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Oral Maxillofacial Surg Clin N Am 18 (2006) 261 – 273

Early Perioperative Care of the Acutely Injured Maxillofacial Patient
Orville D. Palmer, MD, MPH, FRCSCa,b,T, Vaughn Whittaker, MDc, Carolyn Pinnock, MBBS, DMd,e
a

Division of Otolaryngology, Head and Neck Surgery, Department of Surgery, Harlem Hospital Center, 506 Lenox Avenue, New York, NY 10037, USA b Department of Otolaryngology, Columbia College of Physicians and Surgeons, New York, NY USA c Department of Surgery, Harlem Hospital Center, New York, NY USA d Bustamante Hospital for Children, Kingston, Jamaica e Department of Surgery, University of the West Indies, Kingston, Jamaica

Maxillofacial trauma involves injury to the facial soft tissue or its bony structure. It is commonly associated with multiple system injuries and occurs in 33% of severely injured trauma victims brought into emergency rooms [1]. The most common mechanisms of injury are blunt or crush injuries caused by personal assault and motor vehicle accidents [2,3]. These injuries often are associated with other serious injuries in as many as 54.8% to 70.2% of victims [2]. These concomitant injuries include cranial, spinal, and upper and lower body injuries [4,5]. Patients who have maxillofacial injuries are first and foremost trauma patients who must be seen and assessed by the trauma team, and the care must be multidisciplinary [6]. At the time of injury, patients should be transported immediately to the closest and most appropriate facility, preferably a confirmed trauma center [7]. Adequate prehospital stabilization includes maintaining the airway with immobilization of the cervical spine, providing effective oxygenation, controlling external hemorrhage, and starting fluid resuscitation. The trauma center or receiving facility must be informed of patient arrival so that the appropriate team can be mobilized and

be on standby [7]. Patients must be triaged with special consideration given to the early securing of the airway. Advanced trauma life support guidelines are helpful, but patients may deteriorate rapidly if inappropriate attempts at intubation are made. An otolaryngologist should be summoned as soon as possible if a patient is suspected of having significant laryngeal or tracheal injury. Patients who were unrestrained in a motor vehicle (including motorcycles) are more likely to suffer uncommon laryngeal and tracheal injuries. A high index of suspicion is necessary for early detection. Early referral to an ophthalmologist to evaluate for injuries to the eye, orbital wall, and its adnexae is important [8]. A complete ocular examination should be performed [2]. A neurosurgeon is consulted if there are associated head injuries, traumatic cerebrospinal fluid (CSF) leaks, and complicated skull fractures [9]. Various other specialties are included as dictated by the injury profile of the patient.

Review of advanced trauma life support protocol Universal infection control precautions must be stressed while caring for these patients. The initial evaluation is performed following the advanced trauma life support protocol. After efficiently obtaining the vital signs, a primary survey is undertaken using the ‘‘ABCDEs’’ of trauma care. Only after a

T Corresponding author. Division of Otolaryngology, Head and Neck Surgery, Department of Surgery, Harlem Hospital Center, 506 Lenox Avenue, New York, NY 10037. E-mail address: odp3@columbia.edu (O.D. Palmer).

1042-3699/06/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.coms.2006.02.001

