Midface Trauma

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MIDFACE TRAUMA

❖ well equipped to withstand forces directed superiorly or inferiorly

❖ poorly withstands lateral and frontal forces

❖ midface absorbs, conducts and effectively dissipates forces

❖ horizontal and vertical buttresses resist/transmit forces to base of skull

MIDFACE TRAUMAVertical Buttresses

❖zygomatico-maxillary

❖pterygomaxillary

❖nasomaxillary

MIDFACE TRAUMAHorizontal Buttresses

❖ Pyriform Aperture

❖ Maxillary Alveolus and Palate

❖ Orbital Rims

❖ Base of skull

MIDFACE TRAUMA

❖ Le Fort I, II & III

❖ NOE

❖ ZMC

❖ isolated maxillary, zygomatic, nasal

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EMERGENCY TREATMENT

Airway/Breathing

❖ airway evaluation

❖ supraglottic obstruction due to secretions &/or debris

❖ intraoral wounds managed locally

❖ ET tube for severe bleeding

❖ C-spine fx must be ruled out or stabilized prior to ET tube placement

EMERGENCY TREATMENT

Tracheotomy vs ET tube

❖ upper airway obstruction w/ c-spine fx perform trach or cricothyroidotomy

❖ avoid c-spine manipulation and movement with ET tube

❖ laryngeal fx is indication for trach

❖ reconstructive procedure hampered by ET tube

EMERGENCY TREATMENT

Circulation

❖ blood volume: vitals, central subclavian catheter

❖ NS or LR through 2 large bore IV lines

❖ vascularity of region may result in severe hypovolemia

❖ typed/crossmatched blood

❖ ateriogram/esophagram

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MIDFACE TRAUMA

Sensory Innervation

❖ 1st & 2nd divisions of trigeminal nerve

❖ V2 emerges from infraorbital foramen

❖ supplies lateral nasal, inferior palpebral, & superior labial regions

Classification of Le Fort Fractures

❖ Le Fort I- force delivered above level of teeth

❖ Le Fort II- force delivered at level of nasal bones

❖ Le Fort III- force delivered at orbital level resulting in craniofacial dysjunction



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Le Fort I Fracture

❖ lateral border of pyriform sinus across lateral antral wall

❖ behind maxillary tuberosity

❖ across pterygoid jct

❖ concomitant nasal septum fx may be present

❖ unilateral fx may occur coursing through palatal suture line

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Le Fort I Fractures

Muscular Attachments

❖ medial pterygoid

❖ lateral pterygoid

❖ post/inf pull seen in fx of maxilla

❖ palatal ecchymosis from unilateral fracture

❖ posterior, inferior displacement creating a classic open bite

❖ segment can be impacted, immoveable, free floating

❖ displacement of fractured fragment

❖ CN V injury (infraorbital branch)

❖ movement of maxilla in AP direction with no movement of midface

Le Fort I FracturesPhysical Exam Findings

Le Fort I FracturesFracture Management

❖ minimally displaced fx

❖ early MMF

❖ 4-6 weeks of immobilization

❖ open reduction with plating

Le Fort I Fractures

Fracture Management

❖ significant displacement or impaction

❖ disimpaction forceps

❖ maxilla pulled forward and down

❖ rigid fixation with miniplates

❖ skeletal suspension with circumzygomatic wiring

❖ external fixation

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Le Fort II Fractures

❖ pyramidal fracture

❖ fracture line along nasofrontal suture

❖ through lacrimal bones

❖ across inferior orbital rim in area of ZM suture

❖ along lateral antral wall at jct of pterygoid plates

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Le Fort II FracturesPhysical Exam Findings❖ bilateral periorbital edema and eccymosis; “raccoon sign”

❖ CN V injury (infraorbital nerve)

❖ malocclusion, open bite

❖ step deformity of infraorbital rim region or nasofrontal suture region

❖ mobility of fractured complex by grasping the mx anterior teeth and moving complex AP

❖ orbital blowout fx

❖ epistaxis

Le Fort II FracturesPhysical Exam Findings

❖ CSF rhinorrhea due to dural tear lateral to cribriform plate

❖ disruption of sphenoid, ethmoid, and frontal sinuses

❖ leakage generally noted immediately following trauma

❖ diagnosis of CSF is difficult if mixed with blood

❖ must be distinguished from nasal secretions & lacrimal secretions

❖ Glucose level of 45mg/dL

❖ will not stiffen handkerchief or guaze

❖ forms characteristic concentric rings

❖ pt may report “salty taste”

❖ high resolution CT cisternogram w/ intrathecal florescein

❖ beta-2-transferrin

Le Fort II FracturesPhysical Exam Findings

Le Fort II FracturesConsiderations within ER setting

❖ semirecumbent position

❖ no nose blowing, no straining, sneezing with mouth open

❖ abx therapy to counter development of meningitis

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Le Fort II FractureTREATMENT

