Chapter 23. Maxillofacial & Neck Trauma

Emergency management of life-threatening associated conditions is described in Chapter 12.

Airway

Evaluate the patient's entire airway with direct visualization while maintaining immobilization of the cervical spine (C-spine) with a cervical collar. The patient should remain fully immobilized until spinal column injury is ruled out.

Diligent continuous monitoring of the airway should be performed for any patient with significant maxillofacial or neck trauma, as airway compromise can be abrupt. Keep a low threshold for intubation of any patient with impending airway obstruction. Soft tissue swelling and edema may result in delayed airway compromise. Warning signs include hoarseness, subcutaneous emphysema of the neck, laryngeal pain, visible edema, or the presence of an expanding hematoma.

Perform a jaw thrust to allow for ventilation while aggressively clearing and suctioning the obscuring material. The chin lift maneuver is contraindicated in any patient with potential cervical spinal trauma. Rapid-sequence intubation (RSI) with in-line C-spine stabilization is the preferred method of securing an airway in any patient without contraindications. Avoid using paralytics if the patient's facial trauma might preclude successful bag-valve-mask ventilation. Intubation with sedatives alone is an alternative. Fiberoptic and videolaryngoscopic intubations are difficult in maxillofacial trauma patients secondary to poor visualization resulting from blood, secretions, and vomitus in the airway. LMA should only be considered as a bridging device when immediate ventilation is needed and only used until a definitive airway can be established. Surgical airways and direct laryngoscopy are still the best options for definitive airway management. Nasogastric (NG) or orogastric tube placement if facial trauma is present, should be performed after intubation for gastric decompression.

Laryngeal Airway Injury

Hoarseness, dysphonia, edema, persistent pain below the hyoid bone or crepitance over the thyroid cartilage implies a laryngeal injury. Presence of these signs necessitates a definitive airway. Endotracheal intubation is not contraindicated but may be difficult in this situation secondary to disruption and displacement of normal anatomic structures. If direct laryngoscopy is impossible, a cricothyroidotomy with prompt revision to a tracheostomy is the preferred alternative.

Tracheal Airway Injury

Tension pneumothorax or persistent air leak from chest tube may indicate a tracheal or bronchial injury. A chest X-ray may demonstrate signs of an occult upper airway injury by demonstration of mediastinal air. Bronchoscopy may be necessary for definitive diagnosis. Endotracheal intubation is not contraindicated in injury to the trachea below the cricothyroid membrane and should be attempted. Preparations for a surgical airway should be ongoing simultaneously. Tracheotomy below the trauma is the preferred alternative and should be performed immediately after the initial attempt at endotracheal intubation fails. Endotracheal or tracheostomy tubes may also be placed during diagnostic bronchoscopy if necessary.

Intubation through a Traumatic Opening

Dashboard trauma to the neck in motor vehicle accidents and “clothes-line” injuries from motorcycle or skiing injuries can sever the soft tissue of the neck and the tracheal cartilage leaving a defect sufficient for intubation. Often this site is the laryngotracheal junction adjacent to the cricoid cartilage. Intubation of this defect is the preferred method of securing an airway in these patients, as endotracheal intubation will often result in the tube exiting the neck through the defect. A small-lumen (6.0 or smaller) ET tube can be inserted directly into the wound. If impossible, convert to tracheotomy.

Breathing

Treat Tension Pneumothorax and Pneumothorax

See Chapter 24.

Maintain Oxygenation and Ventilation

After securing an airway, monitor gas exchange with periodic arterial blood gases. Patients with concomitant lung injury may require higher Fio2 and positive endexpiratory pressure (PEEP) to maintain oxygenation. Cervical cord transection resulting in paralysis of the diaphragm or intercostal muscles precludes a strong cough making it difficult to tolerate secretions. Aggressive suctioning may be necessary.

Circulation

Control Hemorrhage

Neck trauma with vascular injury may present with moderate to large hematomas, a pulsatile stable hematoma, pulse deficits, or a bruit. Look for any mediastinal changes on chest X-ray. Expanding hematomas can cause rapid airway compromise and necessitate intubation. Never remove impaled foreign bodies, as they may be preventing massive hemorrhage.

Pressure

Direct firm pressure is the mainstay of stopping bleeding on the face and neck. Circumferential neck dressings are contraindicated as they may act as a noose if edema or hematomas worsen and will inevitably increase intracranial pressure (ICP).

Pressure and Clamping

If direct pressure alone fails, clamping with hemostats or suturing with a “figure of eight” stitch can control arterial bleeds. Direct visualization of the artery must be achieved before this is attempted to avoid vagus or phrenic nerve injury. Never blindly clamp large amounts of tissue.

Foley Catheter Balloon Tamponade (FCBT)

If bleeding cannot be controlled with direct pressure then consider balloon tamponade. A foley catheter is inserted into the wound in the direction of active bleeding. Inflate the balloon with saline until bleeding stops or resistance develops. Gently pull back on the foley providing traction and compression. The need for FCBT does not imply a definitive vascular injury. If no vascular injury is detected in angiography then balloon catheter can be removed after 48–72 hours in the operating room.

Treat Shock

Hypotension (SBP < 90 mm Hg) and shock (cool, pale skin, abnormal mentation) may be due to blood loss (hypovolemic shock) or poor sympathetic tone below a spinal cord lesion (neurogenic/spinal shock). The etiology of shock in the vast majority of trauma patients is hypovolemia.

Hypovolemic Shock

See Chapter 11 for a more detailed discussion of shock. If hypovolemic shock is present, place two large-bore (16-gauge) intravenous catheters. If this fails, immediately place a triple-lumen central line with the largest internal diameter available. Obtain blood for a complete blood count, coagulation profile, electrolytes, renal function tests, and a type and crossmatch. Immediately infuse 2 L of isotonic crystalloid. If the systolic blood pressure remains below 90 mm Hg, infuse two units of un-crossmatched packed red blood cells (crossmatched if available). Continue administering blood products and crystalloid to improve hemodynamic stability while simultaneously arranging transfer of care to a trauma center.

