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Faciomaxillary Injuries

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Dr Asmatullah Achakzai
Dr Asmatullah Achakzai

Maxillofacial fractures can result from accidental trauma, physical combat, or sports injuries. They require immediate care to secure the airway and control bleeding. The fractures can involve the upper, middle, or lower third of the face. Nasal bone fractures are common and may involve the septum or extend to the ethmoid sinuses. Treatment depends on the location and severity of the fractures but often involves reduction, immobilization, antibiotics, and anti-inflammatory drugs.

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Faciomaxillary Injuries
Faciomaxillary Injuries Dr Asmatullah Achakzai Associate Professor ENT Department
MAXILLOFACIAL FRACTURES Fractures of the facial skeleton including the nose, mandible, zygoma and orbit are most commonly due to: Accidental trauma Physical combat Sports injuries. Maxillofacial fractures, besides causing cosmetic deformity, loss of function and brain damage can also result in endangerment to the airway.
Faciomaxillary Injuries
Care of Patient in Emergency The first priority Is securing the airway and controlling bleeding when the patient presents in the emergency. For this, the following factors for care of patient In emergency include: Airway is to be maintained by alignment of neck and endotracheal intubation is undertaken in unconscious patient. Breathingto assess and establish breathing to ensure adequate ventilation. Circulationto maintain and improve blood circulation and to control blood loss by anterior nasal packing (ANP), suction, suture or arterial ligation. Dysfunctionto assess levels of consciousness and neurological deficit. To carefully expose the patient to identify all other injuries. Clinical examination Includes that of eyes, nose, maxilla, mandible, mucosa and dentition. Any lacerations should be cleaned and sutured. The fractured fragments should be accurately reduced, immobilized and maintained free by infection by antibiotics and anti-inflammatory drugs.
CLASSIFICATION The Faciomaxillary injuries can be divided into: Fracture of upper third of face. Fracture of middle third of facecentral/lateral Fracture of lower third of face.
FRACTURES OF UPPER THIRD OF FACE The upper third of face includes the region of face above the supraorbital ridge. In this region, there can be trauma to frontal sinus, supraorbital ridge and fracture of frontal bone. Main Features They are as follows: If frontal sinus is involved: Dural tears/brain injury Cosmetic deformity on forehead Cerebrospinal fluid (CSF) rhinorrhea. If supraorbital ridge is fractured, it results in: Periorbital ecchymosis. Proptosis/downward displacement of eye.
Management Reduction of fracture through an open wound/bow, incision/turnovers skin line on forehead. If Dural tears present, these can be covered by temporalis fascia. Neurosurgical consultation fot brain injury and/or cerebral edema.
FRACTURES OF MIDDLE THIRD OF FACE Middle third of face includes region between supraorbital ridge and upper teeth Depending on the site of involvement, fractures of middle third of face can be: Central (nasomaxillary) includes fracture nasal bones/ naso-orbital fracture Lateral (malar-maxillary).
Central (Naso-maxillary) Fractures Clinical features Epistaxis is the common symptom. It may be temporary or continuous. External nasal deformity due to dislocated bony fragments and edema of tissues due to trauma or hematoma. Nasal obstruction is present due to blood clots, septal hematoma or septal deformity. Palpation over the nasal bridge will elicit tenderness and bony crepitations. Edema usually sets in within 4 to 6 hours of injury. So fracture can be best assessed within 2 to 4 hours of trauma or after 6 to 8 days when edema subsides. Watery nasal discharge is indicative of CSF leak due to fracture of cribriform plate in the roof of nose.
Investigations Anterior rhinoscopy should be carried out to ascertain nasal patency and to remove any blood clot. Any septal dislocation/septal hematoma can be noted. X-ray lateral view and anteroposterior (AP) view of nasal bones demonstrate the fracture line. X-ray skull and computed tomography (CT) scan are done to detect associated head injury, if suspected.. Examination of eyes to rule out subconjunctival hemorrhage.
