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1. Dr. Srinivas Pennam Maxillo-facial Trauma

2. AETIOLOGY Road traffic accidents Sports injuries Personal accidents War accidents Assaults & fights Birth injuries

3. Nasal and Facial Trauma Nasal trauma is extremely Common From birth onwards nose is assaulted Up to 20 % babies are found have Squished noses Majority spring back, but about 1-2 % are left with a permanent deviations Early detection of septal abnormalities and correction with Gray’s struts prevents idiopathic deviated septum

4. Emergency room management Air way maintenance by intubation or tracheostomy Hemorrhage : By packing, pressure, or ligation of blood vessels Tetanus Associated major injuries to other regions like head, chest, spine, abdomen, neck, larynx, orbit Soft tissues of face Facial nerve Salivary glands

5. Bone injuries Divisions of the facial bone injuries Upper third – Above the level of supra orbital ridge Middle third – Between supra orbital ridge and upper teeth Lower third – Mandible and lower teeth

6. Structures involved Nasal bones and septum Naso orbital region Zygomatic arch Zygoma Orbital floor Maxilla Fractures of middle third of face

7. Fracture of Nasal Bones Very common injury due to prominent projection of nose on the face Direct blows or falls As a part of facio maxillary injuries Often associated injuries to septum like dislocation, fracture, buckling, haematoma formation

8. Type of Nasal Injury depends on Direction of Blow: Frontal/Lateral/ From Below Force of Blow Nasal Fractures divided into 3 Types ( Moore 1989) Class 1: Green Stick Injury Simple Depression of Nasal Bone Chevallet Fracture Class 2 : Jarjavay Fracture Class 3 : Naso - orbito -ethmoid Fracture

9. Depressed fracture Medium force – O pen book fracture where nasal septum collapses and nasal bones splay out Greater force – Nasal bones shattered, splaying of frontal processes of maxilla

10. Depressed fracture

11. Angulated fracture Medium force  I psilateral nasal bone fracture Greater force  B/L nasal bones and septum fracture and deviation of nasal bridge

12. Clinical features External nasal deformity Epistaxis Laceration of skin of nose Edema over nasal bridge (within few hours of injury ) Peri -orbital ecchymosis Nasal bone tenderness Nasal bone crepitus

13. Septal Fracture Horizontal with posterior fracture (Jarjavay) Vertical with anterior fracture (Chevallet) S and C shaped deformities with healing Telescoping of segments prevents closed reduction Fracture of Chevallet Fracture of Jarjavay

14. Septal Fracture

15. Nasal Fractures Clinical findings: Nasal deformity Edema and tenderness Epistaxis Crepitus and mobility

16. Clinical Features External deformity due to Fracture dislocation of fractured bone fragments Odema of soft tissue Skin over the nasal bridge discolored or lacerated Palpation over the bridge – Tenderness or crepitus

17. Clinical Features Nasal obstruction – Due to Blood clots, septal haematoma or septal deformity Peri orbital echymosis , sub conjunctival haematoma Associated facio maxillary or head injury Watery nasal discharge - suspect CSF leak

18. Clinical Features Bony injury will be obscured by the oedema which sets after 4 -6 hours Exact bony deformity can be assessed within 2 -4 hours of trauma (or) after 6-7 days when oedema subsides

19. Diagnosis Clinical examination X-ray of the nasal bones X-ray P.N.sinuses

20. X- Ray nasal bones showing fracture

21. Diagnosis X-ray or CT scan of brain if associated head injury suspected Haemoglobin to assess blood loss, Blood group & cross matching if Hb is low. Opthalmological examination

22. Treatment Fractures without displacement : no treatment Fractures with displacement : closed reduction Open reduction required rarely for Infection Comminuted fracture Failed closed reduction

