MAXILLOFACIAL TRAUMA/INJURIES
Alexander C. Cabungcal, MD, FPSO-HNS, FPCS
January 14, 2015; 1:00-3:30pm
Otorhinolaryngology
THE FACE
The following discussions were lifted from Moore’s Clinically
th
Oriented Anatomy 5 edition and online references:
The face is the anterior aspect of the head from the
forehead to the chin and from one ear to the other. The
basic shape of the face is determined by the underlying
bones. The individuality of the face results primarily
from anatomical variations in the shape and relative
prominence of the features of the underlying cranium; in
the deposition of fatty tissue; in the color and effects of
aging on the overlying skin; and in the abundance,
nature, and placement of hair on the face and scalp.
THE FACIAL SKELETON
The facial skeleton comprises of 15 irregular bones: 3
singular bones centered on or lying in the midline
(mandible, ethmoid, and vomer), and 6 bones occurring
as bilateral pairs (maxillae; inferior nasal conchae; and
zygomatic, palatine, nasal, and lacrimal bones).
Transcribers: Banyo Queen, Mang Raul
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FEATURES OF THE FACIAL SKELETON
FRONTAL BONE
Specifically its squamous (flat) part, the frontal bone
forms the skeleton of the forehead, articulating inferiorly
with the nasal and zygomatic bones.It also articulates
with the lacrimal, ethmoid, and sphenoids; a horizontal
portion of bone (orbital part) forms both the roof of the
orbit and part of the floor of the anterior part of the
cranial cavity
The supra-orbital margin of the frontal bone, the
angular boundary between the squamous and orbital
parts, has a supra-orbital foramen (notch) in some
crania for passage of the supra-orbital nerve and
vessels. Just superior to the supra-orbital margin is a
ridge, the superciliary arch, which extends laterally on
each side from the glabella. The prominence of this
ridge, deep to the eyebrows, is generally greater in
males
CRANIOMETRIC POINTS
Specific points in the face used radiographically in
medicine (or on dry crania in physical anthropology) to
make cranial measurements, compare and describe the
topography of the cranium, and document abnormal
variations
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ZYGOMATIC BONE
Also known as the cheek bones/malar bones, it forms
the prominences of the cheeks, lie on the inferolateral
sides of the orbits and rest on the maxillae. The
anterolateral rims, walls, floor, and much of the infra-
orbital margins of the orbits are formed by these
quadrilateral bones. The zygomatic bones articulate with
the frontal, sphenoid, and temporal bones and the
maxillae. It also where the masseter attaches; thus
injury to this area can affect mastication.
Zygomatic Arch - formed by the union of the temporal
process of the zygomatic bone and the zygomatic
process of the temporal bone.
Pterion – located at the anterior part of the temporal
fossa, 3–4 cm superior to the midpoint of the zygomatic
arch. It is usually indicated by an H-shaped formation of
sutures that unite the frontal, parietal, sphenoid (greater
wing), and temporal bones. Less commonly, the frontal
and temporal bones articulate; sometimes all four bones
meet at a point.
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Formatting: Ang nagmahal, Ang minahal,
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MAXILLA AND MANDIBLE
The maxillae form the upper jaw; their alveolar
processes include the tooth sockets (alveoli) and
constitute the supporting bone for the maxillary teeth.
The two maxillae are united at the intermaxillary suture
in the median plane.
The mandible is a U-shaped bone with an alveolar
process that supports the mandibular teeth. It consists of
a horizontal part (the body), and a vertical part (the
ramus). Inferior to the second premolar teeth are the
mental foramina for the mental nerves and vessels. The
mental protuberance, forming the prominence of the
chin, is a triangular bony elevation inferior to the
mandibular symphysis, the osseous union where the
halves of the infantile mandible fuse
The maxillae contribute the greatest part of the upper
facial skeleton, forming the skeleton of the upper jaw,
which is fixed to the cranial base. The mandible forms
the skeleton of the lower jaw, which is movable because
it articulates with the cranial base at the
temporomandibular joints
WALLS/BUTTRESSES OF THE CRANIUM
The bony substance of the cranium is unequally
distributed. Relatively thin (but mostly curved) flat bones
provide the necessary strength to maintain cavities and
protect their contents. Thickened portions of the cranial
bones form stronger pillars or buttresses that transmit
forces, bypassing the orbits and nasal cavity. Buttresses
provide strength and stability to the cranium.
(see color coding at next page)
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 COLOR CODING OF BUTTRESSES
HORIZONTAL BUTTRESS VERTICAL BUTTRESS Buttresses are important because when we repair our
zygomaticotemporal (yellow) nasomaxillary (red) maxillofacial trauma patients, we usually repair the
lower transverse maxillary zygomaticomaxillary buttresses. Repairing the buttresses is enough to
(green) (blue) maintain the facial skeleton of your patient
upper transverse mandibular pterygomaxillary
(orange) (magenta, below blue) TEMPORAL BONE
lower transverse mandibular posterior vertical
(purple) mandibular (purple)