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The indications are discussed later. or tracheal fracture (bruising and deformity). In an unconscious. If laryngeal or tracheal injury is suspected. which may produce significant blood loss and circulatory collapse. As with airway patency. ashen gray skin of the face. Airway patency must be assessed rapidly for foreign bodies and mandibular. The presence of air or fluid in the pleural cavity usually can be detected by percussion and auscultation. but O-negative blood can be used when it is not available. when associated with multiple other injuries. At the initial vasculatory access. In a patient who has maxillofacial trauma. and rapid restoration of circulating volume may prevent death. or paradoxical movement. Hemodynamic compromise is characterized by altered mental levels of consciousness. Inspection of the chest wall may reveal bruises. which suggest rib fractures. As a general principle. Circulation and hemorrhage control In any trauma patient. drunk. a nasopharyngeal airway may be used. pale extremities and mucosa. Breathing and ventilation Rapid assessment of the mechanics of ventilation is the next step in the primary survey. one must have a high index of suspicion for laryngeal fracture or incomplete upper airway transaction because these injuries are uncommon and. and rapid thready pulses that are absent peripherally and weak centrally. A subgroup of these patients requires management with a tracheostomy or other surgical airway. Rapid volume replacement is essential to avoid complete circulatory collapse. The patient who has maxillofacial trauma can have profound bleeding. The airway should be secured while cervical immobilization is ensured using devices such as collars and supports or manual inline immobilization. skin color. or severely injured patient. ideally during the prehospital phase of resuscitation. an individual with multiple facial trauma (MFT) should be given special considerations because of the increased risk to the airway and highly sensitive neurologic structures. The aim of the ‘‘ABCDEs’’ of trauma care is to identify life-threatening injuries and resuscitate vital functions. obtunded. If a patient remains unstable or more than half the estimated blood volume has been infused. hypotension is most likely caused by blood loss. which must be treated immediately upon detection. Pulse oximetry is a useful adjunct for monitoring hemoglobin saturation and the effectiveness of ventilatory efforts. frequent reevaluation of breathing is important to detect any deterioration in clinical status [9]. a definitive airway should be established if there are any doubts about a patient’s ability to maintain airway integrity. blood should be drawn for the standard laboratory investigations. Frequent reassessment of airway patency is critical because a patient who has maxillofacial injuries is always at risk for progressive airway obstruction [9]. The placement of two large-bore intravenous catheters should be established early. and pulse [9]. intubation should be performed in the presence of an otolaryngologist whenever possible. including type and screen and b-human chorionic gonadotropin for all women of childbearing age. An adequately perfused patient is alert and pink and has full.262 palmer et al patient is stable will a more detailed secondary survey follow to assess injuries and plan for definitive care [8]. An opened wound may suggest a tension pneumothorax. During this phase. and regular pulse. it is important to differentiate an airway problem from a ventilatory problem. The cervical spine must be immobilized until radiologic confirmation of normalcy is attained [11]. The head . then blood should be infused. airway integrity is of utmost importance. which suggests a flail chest segment. During the early evaluation. Rapid clinical assessment of the hemodynamic status of a patient is performed by looking at the level of consciousness. The initial volume replacement should be performed with crystalloids. laryngeal. Chin lift and jaw thrust are used initially to achieve the task of airway control. Ventilatory effort and chest excursion are assessed and wounds noted. are often missed on initial assessment [10]. Patients who have severe head injury and altered mental status as evaluated by the Glasgow Coma Score of 8 or less require a definitive airway by either nasal or oral endotracheal intubation. slow. ‘‘ABCDEs’’ of trauma care A Airway maintenance with protection of the cervical spine B Breathing and ventilation C Circulation and hemorrhage control D Disability and neurologic status E Exposure/environmental control: completely undress the patient but prevent hypothermia [9] Airway management with cervical spine protection Supplemental oxygen must be provided to all trauma patients. when necessary. If this does not render the airway patent. Typespecific blood is ideal.

The Glasgow Coma Score is a more detailed and reliable method of assessing patient level of consciousness and has good prognostic value for predicting early hospital mortality (81. ventilation. ligation of the maxillary artery can be achieved by incising the buccal mucosa adjacent to the ipsilateral maxillary tuberosity and ligating the main trunk before it enters the pterygopalatine fossa. resuscita- . a combined middle cranial fossa and infratemporal fossa approach to the skull base for bypass or ligation may be necessary. When this approach is not successful. the alteration should be considered to be the result of trauma to the central nervous system until proven otherwise. which are branches off the aortic arch on the left and the brachiocephalic trunk on the right. In instances in which a more expeditious approach is needed. however. and perfusion status. Exposure A patient should be completely undressed even if it seems that the trauma involves only the maxillofacial region. Many instances of life-threatening injuries being missed by narrowly focusing on the maxillofacial region have been reported. The ophthalmic artery (from the internal carotid) sends supraorbital and supratrochlear arteries to the forehead [3. Any alterations in the level of consciousness should prompt immediate re-evaluation of a patient’s oxygenation. Subtle changes may be a clue to ongoing neurologic injury. Neurologic status must be evaluated frequently and continuously until it is certain that neurologic damage is not progressive. Secondary survey A patient undergoes secondary survey after the primary survey (ABCDEs) is completed. Occasionally. Disability (neurologic evaluation) Head injuries with underlying central neurologic deficits are often associated with maxillofacial trauma. The external carotid supplies the face via the facial artery through its superior and inferior labial arteries. and oral packing. After controlling the bleed with local.9% predictive value). but angiography always should be considered when in doubt. and only rarely does exploration for a source of bleeding become necessary. Brisk arterial bleeding from the nose or ears is unusual and requires urgent specialist assessment.12]. The APACHE III (82. respectively. soft tissue bleeding subsides after the suturing of orofacial lacerations.4% predictive value) provides prognosis of late mortality and functional outcome [13]. All infused fluids should be warmed. nasal. The maxillary artery is divided into three parts (in relation to the lateral pterygoid muscle). Most nosebleeds and bleeding from the ear are venous (slow) and do not require immediate control measures. Internal carotid bleed usually can be controlled by intra-arterial balloon occlusion. The external carotid terminates in the superficial temporal and maxillary arteries. a major bleed may require nasal or intraoral packing for control during the early management of patients who have MFT. An undressed individual should be warmed using blankets or heaters. Resulting deficits may vary from having no clinical manifestations to deep coma. Injuries identified by the primary survey may be life threatening and should be treated rapidly and efficiently while aggressively resuscitative measures are used to ensure that a patient has an optimal chance of survival. such as a case of a bleed in which a patient was initially lucid. a maxillary artery bleed can be controlled with transantral sphenopalatine hemoclips. Direct pressure is the most effective means for immediate control of active bleeding in MFT.) Once hypoxia and hypovolemia are excluded. In most instances. When this occurs the two common sources of bleeding are the maxillary artery at the level of the pterygopalatine fossa. Early involvement of a neurosurgeon can be life saving. Control of major maxillofacial bleeding Minor nasal or oral bleed is a common feature of facial bone fractures. The internal carotid supplies the intracranial structures. (It also may be affected by alcohol or drugs. and the common carotid at the level of the skull base. Localizing the source of bleeding usually can be achieved by clinical examination only. The common carotid terminates in the internal and external carotids. each with five branches.perioperative care of the maxillofacial patient 263 and face have an extensive blood supply from the common carotid and subclavian arteries. Initial rapid assessment of the level consciousness in the trauma patient is available with the use of the AVPU method [9]: A Alert V Responds to vocal stimuli P Responds only to painful stimuli U Unresponsive to all stimuli. which manifests as a bluish discoloration and an obvious bulging of the buccal mucosa caused by hematoma.