Neurogenic Shock

Hypotension and bradycardia are hallmark signs of neurogenic shock due to spinal cord injury. Sympathetic interruption results in unopposed vagal tone. This must be differentiated from “spinal” shock which is a temporary loss of spinal reflex activity below the level of cord injury. Keeping the patient supine is often adequate to maintain adequate blood pressure, as little sympathetic tone is required. However, in the patient with persistent hypotension, infuse crystalloids to maintain a mean arterial pressure above 70 torr. Vasopressors should be used when hypotension inadequately responds to volume resuscitation. Phenylephrine is the therapy of choice. Atropine can be used for severe bradycardia.

Disability

Suspect Spinal Cord Injury

Patients with blunt head trauma or multiple injuries from blunt or penetrating trauma should be assumed to have vertebral column injuries until proven otherwise. Complete immobilization in a cervical collar and on a spine board should be maintained until radiographically and/or clinically cleared. If neurological deficits are present, although controversial, some clinicians will consider starting methylprednisolone within 8 hours of injury. A 30 mg/kg bolus followed by 5.4 mg/kg/h infusion over next 23 hours.

Neck Trauma

Type of Trauma

Penetrating Neck Trauma

Penetrating neck trauma management will vary depending on the anatomical zone. Please see Figure 23–1.

Knife Wounds

Stab wounds to the neck can injure a variety of vital structures and require extensive diagnostic tests and/or surgical exploration depending on the location of the injury and associated symptoms. Leave any impaled objects in place as they may be providing local tamponade. If not present, determine the character of the weapon, its length, and the direction of entry to help assess the depth and extent of injury. Avoid nasogastric or orogastric tube placement as this may rupture contained pharyngeal hematomas.

Bullet Wounds

High velocity missiles follow direct trajectory pathways. These bullet wounds can generate blast effect and secondary injury from bullet and bone fragmentation. Low velocity missiles are unpredictable and the path of trajectory does not appear to coincide with entrance or exit wounds. All structures in the neck must be evaluated including the airway, esophagus, vessels, and nerves. Surgical exploration is often necessary as well, depending on location.

Blunt Neck Trauma

Blunt trauma is most often associated with tracheal, laryngeal, or C-spine trauma due to the ability of each to fracture. Softer structures such as vessels and the esophagus are rarely injured. If injury occurs, it may manifest as hematomas and hematemesis, due to shearing of vessels. Occasionally, blunt carotid or vertebral injury can result in symptoms typically associated with cerebrovascular accidents and have a high associated mortality. Pneumomediastinum can indicate esophageal or airway injury. See Figure 23–2.

Location of the Injury

The location of a neck injury is critical to its treatment. Any injury penetrating the platysma should be described as in zone I, II, or III (Figure 23–3) and explored by a surgeon, not in the ED. The inferior border of zone I is the suprasternal notch and clavicles and the superior border is the inferior portion of the cricoid cartilage. Zone II extends from the inferior border of cricoid cartilage to the angle of the mandible. Classically, all zone II neck injuries penetrating the platysma warranted surgical exploration. With the combination of conventional angiography, CT angiography, CT scan, 2D Doppler, and esophagoscopy, exploration is now more selective. Zone III extends from the angle of the mandible to the base of the skull. Zone I and III injuries are not surgically explored. They present the problem of proximal and distal control of bleeding, respectively.

Airway Injury

Injuries perforating the airway may manifest with air leak, subcutaneous pneumomediastinum or pneumothorax with persistent air leak despite chest tube placement. Other injuries including laryngeal fracture or tracheal contusion can present with stridor, hoarseness, painful phonation, hemoptysis, or hemothorax. Always monitor the patient's airway. Bronchoscopy should be performed in any suspected airway injury. A high level of suspicion followed by bronchoscopy will identify the occult injury. Evaluate the C-spine with plain radiographs or CT scan when injury is suspected.

Esophageal Injury

Esophageal injury manifests as hematemesis, dysphagia, odynophagia, soft tissue crepitus, saliva leak from wound, blood in nasogastric tube, prevertebral air on lateral C-spine, or pneumomediastinum on chest X-ray. Esophagogram with water-soluble contrast may reveal the injury but esophagoscopy is often necessary if symptoms persist despite a negative study.

Vascular Injury

While external bleeding is obvious, vascular injuries may be more insidious. An expanding hematoma may compress the trachea causing dyspnea. Palpate for a pulse deficit, bruit or thrill. Doppler ultrasound may be used as a screening test in low risk patients. Penetrating vascular injuries must be classified into zone I, II, or III. Zones I and III usually require angiography. The use of CT angiography is becoming more prevalent secondary to availability and being able to provide clinician with visualization of adjacent anatomic structures. However, conventional angiography remains the gold standard for identification of vascular injury. A trauma or cardiothoracic vascular surgeon should be involved immediately in suspected vascular injury as decompensation may occur rapidly.

Nerve Injury

Test all nerves in the neck at risk for injury.

Vagus, Recurrent Laryngeal

Voice abnormalities, vocal cord asymmetry, hoarseness.

Spinal Accessory

Sternocleidomastoid and trapezius weakness, inability to shrug shoulder of affected side and rotate chin against resistance to the opposite side.

Hypoglossal

Deviation of the protruded tongue to the side of the injury.

Phrenic

Use of respiratory accessory muscles, asymmetry of the diaphragm on chest X-ray.

Disposition

All penetrating neck trauma deep to the platysma should have immediate surgical consultation and admission to the hospital. Blunt neck trauma with no symptoms of airway, esophageal, vascular, or nervous injury can be discharged safely. Always evaluate the C-spine and chest adequately in any neck injury.

Maxillofacial Trauma

Type of Injury

Blunt trauma is the most common form of injury to the face followed by soft tissue lacerations and high velocity missile injuries. CNS involvement is common in missile injuries to the face and should take priority after the patient's airway, breathing and circulation are assessed.

Airway Injury

Mandibular fractures and traumatic facial injuries are often associated with difficult airways. If simple removal of debris and jaw-thrust maneuver fail, secure an airway with endotracheal intubation, cricothyroidotomy, or tracheostomy, in that order of preference. Avoid NG tubes if maxillary trauma exists.