The temporal bones are situated at the sides and base

Pterygomaxillary Buttress (other angle) – includes the
of the skull, and lateral to the temporal lobes of the
pterygoid plates of the sphenoid and maxillary
cerebrum. The temporal bone supports that part of the
tuberculosis. Due to its inaccessibility, IT’S RELATIVELY
face known as the temple and houses the structures of
IMPOSSIBLE TO RECONSTRUCT THIS STRUCTURE
the organ of hearing. The lower seven cranial nerves
ONCE THIS IS FRACTURED
and the major vessels to and from the brain traverse
the temporal bone.

FACIAL MUSCULATURE

MIDFACE BUTTRESS – formed from the combination of

the frontal bar (horizontal buttress at the upper margins
of the orbits and nasion) together with the
nasomaxillary, zygomaxillary and pteryogmaxillary
buttresses as well as the zygomatic arch.

MUSCLE FUNCTION
Occipitofrontalis – Front Belly
 Origin: Epicranial Elevates eyebrows and
Aponeurosis wrinkles skin of forehead;
 Insertion: Skin and protracts scalp (indicating
subcutaneous tissue of surprise or curiosity)
eyebrows and forehead
Occipitofrontalis – Occipital Belly
 Origin: Lateral two- Retracts scalp; increasing
thirds of superior nuchal effectiveness of frontal belly
Zygomaticomaxillary Complex (ZMC) – quadripod line
bony structure in the face composed of the lateral and  Insertion: Epicranial
inferior orbital rims, the zygomatic arch and the aponeurosis
zygomatciomaxillary buttress. Other bony buttresses Orbicularis oculi
(zygomaticomaxillary, zygomaticotemporal and  Origin: Medial orbital Closes eyelids: the palpebral
margin; medial palpebral part does so gently while
zygomaticofrontal) are connected in ZMC as well. The the orbital does so tightly
ligament lacrimal bone
point of connections of these buttreses is relatively  Insertion: Skin around (winking)
weak, resulting in an increased likelihood of fractures margin of orbit; superior
in this area. and inferior tarsal plates