264 palmer et al tion is well established. CT has a greater sensitivity and specificity for diagnosing cervical spine injuries. If a patient is in coma or under neuromuscular blockade and there is no observed movement of the lower extremities. Examination of the nose and midface Patients who have fracture of the midface are at risk for fracture of the cribriform plate. 2.14 – 16]. the CT is without abnormality. and the spine is cleared if physical examination evaluation is negative. ears. which consists of lateral. The ‘‘AMPLE’’ pneumonic is the recommended guide for this brief but important history taking [9]. CT scanning using these protocols for cervical spine injury had a sensitivity of 99% and specificity of 100%. or distracting injury undergoes cervical spine evaluation by clinical examination in the trauma room. but normal radiologic examinations in the presence of neck pain. nose/midface. and neck should be examined during the secondary survey. drug intoxication. and vital signs are returning to normal. 5. and neck must be made in the trauma patient who has damage to the maxillofacial region. anteroposterior.18]. face. he or she is kept in spinal precautions until such movement is observed or until MRI scan is obtained.04% risk of missing injuries. with a 0. alcohol. A common approach in many hospital emergency departments is to use a plain radiographic series. head-to-toe physical examination. and odontoid views [16]. Any patient who does not meet criteria to have the spine clinically cleared (eg. Special considerations for the examination of the eye. tenderness. Head and neck examination in maxillofacial trauma The entire scalp. Guidelines from Santa Barbara Cottage Hospital for the evaluation of the cervical spine are as follows: 1. head. 4. A Allergies M Medications currently used. If a patient is not evaluable secondary to coma. It had a positive predictive value of 100% and negative predictive value of 99% [20]. continued neck pain. Inspection of the oral cavity may reveal a hematoma. P Past illnesses/pregnancy L Last meal E Events/environment related to the injury. If a patient has a normal CT scan but neurologic deficit is present. which gives clues into the expected pattern of injury. an MRI is obtained. Any patient without clinical evidence of neurologic injury. and the patient is moving all four extremities upon arrival to the emergency department. Clinical judgment of spinal injury has a diagnostic accuracy of only 50% [10]. Initial radiologic investigations are performed during this survey. which suggests major arterial injury. Examination of the eye Periorbital edema may limit eye examination. and gastric intubation should be performed from the oral route. especially when used as an evaluating tool. but it should evaluated for Visual acuity Pupillary size Hemorrhage of the conjunctiva and fundi Penetrating injury Contact lenses (remove before edema occurs) Dislocation of lenses Ocular entrapment The ophthalmology service should be contacted early if there is any suspicion of ocular/visual injury. The history focuses on current or past medical information that may influence immediate treatment options and looks at the mechanism of injury. altered mental status) undergoes CT scanning with 3-mm cuts of the entire cervical spine with reformats of sagittal images. Delay in diagnosis or unwarranted manipulation of the injured spine can increase neurologic morbidity and mortality to as much as 3% to 25% [11. Minor nasal or oral bleed is not an uncommon feature of facial fractures. 3. Cervical spine assessment Cervical spine injury occurs in 2% to 3% of trauma patients and is missed in up to 10% of patients [11]. and frequent reevaluation of vital signs. the cervical spine is cleared and spinal precaution removed. This survey includes a focused history. altered mental status. and plain radiographs only improved the accuracy of diagnosis to 52% from pooled figures of a meta-analysis [19]. . and neurologic deficit do not rule out cervical spine injury [17. Radiologic investigations are the hallmark for evaluating spinal injuries.