Vascular Injury

Direct pressure is typically sufficient to stop any facial bleeding but pharyngeal packing may be necessary in some cases. Secure an airway before packing the mouth and pharynx. Avoid clamping facial arteries, as they are adjacent to important and difficult-to-visualize nerves.

Nerve Injury

Test all nerves of the face at risk for injury. Early diagnosis of nerve injury is crucial, as edema and pain may obscure examination as time passes.

Facial Nerve

Temporal Branch

Frontalis muscle: inability to wrinkle the forehead.

Zygomatic Branch

Orbicularis oculi: inability to shut eyes tightly.

Buccal Branch

All smiling muscles: inability to smile widely, wrinkle nose, or elevate the upper lip.

Marginal Mandibular Branch

Lower lip depressors: inability to pucker or hold cheeks full of air.

Trigeminal Nerve

Sensory deficit to any part of the entire face or upper neck.

Auditory Nerve

Sensorineural hearing loss.

Lingual

Sensory loss to the anterior 2/3 of the tongue.

Hypoglossal

Deviation of the protruded tongue to the injured side.

Parotid Gland Injury

Evaluation of the parotid gland is essential if there is any chance of injury. Laceration of Stensen's duct results in a difficult-to-repair salivary fistula if left untreated. Probe the duct with a lacrimal probe entering through the buccal opening. If the probe exits through the laceration, surgical repair is necessary. See Figure 23–4 as it demonstrates the area of high probability for Stensen's duct as well as facial nerve injury. Consultation with a maxillofacial surgeon for any suspected parotid injury is recommended.

Mouth Injuries

The presence of malocclusion suggests a mandible fracture. Inspect and palpate the hard palate, in order to identify any bony irregularity or instability which may be present in maxillary fractures. Check for crepitus upon moving the teeth and for loose or missing teeth, which can be an airway hazard if aspirated. Closely inspect the soft tissues including the lips, tongue, gingiva, buccal mucosa, floor of the mouth, and posterior pharynx for injury.

Eye Injury

An irregular pupil or hyphema on gross examination may indicate a ruptured globe. Fundoscopic exam will reveal a difficult-to-visualize optic nerve and posterior pole. Slit lamp exam may demonstrate a shallow anterior chamber. If a ruptured globe is suspected, apply a rigid shield, administer prophylactic antibiotics, and consult an ophthalmologist. Diplopia, enophthalmos, or subcutaneous emphysema may indicate an orbital blowout fracture. Bilateral periorbital ecchymoses (“raccoon eyes”) are a sign of a basilar skull or ethmoid fracture. Diagnose all of these fractures definitively with a facial CT scan. Evert the lids, removing any foreign bodies, and stain the eye with fluorescein to reveal corneal abrasions. All ocular trauma patients should receive a slit lamp exam if possible.

Nasal Injury

Look into the nares and remove any blood clots or debris that may obscure a clear view. Assess for possible septal hematoma as this requires emergent drainage if present. Palpate the nasal bone for crepitus. Epistaxis is common with nasal injuries and may obscure full examination. Control any active epistaxis with nasal packing. Watch for aspiration of blood from the posterior nasopharynx if the bleeding is significant. Search for CSF rhinorrhea, which would necessitate a CT of the brain and neurosurgical consultation. There is no reliable way to distinguish CSF from thin nasal mucous in the ED.

Ear Injury

Blunt ear trauma often creates occult injury. Inspect the tympanic membrane (TM) for rupture and the canal for lacerations. Hemotympanum, blood in the external canal, CSF otorrhea, posterior auricular hematoma (Battle's sign), facial nerve palsies, and sensorineural hearing loss can indicate a temporal bone fracture. Inspect the external ear. Subperichondrial hematomas are usually obvious and must be drained to prevent “cauliflower ear.” Close any auricle lacerations making sure to determine if cartilage is involved. If the cartilage is in need of repair, do not put a suture directly through the auricular cartilage. Sutures should be gently placed in the perichondrium in order to approximate underlying cartilage. Once repair is done, apply Vaseline gauze or saline soaked cotton balls that conform to the ear's anatomy. Place gauze behind ear for posterior support. Cover packed anterior ear with bulky fluffed gauze. Wrap the head in a firm, conforming dressing to prevent further hematoma formation and to secure dressing in place.

Disposition

(See each specific condition in this chapter for details.) Open fractures and virtually any significant injury to the eye, ear, or salivary gland should be hospitalized and treated by the appropriate specialty. Uncomplicated fractures, simple lacerations, and contusions can be safely discharged with appropriate follow-up.

Essentials of Diagnosis

• Note any obvious jaw swelling or asymmetry
• Have the patient bite down and ask, “Do your teeth feel normal and line up correctly? Do you have any pain in your jaw or ears?”

Facial Fractures

Mandible Fractures

General Considerations

The mandible is a U-shaped bone with left and right components fused together at the symphysis in the anterior midline. It is fractured more frequently than any other bone on the face except the nasal bone. The mandible is divided into five anatomic regions which are used to describe the location of any fractures or other abnormalities. These regions include the body, angle, ramus, parasympheseal, coronoid, and condyle. The mandibular condyle forms the mandibular portion of the temporomandibular joint. As always, when managing a known or suspected mandible fracture, evaluation of the airway is paramount. Trauma to the face can cause airway obstruction through soft tissue swelling or anatomic distortion from severely displaced fractures or concomitant craniofacial injury. Because of the force required to fracture the mandible, other injuries must be ruled out, specifically C-spine injuries, other facial fractures, and traumatic brain injury.

Clinical Findings

Mandible fractures almost always present with pain in at least one area of the jaw. In addition to pain as a presenting symptom, malocclusion (the subjective sensation by the patient that the maxillary teeth and mandibular teeth do not align correctly when the mouth is closed) is a very common complaint. This is especially true in displaced fractures of the mandible. Other symptoms include trismus, mucosal lacerations, and dysphagia.

When concern exists for a mandible fracture, the physical exam must include close inspection of the mouth and auditory canals. Mandible fractures can disrupt the gingival and dislodge teeth intraorally creating a grossly open fracture that requires more aggressive treatment. In cases of posterior dislocation of the temporomandibular joint, the anterior wall of the auditory canal can be disrupted, creating an open dislocation.