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 MUSCLE
Corrugator supercilli
 Origin: Medial end of
supercillary arch
 Insertion: Skin superior
to middle of supraorbital
margin and supercillary
arch
Procerus + transverse part of
Nasalis
 Origin: Fascia
aponeurosis covering
nasal bone and lateral
nasal cartilage
 Insertion: Skin of inferior
forehead between
eyebrows
Alar part of nasalis + Levator labii
superioris alaeque nasii
 Origin: Frontal process
of maxilla (inferomedial
margin of orbit)
 Insertion: Major alar
cartilage
Orbicularis oris
 Origin: Medial maxilla
and mandible; deep
surface of peri-oral skin,
angle of mouth
(modiolus)
 Insertion: Mucous
membrane of lips
Levator labii superioris
 Origin: Infraorbital
margin (maxilla)
 Insertion: Skin of upper
lip
Zygomaticus minor
 Origin: Anterior aspect,
zygomatic bone
 Insertion: Skin of upper
lip
Buccinator
 Origin: Mandible,
alveolar processes of
maxilla and mandible,
pterygomandibular
raphe
 Insertion: Angle of
mouth (modiolus);
orbicularis oris
Zygomaticus major
 Origin: Lateral aspect of
zygmoatic bone
 Insertion: Angle of
mouth (modiolus)
Levator anguli oris
 Origin: Infraorbital
maxilla (canine fossa)
 Insertion: Angle of
mouth (modiolus)
Risorius
 Origin: Parotid fascia
and buccal skin (highly
variable)
 Insertion: Angle of
mouth (modiolus)
Depressor anguli oris
 Origin: Anterolateral
base of mandible
 Insertion: Angle of
mouth (modiolus)
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Formatting: Ang nagmahal, Ang minahal,
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FUNCTION
Depressor labii inferioris
Draws eyebrow medially
and inferiorly, creating
vertical wrinkles above nose
(demonstrating concern or
worry)
Mentalis
Depresses medial end of
eyebrow; wrinkles skin over
dorsum of nose (conveying
disdain or dislike)
Platysma
Depresses ala laterally,
dilating anterior nasal
aperture (flaring nostrils) as
during anger or exertion
Tonus closes oral fissure;
phasic contraction
compresses and protrudes
lips (kissing) or resists
distension (when blowing)
Part of dilators mouth:
retract (elevate) and/or
evert upper lip; deepen
nasolabial sulcus (showing
sadness)
Presses cheek against molar
teeth; works with tongue to
keep food between occlusal
surfaces and out of oral
vestibule; resists distension
(when blowing)
Part of dilators of mouth:
elevate labial commissure—
bilaterally to smile
(happiness); unilaterally to
sneer (disdain)
Part of dilators of mouth:
widens oral fissure as when
grinning or grimacing
Opthalmic
Part of dilators of mouth:
depresses labial
commissures bilaterally to
frown (sadness)
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MUSCLE FUNCTION
 Origin: Platysma and Part of dilators of mouth:
anterolateral body of retracts (depresses) and/or
mandible everts lower lip (pouting,
 Insertion: Skin of lower sadness)
lip
 Origin: Body of mandible Elevates and protrudes
(anterior to roots of lower lip; elevates skin of
inferior incisors) chin (showing doubt)
 Insertion: Skin of chin
(mentolabial sulcus
 Origin: Subcutaneous Depresses mandible
tissue of infraclavicular (against resistance): tenses
and supraclavicular skin of inferior face and neck
regions (conveying tension and
 Insertion: Base of stress)
mandible: skin of cheek
and lower lip; angle of
mouth (modiolus);
orbicularis oris
The facial muscles are innervated by facial nerve (CN VII)
with each nerve serving one side of the face. In contrast,
the nearby masticatory muscles are innervated by the
mandibular nerve (CN V3).
NERVE SUPPLY IN THE FACE
TRIGEMINAL NERVE
The trigeminal nerve (CN V) originates from the lateral
surface of the pons of the midbrain by two roots: motor
and sensory. The sensory root of CN V consists of the
central processes of pseudounipolar neurons located in a
sensory ganglion (trigeminal ganglion) at the distal end
of the root, which is bypassed by the multipolar neuronal
axons making up the motor root. The peripheral
processes of the neurons of the trigeminal ganglion
constitute three divisions of the nerve:
DIVISIONS
The superior division of the trigeminal nerve is the
(V1) smallest of the three divisions of CN V. It arises
from the trigeminal ganglion as a wholly
sensory nerve and supplies the area of skin
derived from the embryonic frontonasal
prominence. As CN V1 enters the orbit through
the superior orbital fissure, it trifurcates into:
 Frontal
 Nasociliary
 Lacrimal
Except for the external nasal nerve, the cutaneous
branches of CN V1 reach the skin of the face via
the orbital opening
Maxillary The intermediate division of the trigeminal nerve External nasal
(V2) also arises as a wholly sensory nerve. It passes emerges from nasal
anteriorly from the trigeminal ganglion and leaves cavity by passing
the cranium through the foramen rotundum in the between nasal bone and
base of the greater wing of the sphenoid. The lateral nasal cartilage
maxillary nerve enters the pterygopalatine fossa,
where it gives off branches to the pterygopalatine
ganglion and continues anteriorly, entering the
orbit through the inferior orbital fissure. It gives
off the zygomatic nerve and passes anteriorly into
the infra-orbital groove and foramen as the
From branches of Maxillary (V2)
infraorbital nerve
Mandibular It is the inferior and largest division of the Infraorbital
(V3) trigeminal nerve. It is formed by the union of transverses infraorbital
sensory fibers from the sensory ganglion and the groove and canal in
motor root of CN V in the foramen ovale in the orbital floor, giving rise to
greater wing of the sphenoid, through which CN superior alveolar
V3 emerges from the cranium. CN V3 has three branches, then emerges
sensory branches that supply the area of skin and via infraorbital foramen
also supplies motor fibers to the muscles of
mastication. The major cutaneous branches of CN
V3 are the:
 Auricotemporal
 Buccal Zygomaticofacial
 Mental transverse
En route to the skin, the auriculotemporal nerve zygomaticofacial canal in
passes deep to the parotid gland, conveying zygomatic bone at
secretomotor fibers to it from a ganglion inferolateral angle of
associated with this division of CN V. orbit: inside the red circles