Head elevation is an adjunct in conservative management. The studies are complementary [26]. More than 99% of CSF leaks secondary to trauma resolve within a week of conservative management [23]. and all appropriate radiologic and endoscopic investigations must be obtained at that time. Investigations to determine the localization of injury High-resolution. paradoxical rhinorrhea) CSF leak occurs in 4.21]. Bony defects are easily detected. The leader of the trauma team must ensure that re-evaluation of vital signs and physical findings. paradoxically. A patient must be examined front and back and log-rolled to ensure spinal stabilization. appropriate investigations. Management of cerebrospinal fluid leak/fistula Management of cerebrospinal fluid leak/fistula (rhinorrhea. which occurs when blood-stained CSF spreads onto an absorbent surface. Conservative management involves continuous lumbar CSF drainage (ventricular drainage in some cases). Antibiotic prophylaxis is especially useful if a patient is immunocompromised or has indwelling drains or when gross soilage/ contamination has occurred [3]. The body Examination of the chest. Investigations are used to (1) confirm the presence of CSF in the fluid seen and (2) identify the site of the leak (bone and dura). In the middle cranial fossa. perilymph. perineum. and as many as 3% to 6. Distinct indications for surgical management of traumatic CSF fistulae are midline fractures. In a difficult to localize CSF leak. such as fluid versus blood glucose levels or the halo sign. metrizamide CT cisternography may be helpful. Management of CSF leaks is influenced by injuries within other organ systems that may delay intervention and the presence of concomitant maxillofacial injuries. Is this cerebrospinal fluid? The presence of b2-transferrin (tau protein) in the leaking fluid is the most sensitive test to detect the presence of CSF. otorrhea.7% of patients with MFT have an underlying cervical spinal injury [13. are of limited use. Mixture of blood with tears or saliva can give the same effect (false positive).to high-risk patients seen and treated in urban trauma center reduces the incidence of paralysis and institutional costs [22].6% of patients who have maxillofacial trauma [23]. It should be avoided unless clinically warranted by a dirty wound or gross contamination of an open fracture. and appropriate urgent referrals to specialist services be coordinated and executed while patient stability is maintained. and musculoskeletal system in the secondary survey should be performed with a high index of suspicion based on the mechanism of injury. however. The halo sign is present when nasal secretions on bed linens or dressings form a halo. CT is also the best choice for ruling out cervical spinal injury in a patient with MFT. because of the poor penetration of uninflamed meninges and the possibilities for developing resistant strains [27]. fracture of the temporal bone may result in otorrhea [24]. and vitreous humor. The use of prophylactic antibiotic is considered by some clinicians to be unwarranted. The cost benefit analysis of CT scanning of the cervical spine versus plain radiography shows a distinct advantage for CT scanning. which could lead to a possible false-positive result [13. fracture of the frontobasal skull (usually the cribriform plate) may present with CSF rhinorrhea [2]. and the use of antibiotic prophylaxis. the CSF may track along the Eustachian tube and result in what is referred to as ‘‘paradoxical’’ rhinorrhea. complete physical examination. because it is found only in the CSF. particularly with an inactive tear (no clinical leak). bed rest. Caution must be exercised in patients who have cirrhosis who may have abnormally elevated b2-transferrin levels in the blood. Less sensitive tests. MRI has been useful for the evaluation of CSF fistula with no clinical evidence of leaking. but the dural defect is more difficult to identify.perioperative care of the maxillofacial patient 265 Maxillofacial trauma is considered a distracting injury when assessing cervical spinal integrity. Leaks result from a skull fracture with an associated dural tear. abdomen.25]. bone displacement >1 cm. Pain control measures also must be implemented once the patient is stable. largely . In suspicious cases of possible spinal injury. Within the anterior cranial fossa. comminuted. which may influence surgical access [2]. The blood (darker) forms a ring/ halo around the CSF (lightly stained center). There is convincing evidence that spiral CT of the cervical spine as an initial screening tool for moderate. carbonic anhydrase inhibitor. fine-slice (1 mm) CT scanning with multiplanar reconstruction is the standard imaging method for identifying bony and dural points of injury. compound.