Imaging

Panorex and computed tomography of the face are the two principal methods of imaging the mandible when concern for fracture exists. Panorex exposes the patient to less radiation but is less sensitive in detecting mandible fractures. Panorex does not adequately image other facial bones. CT of the face increases radiation exposure to the patient but is a more sensitive exam. CT of the face also has the added benefit of enabling visualization of other facial bones in addition to the mandible. If there is a low pretest probability of mandible fracture and no need to image the other bones of the face, a Panorex may be used to limit radiation exposure. However, if cases of high pretest probability based on clinical exam and mechanism, or if other bones of the face need to be imaged, a CT scan should be utilized for radiologic diagnosis. When the patient is in a cervical collar then a CT scan should be used in order to maintain C-spine precautions prior to clearance.

Treatment

Tetanus Prophylaxis

In open mandible fractures, administer tetanus toxoid to patients without immunization in the last 5 years.

Antimicrobial Prophylaxis

As in oral infections, the chosen antibiotic should cover both oral aerobes and anaerobes. Penicillin 2–4 million units IV, clindamycin 600–900 mg IV, or erythromycin 500–1000 mg IV is preferred, in that order.

Relocate the Jaw

If a TMJ dislocation is present, place the thumbs on the inferior molars and relocate with firm downward and backward pressure (Figure 23–5).

Immobilize the Jaw

Patients in considerable pain may find relief if a Barton bandage is used. A Barton bandage is created by wrapping an elastic bandage around the top of the head and below the mandible. This immobilizes the mandible and serves a similar purpose as a splint.

Disposition

Open fractures, complex fractures associated with dislocation, grossly displaced fractures, or any injury with potential for airway compromise should be seen by a maxillofacial surgeon as these injuries commonly require surgical fixation. Ideally, all patients with mandibular fractures should be treated definitively in the ED, but it is widely accepted to discharge uncomplicated fractures without concomitant injury. Provide appropriate antibiotics and analgesics and arrange follow-up within the next few days. The patient should keep the jaw fully immobilized.

Maxillary (Le Fort) Fractures

Essentials of Diagnosis

• Note any midface mobility, swelling, ecchymosis, or asymmetric deformity.
• Consider other injuries, as Le Fort fractures result from high-energy injury

General Considerations

The Le Fort classification system of maxillary injuries was designed to describe common patterns of maxillary fractures resulting from blunt trauma. It is not all-inclusive, and combinations of different patterns may often be seen in the same patient. Its utility lies in the ease of description to consultants and help in recognizing the need for diagnostic tests. Le Fort fractures exist only after high-energy injury; therefore, intracranial and C-spine injury should be expected in any case. Always consider the airway first.

Clinical Findings

When a Le Fort fracture is present, facial trauma is obvious in most cases because of significant swelling, ecchymosis, and possible deformity. Grasping the hard palate and rocking the maxilla may reveal midface instability, but this is present only in bilateral maxillary fractures. The patient may sense malocclusion and will certainly have localized maxillary tenderness. Diplopia from orbital involvement, facial emphysema from extension into the sinuses, and cerebrospinal fluid rhinorrhea from extension into the calvarium may also be present.

Imaging

Facial CT scan is the test of choice to identify maxillary fractures and determine their classification. Le Fort fractures are divided into three major types (Figure 23–6). Plain radiographs play no role in diagnosis because of their lack of sensitivity.

Le Fort I Fracture

(See Figure 23–6A.) Le Fort I fractures include the maxilla parallel to the alveolar process and hard palate extending posteriorly behind the maxillary molars and across the lateral wall of the maxillary sinus. Essentially, this fracture separates the maxillary teeth from the face.

Airway complications are rare in Le Fort I injuries. Malocclusion and local tenderness, swelling, and ecchymosis occur. With stress, the hard palate and upper teeth move. After identifying the fracture with a facial CT scan and ruling out concomitant injury, no specific ED management is necessary. Consultation with a maxillofacial trauma surgeon should occur within the ED. The patient can then be safely discharged with appropriate analgesia.

Le Fort II Fracture

(See Figure 23–6B). Le Fort II fractures include the fracture lines of a Le Fort I fracture but now involve the bony nasal skeleton becoming a pyramidal fracture.

Once again, airway complications are rare. Malocclusion again exists along with ecchymosis of the nasal dorsum and lower eyelids. The infraorbital nerve canal is involved and injury to this nerve causes a sensory deficit below the involved lower eyelid. Stress moves the hard palate, teeth, and nose, but not the eyes. CT scan of the face is the imaging modality used to identify the fracture, and maxillofacial consultation in the ED should be used to determine the disposition of the patient. In the absence of concomitant injury, a patient may be discharged with analgesics unless surgical repair is eminent.

Le Fort III Fracture

(See Figure 23–6C). Le Fort III fractures define craniofacial disjunction. The fracture extends through the frontozygomatic suture lines, across the orbit and through the base of the nose and ethmoid region. The zygoma may become completely separated in some patients.

Airway complications are common with Le Fort III fractures resulting from massive edema and hematomas that can dissect into the palate, pharyngeal walls, or tonsilar pillars. Address the airway first. Nasotracheal intubation and NG tubes are contraindicated. If possible, the patient's visual acuity should be tested due to the high incidence of blindness with Le Fort III fractures. Head CT as well as C-spine imaging should accompany facial CT in all patients with this injury. A maxillofacial surgeon should determine final disposition.

Zygomaticomaxillary Complex Fracture

Essentials of Diagnosis

• Lower eyelid swelling and ecchymosis
• Flattened “cheekbone”
• Diplopia with upward gaze
• Trismus

General Considerations

Zygomaticomaxillary (ZMC) fractures are the second most common facial fracture. They consist of three fracture lines including the infraorbital rim, the zygomatic–frontal suture, and the zygomatic–temporal junction at the arch (Figure 23–7). The three fracture lines give the fracture its more common name, a tripod fracture. However, this is a quadripod structure as there is a relationship to the base of the skull as well. The ZMC fracture results from a medially directed blunt force on the cheekbone. The orbital floor is disrupted and entrapment of the inferior oblique can result, but it is not a blowout fracture and does not have the same complications. Tripod fractures do not require the high energy that Le Fort or frontal sinus fractures require so concomitant injury is less common but should not be overlooked.