❖ IMF x 4-6 weeks

❖ disimpaction forceps

❖ orbital floor exploration and release of entraped muscle

❖ rigid fixation across nasofrontal sutures, zygomaticomaxillary sutures, or inferior orbital rims

❖ fx courses through ZT and ZF sutures

❖ along lateral orbital wall

❖ through inferior orbital fissure

❖ medially through nasofrontal suture

❖ ending at pterygomaxillary fissure

Le Fort III Fractures

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Le Fort III Fracture

Physical Exam Findings

❖ mobility of zygomaticomaxillary complex

❖ CSF leakage

❖ periorbital edema and ecchymosis

❖ traumatic telecanthus

❖ epiphora

❖ epistaxis

Le Fort III Fracture

Treatment❖ establish outer framework

❖ immobilization of ZF, ZT and NF sutures

❖ if mand or mx involved 1st establish proper occlusion

❖ bicoronal, infraorbital, lateral brow &/or nasofrontal incision

❖ expose nasoethmoid complex, lateral rims and zygomatic arch

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Zygomaticomaxillary Complex (ZMC)Fractures

❖ 2nd most common facial fx after nasal

❖ high incidence due to prominent position within facial skeleton

❖ male predilection 4:1

❖ 2nd and 3rd decades of life

❖ altercations & MVA

❖ greater incidence of left sided injury

❖ b/l fx most commonly result of MVA

❖ zygoma is major buttress of the facial skeleton

❖ important role in facial contour

❖ quadrilateral in shape (4 sided pyramid)

❖ articulates with 4 bones

❖ fx can result in ocular and mandibular functional impairment

❖ origin to masseter muscle & attachment to temporalis fascia, temporal and zygomatic muscles

Zygomaticomaxillary Complex (ZMC)Fractures

ZMC FracturesPhysical Exam Findings

❖ periorbital edema & ecchymosis

❖ flattening of malar prominence

❖ ecchymosis of maxillary buccal sulcus

❖ trismus-impinging coronoid

❖ infraorbital nerve deficit

❖ epistaxis

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ZMC FracturesOcular Exam Findings

❖ subconjuctival ecchymosis

❖ crepitation from air emphysema

❖ displacement of palpebral fissure

❖ antimongoloid slant to eye

❖ unequal pupillary levels

❖ diplopia

❖ muscle entrapment & enophthalmus

ZMC FracturesTreatment Considerations

❖ edema-may need to postpone surgery

❖ neurologic state

❖ status of contralateral eye

❖ prolapse of orbital soft tissue into mx sinus

❖ thin plates due to thin periorbital skin

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Naso-Orbital-Ethmoid Fracture

Physical Exam Findings❖ fractured nose

❖ widened nasal bridge

❖ epistaxis

❖ periorbital edema and ecchymosis

❖ disruption of lateral canthal ligament

❖ traumatic telecanthus

❖ damage to lacrimal apparatus (20% of pt’s)

❖ epiphora


Physical Exam Findings

❖ average intercanthal distance: 33-34mm (males), 32-34mm (females)

❖ intercanthal distance > 35mm are suggestive of NOE fx

❖ distances >40mm are generally diagnostic

❖ intercanthal distance roughly 1/2 the interpupillary distance

❖ crepitus/movement of medial orbital rim indicates instability


Markowitz & Manson Classification System

❖ Class I: canthal ligament attached to large fragement/no comminution

❖ Class II: canthal ligament attached to substantial fragment of bone despite some comminution

❖ Class III: detachment of canthal ligament, severe comminution, ligament attached to very small fragment of bone

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Treatment

❖ adequate exposure

❖ coronal flap with lower eyelid incisions

❖ existing lacerations

❖ medial canthal tendon injury may require canthopexy with transnasal wiring

❖ ORIF of nasal bones to frontal bone & inferior & medial orbtial rims

❖ nasal dorsum bone grafting


Nasolacrimal Injury

❖ loss of protection provided by medial canthal ligament

❖ ORIF of fx segments to reestablish lacrimal drainage

❖ stent (Crawford tube) to bridge two severed ends & closure of pericannular tissue

❖ dacrocystography

❖ uncorrected epiphora may require dacrocystorhinostomy


Dacrocystorhynostomy

❖ incision midway between corner of eye and bridge of nose

❖ lacrimal sac located and connected to nasal mucosa

❖ new tear drainage pathway

❖ stent placed to prevent scarring

Complications of Midface Trauma

❖ CSF otorrhea & rhinorrhea

❖ Damage to Lacrimal System

❖ Ocular

❖ Neurologic

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Ocular Complications of Midface Trauma

❖ Diplopia

❖ Enophthalmos

❖ Retrobulbar Hematoma

❖ Superior Orbital Fissure Syndrome

❖ Orbital Apex Syndrome

❖ Blindness

Traumatic Diplopia❖ most frequent complication

❖ usually temporary but may become permanent if not treated

❖ must distinguish between neurologic damage and muscle entrapment & edema

❖ forced duction test

❖ limitation of motion may indicate entrapment

❖ absence of resistance may indicate neurologic deficit

Traumatic DiplopiaCauses

❖ interference with function of EOM

❖ displaced globe

❖ muscle or fat entrapment

❖ bony displacement (orbital floor)