23. Guidelines for treatment of nasal bone fractures Closed reduction done before edema appears (3hours) or after edema subsides (7 days) Nasal fracture heals by 2 wk in adults and 1 wk in children. Closed reduction is to be done before healing Healed deformities corrected by rhinoplasty or septo-rhinoplasty

24. Closed reduction Lift non-depressed nasal bone laterally with Walsham’s forceps Lift depressed nasal bone laterally with Walsham’s forceps Nasal septal fracture reduced by lifting it with Asch’s forceps Both nasal bones brought into midline by firm digital pressure from outside

25. Closed reduction

26. Closed reduction

27. Instruments used for reduction of fracture nasal bone

28. Left Walsham Forceps

29. Right Walsham Forceps

30. Asch Septum Forceps

31. Boies elevator Boies elevator is inserted into the nostril deep to displaced nasal bone Blade of elevator opposes thumb of surgeon placed outside the nose Raise & depress misaligned bones to their original configuration between the thumb & elevator

32. External splinting

33. Lead plate splinting for comminuted fractures

34. Rhinoplasty for healed deformity

35. Septal Fracture reduction

36. Frontal Sinus/ Bone Fractures Pathophysiology Results from a direct blow to the frontal bone with blunt object. Associated with: Intracranial injuries Injuries to the orbital roof Dural tears

37. Frontal Sinus/ Bone Fractures Clinical Findings Disruption or crepitance orbital rim Subcutaneous emphysema Associated with a laceration

38. Frontal Sinus/ Bone Fractures Diagnosis Radiographs: Facial views should include Waters, Caldwell and lateral projections. Caldwell view best evaluates the anterior wall fractures.

39. Frontal Sinus/ Bone Fractures Diagnosis CT Head with bone windows: Frontal sinus fractures. Orbital rim and nasoethmoidal fractures. R/O brain injuries or intracranial bleeds.

40. Frontal Sinus/ Bone Fractures Treatment Patients with depressed skull fractures or with posterior wall involvement. ENT & neurosurgery consultation. Admission. IV antibiotics. Patients with isolated anterior wall fractures, nondisplaced fractures can be treated outpatient after consultation with neurosurgery.

41. Frontal Sinus/ Bone Fractures Complications Associated with intracranial injuries: Orbital roof fractures. Dural tears. Mucopyocoele. Epidural empyema. CSF leaks. Meningitis.

42. Naso -Orbital-Ethmoidal fracture Fractures that extend into the nose through the ethmoid bones. Associated with lacrimal disruption and dural tears. Suspect if there is trauma to the nose or medial orbit. Patients complain of pain on eye movement.

43. Naso-Ethmoidal-Orbital Fracture Clinical findings: Flattened nasal bridge or a saddle-shaped deformity of the nose. Widening of the nasal bridge ( telecanthus ) CSF rhinorrhea or epistaxis. Tenderness, crepitus, and mobility of the nasal complex. Intranasal palpation reveals movement of the medial canthus.

44. Naso-Ethmoidal-Orbital Fracture Imaging studies: Plain radiographs are insensitive. CT of the face with coronal cuts through the medial orbits. Treatment: Antibiotic Maxillofacial consultation.

45. Orbital Blowout Fractures Blow out fractures are less common. Occur when the the globe sustains a direct blunt force 2 mechanisms of injury: Blunt trauma to the globe Direct blow to the infraorbital rim

46. Orbital Blowout Fractures Clinical Findings Periorbital tenderness, swelling, ecchymosis. Enopthalmus or sunken eyes. Impaired ocular motility. Infraorbital anesthesia. Step off deformity

47. Orbital Blowout Fractures Imaging studies Radiographs: Hanging tear drop sign Air fluid levels Orbital emphysema

48. Orbital Blowout Fractures Imaging studies CT of orbits Details the orbital fracture Excludes retrobulbar hemorrhage. CT Head R/o intracranial injuries

49. Orbital Blowout Fractures Treatment Blow out fractures without eye injury do not require admission Maxillofacial and ophthalmology consultation Decongestants for 3 days Prophylactic antibiotics Avoid valsalva or nose blowing Patients with serious eye injuries should be admitted to ophthalmology service for further care.