Classification of fracture nasal bones Class 1 Fracture Fracture Fractures involving nasal bones and septal cartilage. (Chevallet fracture). Class II Fracture It causes significant cosmetic deformity. (Jarjavay fracture). Class III Fracture Fracture The fractures extend to include the ethmoidal labyrinth. It is currently known as naso-orbitoethmoid (NOE) fracture.
Faciomaxillary Injuries
Faciomaxillary Injuries
Faciomaxillary Injuries
Naso-orbitoethmoid fracturesubtypes In this type, anterior skull base, posterior wall of frontal sinus and optic canal remain Intact. The ethmoidal labyrinth collapses or telescopes on itself causing a classical pig-like appearance to the face with foreshortening of nose and increased space between the eyes (telecanthus). In this type, there is disruption of posterior frontal sinus wall, multiple fractures of roof of ethmoid and orbit extending as far back as sphenoid and parasellar region. It may result in dural tears, CSF leakage and cerebral herniation.
Management of nasal fractures In case of head injury or vehicular accidents, maintain the vital parameters of the patient Epistaxis, if present, is treated by anterior nasal packing Any open wounds are to be cleaned and sutured Antibiotics and anti-inflammatory analgesics to be given to the patient If the patient is seen within 1 to 2 hours of trauma, the fracture can be reduced under LA using Asche's or Walsham's forcep If edema has already set in, it is better to wait for 7 to 8 days to allow the edema to subside and then to reduce the fracture under general anesthesia (GA) If there is septal deformity, septal hematoma, it is to be treated at the same time as fracture reduction.
Faciomaxillary Injuries
Asches Septal Forcep Walshams Forcep
Fractures of orbit floor Result from direct trauma to the orbit, usually occur when a large blunt object strikes the globe resulting in blow out fractures. In this, the orbital contents may herniate into the antrum. Clinical features Ecchymosis of lid, conjunctiva and sclera, epiphora, subconjunctival hemorrhage and diplopia.
Fracture of the Maxillary Sinus There is step deformity of infraorbital margin due to fracture, edema of soft tissues and anesthesia or numbness over cheek due to involvement of infraorbital nerve. It is based on the extent of bone involvement (Figures 27.2A and B). LeFort I (Transverse) In this, there is transverse fracture of maxilla involving the palate only, running above floor of nasal cavity through the nasal septum and maxillary sinus. LeFort ll (Pyramidal) Runs from floor of mwdllary sin uses superiorly to the infraorbital margin, through the zygomati-comaxillary suture and through the orbit. The infraorbital nerve is often damaged in this.
LeFort's classification for central fractures It is based on the extent of bone involvement. LeFort I (Transverse) LeFort ll (Pyramidal) LeFort lll (Craniofacial dysotosis)
Faciomaxillary Injuries
Lateral Fracture of the Middle Third (Malar Maxillary) These are due to blow from side of face. Direct trauma causes lower segment of zygoma to be pushed medially and posteriorly causing flattening of malar prominence and step defomity of infraorbital margin. Fracture line passes through zygomaticofrontal suture, orbital floor, Infraorblial in gin And anterior wall of maxillary sinus.
Faciomaxillary Injuries
Continued.. Clinical Features They include flattening of malar prominence, 11-knit's, anesthesia in distribution of infraorbital nerve, step deformity of infraorbital margin and diplopia. Diagnosed by X-ray PNS (Water's view) and in case of CSF rhinorrhea. Cr might also be undertaken to show site of leakage. Treatment Fracture is reduced under GA and the fractured fragments are kept in contact with the help of steel wires, splints and rods using various techniques of external or internal fixation.
FRACTURES OF LOWER THIRD OF FACE These include fractures of mandible. Subcondylar region fractures are the most common (35%) followed by those of angle, body and symphysis. Most fractures are caused by indirect trauma to chin. Clinical Features If undisplaced fracture, pain and trismus are mainly observed and there is tenderness at the site of fracture Displaced fragments of mandible result in malocclusion of teeth and deviation of jaw to opposite side Diagnosis is by X-ray skull (poster anterior [PA] view) and X-ray right and left oblique view of mandible. Management is by interdentally wiring, intermaxillary fixation, transosseous wiring and bone plates by both open or closed reduction techniques.
