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IN THE NAME OF ALLAH, THE MOST BENEFICENT, THE
MOST MERCIFUL
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Nasal and Facial Trauma

• Brigadier Nasir Ullah Khan
• Classified ENT Specialist
• CMH Rawalpindi

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Sequence

• Facial trauma in general
• Nasal trauma
• Mandibular fractures
• Fractures of the maxilla
• Zygomatic complex fractures
• Orbital floor fractures
• Upper third fracures involving the frontal sinus
• Soft tissue injuries

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Facial Trauma

• 10 of all accidents are related to facial
  injuries
• Endanger the airway
• Associated cervical spine injuries

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Aetiology
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Aetiology

• Road Traffic Accidents
• Physical violence
• Attempted suicide
• Sports accidents

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Causes of Mortality

• Acute
• Airway compromise
• Exsanguination
• Associated intracranial or cervical-spine injury
• Delayed
• Meningitis
• Oropharyngeal infections

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Management

• Primary survey and care
• Airway
• Breathing
• Circulation
• Dysfunction
• Exposure

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Management

• Secondary survey
• Exclude other injuries
• Extent of facial injuries
• Radiological evaluation - chest, cervical spine
  and pelvis
• Intervention

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Management

• Facial swelling - head up position, ice packs
  and dexamethasone
• Facial wounds closed as early as possible
• Fractures reduced and fixed
• Give tetanus prophylaxis

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• Nasal Fractures

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Introduction

• Isolated nasal fractures account for about 40
  percent of all facial fractures
• Delays in management can result in significant
  cosmetic and functional deformity
• Management of nasal fractures is an important
  part of everyday ENT practice

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Nasal trauma

• More common in young men than women
• 15 30 years
• Aetiology
• In young adults (peak incidence)
• Assaults
• Contact sports
• Adventurous leisure activities
• In childhood
• Accident prone toddlers not infrequently fracture
  their noses
• In elderly
• Compound and comminuted fractures due to falls

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Nasal trauma

• Apart from actual fracture of nasal bones,
  injuries include
• - Soft tissue
• - Septal cartilage fracture
• - Septal bone fracture
• - Septal haematoma
• - CSF leak

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Nasal trauma

• Injury results from
• - lateral
• - frontal
• - combined

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Extent of deformity

• Grade 0 bones perfectly straight
• Grade 1 bones deviated less than half of the
  width of the bridge of nose
• Grade 2 half to one full width of the bridge of
  nose
• Grade 3 greater than one full width of the
  bridge
• Grade 4bones almost touching the cheek

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Nasal fractures - classification

• Class 1 Fracture
• Class 2 fracture
• Class 3 fracture naso-orbito-ethmoid
• Type I
• Type II

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Nasal trauma

• May be part of more extensive injury to face,
• skull, skull-base, neck, chest .
• REMEMBER TO CONSIDER THE AIRWAY AND EXCLUDE
• CERVICAL SPINE INJURIES

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Clinical features

• Epistaxis
• Deformity
• Nasal obstruction
• Diplopia
• Epiphora
• Visual disturbance
• Watery rhinorrhoea

Naso-fronto-ethmoid fractures
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Clinical features

• Signs
• External deformity, swelling, lacerations
• Tenderness, crepitus
• Septal haematoma/ abscess
• There is often periorbitaln swelling and there
  may be periorbital and subconjunctival echymosis

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Investigations

• X rays
• CT scan
• Beta transferrin

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Management - soft tissue

• Clean wounds and remove foreign material
• Anti-tetanus and antibiotic cover if appropriate
• Abrasions cleaned and left open
• Steristrips to small lacerations
• Fine monofilament sutures to large lacerations

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Management - fracture

• Nothing if no deformity. Reassure and review
• Class 1 - reduce if early
• - disimpact and realign
• - if swollen, manipulate and reduce at 5-7
  days

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Management - fracture

• Class 2 - septal fracture is often overlapping so
  fractures redisplace
• - manipulation of the nasal bones should
  follow excision of overlapping edges