CUTANEOUS NERVE DISTRIBUTION IN THE FACE

From branches of Opthalmic (V1)

Zygomaticotemporal
sends communicating
Supraorbital branch to lacrimal nerve
emerges from in orbit; then passes to
supraorbital foramina temporal fossa visa
zygomaticotemporal
canal

From branches of Mandibular (V3)

Auricotemporal
Supratrochlear passes posteriorly deep to
continuous antermedially ramus of mandible and
along roof of orbit: look superior deep part of
at the blue area at the parotid gland: inside the
picture on right red circle

Buccal
Lacrimal passes between 2 parts of
runs superolaterally lateral pterygoid muscles
through orbit: inside the emerging anteriorly from
red circle cover of ramus: inside the
red oblong

Infratrochlear
follows medial wall of
Mental
orbit, inferior to trochlea
emerges from mandibular
canal via mental foramen
in anterolateral aspect of
the mandible

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FACIAL NERVE
CN VII, the facial nerve, has a motor root and a
sensory/parasympathetic root (the latter being the
intermediate nerve). Following a circuitous route through
the temporal bone, CN VII emerges from the cranium
through the stylomastoid foramen located between the
mastoid and styloid processes. It immediately gives off
the posterior auricular nerve, which passes
posterosuperior to the auricle of the ear to supply the
auricularis posterior and occipital belly of the
occipitofrontalis muscle.
The main trunk of CN VII runs anteriorly and is engulfed
by the parotid gland, in which it forms the parotid
plexus. This plexus gives rise to the five terminal
branches of the facial nerve:
BRANCHES
Temporal Emerges from the superior border of the
parotid gland and crosses the zygomatic
arch to supply the auricularis superior and
auricularis anterior; the frontal belly of the
occipitofrontalis; and, most important, the
superior part of the orbicularis oculi.
Zygomatic Passes via two or three branches superior
and mainly inferior to the eye to supply the
inferior part of the orbicularis oculi and
other facial muscles inferior to the orbit.
Buccal Passes external to the buccinator to supply
this muscle and the muscles of the upper
lip (upper parts of orbicularis oris and
inferior fibers of levator labii superioris)
Marginal Supplies the risorius and muscles of the
Mandibular lower lip and chin. It emerges from the
inferior border of the parotid gland and
crosses the inferior border of the mandible
deep to the platysma to reach the face. In
approximately 20% of people, this branch
passes inferior to the angle of the mandible
Cervical Passes inferiorly from the inferior border of
the parotid gland and runs posterior to the
mandible to supply the platysma
So that ends our brief Anatomy discussion: 6 pages
right? Let’s now proceed to the ENT proper.
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FACIAL FRACTURES
Nowadays, we see less of facial traumas because
patients are either confined solely in the hospital or they
don’t actually reach the hospital (they die on the spot).
This is true especially of motorcycle injuries (those
drivers who don’t wear a helmet)
Pathophysiology
 The amount of force to fracture different facial
bones have been studied and have been divided
into:
 High Impact: (greater than 50 times
gravity)
 Supraorbital rim – 200 G
 Symphysis of the Mandible –
100 G
 Frontal – 100 G
 Angle of the mandible – 70 G
 Low Impact: (less than 50 times
gravity)
 Zygoma – 50 G
 Nasal bone – 30 G
Etiology
 60% of patients with severe facial trauma
have multisystem trauma and the potential
for airway compromise.
 20-50% concurrent brain injury.
 1-4% cervical spine injuries.
 Blindness occurs in 0.5-3%
INITIAL MANAGEMENT
Advanced Trauma Life Support
 Primary Survey
 Resuscitation
 Secondary Survey
 Definitive treatment
PRIMARY SURVEY
A - Airway maintenance with cervical spine control
B - Breathing and ventilation
C - Circulation with hemorrhage control
D -Disability assessment of neurological status
E - Exposure and complete examination of the patient
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HEMORRHAGE CONTROL  Put a Combitube, Laryngeal Mask Airway (LMA)

Bleeding from facial injuries typically is profuse but Laryngeal Mask Airway
rarely causes hypovolemia or shock. In hypotensive
patients, look for other sources of blood loss such as
intrathoracic, intraabdominal, and retroperitoneal
hemorrhage.

Maxillofacial bleeding:
 Direct pressure.
 Avoid blind clamping in wounds.
Nasal bleeding:
 Direct pressure.
 Anterior and posterior packing.
Pharyngeal bleeding:
 Packing of the pharynx around Endotracheal
(ET) tube.