The main sequelae of a CSF leak are meningitis and pseudomeningocele. particularly when the head is flexed and the sternocleidomastoid muscles protect this vital organ laterally. The most common mechanisms of injury to the larynx are a road traffic accident during which a driver’s extended neck impacts on the steering wheel and a motorcycle accident in which the rider suffers from a clothesline-type injury [31]. The bony structures of the mandible and sternum offer protection superio-inferiorly. but the use of seat belts and airbags most likely decreases the risk of serious laryngeal injuries [31]. and martial arts. and combined transmastoid – middle fossa approach are the common surgical techniques used. increased risk of epilepsy. The disadvantages are longer recovery time. Seatbelt harness injury of the larynx has been described. open trauma. It is associated with loss of airway and immediate death at the time of incident. ice hockey. The middle cranial fossa approach offers superior access to the anterior tegmen down to the petrous apex and enables easier graft placement at the time of fistula repair. The approach to surgical management of CSF leak depends on the results of localization studies and the regions of the fractured skull. well-localized fistulas and may not be suitable for patients who have MFT with open trauma or severe destruction of the nose or paranasal sinuses. defects in this area can be sealed well with a low complication rate and a low incidence of postsurgical epilepsy. The transcranial approach provides superior access and is used in more significant CSF rhinorrhea with encephalocele or myelocele. and depressed fractures [2]. High-velocity sports. and continued CSF leak for more than 1 week with conservative management.15]. and tracheal ring. This procedure tends to be limited to smaller. and the presence of concomitant injuries that may require urgent operative interventions. Patients may warrant emergency intervention if extensive pneumocephalus. Clinical indicators of laryngeal injury include hoarseness. the transmastoid craniotomy approach. Delay is warranted in cases of cerebral edema and raised intracranial pressure (ICP) that results from severe head injury. Recurrence rates seem to be higher with this approach [28]. which is technically easier and has fewer associated risks and lower complication rates. There is quicker recovery time and less long-term risk of epilepsy. which accompanies the intracranial technique [28].04% of trauma cases in one series [30] and is often linked with other life-threatening injuries.266 palmer et al extended. Frontobasal fistulas Approach to the frontobasal fracture can be extracranial or transcranial The extracranial approach can be via the ethmoid or frontal paranasal sinuses or directly through the nose (transnasal approach). myelocele. Defects in the tegmen are approached by the middle fossa craniotomy [28]. including the thyroid cartilage. The use of nasal endoscopy has revolutionized the transnasal approach and minimized scarring and iatrogenic disfigurement of the face. Management of laryngeal injuries Laryngeal injury is an uncommon injury. Temporal bone fistulas For temporal bone fracture. motorcycle racing. and relative inaccessibility to posterior fossa fistulae [29]. Timing of surgery depends on patient stability. however. The disadvantage. severe bone derangement. Posterior defects are approached via a transmastoid approach [10. then closure or repair of the CSF leak at the time of surgery is indicated. middle fossa approach. It is well protected by virtue of its location and composition. The advantage of the transmastoid approach is that it gives good access to the posterior cranial fossa.33]. or gross open craniofacial disruption trauma is present. The larynx functions to maintain airway patency and produce speech. If surgical intervention is undertaken for the repair of associated maxillofacial fractures. Assault accounts for a small number cases. This elastic framework is at increased risk for disruption in elderly persons (because of calcification) and in victims of highvelocity trauma. hematoma. subcutaneous . cricoid. such as cycling. The main advantage of the extracranial approach is the decreased risk of seizures in the long-term. is the inaccessibility to anterior tegmen defects without significant ossicular displacement. There is a higher rate of recurrent CSF leak in patients managed conservatively compared with patients treated surgically [2]. It occurred in 0. are also associated with laryngeal trauma [32. encephalocele. involvement of the cribriform plate. localized pain. The elastic properties of the laryngeal cartilages allow some degree of deformity without fracturing the framework. significant intracranial hematoma. the extent of injury. dyspnea.