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Faciomaxillary Injuries

  • 2. Faciomaxillary Injuries Dr Asmatullah Achakzai Associate Professor ENT Department
  • 3. MAXILLOFACIAL FRACTURES Fractures of the facial skeleton including the nose, mandible, zygoma and orbit are most commonly due to: Accidental trauma Physical combat Sports injuries. Maxillofacial fractures, besides causing cosmetic deformity, loss of function and brain damage can also result in endangerment to the airway.
  • 5. Care of Patient in Emergency The first priority Is securing the airway and controlling bleeding when the patient presents in the emergency. For this, the following factors for care of patient In emergency include: Airway is to be maintained by alignment of neck and endotracheal intubation is undertaken in unconscious patient. Breathingto assess and establish breathing to ensure adequate ventilation. Circulationto maintain and improve blood circulation and to control blood loss by anterior nasal packing (ANP), suction, suture or arterial ligation. Dysfunctionto assess levels of consciousness and neurological deficit. To carefully expose the patient to identify all other injuries. Clinical examination Includes that of eyes, nose, maxilla, mandible, mucosa and dentition. Any lacerations should be cleaned and sutured. The fractured fragments should be accurately reduced, immobilized and maintained free by infection by antibiotics and anti-inflammatory drugs.
  • 6. CLASSIFICATION The Faciomaxillary injuries can be divided into: Fracture of upper third of face. Fracture of middle third of facecentral/lateral Fracture of lower third of face.
  • 7. FRACTURES OF UPPER THIRD OF FACE The upper third of face includes the region of face above the supraorbital ridge. In this region, there can be trauma to frontal sinus, supraorbital ridge and fracture of frontal bone. Main Features They are as follows: If frontal sinus is involved: Dural tears/brain injury Cosmetic deformity on forehead Cerebrospinal fluid (CSF) rhinorrhea. If supraorbital ridge is fractured, it results in: Periorbital ecchymosis. Proptosis/downward displacement of eye.
  • 8. Management Reduction of fracture through an open wound/bow, incision/turnovers skin line on forehead. If Dural tears present, these can be covered by temporalis fascia. Neurosurgical consultation fot brain injury and/or cerebral edema.
  • 9. FRACTURES OF MIDDLE THIRD OF FACE Middle third of face includes region between supraorbital ridge and upper teeth Depending on the site of involvement, fractures of middle third of face can be: Central (nasomaxillary) includes fracture nasal bones/ naso-orbital fracture Lateral (malar-maxillary).
  • 10. Central (Naso-maxillary) Fractures Clinical features Epistaxis is the common symptom. It may be temporary or continuous. External nasal deformity due to dislocated bony fragments and edema of tissues due to trauma or hematoma. Nasal obstruction is present due to blood clots, septal hematoma or septal deformity. Palpation over the nasal bridge will elicit tenderness and bony crepitations. Edema usually sets in within 4 to 6 hours of injury. So fracture can be best assessed within 2 to 4 hours of trauma or after 6 to 8 days when edema subsides. Watery nasal discharge is indicative of CSF leak due to fracture of cribriform plate in the roof of nose.
  • 11. Investigations Anterior rhinoscopy should be carried out to ascertain nasal patency and to remove any blood clot. Any septal dislocation/septal hematoma can be noted. X-ray lateral view and anteroposterior (AP) view of nasal bones demonstrate the fracture line. X-ray skull and computed tomography (CT) scan are done to detect associated head injury, if suspected.. Examination of eyes to rule out subconjunctival hemorrhage.