Try to control bleeding with direct pressure. Blind Combitube

clamping should be avoided because injury to
important nonvascular structures such as the facial
nerve and parotid duct can result. Anterior and
posterior packing may be needed in patients with nasal
bleeding that does not resolve with direct pressure
alone. Pharyngeal bleeding may require packing
around the ET tube

DO RESUSCITATION

 Jaw thust / Chin lift / Head tilt

 Definitive airway (Cuff in trachea)

 Oro / Naso tracheal intubation
 Usually, maxillofacial trauma patients
would not need intubation if the injury
is not that severe. Should he/she need
it, the oral-tracheal intubation is the
primary means to provide a secure
airway.
 Nasotracheal intubation has to be
avoided:
 It is a lot more difficult than
oral-tracheal intubation
 Secure a Naso / Oropharyngeal airway  In some severe injuries,
passage of tube into the nose
might cause this tube to go
directly to the cranium
 Nasal haemorrhage might be
present. This will make the
procedure even more difficult
and risky to do
 Rapid Sequence Intubation has to be
avoided as much as possible because
this might paralyze the patient upon
intubation. As an end result, you would
fail to actually intubate/ventilate your
patient
 Rapid Sequence Intubation is
a way of intubating patients
who have a gag reflex and
would be difficult to intubate.
This is done by sedating and
temporarily paralyzing the
patient

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  If you have a patient who’s airway from occluding (blocking) the entrance
cannot be secured immediately, you to the trachea, helping to ensure a
can do “AWAKE INTUBATION” patent (secure) airway.
 Placing an ET tube in the
trachea of the patient while
the patient is breathing
 If you need seadation, you may use
BENZODIAZEPINES

Nasotracheal Orotracheal
Intubation Intubation
*Left picture: Jaw thrust; Right picture: Chin Lift*

 Oropharyngeal suctioning
o To clear out secretions

 Manually move the tongue forward: the tongue

may cause airway obstruction, therefore try to
move it forward to secure patent airway

 Surgical cricothyroidotomy
 If all else fail, proceed with
cricothyroidotomy

 Maintain cervical immobilization

 Existence & identification of obstruction
 fractured teeth, displaced dentures,
blood clots, oral secretions
 Manually clear of fractured teeth, blood clots,
dentures

DISABILITY ASSESSMENT & NEUROLOGIC STATUS

Rapid assessment of neurological disability is made by

Also consider looking for any tension pneumothorax or noting the patient response on four points scale:
hemothorax that might prevent the patient from  A Responds appropriately, is Aware
adequately respirating:  V Response to verbal stimuli
 Small pneumothorax isn’t usually addressed. If  P Response to painful stimuli
you’re thinking of giving the patient Positive  U Does not respond, Unconscious
Pressure Ventiation: THINK AGAIN. Giving
Positive Pressure Ventilation in these patients GLASGOW COMA SCALE (GCS)
may lead to enlargement of the small (Teasdale and Jennett, 1974)
pneumothorax. This in turn, would be a big
problem during surgery

EMERGENCY MANAGEMENT AIRWAY CONTROL

 Chin lift – check first if patient has no spinal

injuries
 Jaw thrust.
o The jaw thrust is a technique used on
patients with a suspected spinal injury
and is used on a supine patient. The
practitioner uses their thumbs to
physically push the posterior (back)
aspects of the mandible upwards - only EXPOSURE
possible on a patient with a GCS < 8
(although patients with a GCS higher  All trauma patient must be fully exposed in a
than this should also be maintaining warm environment to disclose any other hidden
their own patent airway). When the injuries
mandible is displaced forward, it pulls
 This is the start of your secondary survey
the tongue forward and prevents it