however. This tool plays a dual role of being diagnostic for the laryngeal injury and therapeutic in securing the airway.perioperative care of the maxillofacial patient 267 emphysema. permanent tracheostomy. fully visualized and controlled fashion.40]. but it can be added if CT scanning of the head is being performed. draw attention from the larynx [31]. we recommend that intubation should be performed in the presence of an attending otolaryngologist. The associated distortion of anatomy caused by underlying laryngeal damage may lead to inadequate ventilation because of distal obstruction and an inadequate seal around the laryngeal inlet with air leak. lingual [35– 38]. In the multi-trauma patient who has MFT. including difficult decannulation. Mucosal injury. Methods used to secure the airway in patients who have MFT with suspected or confirmed laryngeal trauma depend on airway patency at the time of assessment. In experienced hands. 1. The use of endotracheal intubation and laryngeal mask airway is not recommended for patients who have laryngeal trauma. Attempt at endotracheal intubation may worsen pre-existing injuries and possibly cause further tears or cricotracheal separation [31]. . laryngeal fractures are often missed in the primary assessment because other injuries. Fig. Late presentation and delayed management can result in higher risk of complications. Paraglottic hematoma. Information gained from this approach to intubation may obviate the need for further investigation and allows for early planning of subsequent operative or nonoperative intervention. then an emergency tracheostomy must be performed. hematoma. Flexible laryngoscopy/anterior commisuroscopy also should be performed when feasible. a carefully performed esophagoscopy is a valuable tool Laryngeal mask airway This device plays a definite role in severe cervical injury in which neck flexion is limited because it can be placed with the neck in the neutral position. Failure rates as high as 30% have been noted in elective cases. It is our experience that sedation is helpful in these patients. A high index of suspicion is important in patients who have MFT. then appropriate investigations can be undertaken while closely monitoring the airway and oxygenation. It is not used in unstable patients unless direct visualization was not possible at the time of intubation. such as to the head and cervical spine. If a patient has a patent airway and laryngeal injury is suspected. Patients who have with multiorgan injuries and laryngeal injury who require emergency surgery should have a tracheostomy for safe and effective airway management. The use of a laryngeal mask airway may result in worsening of laryngeal injury and cause neural injuries. It is also helpful in patients with maxillofacial trauma in whom the anatomy is distorted or there is visual impairment with blood and secretions [31]. insufficient oxygenation. If a patient has failure of airway patency. Esophagoscopy is important in the initial evaluation of these patients. and recurrent laryngeal nerves [39. Definitive management must be individualized for patients. There is controversy regarding its use as a primary airway device or as an adjunct to fiberoptic intubation in trauma patients. Investigations CT scan plays a definite role in stable patients who have clinical evidence of laryngeal injury without airway compromise (Figs. and aspiration with a laryngeal mask airway. An anterior commisurescope should be used to assess fully the airway and guide the intubation in a direct. and hemoptysis. most commonly to the hypoglossal [34]. and distortion of anatomy because of cartilaginous fracture can be detected. New proposal For patients who have laryngeal trauma. 1 and 2). and a poor or absent voice.

This life-saving procedure is not without complications. Most tracheotomies are performed for midface fractures 92% [18]. Complications include pneumothorax.44]. Fig. The cricoid cartilage is the only complete cartilaginous ring in the larynx. Tracheostomy is performed in 0. A cut endotracheal tube that fits through the vocal cords with modifications for sutures at its upper end is acceptable. Management of laryngeal injury should seek to restore the skeletal framework and epithelial lining and maintain the functions of airway patency and speech. Preformed laryngeal stents are available from various manufacturers. Other indications include Upper airway obstruction Bilateral condylar fractures associated with symphyseal fracture that decreases tongue support Severe midface fractures (Le Fort type) and injury associated nasal or mandibular fracture Edema of the larynx and glottis Gross retropositioning of the maxilla Suspected cervical spine injury Maxillomandibular fixation in patient in need of reintubation Multiple laceration of the floor of the mouth and tongue Chronic lung disease or respiratory problems that necessitate constant suction of airway secretions Head injury that necessitates prolonged ventilatory support Cricothyroidotomy on arrival to the hospital Operator convenience in fracture management Tracheostomies have been reported to incur a morbidity rate of 14% to 45% and mortality rate of 1.268 palmer et al injury can be treated successfully by stenting. significant swelling. and as such.9% to 12% of patients with facial trauma [6. such as displaced laryngeal cartilage.10. cartilaginous fractures were reduced and fixed with wire or sutures. Traditionally.32. may be managed conservatively or with microendoscopes. and mucosal or cartilaginous injuries frequently lead to stenosis. Tracheostomy and alternatives In the presence of massive bleeding. Comminuted thyroid fracture and cartilage. however. Minor laryngeal injury. Other alternatives to tracheostomy include the judicious use of the endotracheal intubations and cricothyroidotomy. 2. and disruption of the anatomy in the upper airway from fractures of the facial bones and larynx. The use of miniplates offers rigid fixation and decreased hospital stay and have proved to be well tolerated [41 – 43]. and recurrent laryngeal nerve injury.18. Management goals The main goals are vascular control (hemostasis and the evacuation of hematoma) and restoration of laryngeal anatomy (evacuation of deforming hematoma and covering denuded cartilage). Stents are fixed externally with nonabsorbable sutures and should be removed endoscopically between 2 and 4 weeks postoperatively. More significant injuries. hemorrhage. Surgical considerations Mucosal lacerations not only are closed but also the mucosa must be approximated to the underlying perichondrium by way of absorbable sutures. infections. are best managed through open exploration. Cricoid . however. its role and indications are constantly being re-evaluated. in completing an evaluation in patients who have upper airway injury. tracheostomy is the most reliable method of securing an airway in patients who have maxillofacial trauma.25. such as nondeforming hematoma and undisplaced laryngeal fracture.6% to 16% [44].

