.

Despite this, most bleeding can be controlled with pressure, whether by direct digital pressure or packing. Instruments should not be inserted into wounds in attempts to stem arterial bleeders. The parotid duct, facial nerve, and other delicate structures are at risk of injury. The risk of airway obstruction from hemorrhage is the most serious concern.

Epistaxis

Nasopharyngeal bleeding can usually be controlled by direct pinch pressure on the nose. Thirty minutes of direct pressure without release is often sufficient. If this fails to control the hemorrhage, nasal packing should be performed. Anterior nasal bleeding can be treated by direct external pressure or cautery of the bleeding vessel. If the bleeding cannot be controlled by these measures, packing is indicated. Ribbon gauze impregnated with petroleum jelly works well for this purpose. Bayonet forceps and a nasal speculum are used to approximate the accordion-folded layers of the gauze, which should extend as far back into the nose as possible. Each layer should be pressed down firmly before the next layer is inserted. Posterior epistaxis requires posterior packing, which is accomplished by passing a catheter through one or both nares, through the nasopharynx, and out the mouth. A gauze pack then is secured to the end of the catheter and positioned in the posterior nasopharynx by pulling back on the catheter until the pack is seated in the posterior choana, sealing the posterior nasal passage, and applying pressure to the site of the posterior bleeding. Various balloon systems are effective for managing posterior bleeding and are less complicated than the packing procedure. If nasal packs or balloon systems are not available, a Foley catheter (10 to 14 French) with a 30-ml balloon may be used. The catheter is inserted through the bleeding nostril and visualized in the oropharynx before inflation of the balloon. The balloon then is inflated with approximately 10 ml of saline, and the catheter is withdrawn gently through the nostril, pulling the balloon up and forward. The balloon should seat in the posterior nasal cavity and will tamponade a posterior bleed. With traction maintained on the catheter, the anterior nasal cavity is then packed as previously described. Traction is maintained by placing an umbilical clamp or suture across the catheters outside the nostrils, with padding in between to prevent pressure necrosis of the columella.

Scalp Lacerations

The scalp is richly vascularized and thus lacerations can cause profuse bleeding. A surgical stapler can be used to quickly control this bleeding in an emergent situation. Both edges of the laceration should be stapled, parallel to the wound edge. This will provide hemostasis on a temporary basis until a formal repair can be performed.

Tongue Lacerations

Deep tongue lacerations may cause injury to the lingual artery. Control of this bleeding can be performed by suture ligation of the damaged lingual artery. After a bite block is placed in the mouth, a towel clip or a large suture is used to retract the tongue forward. The bleeding vessel then can be ligated and a formal repair of the tongue can be performed at this time if more serious injuries have already been addressed.

Hemorrhage from LeFort Fractures

In the case of severely displaced LeFort fractures, hemorrhage can be controlled by manually reducing the fracture. This is performed by grasping the maxillary arch of the hard palate and realigning the displaced segments.

HISTORY AND PHYSICAL EXAM

Once all life-threatening injuries have been addressed, a short history should be conducted. The acronym AMPLE can serve as a preliminary assessment: allergies (A), medications (M), past medical history (P), last meal (L), and events of the injury (E). A more involved history pertaining to maxillofacial trauma should investigate the mechanism of injury. This can be useful since certain force vectors produce predictable fracture patterns. Ask patients about any dental or orthodontic history, including the nature of their occlusion prior to injury (e.g., overbite, cross-bite). Ask about any prior facial injuries or surgery. In addition, old photographs of the patient can prove useful in reconstructive efforts.