Clinical Findings

Most common symptoms include pain, swelling, and ecchymosis of the cheek, which may obscure the classic finding of a flattened “cheekbone.” Palpable periorbital stepoffs are often present. Look for trismus and subcutaneous emphysema. Epistaxis may be present. Involvement of the infraorbital nerve as it exits its foramen may result in paresthesias of the lower eyelid, adjacent cheek, nose, and upper lip. Diplopia may result from extraocular muscle contusion, entrapment or from an orbital hematoma or “sagging” of the eyeball into the disrupted orbital floor. Upward gaze diplopia is most common. Investigate for a retrobulbar hematoma or a ruptured globe, which require immediate ophthalmologic intervention. Extraocular muscle entrapment or herniation of orbital contents into the fracture is less common than in blowout fractures. Fracture extension into the paranasal sinuses is exhibited by subcutaneous emphysema.

Imaging

Plain films are not necessary. All tripod fractures should be evaluated with a facial CT scan. Three-dimensional reconstruction reveals any displacement of the fracture and guides surgical repair (Figure 23–8). Always image the C-spine if any tenderness is present.

Treatment

When ZMC fractures are diagnosed an ophthomalogic consultation should be obtained. Provide adequate analgesics and antibiotic prophylaxis if there is extension into the sinuses (penicillin, amoxicillin, fluoroquinolones, doxycycline, or clindamycin). If epistaxis is present, control the bleeding with packing or cautery.

Disposition

A maxillofacial surgeon should evaluate all ZMC fractures in the ED. Serious consideration should be given to consulting an ophthalmologist in-house as well, despite an absence of immediate ocular findings. Isolated ZMC fractures can be treated conservatively with close follow-up, adequate analgesics, and soft diet unless immediate surgical repair is planned.

Orbital Floor (“Blowout”) Fracture

Essentials of Diagnosis

• Presence of enophthalmos
• Diplopia with upward gaze
• Decreased eye movement

General Considerations

If viewed in sagittal cross-section the orbit takes on the appearance of a cone with the base anterior and the apex posterior. The orbital walls are formed by relatively thin-walled and weak bones while the rim is formed by much thicker and stronger bone. When an external force is applied to the globe, intraorbital pressure increases to the point that one or more of the thin-walled bones of the orbit “blow-out” or fracture. Interestingly, the release of pressure after an orbital blowout oftentimes prevents significant ocular trauma (Figure 23–9). The most common bone fractured is the maxillary bone which comprises the floor of the orbit. The orbital contents can be significantly displaced inferiorly after orbital blowout fracture.

Clinical Findings

Essentially all patients with an orbital blowout fracture will present with pain, and the vast majority will present with periorbital ecchymosis. A majority of patients will present with diplopia on upward gaze due to entrapment of the inferior rectus muscle. A significant proportion of patients with orbital blowout fracture will also have ipsilateral anesthesia in the V2 distribution secondary to infraorbital nerve entrapment. The most concerning clinical finding is enophthalmos as this indicates significant inferior displacement of the orbital contents through the floor. Ocular trauma frequently occurs, and a thorough examination including slit-lamp and dilated exam should be completed to investigate for lens dislocation, corneal abrasion, globe rupture, commotio retinae, or retinal detachment. If the periorbital emphysema is severe, measure the intraocular pressure and emergently consult an ophthalmologist for possible cantholysis.

Imaging

CT scan of the face is the study of choice for diagnosis and management of orbital blowout fractures. CT is highly sensitive and specific in terms of diagnosis and also provides the consulting surgeon valuable information if surgical intervention is deemed necessary. Historically, radiographs of the orbits were used, but their sensitivity is unacceptably low to rely on them for diagnostic purposes.

Treatment

Initial treatment in the emergency department includes appropriate tetanus prophylaxis and pain control as well as avoiding any valsalva maneuvers. Prophylactic anti-emetics may be appropriate. Give instructions to the patient to not blow their nose. Long-term treatment may be managed either nonoperatively or operatively depending on the presence of enophthalmos and extraocular muscle entrapment. If surgical management is planned, it is typically delayed 7–10 days after the initial trauma.

Disposition

Emergent surgical intervention is rarely indicated. All orbital blowout fractures with significant entrapment or enophthalmos should be seen by a maxillofacial surgeon as well as an ophthalmologist for detailed ocular exam. If there is no entrapment or enophthalmos then discharge with close outpatient follow up is appropriate.

Nasal Fractures

Essentials of Diagnosis

• Control any epistaxis
• Identify displacement
• Discover and drain any septal hematomas

General Considerations

The nasal bone is the most frequently fractured bone of the face, accounting for approximately 40% of all facial fractures. The nose is composed by cartilage distally, the frontal bones superiorly, the maxillary bone laterally, and the nasal bone anteriorly. Nasal bone fractures most commonly occur with a blow to the face in the anterior–posterior direction but can also occur with a lateral blow. An adequate cosmetic result is the chief long-term concern for nasal bone fractures.

Clinical Findings

The patient will typically complain of pain in the nose, and most will have at least some epistaxis after the trauma. Patients may also complain of deformity of the nose. Referring to a photograph of the patient's face prior to the injury will assist the physician in determining the significance of any deformity. Nasal bone fractures frequently occur in conjunction with other facial fractures. If the patient has tenderness or significant ecchymosis of other areas of the face then investigations into other fractures must also take place.

Imaging

No imaging is necessary for simple nasal fractures as it is typically a clinical diagnosis. If a concomitant injury to the face is suspected then maxillofacial CT should be utilized.

Treatment

First, assess the patient's ability to breath and maintain an airway. After the airway has been addressed, next turn attention to the control of any epistaxis. Ideally, displaced fractures should be reduced immediately, however reduction prior to early fixation (3–5 days) is a reasonable alternative. An ED physician can reduce nasal fractures, but significantly displaced fractures should also be evaluated by a maxillofacial surgeon. Septal hematomas must be drained to avoid septal necrosis and disfigurement. Give the patient both oral analgesics and nasal decongestants prior to discharge.