❖ displacement of Lockwood’s inferior suspensory ligament

❖ impingement of CN III, IV, VI

Traumatic DiplopiaTreatment

❖ large defects

❖ displaced zygoma

❖ orbital floor defect with damage to Lockwood’s ligament

❖ inferior repositioning of globe

❖ trap door injury with physical restriction of movement

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Traumatic DiplopiaTreatment

❖ edema

❖ steroids for 5-7 days

❖ determine if diplopia secondary to edema or entrapment

❖ CT scan with 3mm cuts

❖ result of forced duction test

Traumatic DiplopiaTreatment Objectives

❖ prevent loss of orbital contents

❖ provide support for orbital contents

❖ reconstruct floor to mirror opposite side

❖ retrieve herniated fat in trap door injury

Traumatic DiplopiaMonocular Diplopia

❖ detached lens

❖ hyphema

❖ traumatic globe injury

Enophlalmos❖ loss/atrophy of orbital fat

❖ enlargement of bony orbit

❖ cicatricial contraction of retrobulbar tissue

❖ unrepaired fracture of orbital wall

❖ displacement of orbital tissue

❖ increased orbital volume, decrease orbital contents, disruption of ligamentous structures

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EnophlalmosTreatment

❖ ORIF orbital fx

❖ repair orbital floor and restoration of orbital contents

❖ freeing of soft tissue from herniated positions

❖ repair of zygoma fx

Retrobulbar Hematoma

❖ compromise optic nerve function

❖ central retinal artery obstruction

❖ infraorbital arterial rupture

❖ anterior/posterior ethmoid arterial rupture

Retrobulbar Hematoma

Subjective/Objective Findings

❖ severe aching pain

❖ progressive loss of vision

❖ proptosis

❖ increased IOP (normal:12-20mm Hg)

❖ subconjunctival hemorrhage

❖ gross eyelid swelling

❖ fixed, dilated pupil

Retrobulbar HematomaTreatment

❖ post-surgical wound opening

❖ IV injection of acetazolamide to decrease IOP (up to 500mg)

❖ lateral canthotomy

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Superior Orbital Fissure Syndrome

❖ direct compression or hematoma on contents of superior orbital fissure

❖ pupillary dilation due to altered CN III function

❖ unopposed sympathetic control

❖ paresis of CN III, IV, VI resulting in ophthalmoplegia

❖ ptosis from paresis of levator palpebrae superiorus

❖ neurosensory disturbance CN V (frontal branch causing loss of sensation over forehead)

❖ deficit of supraorbital/supratrochlear nerves

❖ loss of corneal reflex (nasociliary branch of CN V)

❖ proptosis from engorgement of ophthalmic vein and lymphatics

Orbital Apex Syndrome

❖ superior orbital fissure syndrome

❖ optic nerve involvement

❖ change in visual acuity

Blindness

❖ 0.03-2.1%

❖ retrobulbar hemorrhage

❖ occlusion of ciliary arteries

❖ ischemia leads to optic neuropathy

❖ prompt diagnosis and treatment

❖ rapid evacuation of hematoma

BlindnessImmediate Reduction in IOP

❖20% mannitol (2g/kg IV, max 12.5g in 3-4min)

❖Acetazolamide sodium (Diamox) 500mg IV

❖Methylprednisolone sodium succinate (Solu-Medrol) 1g IV

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Bibliography❖ Fonseca R et al, Oral & Maxillofacial Trauma. Vol I &II,

2005

❖ Bagheri S, Jo C, Clinical Review of Oral & Maxillofacial Surgery. 2008

❖ Zacharides et al, The Superior Orbital Fissure Syndrome. J Maxillofacial Surg: 125-8, 1985

❖ Zacharides et al, Orbital Apex Syndrome. Int J Oral & Maxillofacial Surg: 352-4, 1987

❖ Markowitz BL, Manson PN, Sargent L, et al: Management of the Medial Canthal Tendon in NOE Fractures; the Importance of the Central Fragement in Classification & Treatment. Plast Reconstr Surg: 843, 1991

Bibliography❖ Manson P et al, Structural Pillars of the Facial Skeleton,

An approach to the Management of Le Fort Fractures. Plastic & Reconstructive Surgery: 57, 1980

❖ Manolidis S, Management of Frontal Sinus Trauma. Seminars in Plastic Surgery: 261-271, 2002

❖ Assael LA, Atlas of Facial Fractures. OMS Clinics of N.America:Vol 11, 320-1, 1999

❖ Osguthorpe JD, Hoang G, Nasolacrimal Injuries,Evaluation & Management. Otolaryngologic Clinics of N. America: 59-78, 1991

The End

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Midface Trauma