Maxillofacial trauma

Airway and breathing

In trauma, the first priority is securing the upper airway, followed by ensuring adequate ventilation and prevention of aspiration. Injury to the maxillofacial region can compromise the airway in several ways including tissue displacement, edema, and hemorrhage. Multiple fractures to the mandible, nasal bones, or maxilla can also lead to loss of the airway. Anatomically, the tongue is secured in the oral cavity by connection to the mandible. Any compromise of this relationship may cause the tongue to descend into the oropharynx, thus obstructing the airway. Surrounding tissue edema and local hematoma may also narrow the airway. Additionally, blood, emesis, avulsed teeth or dentures, and foreign objects can obstruct the airway. Physical signs of airway obstruction include stridor, cyanosis, and drooling. Patients may also lack a protective gag reflex, owing to alcohol or drug intoxication or concomitant traumatic brain injury. In these cases, endotracheal intubation or cricothyrotomy is indicated. Nasotracheal intubation is technically more difficult. It causes more complications and requires a patent nasal passage.

Circulation and control of hemorrhage

Arterial supply to the face is derived from multiple branches of the external carotid artery. Extensive anastomosis creates a rich vascular network that resides superficially in the maxillofacial skeleton and therefore is vulnerable to traumatic injury. Most superficial arterial bleeding can, however, be controlled with pressure and rarely requires vessel repair. Also, because of the rich anastomotic network, ligation of superficial vessels should not compromise blood supply to adjacent facial structures. Arterial repair should be undertaken in the operating room only when a large-caliber artery is damaged.

Veins are more likely to be injured in facial trauma because they are more superficial to arteries and are valveless. Therefore, they are prone to profuse bleeding. This is often managed by pressure and vessel ligation.

Treatment of airway obstruction secondary to hemorrhage is a priority. Bleeding can potentially impede the view of the upper aerodigestive tract. Often, an inadequate assessment of the vocal cords makes orotracheal intubation challenging. A surgical airway should be considered in such instances. Bleeding from soft tissue lacerations may be addressed after patients are stabilized. Surgical management of soft tissue lacerations is reviewed later in this chapter. Hemorrhage from facial fractures is generally managed with fracture reduction.

Epistaxis

Epistaxis is commonly encountered after facial trauma. Often it is self-limited and associated with nasal fracture. Bleeding can be from the anterior or posterior nasal cavities. Identification is important for definitive management. Nasal bleeding is frequently controlled with direct pressure for a minimum of 30 minutes. If bleeding persists, the nasal cavity should be packed. Ribbon gauze impregnated with petroleum jelly is generally employed. For anterior bleeding, a nasal speculum is used to visualize and open the nasal cavity. Gauze is then introduced into the nasal cavity layer by layer with the aid of bayonet forceps. Adequate packing should be performed by firmly pressing down after each layer, only tight enough to stop bleeding without causing mucosal or septal necrosis. Direct cautery with silver nitrate is also effective when a localized point of bleeding is easily identifiable.

Posterior nasal bleeding can be controlled by posterior nasal packing. This is accomplished with the aid of a catheter that introduces the packing though the nares into the nasopharynx and can be passed through the oral cavity. Use of a nasal balloon catheter may be simpler. If nasal balloons are not available, a 10 Fr to 14 Fr Foley catheter with a balloon can be used to control posterior bleeding. It is passed into the oropharynx, inflated to 10 mL, and then carefully pulled anteriorly toward the nasal cavity until bleeding ceases. Hyperinflation of the balloon must be avoided so that pressure necrosis does not occur. Cautery, in the form of bipolar diathermy, electrocautery, or chemical cautery, can also be used when the site of bleeding is visible.

History and physical examination

Once the primary survey is complete, the secondary survey is initiated, followed by a brief history and comprehensive physical examination. The acronym AMPLE is used to remember the pertinent history in the trauma patient: A llergies, M edications, P ast medical history, L ast meal, and E vents of the injury. In patients with evident facial trauma, the determination of mechanism of injury is extremely important. This information may assist the clinician in predicting the extent and magnitude of injury, as well as raise suspicion to the possibility of associated occult injury. A history of motor vehicle crash or gunshot wound suggests possible panfacial fractures. Sports injuries often result in an isolated upper midfacial fracture. History of assault is often associated with a unilateral mandible fracture. Facial trauma as a result of gunshot wound or motor vehicle accident is often more severe than trauma resulting from assault, fall, or athletic injury.

The physical examination must be conducted in an orderly fashion from head to toe in order to avoid missing any injuries. It is necessary to document any asymmetry or gross facial deformities. Starting from the scalp downward, assess for soft tissue swelling, lacerations, abrasions, and contusions. Evaluate the mandible and maxilla for any missing or broken teeth as well as malocclusion. When palpating the bony regions of the face, note any crepitus, step-off points, or areas of tenderness. Normally, jaw excursion is about 4 to 5 cm when measured from the edges of the incisors. Lateral jaw movement is normally about 1 cm and must also be documented. Otoscopic examination, in addition to visualization of the nares and oral cavity, is required to evaluate for additional sites of occult injury. Examination of the cranial nerves is necessary to ascertain any localized deficits.

Reevaluation of the patient is crucial. Many causes of morbidity and subsequent fatality may not be seen on the initial examination. For example, patients may vomit at any given time, and this will place them at risk for aspiration; bleeding or edema may accumulate over time, resulting in eventual respiratory distress.