Fracture Reduction

First provide analgesia. Narcotics combined with topical cocaine should be sufficient. Place cylindrical cotton or gauze soaked in cocaine solution in the patient's nose for 15 minutes. Laterally displaced fractures are reduced with simple lateral thumb pressure. Impacted fractures require both anterior and lateral manipulation with Kelly clamps or Asch septal forceps on the nasal septum (Figure 23–10). Failure to reduce requires immediate ENT consultation. Lacerations over the fracture site can be irrigated well and primarily closed. Complex lacerations involving intranasal structures, septum, or causing significant deformity should be repaired in the ED by a consultant. As the nose harbors Staphylococcus, provide antimicrobial prophylaxis (amoxicillin/clavulanate, sulfa, cephalexin, or erythromycin). Secure fracture reductions simply with tape over the nasal bridge.

Drain Hematomas

Septal hematomas should be drained prior to discharge from the emergency department because of the high incidence of septal necrosis which causes a saddle deformity. Incise the anterior nasal mucosa with a No. 11 blade at the inferior portion of the hematoma allowing it to drain. Packing the incision following drainage is recommended so that the incision will not close. Provide prophylaxis with the same antibiotics as above.

Disposition

All nasal bone fractures can be discharged safely with analgesics if no concomitant injury is present. Follow-up with an otolaryngologist is mandatory and should be done within 1 week.

Frontal Sinus Fractures

Essentials of Diagnosis

• High-energy mechanism, consider intracranial and C-spine injury
• Rare in children, unlikely in early teens

General Considerations

A tremendous amount of energy is required to cause frontal sinus fractures. Most frontal sinus fractures are encountered in the setting of motor vehicle accidents. Because of this, frontal sinus fractures are usually associated with another craniofacial injury or traumatic injury elsewhere. Anytime a frontal sinus fracture is encountered a thorough evaluation is warranted to search for a possible secondary injury. The frontal sinus has an anterior wall (called the anterior table) just deep to the soft tissues of the face and a posterior wall (called the posterior table) that sits adjacent to the brain. Fractures of the frontal sinus can be of the anterior table alone or a combined anterior and posterior table fracture.

Clinical Findings

Contusion, swelling, and ecchymosis will be present as well as possible lacerations of the forehead and crepitus over the sinus. CSF rhinorrhea is possible if a posterior table fracture exists as a dural tear may have occurred. A dural tear may present as postnasal drip as opposed to typical CSF rhinorrhea. Anesthesia of the forehead in the setting of a frontal sinus fracture indicates damage to the supraorbital nerve. Other facial fractures, depressed skull fractures, and orbital fractures will often be present as well.

Imaging

An axial and coronal CT scan of the face and head as well as C-spine imaging should be ordered on every patient. Historically, plain radiographs were utilized. However, plain radiographs have been replaced by CT as the diagnostic modality of choice because of its superior sensitivity and its ability to assist in operative planning for consulting surgeons.

Treatment

Elevate the patient's head to decrease venous pressure and ICP. Antibiotics are now controversial and should be discussed with the consultant. Urgently consult a maxillofacial surgeon and neurosurgeon (with posterior table involvement) for an ED evaluation. An ophthalmologist should also be consulted if significant involvement of the orbit exists. Surgical correction is indicated for CSF rhinorrhea, open fractures, and significantly displaced fractures, posterior wall fractures. As in any trauma evaluation, maintain C-spine precautions at all times. If there are open fractures, cover the lacerations with gauze to prevent contamination.

Disposition

Patients with isolated nondisplaced frontal sinus fractures may be discharged after being evaluated by a specialist and after an adequate observation period has occurred. Displaced fractures are typically admitted for surgical fixation and close observation.

Temporal Bone Fractures

Essentials of Diagnosis

• Can include hearing loss, facial nerve injury, or intracranial injury
• External clinical signs can be absent

General Considerations

Most basilar skull fractures include fractures of the temporal bone. Because the temporal bone houses the cochlea, vestibule, facial nerve canal, jugular vein, and internal carotid artery, fractures can have serious sequelae. High-energy mechanisms are usually required and are usually associated with severe brain injury which limits clinical symptoms and signs expected from such injury. Clinical appearance, if present, includes partial or complete facial nerve palsies, conductive, sensorineural or mixed hearing loss, vertigo, dizziness, otorrhagia, CSF otorrhea, TM perforation, hemotympanum, and canal lacerations. Due to irregularity of fracture patterns, clinical features, treatment, and disposition depend on the evaluation of function more than type of fracture. Each type may be associated with intracranial bleeding, brain injury, and subsequent meningitis. Because of this, neurosurgical consultation as well as maxillofacial surgical consultation is a must.

Clinical Findings

Longitudinal Fractures

Longitudinal fractures account for 80% of all fractures of the temporal bone. They are so named because the fracture line parallels the bone's long axis. Mastoid ecchymosis (“Battle's” sign), periorbital ecchymosis (“raccoon eyes”), hemotympanum, and bleeding into ear canal from skin and TM laceration are often seen. The TM is often torn and a step-off may be seen in the external auditory canal. CSF otorrhea is common. The ossicles may be dislocated creating conductive hearing loss. The cochlea is spared; therefore, sensorineural hearing loss is absent. Facial nerve paralysis may be present but is usually delayed. This implies a better prognosis than that for immediate paralysis, which requires surgical exploration of the nerve canal and the nerve trunk.

Transverse Fractures

Although less common, transverse fractures cause more severe injury to the contents of the temporal bone. The fracture usually begins in the internal auditory canal and traverses the cochlea and facial nerve canal perpendicular to the long axis of the temporal bone. Often complete sensorineural hearing loss occurs along with severe vertigo and intense nystagmus or immediate facial nerve paralysis. Over 50% of patients will have facial nerve injury. Mastoid ecchymosis (“Battle's” sign), periorbital ecchymosis (“raccoon eyes”), and hemotympanum are often seen.

Imaging

CT scan of the face and head is the imaging study of choice to identify all three types of the temporal bone fractures as well as any intracranial pathology. Once again, always consider C-spine imaging.