In an alert. and failed/contraindicated endotracheal intubation [45. The use of serial examination of function cannot be overstated [49. Intranasal endoscopy is a useful adjunct in selected cases and offers the advantages of decreased morbidity. then surgical decompression is indicated [51]. and associated fractures can be detected [48]. loading dose 30 mg/kg IV over 15 minutes then 5. but alternative procedures may be used in select patients.  If there is a delay in the development of visual Ophthalmic considerations in maxillofacial trauma Maxillofacial trauma is associated with ophthalmologic injuries in as many as 20% of patients. pattern-evoked potentials are obtained [52]. and optic nerve. The procedure is contraindicated in patients with complete disruption of the optic nerve or chiasm. cooperative patient with at least 10% visual acuity. or visual pathways. particularly when a history of nonuse of seatbelts is obtained. severe maxillofacial injuries.4 mg/kg/hr IV infusion for 23 hours) and surgical decompression. Management of optic nerve injury may be conservative (high-dose steroids) or operative (decompression). and compression of the nerves. globe. Blindness occurs in 0. out injury to the conjunctiva. . Perineural edema is the most common cause of optic nerve injury. Nasotracheal intubation in patients without nasal bone fractures has been shown to offer adequate airway protection during surgery to repair midface fractures. then there is no intervention. complete atrophy of the optic nerve. rapid recovery time. This may be followed by orotracheal intubation after repair [44]. Visual evoked potentials are performed using light-evoked potentials if a patient is unconscious or unable to cooperate. Direct nerve injury involves nerve compression with resultant ischemic optic neuropathy that can be caused by retrobulbar hemorrhage. perineural edema. optic nerve. Other studies suggest concomitant use of high-dose steroid (methylprednisone. the prognosis for recovery is better than for immediate visual loss. tracheostomy is the gold standard in securing a difficult and complex airway in maxillofacial trauma [47]. perineural edema. is that which occurs with no initial ophthalmologic or external signs with a traumatic cause. There always should be a high index of suspicion of eye injury with MFT.5% to 3% of cases of midfacial fracture [48]. a more acceptable cosmetic result. and fundoscopic examination and visual evoked response [49]. and less operative stress on patients. This severity is linked to the nonuse of seatbelts. preservation of olfaction. Optic nerve injury can be direct or indirect. Early input by an ophthalmologist is important to rule loss or progressive loss on serial examination. Patients who undergo craniotomy for any reason can have optic nerve decompression performed at the same time [52]. Cricothyroidotomy The most common indications for cricothyroidotomy are clenched teeth (inability to open the mouth). In summary. Indirect optic nerve injury. and carotid cavernous sinus fistula. pupillary reflex.46]. then surgical exploration and decompression of the optic nerve are indicated. then high-dose (megadose) steroid is used as an adjunct to surgical management. A transethmoidal approach to surgical decompression of the optic nerve is popular and straightforward. or orbital apex syndrome. inaccessibility because a patient was trapped in the acute setting.perioperative care of the maxillofacial patient 269 Endotracheal intubation Orotracheal and nasotracheal intubations are reasonable alternatives to tracheostomy in stable patients who have midface fractures. contusion. which increases the risk of blindness with MFT from 2% to 20% [48]. as described by Walsh and Hoyte [50].  In ischemic ophthalmic retinopathy caused by retrobulbar hematoma. reversible neuropathy caused by edema. and there is a high correlation between the severity of maxillofacial injury and ocular injury leading to blindness.51]. retrobulbar hematoma. Traumatic blindness is caused by injury to the eyeball. When visual loss is delayed or progressive.The degree to which a patient is examined is based on the degree of injury. or thrombosis [49]. Optic nerve injury should be assessed clinically by visual acuity. vascular spasm. Kline and colleagues [49] proposed the following algorithm regardless of the method of injury in the absence of clear-cut transection of the optic nerve:  If there is loss of vision. If vision is restored on high-dose steroids and subsequent loss of acuity occurs when steroids are tapered or discontinued. Early diagnosis of visual impairment is linked directly to preventing visual loss. blood or vomit obscuring visualization of the upper airway. visual field. Perineural edema. High-resolution CT scan is the examination of choice in patients with suspected ocular injury and orbital cavity and bony injuries.

