Maxillofacial Trauma
General Treatment
1. Perform a primary survey, paying particular attention to airway compromise from aspiration of blood, avulsed teeth or dental appliance, direct trauma and swelling, or a retrusive tongue secondary to a mobile mandibular fracture. The most important part of care for maxillofacial trauma is maintenance of a clear airway. If the airway is threatened by edema or inability of the patient to keep the airway clear, early intubation is recommended. Cricothyrotomy (see Chapter 10) may be necessary.
a. Remove any loose material (teeth, clots, soft tissue, foreign material) from the oropharynx to clear the airway.
b. Note any deformity or asymmetry of the facial structures, which may indicate underlying bone fracture.
c. Enophthalmos may be one sign that an orbital blowout fracture is present.
d. Look for malocclusion or a step-off in the teeth as an indication of mandibular or maxillary fracture.
e. Observe the position and integrity of the nasal septum. If the septum is bulging on one side into the nasal cavity, it could indicate a septal hematoma. A septal hematoma can be drained in the field by making a small incision into the septum with a safety pin or point of a knife, allowing the blood to drain out.
f. Examine soft tissue injuries, looking for foreign bodies, including avulsed teeth.
g. Test motor and sensory function by checking for sensation on each side of the face and by having the patient wrinkle the forehead, smile, bare the teeth, and close the eyes tightly.
h. Gently palpate the facial structures, noting areas of tenderness, bony defects, crepitus, and false motion.
i. Test dental integrity by grasping the front and bottom anterior teeth and checking for motion.
j. If the patient is unconscious but breathing well and shows no sign of hemorrhaging into the airway, you can use an oropharyngeal or nasopharyngeal airway to ensure airway patency.
2. Anticipate cervical spine trauma, and immobilize the spine if indicated (see Box 12-5). If cervical spine injury is possible and airway protection is required, perform endotracheal intubation or cricothyrotomy while maintaining manual cervical spine immobilization.
3. Control bleeding with direct pressure.
a. For intraoral bleeding, have the patient bite firmly on a gauze pad.
b. For bleeding from the nose, squeeze and hold the nostrils together, use nasal packing, or deploy a Foley catheter (see Nasal Fracture and Epistaxis, later).
4. Treat shock (see Chapter 13).
5. Recover any completely avulsed teeth or other tissues, irrigate with normal saline solution, and transport in a saline-soaked gauze sponge.
Disorders
Signs and Symptoms
1. Lacrimal drainage system: injury confirmed if a probe inserted into the punctum at the medial canthus of the eye emerges from the laceration
2. Parotid duct: injury suspected if there is buccal nerve paralysis or leakage from the wound when Stensen’s duct is irrigated with saline solution or water
3. Facial nerve: asymmetry when the patient moves the eyebrows, eyelids, and mouth