Treatment and Disposition

Patients with temporal bone fractures frequently have multiple other injuries. This can lead to delay in diagnosis and treatment. Maintain C-spine precautions until associated injury can be excluded. Once a temporal bone fracture is diagnosed then it is important to assess status of external canal by checking for blood and CSF and to evaluate facial nerve. Do not lavage external auditory canal or insert packing due to risk of introducing infection to inner ear, brain, and meninges. Immediate maxillofacial or ENT surgical consultation is required. Neurosurgery consultation should be obtained for any associated intracranial injury. All patients with temporal bone fractures should be admitted to the hospital.

Dental Trauma

Tooth Avulsion

Tooth avulsion is complete displacement of tooth out of socket. This can result from any oral trauma and necessitates immediate action. Reimplantation success rates decrease by 1% every minute the tooth is out of the socket. The goal is to restore the tooth to its correct anatomical location in a quick and secure manner.

Rinse the tooth gently with saline. Administer local anesthesia or a regional intraoral nerve block. Replace the tooth in the socket and immediately consult a dentist or oral surgeon. If this is impossible, place the tooth in a transportation media such as Viaspan, Hank's solution, cold milk, saliva (in the patient's mouth) or saline in that preferential order. Tooth avulsion with concomitant mandible fracture is an open fracture. Consider a chest X-ray to rule out aspiration of tooth fragments.

Tooth Subluxation

Tooth subluxation is loosening of the tooth secondary to trauma. It should be treated with gentle manipulation of the tooth into its proper position. Consult a dentist or oral surgeon during the ED visit for possible splinting. Children tend to subluxate rather than fracture their primary teeth.

Tooth Fracture

Rule out any fragment aspiration with a chest X-ray. Tooth fractures are best classified and treated using the Ellis classification. Ellis I fractures involve the enamel only. They require only smoothing of the rough edges and dental follow-up. Ellis II fractures involve the enamel and yellow dentin may be visible. These teeth are sensitive to air exposure and tender to touch. The exposed area should be covered with Calcium Hydroxide paste, glass ionomer or a strip of adhesive barrier (eg, Stomahesive). Dermabond is acceptable if no other material is available. A 24-hour dental follow-up is adequate. Ellis III fractures involve the enamel, dentin, and pulp and require immediate dental consultation. Cover the exposed area with Calcium Hydroxide paste or glass ionomer. Patients should be put on antibiotics that cover oral flora such as Clindamycin. Local anesthesia or nerve blocks should be considered. Avoid topical anesthetics. Panorex may be necessary to rule out alveolar ridge fractures.

External Ear Trauma

Auricular Hematoma

Clinical Findings

Blunt trauma to the ear often results in bleeding between the perichondrium and auricular cartilage. This injury is common in wrestlers and boxers. If left untreated, cauliflower ear deformity will result from proliferative scarring in the hematoma site.

Treatment

Administer local anesthesia or perform an auricular block. Treatment consists of needle aspiration or incision and drainage of any subperichondrial blood. Make a 1 cm incision along the natural skin folds and then evacuate the hematoma with gentle manual expression through the opening. Cover the wound with antibiotic ointment. Suture dental pledget bolsters to either side of the auricle or apply Vaseline gauze or saline soaked cotton balls that conform to the ear's anatomy. Place gauze behind ear for posterior support. Cover packed anterior ear with bulky fluffed gauze. Wrap the head in a firm, conforming dressing to prevent further hematoma formation and to secure dressing in place.

Disposition

Hospitalization is not required. Antibiotics for skin flora should be prescribed. A maxillofacial surgeon should see the patient within 24 hours to be examined for reoccurrence.

Lacerations of the Auricle

Treatment

Meticulous repair of auricle lacerations is required to prevent deformity. Regional nerve blocks are preferred as local infiltration can distort anatomical landmarks. Medical literature now supports the use of epinephrine when anesthetizing the ear. Closure of the perichondrium is achieved with 6.0 synthetic absorbable suture. Sutures should not go through the cartilage but only through the perichondrium to approximate cartilage. The overlying skin should be closed with 6.0 nylon or skin tape. Cover with antibiotic ointment and a petroleum gauze dressing under light pressure. Reserve antibiotic prophylaxis for the immunocompromised, bite injuries, or contaminated wounds.

Disposition

Simple lacerations can be closed in the ED and referred to a facial surgeon in 1–2 days. Complex lacerations with extensive cartilage injury or tissue loss should be closed by a maxillofacial surgeon either in the ED or in the operating room.

Middle and Inner Ear Disorders Following Head Trauma

Cerebrospinal Fluid Otorrhea

Clinical Findings

Cerebrospinal fluid otorrhea and rhinorrhea often results from minimal head injuries. A CSF leak is indicative of a communication between the subarachnoid space and the nasal cavity or paranasal space. Eighty per cent of post-traumatic leaks occur in first 48 hours post-trauma. Patients complain of a salty or sweet taste. Clear drainage is exacerbated by valsalva maneuver. Halo sign may be present on tissue paper or bed linens. The risk of meningitis is high. A CT scan with axial and coronal views will help diagnose the injury and any concomitant intracranial bleeding or brain injury.

Treatment and Disposition

Testing of fluid for the β-2 transferrin is highly sensitive and specific for CSF. Hospitalization and urgent neurosurgical consultation are indicated for all patients with CSF leakage. The use of prophylactic antibiotics is controversial.

Facial Nerve Paralysis

Clinical Findings

Basilar skull fractures, direct facial injury, penetrating trauma to middle ear, barotrauma (altitude paralysis or scuba diving), and lightening injuries are all causes of traumatic facial nerve paralysis. Paralysis may be partial or complete depending on the location of the injury. Varying patterns of motor and sensory loss can occur. Examine the face for lost or decreased movement, decreased tear production, or altered sensation on the affected side of the face. CT and MRI are useful diagnostic studies. Consult a maxillofacial surgeon if any signs are present.

Treatment and Disposition

Patients with facial nerve paralysis should be hospitalized and evaluated immediately by a maxillofacial surgeon.