55]. In managing a patient with acute head injuries. 3 and 4). which is a leading cause of mortality in trauma patients [54]. hypovolemia. Standard fluid therapy includes the use of mannitol. Acute repair over a silastic stent should be considered in the obviously transected lacrimal duct system. The degree of cerebral injury sustained can be assessed with the simple AVPU system or the Glasgow Coma Score. History and physical examination are of importance in determining whether to operate. Once hemodynamic stability has been achieved. Acute head injury and fluid management One in three patients with multiple trauma has associated cerebral injury. Hyperventilation is not used because it may worsen brain injury in some patients (cerebral vasoconstriction.270 palmer et al Retrobulbar hematoma requires urgent decompression using lateral canthotomy with cantholysis. Axial and coronal CT scans. cerebral hypocapnea). give far superior information in suspected comminuted fractures. It also includes significant reduction in ICP [56]. Early fluid resuscitation of the multitrauma patient with head injury must achieve restoration of circulating volume and the efficient correction of shock. however [53]. Injury to the lacrimal canalicular system usually has a delayed presentation. Jones dye tests I and II can help to determine the level of lacrimal system disruption. Definitive repair may include dacrorhinocystostomy. or fractures associated with gross deformity are treated with immediate surgery. The Schirmer test can be used to assess for true epiphora. and pulmonary artery occlusion pressure. Efforts also are geared toward controlling increased ICP that may occur later [54]. however. Its shortcomings include hypovolemia and induction of hyperosmotic state. Simple displaced nasal fractures seen within the first 4 to 6 hours. Patients who are unfit for general anesthesia should be decompressed under local anesthesia by means of lateral canthotomy and inferior cantholysis. For more stable patients. The literature also supports the use of hypertonic saline [54. Other actions include reduction of blood viscosity. Secondary ischemic injury caused by reduced cerebral perfusion pressure and inadequate ventilation is more common than primary traumatic cerebral injury. deserve special mention.9%) or Ringer’s lactate is often used to resuscitate trauma patients. The key to managing a patient who has head injury is preventing secondary brain injury from hypoxia. Its hemodynamic profile includes improving preload and cerebral perfusion pressure and reducing ICP through cerebral autoregulation. It is recommended that early repair be performed over a silastic stent. which may be simple or open. The hemodynamic profile of hypertonic saline includes improved cerebral perfusion pressure. lateral brow incision and orbital decompression through a pterional approach are used.9% and 23. Frequent re-evaluation is key to detecting deterioration in neurologic function. however (2 – 3 weeks after the acute traumatic event). cardiac index. Nasal bone fractures. although they may be useful in cases with significant fracture displacement or comminution. acute raised ICP should be managed by CSF drainage and head elevation to 30°. basal secretion. Plain facial radiographic views are still used to delineate most facial fractures when CT scan is not available. the Glasgow Coma Score is an important monitoring tool.8% chance of concomitant neurologic injury. which acts as a diuretic. The infusion of normal saline (0. CT reconstruction views are rarely needed. It acts as an osmotic agent that dehydrates normal and abnormal brain. The transethmoidal transantral approach is a more familiar approach. Monitoring should keep osmolality less than 320 mOsm/kg [55]. ICP should be assessed (clinical and investigations: ICP monitoring). Rebound CSF acidosis and vasodilation occur when eucapnia is restored [56]. The volume required to restore circulating volume (4 – 6 L) may worsen ICP by enhancing brain edema. Facial bone fractures The diagnosis of facial fractures is based on history and physical examination and is confirmed with radiographs. Radiographs have no place in the decision-making process regarding management of simple nasal bone fractures [57]. open fractures. MRI plays a limited role except in the evaluation of orbital and intracranial pathology. Others are reassessed in 3 to 4 days . and orbital apex fractures (Figs. Colloids (typespecific blood or O-negative blood when typespecific is not available) should be infused once more than half a patient’s estimated blood volume must be given. however. and stimulated tear production in the affected eye. Patients present with epiphora. posterior wall of frontal sinus fractures. Patients with midface and orbital blowout fractures have a 21. respectively [8]. and increased ICP. Adequate oxygenation and hemodynamic stability are vital for controlling this preventable injury. which avoids secondary ischemic insult to the brain.

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