50. Transconjunctival approach

51. Transantral approach

52. Endoscopic Balloon catheter repair Wide MMA Insert Foley and inflate Leave in place for 7-10 days Broad spectrum antibiotics

53. Fracture of middle third of the face It is the fracture of facial bones, supra orbital ridge and upper teeth Types : Depending on the site Central (Naso maxillary bones) Lateral (Malar maxillary bones)

54. Maxillary Fractures High energy injuries. Impact 100 times the force of gravity is required . Patients often have significant multisystem trauma. Classified as LeFort fractures.

55. Types Le Fort 1 = Transverse Le Fort 2 = Pyramidal Le Fort 3 = Cranio -facial dysjunction

56. Le Fort 1 (Guerin) fracture Runs above nasal floor, through nasal septum, maxillary sinuses & inferior parts of pterygoid plates

57. Le Fort 2 fracture Runs obliquely from maxillary sinus floor to infraorbital margin, across orbital floor & lacrimal bone to nasion

58. Le Fort 3 fracture Runs from medial orbit wall to superior orbital fissure across sphenoid & zygomatic bone to zygomatico -frontal suture inferiorly to pterygoid plates

59. Clinical Features Nose Collapse of nasal bridge Oedema of soft tissues Epistaxis Septal haemotoma Nasal obstruction C.S.F Rhinorrhoea

60. Maxillary sinus Step deformity of infraorbital margin due to fracture Oedema of soft tissues Infra orbital involvement – Anaesthesia or numbness over cheek

61. Face Flattening of face – Dish faced deformity Mal occlusion of jaws Eyes Epiphora Sub conjunctival haemorrhage Diplopia Enophthalmos

62. Fracture reduction Closed methods Hard palate disimpaction with Rowe’s forceps External fixation on halo frame, box frame Inter-maxillary fixation Open methods Inter-osseous wiring Compression plates & screws

63. Hard palate disimpaction

64. External fixation

65. Inter-maxillary fixation

66. Inter-osseous wiring

67. Compression plates

68. Lateral Type - Zygoma Fractures Malar maxillary complex fracture due to blow from the side of the face Two types of fractures can occur: Arch fracture (most common) Tripod fracture (most serious)

69. Zygoma Arch Fractures Can fracture 2 to 3 places along the arch Lateral to each end of the arch Fracture in the middle of the arch Patients usually present with pain on opening their mouth.

70. Zygoma Arch Fractures Clinical Findings Palpable bony defect over the arch Depressed cheek with tenderness Pain in cheek and jaw movement Limited mandibular movement

71. Zygoma Arch Fractures Imaging Studies & Treatment Radiographic imaging: Submental view (bucket handle view) Treatment: Consult maxillofacial surgeon Ice and analgesia Possible open elevation

72. Zygoma Tripod Fractures Tripod fractures consist of fractures through: Zygomatic arch Zygomaticofrontal suture Inferior orbital rim and floor

73. Clinical features: Periorbital edema and ecchymosis Hypesthesia of the infraorbital nerve Concomitant globe injuries are common Flattening of malar prominence External swelling Step deformity of infra orbital ridge Enopthalmos Trismus Diplopia

74. Zygoma Tripod Fractures Imaging Studies Radiographic imaging: Waters, Submental and Caldwell views Coronal CT of the facial bones: 3-D reconstruction

75. Zygoma Tripod Fractures Treatment Nondisplaced fractures without eye involvement Ice and analgesics Delayed operative consideration 5-7 days Decongestants Broad spectrum antibiotics Displaced tripod fractures usually require admission for open reduction and internal fixation.