  • 12. Classification of fracture nasal bones Class 1 Fracture Fracture Fractures involving nasal bones and septal cartilage. (Chevallet fracture). Class II Fracture It causes significant cosmetic deformity. (Jarjavay fracture). Class III Fracture Fracture The fractures extend to include the ethmoidal labyrinth. It is currently known as naso-orbitoethmoid (NOE) fracture.
  • 16. Naso-orbitoethmoid fracturesubtypes In this type, anterior skull base, posterior wall of frontal sinus and optic canal remain Intact. The ethmoidal labyrinth collapses or telescopes on itself causing a classical pig-like appearance to the face with foreshortening of nose and increased space between the eyes (telecanthus). In this type, there is disruption of posterior frontal sinus wall, multiple fractures of roof of ethmoid and orbit extending as far back as sphenoid and parasellar region. It may result in dural tears, CSF leakage and cerebral herniation.
  • 17. Management of nasal fractures In case of head injury or vehicular accidents, maintain the vital parameters of the patient Epistaxis, if present, is treated by anterior nasal packing Any open wounds are to be cleaned and sutured Antibiotics and anti-inflammatory analgesics to be given to the patient If the patient is seen within 1 to 2 hours of trauma, the fracture can be reduced under LA using Asche's or Walsham's forcep If edema has already set in, it is better to wait for 7 to 8 days to allow the edema to subside and then to reduce the fracture under general anesthesia (GA) If there is septal deformity, septal hematoma, it is to be treated at the same time as fracture reduction.
  • 20. Fractures of orbit floor Result from direct trauma to the orbit, usually occur when a large blunt object strikes the globe resulting in blow out fractures. In this, the orbital contents may herniate into the antrum. Clinical features Ecchymosis of lid, conjunctiva and sclera, epiphora, subconjunctival hemorrhage and diplopia.
  • 21. Fracture of the Maxillary Sinus There is step deformity of infraorbital margin due to fracture, edema of soft tissues and anesthesia or numbness over cheek due to involvement of infraorbital nerve. It is based on the extent of bone involvement (Figures 27.2A and B). LeFort I (Transverse) In this, there is transverse fracture of maxilla involving the palate only, running above floor of nasal cavity through the nasal septum and maxillary sinus. LeFort ll (Pyramidal) Runs from floor of mwdllary sin uses superiorly to the infraorbital margin, through the zygomati-comaxillary suture and through the orbit. The infraorbital nerve is often damaged in this.
  • 22. LeFort's classification for central fractures It is based on the extent of bone involvement. LeFort I (Transverse) LeFort ll (Pyramidal) LeFort lll (Craniofacial dysotosis)
  • 24. Lateral Fracture of the Middle Third (Malar Maxillary) These are due to blow from side of face. Direct trauma causes lower segment of zygoma to be pushed medially and posteriorly causing flattening of malar prominence and step defomity of infraorbital margin. Fracture line passes through zygomaticofrontal suture, orbital floor, Infraorblial in gin And anterior wall of maxillary sinus.
  • 26. Continued.. Clinical Features They include flattening of malar prominence, 11-knit's, anesthesia in distribution of infraorbital nerve, step deformity of infraorbital margin and diplopia. Diagnosed by X-ray PNS (Water's view) and in case of CSF rhinorrhea. Cr might also be undertaken to show site of leakage. Treatment Fracture is reduced under GA and the fractured fragments are kept in contact with the help of steel wires, splints and rods using various techniques of external or internal fixation.
  • 27. FRACTURES OF LOWER THIRD OF FACE These include fractures of mandible. Subcondylar region fractures are the most common (35%) followed by those of angle, body and symphysis. Most fractures are caused by indirect trauma to chin. Clinical Features If undisplaced fracture, pain and trismus are mainly observed and there is tenderness at the site of fracture Displaced fragments of mandible result in malocclusion of teeth and deviation of jaw to opposite side Diagnosis is by X-ray skull (poster anterior [PA] view) and X-ray right and left oblique view of mandible. Management is by interdentally wiring, intermaxillary fixation, transosseous wiring and bone plates by both open or closed reduction techniques.