Maxillofacial Trauma

Combination of facial fractures and soft tissue damage that may be life-threatening due to:

Epidemiology and Risk Factors

Associated with:

  • Young
    Predominantly 15-25.
  • Male
  • Alcohol

Pathophysiology

Mandibular fractures:

  • Commonly occur at structurally vulnerable sites, independent of point of impact
    • Condyles
      May limit mouth opening, even after muscle relaxation.
    • Symphysis
      Point of midline fusion.
    • Angle
  • Multiple fractures are common

Mid-face fractures:

The midface acts similarly to a crumple zone on a car and collapses progressively under impact. Multiple complex facial fractures are therefore the most common presentation.

  • Facial skeleton consists of several small compartments supported by three vertical buttresses
    • Compartments:
      • Orbits
      • Nasal cavities
      • Paranasal sinuses
    • Buttresses:
      • Nasomaxillary pillars
      • Zygomaticomaxillary pillars
      • Pterygomaxillary pillars
  • Fracture-dislocations occur as the facial skeleton collapses around these pillars
    Occurs in a predictable fashion, giving rise to the Le Fort classification:
    • Le Fort I
      Horizontal fracture of the maxilla at the plane of the nose.
      • Direct maxillary impact
    • Le Fort II
      Freely mobile pyramid of maxilla.
      • Most common fracture
      • Inferior or lateral mandibular impact with a closed mouth
    • Le fort III
      Separation of midface from the base of the skull.
      • Also known as craniofacial disjunction
      • May result in cribiform plate transection and CSF leak

Orbital fractures:

  • Inferior orbital wall fracture most common
    Direct pressure on globe is transmitted back to the orbit, with the weakest wall shattering.
  • May result in entrapment of globe or extra-ocular muscles
  • Loss of visual acuity
  • Abnormal eye movements

Aetiology

Facial injures are almost all related to blunt trauma; common causes include:

  • MVA
  • Assault
  • Falls
  • Sport
  • Industrial accidents

Clinical Manifestations

Evaluation should include:

  • Visible deformity
    • Asymmetry
    • Nasal septal deviation
  • Fracture stability
    • Palpation of midface for mobile segments
    • Dental malocclusion
  • Visual assessment
    • Visual acuity
    • Pupillary reflexes
    • Eye movements
  • Cranial nerve function
    • Facial nerve
  • Evidence of base of skull fracture
    • Enopthalmos
      Retraction of the eye due to blowout fracture. Upward gaze is usually impaired.
    • Bleeding
      • Haemotympanum
      • Battle’s sign
      • Raccoon eyes
  • Orbital bruit
    Suggests carotid-cavernous sinus fistulae.

Diagnostic Approach and DDx

Investigations

Bedside:

Laboratory:

Imaging:

Other:

Management

Airway management can be complex due to interplay of:

  • Trauma
    With effect of other injuries.
  • Oedema
  • Haemorrhage
    • Aspiration
    • Impaired topicalisation
    • Impaired

Resuscitation:

This details management of isolated midface injuries and implies reasonably normal laryngeal and tracheal anatomy.

Laryngotracheal trauma is rarer, and:

  • Evidenced by stridor or hoarseness with overlying neck abnormalities
  • Requires complex airway management strategies
  • Covered under Laryngotracheal Trauma
  • A
    • Basic interventions
      • Head-up position
        Patient may assume unusual positions that limit obstruction, this should be encouraged.
      • High flow oxygen
      • Regular suctioning
    • Advanced airway management
      Planning should include senior airway clinicians. Considerations include:
      • Bag-mask ventilation often difficult
        • Limited mask seal
        • Pain
      • Fibre-optic nasal intubation for mandibular condyle fracture with limited mouth opening, without base of skull fractures
      • Non-condylar mandibular fractures are mobile when pain is controlled
      • Awake oral fibre-optic intubation for:
        • Cervical spine injury
        • Mandibular condyle and base of skull fracture
      • Awake tracheostomy may be considered
  • C
    • Bleeding
      • Direct pressure
      • Aggressive packing to wounds and nasal cavities

Peculiar interventions that may assist airway patency include:

  • Tongue protraction
    Suture through anterior tongue allows tongue to be pulled forwards.
  • Midface protraction
    Anterior traction of the mobile midface may relieve obstruction but ↑↑ venous bleeding.

Specific therapy:

  • Pharmacological
    • Prophylactic antibiotics
      For CSF leak.
  • Procedural
    • Angioembolisation
      1st line for intractable bleeding.
    • Surgical haemorrhage control
    • Debridement and washout
      Within 24 hours.
    • Internal fixation
      Often delayed 4-10 days until swelling has resolved.
  • Physical

Supportive care:

Disposition:

Preventative:

Marginal and Ineffective Therapies

  • Steroids
    No role in optic nerve injuyr.

Anaesthetic Considerations

Complications

Facial fractures have several associated injuries:

  • A
    • Dental injury
  • C
    • Carotid-cavernous sinus fistula
  • D
    • Cervical spine injury
    • Intracranial injury
    • Orbital injury
      Vision loss or blindness in ~1%.
    • Base of skull fracture
      • CSF leak
        • Occurs in 10-30%.
        • May present with either:
          • Rhinorrhoea
          • Otorrhoea
      • Meningitis uncommon despite the prevalance of CSF leak

Bones that may result in dural tears and CSF leak include:

  • Frontal bone
  • Frontal sinus
  • Nasoethmoid complex
  • Fronto-orbital complex

Prognosis

Key Studies

References

  1. Bersten, A. D., & Handy, J. M. (2018). Oh’s Intensive Care Manual. Elsevier Gezondheidszorg.