76. Investigations Radiography CT – If necessary in cases of CSF rhinorrohoea

77. Treatment Reduction of fractures, under GA Reduced fragments are maintained in place by use of steel wires,splints, rods and traction

78. Gillies Reduction

79. Reduction 1.Gillies temporal approach - Infiltration with local anaesthetic and adrenaline Small incision is made down to superficial temporal fascia Fascia is incised and elevator is passed down on temporalis muscle so that its tip lies just under the fracture. The bone is then elevated.

80. 2.poswillo hook Hook is inserted at intersection of a line drawn vertically from lateral orbital margin and a horizontal line drawn from inferior margin of nose. Stab incision is given and hook is inserted Zygoma is lifted back into position

81. 3.Intra oral or keen approach- Mucogingival incision is given in buccal sulcus in molar /premolar region An elevator is passed behind zygomatic body to elevate fracture. Open reduction- Zygoma may be plated at frontozygomatic suture, infra orbital margin, zygomatic buttress ,zygomatic arch Periosteum should be closed meticulously over the plate

82. Post operative care Patient instructed not to blow nose for first 12 hours. Watch out for signs of retrobulbar hemorrhage (increasing pain,proptosis,ophthalmoplegia,diminishing visual acuity) Treatment- Dexamethasone 4 mg/kg bolus,2 mg/kg 6 hrly Acetazolamide 500 mg IV Mannitol 20% 200 ml Remove the sutures and do surgical decompression by lateral canthotomy

83. C.S.F Rhinorrhoea

84. C.S.F Rhinorrhoea It is the flow of cerebrospinal fluid from the nose Sites of CSF Leak Cribriform plate of Ethmoid Frontal sinus Ethmoidal sinus Sphenoid sinus

85. C.S.F Rhinorrhoea Aetiology Congenital – Congenital Dehiscence of Nasal roof Traumatic Head Injury – Fracture of floor of anterior cranial fossa

86. Iatrogenic Functional endoscopic sinus surgery (FESS) Ethmoidectomy, sphenoidectomy Trans nasal hypophysectomy Frontoethmoidal mucocele surgery SMR / Septoplasty

87. C.S.F Rhinorrhoea Spontaneous Raised intracranial tension Hydrocephalus Destructive bony lesions like granulomas Tumors

88. Clinical Features Rhinorrhoea – Unilateral, clear, watery, dripping on looking downwards, increase on coughing, sneezing, and on exertion History of Trauma - Accidental or operation on nose or PNS Head Ache Meningitis – Rarely the presenting feature

89. Diagnosis To be differentiated from nasal discharge History Collection of fluid in test tube, allowed to stand CSF – Remains clear Nasal discharge – forms sediment Handkerchief test for nasal discharge – Handkerchief stiffens

90. Double ring sign or halo sign Traumatic cases Discharge collected on a tissue paper Central spot of blood, CSF spreads as halo around it DIAGNOSTIC NASAL ENDOSCOPY

91. Diagnosis Fluorescein dye test Endonasal endoscopic evaluation following lumbar intrathecal administration of sodium fluorescein. Using flurescein blue light filter system coupled to cold light source the site of leak is assessed accurately Β 2 TRANSFERIN PRESENT IN CSF

92. RADIOLOGICAL X-Ray skull bones CT Scan or CT Cisternography MRI or MRI Cisternography

93. TREATMENT Complete bed rest with raised head end Avoid blowing nose, sneezing or straining Avoid nasal packs or nasal drops Antibiotics Mannitol and acetazolamide to reduce intracranial pressure Treat the cause

94. SURGICAL REPAIR External ethmoidectomy approach (Rarely done now a days) Nasal endoscopic approach Intracranial of approach

95. Marquis Alfonso Corti worked on the mammalian auditory system at the Koelliker Laboratory in Wurzburg (Germany). In 1851, he published a paper describing a structure located on the basilar membrane of the cochlea containing hair cells that convert sound vibrations into nerve impulses: the organ of Corti

96. Knowledge is power THANK YOU