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Management - fracture

• Class 3 - requires open reduction

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Complications

• Bleeding
• Septal haematoma
• CSF rhinorrhoea
• Deformity
• Sensory loss
• Anosmia

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Septal haematoma
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Saddle deformity
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• Mandibular fractures

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Mandible Fracture
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Mandibular fracturesclinical features

• Step deformities
• Pain
• Deranged occlusion
• Blood stained saliva
• Sublingual haematoma
• Mobile teeth
• Lip anaesthesia
• trismus

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Signs and symptoms of condylar neck fractures

• Tenderness
• Trismus
• Lateral and anterior open bite

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Mandibular fracturestreatment

• Reduction
• IMF
• IM bone pins
• Cast silver splints
• Gunning splints
• Fixation
• External
• Internal - plating

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Sites of bone plating
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Fractures of the midface

• Central midface ( maxilla, nasal,
  naso-orbito-ethmoid) fractures
• Lateral ( zygomatic) fractures

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Fractures of the Maxilla
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Maxillary fractures classification

• Le fort 1
• Le Fort 2
• Le Fort 3

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Le Fort 1
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Le fort 2
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Le Fort 3
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Differentiating Le Forts

• Pull forward on maxillary teeth
• Le Fort 1 maxilla only moves
• Le Fort 2 maxilla base of nose moves
• Le Fort 3 whole face moves

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Le Fort fracturessigns and symptoms

• Epistaxis
• Circumorbital ecchymosis
• Facial oedema
• Surgical emphysema
• Infraorbital anaesthesia
• Anterior open bite ( in Le Fort 12)
• Haematoma at the junction of hard and soft palate
• Floating palate and teeth ( Le Fort 1)

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Treatment

• Emergency treatment
• Reduction
• Fixation
• Imf
• External Levant frame
• Internal suspension
• Internal fixation miniplates

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Zygomatic Fractures

• Tripod (tri-malar) fracture
• Depression of malar eminence
• Fractures at temporal, frontal, and maxillary
  suture lines

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Zygomatic Fractures

• Isolated arch fracture
• Less common
• Shows best on submental-vertex x-ray view
• Painful mandible movement
• Usually treated with fixation wire if arch
  depressed

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Zygomatic Fractures

• Tripod S S
• Unilateral epistaxis
• Depressed malar prominence
• Subcutaneous emphysema
• Orbital rim step-off

• Altered relative pupil position
• Periorbital ecchymosis
• Subconjunctival hemorrhage
• Infraorbital hypoesthesia

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Orbital floor fractures

• Blow out fracture of floor
• Symptoms and signs
• Diplopia double vision
• Enophthalmos sunken eyeball
• Impaired EOMs
• Infraorbital hypoesthesia
• Maxillary sinus opacification
• Hanging drop in maxillary sinus

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Upper facial third Fractures

• Frontal sinus fracture
• Often associated with intracranial injury
• Often show depressed glabellar area
• If posterior wall fracture, then dura is torn

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Orbital Fracture Treatment

• Sometimes extraocular muscle dysfunction can be
  due to edema and will correct without surgery
• Persistent or high grade muscle entrapment
  requires surgical repair of orbital floor (bone
  grafts, Teflon, plating, etc.)

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Facial Soft Tissue Injuries

• Before repair, rule out injury to
• Facial nerve
• Trigeminal nerve
• Parotid duct
• Lacrimal duct
• Medial canthal ligament
• Remove embedded foreign material to prevent
  tattooing

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Facial Soft Tissue Rules

• For lip lacerations, place first suture at
  vermillion border
• Never shave an eyebrow may not grow back
• If debridement of eyebrow laceration needed,
  debride parallel to angle of hairs rather than
  vertically

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Facial Soft Tissue Rules

• Most face bite wounds can be sutured primarily
• Clean facial wounds can be repaired up to 24
  hours after injury
• Place incisions or debridement lines parallel to
  the lines of least skin tension (Lines of Langer)

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• Thank you