Conductive Hearing Loss

Clinical Findings

The ear is the most frequently damaged sense organ secondary to trauma. TM perforation, hemotympanum and ossicular chain disruptions can cause traumatic conductive hearing loss. Patients with disarticulation of ossicular chain complain of acute hearing loss. A step-off at 12 o'clock at the medial end of the ear canal is evidence of a temporal bone fracture and suggestive of ossicular dislocation. Bone conduction will be greater than air conduction in such injuries. Audiometric testing can determine whether sensorineural hearing loss is present.

Treatment and Disposition

Hospitalization is not necessary. An otolaryngologist should see patients within a few days for evaluation. The majority of patients with all forms of traumatic conductive hearing loss can be managed conservatively.

Sensorineural Hearing Loss

Clinical Findings

Trauma can cause both temporary (inner ear concussion) or permanent hearing loss. Acoustic trauma from gunshots, fireworks, explosions, barotraumas, traumatic TM rupture, and temporal bone fractures can all cause sensorineural hearling loss. Temporal bone fractures that traverse the cochlea may result in total permanent loss of hearing and severe vertigo for the first few days following injury.

Treatment and Disposition

Control vertigo with diazepam at liberal doses. All patients should be hospitalized for urgent ENT evaluation.

Vertigo

Clinical Findings

Post-traumatic vertigo refers to dizziness after a head or neck injury. Benign positional vertigo (BPV) is common after a head injury. Patient may also develop post-traumatic Meniere's, labyrinthine “concussion,” or cervical vertigo secondary to neck injury or temporal bone fracture. Occasionally, the vertigo is severe and persistent creating difficulty with walking. Nystagmus may be present as well.

Treatment and Disposition

Treatment is individualized to the diagnosis. Treatment includes a combination of medications, lifestyle changes, and physical therapy. Occasionally surgery is needed. Severe vertigo can be treated with diazepam, 2–5 mg orally 2–4 times a day or meclizine at 25 mg 3–4 times a day. Hospitalization is not necessary. Refer the patient to an otolaryngologist for routine follow-up and possible additional testing.

Care of Facial Lacerations

See also Chapter 30.

Closure of Lacerations

Most patients are particularly concerned about scarring of the face after sustaining an open injury. Thus, primary closure, which usually results in the least noticeable scar is the preferred method of treatment for most facial lacerations. Facial laceration repair requires attention to detail and precise wound edge approximation with fine suture material to restore anatomic structure lines. Do not hesitate to request assistance from the appropriate consultant (otolaryngologist, ophthalmologist, plastic surgeon, oral and maxillofacial surgeon) if extensive tissue damage is present or the damage is adjacent to structures requiring complex closure.

Injuries to the lips specifically are common and require precise repair. Clean all debris and clotted blood with a moist sponge. The vermillion border is more easily seen when wet. Place the first suture through the vermillion border to align the two edges. It is important to also align the wet–dry mucosal surfaces in addition to the vermillion border. Repair the rest of the wound once these approximations have been made.

Replacement of Avulsed Tissue

Debridement of skin edges should be done with caution. Because of excellent blood supply to the face, tissue that appears ischemic will often revascularize. Small avulsed pieces of ear, nose, or facial soft tissue may be cleaned and replaced with a reasonable chance for survival. Larger pieces, such as subtotal avulsion of the ear or scalp, should be replaced by a surgeon using microvascular techniques. Attempts to retrieve any avulsed tissue from the scene of injury should be made.

Delay in Closing Lacerations

In general, lacerations of the eyelids, lateral orbit, nasal dorsum, and mandible should not be closed until X-rays have been taken. The lacerations may need to remain for reduction and fixation of the fracture fragments through this opening.

Because of the abundant blood supply to the area, it is acceptable to close facial lacerations that have been open for as long as 24 hours as long as the wounds are cleaned thoroughly. When delayed closure is necessary, the wound should be packed open with saline-soaked gauze until the repair can be completed. Antibiotics (cephalexin, dicloxacillin, erythromycin) should be considered in these cases.

Repair Technique

Once more extensive injuries have been excluded (ie, facial nerve or parotid duct transections), local anesthetic is infused into the wound edges or a regional block is employed. Regional blocks may be preferred, as they will not distort the wound edges. A mental nerve block is best for the lower lip and skin below the lip, an infraorbital nerve block for upper lip, lateral nose, lower eyelid and medial cheek and a supraorbital/supratrochlear nerve block for forehead lacerations. Once the wound is anesthetized, irrigation, selective debridement, and wound exploration should ensue. The extent of injury, number of layers involved, and experience with repair of facial wounds will dictate the choice of suture. Sutures of 6.0 synthetic nonabsorbable monofilament are a good choice for skin closure (nylon, polypropylene, polybutester) due to their high tensile strength and minimal inflammatory response. Synthetic absorbable suture may be used to close subcutaneous structures or mucosal lacerations. These sutures have good tensile strength and minimal inflammatory response in comparison to natural products.

An important aspect of plastic closure of such lacerations is the placement of sutures. Sutures on the face should be placed 3 mm apart and 1–2 mm from skin edge in order to achieve better cosmetic results. The angle of entry of the needle into skin should be at 90°.

Irregular lacerations, lacerations at risk for infection or lacerations in areas of significant swelling should be closed in an interrupted fashion. For linear lacerations, a running suture is acceptable. Small linear lacerations under very little tension may be closed with cyanoacrylate tissue adhesive as an alternative to sutures. Avoid mucous membranes and the eyes during the application. Do not use skin adhesives where hair is present.

Wounds should be kept clean and dry for 48 hours after suture placement. Q-tips with mild soap and water can be used to clean wounds after that time period. Peroxide and betadine should not be applied after wound repair. Patients should be informed that the overuse of topical antibiotic ointments can lessen tension of skin edges and may prevent appropriate closure. Facial skin sutures should be removed no later than 5 days after placement. An ophthalmologic suture scissor or a No. 11 blade is best for removing these fine sutures. After suture removal, the surface should be prepared with benzoin adhesive and skin tape applied (ie, Steri-Strips). This will eliminate any tension on the closure and minimize widening and hypertrophy of the scar. The patient should be told to protect the scar from sunlight for first 6 months and complete scar maturation will take 12 months. A scar revision can be performed at that time.