The physical examination should proceed in a systematic and orderly fashion. Examination from superior or inferior is an acceptable pattern. No specific approach is preferred as long as the examiner is consistent. The face should be evaluated for symmetry and obvious deformity. All bony surfaces should be palpated to assess for step off, crepitus, or point tenderness. When examining the mandible and maxilla, broken or missing teeth should be noted, as well as jaw excursion. Normal excursion is 5–6 cm measured from the incisal edges of the incisors. Normal lateral movement of the mandible is 1 cm in relation to the maxilla. The patient’s occlusion should be documented. When evaluating soft tissue, any contusions, abrasions, or lacerations should be noted. An examination for occult injuries should be performed, including within the ear canal, nares, and oral cavity. A complete sensory and motor exam should also be conducted. Cranial nerves 2–12 are easily tested (Table 1).¹

Table 1 Testing Cranial Nerve Function

Cranial Nerve	Test of Function
(II) Optic	Visual acuity
(III) Occulomotor	Evaluation of extraocular eye movements
(IV) Trochlear
(VI) Abducens
(V) Trigeminal	Test motor function by asking the person to clench his or her teeth while you palpate the masseter and temporal muscle for firmness. Test all three divisions of the trigeminal for intact sensation.
(VII) Facial	Test the facial nerve by asking the person to shut eyes, smile, and frown noting function and asymmetry.
(VIII) Vestibulocochlear	Test the cochlear portion of this cranial nerve by evaluating hearing acuity.
(IX) Glossopharyngeal	Test by checking for an intact gag reflex.
(X) Vagus	Look for symmetrical elevation of the soft palate.
(XI) Spinal accessory nerve	Have patient shrug shoulders against resistance.
(XII) Hypoglossal	Ask the person to stick out the tongue. Note symmetry, atrophy, and involuntary movements.

RADIOGRAPHS

Computed tomography (CT) scans and Panorex films are the studies of choice in facial injuries. CT scans have generally replaced plain films in the diagnosis of facial fractures. Both axial and coronal sections, obtained with 1–2-mm cuts, help determine the location and displacement of facial fractures. Three-dimensional reconstructions can aid in visualization with panfacial fractures and bone loss. A Panorex film is the study of choice for finding fractures of the body, ramus, angle, and condylar regions of the mandible. In lieu of a Panorex, a maxillofacial CT with cuts through the mandible can be obtained.

SOFT TISSUE INJURIES

General Considerations

The initial evaluation of most facial injuries frequently takes place in a busy emergency department or trauma bay. While this may be an acceptable location for diagnosis, it rarely provides a suitable environment for repair of facial trauma. Before beginning any reconstructive effort, an adequate light source, assistants, and all requisite supplies should be present. Extensive soft tissue injuries are optimally repaired in the operating room.

Local Anesthesia

Local anesthesia is the preferred modality for repair of most soft tissue injuries. While general anesthesia is required for major injuries, it is best avoided if possible since trauma patients may bear significant risks for aspiration, either due to intoxication or gastric contents. Local anesthesia can be combined with intravenous sedation to increase patient comfort and cooperation. Depending upon the choice of anesthetic, the effects of local anesthesia can last up to 7 hours (Table 2). When combined with epinephrine, the duration of anesthesia is extended and more importantly, the resultant vasoconstrictive effect provides increased hemostasis in the operative field. Onset of action is from 2 to 5 minutes for all drugs; however, waiting 7 minutes provides maximal effects.²

Table 2 Local Anesthetics Used in the Face

Cocaine (5% solution) is the topical anesthetic of choice for nasal mucous membranes. It can be introduced on cotton pledgets or gauze soaked with the solution.

Antibiotics

The use of antibiotics depends on the location and mechanism of the facial injury. Most soft tissue injuries of the face can be prophylaxed with a first-generation cephalosporin or aminoglycoside in the case of penicillin allergic patients. In the case of animal or human bites, gram negative and anaerobic organism coverage should be provided. Wounds with intraoral involvement should also cover these organisms. Duration of treatment should be determined based upon the extent of injury, contamination, and immune status of the patient ³ (Table 3).

Table 3 Tetanus Prophylaxis

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Immunization Status	Tetanus Toxoid (0.50 ml)	Tetanus Immunoglobulin
Unknown status or no history of immunization	Immediate dose plus two more at monthly intervals	One dose 250 IU
Last immunization greater than 5 years ago	One dose

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