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SECONDARY SURVEY
 Head-to-toe evaluation
 An oromaxillofacial surgeon may be involved at
an early stage if the airway is compromised.
 When the airway is adequately secured the
second survey of the whole body is to be carried
out for:
 Accurate diagnosis
 Maintenance of a stable state
 Determination of priorities in
treatment
 Appropriate specialist referral
 Once the airway is secured and gross
hemorrhage is controlled, only then search for
life threatening injuries to the chest, abdomen
and pelvis.
 Should not be performed until
hemodynamic stabilization is achieved
PRIORITY FOR TREATING INJURIES
1. Head injuries
 If you’re suspecting of a head injury, do
an HOURLY GCS MONITORING
 You should be aware that some
patients might be on anticoagulants
which could compromise their
condition
 Do X-rays, Specialized diagnostic tests
(CT scans, ultrasounds, scopes)
 MOST IMPORTANT PHYSICAL EXAM
FINDING: Otorrhea and Rhinorrhea
since they may indicate CSF leak
2. Abdominal injuries
3. Injuries to the extremities
4. Maxillofacial injuries
 Facial trauma can exacerbate injuries
of airway compromise
You should be aware of possible spine injury to the
patient. These are usually unrecognized during the
accident or in the Emergency Room (ER):
 Cervical spine injuries are more prevalent in the
elderly because of co-morbidiites (e.g., arthritis,
osteoporosis)
 Cervical spine injuries are also commonly found
in patients suffering from laryngeal or
mandibular injuries
 Cervical collar is usually applied if cervical spine
injury is suspected
Again, patient may suffer from neck injuries which are
divided into 3 zones:
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Zone 1:
 From thoracic inlet to cricoid
 Injuries to this zone are usually life threatening
because they may involve your trachea, great
vessels and lungs
 A CT angiography is usually mandatory if there
is a penetrating injury to this zone
Zone 2:
 From cricoid to angle of mandible
 This is the most controversial of all injury zones
since the management varies for different
groups of surgeons
 Check for injuries to theplatysma. If platysma is
penetrated, you can do angiography,
endoscopy, ultrasound and other modalities
Zone 3:
 From mandible to skull base
 Make sure that the carotids are not injured
 Angiograms are needed in dealing with injuries
to this zone
HISTORY
 Acquire history from patient (if he/she can talk),
witness or the emergency personnel who
brought the patient to the ER.
 Get History (AMPLE)
o Allergies
o Medications
o Past medical history
o Last meal (VERY IMPORTANT
especially before any surgery)
o Events leading to the injury (e.g. Was
the patient drunk driving? Was the
patient sleepy prior to injury?)
 Ask SPECIFIC Questions:
 Was there LOC? If so, how long?
 How is your vision?
Monoocular Diplopia:
 In monocular diplopia, there is double vision
even when the other eye is covered
 This is usually seen in patients with:
Retinal Detachment
Lens Disclocation
Corneal laceration
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  Is the patient able to bite down without
Binocular Diplopia: any pain?
 The doubling of vision ends when one eye is  Is there pain with moving the jaw?
covered  Fractures, impingement of the
 This is usually caused by EOM impairment temporalis muscle
due to a bone, nerve or muscle injury:  Is there malocclusion?

Most patients would not know what malocclusion means.

Hence, you ask them if there are noticeable changes in
 Hearing problems? their bite (different from pain sensation). Pain will not tell
 Most of the problems are you whether there is malocclusion since pain can be due to
usually caused by blood a lot of other injuries
dripping into the ear canal
 Is there pain with eye movement? PHYSICAL EXAMINATIONS
 Injury to the globe, orbit
 Are there areas of numbness or  Inspection of the face for asymmetry.
tingling on your face?  Best done at the head of the bed
 Nerve entrapment  Check for malar area asymmetry
 Ask the patient to smile, frown, whistle, raise
Facial anaesthesia may be caused by: their eyebrows and close their eyes.
 Inspect open wounds for foreign bodies
(especially for those patients who were in a
vehicular accident).
 Palpate the entire face.
 Supraorbital and Infraorbital rim
 pay special attention to the
supraorbital rim and lateral
 Infraorbital nerve and medial walls
o often secondary to blowout or rim
fractures
o cause anesthesia of the upper lip

 Mental or Mandibular nerve

o mandibular fractures  Zygomatic-frontal suture
o causes lower lip anesthesia

 Supratrochlear or Supraorbital nerve

o happens due to frontal bone fracture,
hence areas of the frontal bone are
paralyzed

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  Zygomatic arches  Inspect nasal septum for septal hematoma, CSF
or blood. (Place a drop of blood on a paper
towel and look for a halo sign, nonspecific).

 Note ecchymosis (Battle’s sign, Raccoon eyes)

Septal hematoma
Raccoon’s Eyes
 bilateral
periorbital
ecchymosis
 This may indicate
basilar skull
fracture, Le Fort
fracture, and
NEO
(Nasoethmoidal-
orbital) injuries
Halo sign:
Once you drop a blood discharge on a towel, look for its
Battle's Sign smudge characteristic: if there’s a clear liquid film encircling
 Bluish the blood droplet, it’s probably CSF
discoloration of
the post-  Palpate nose for crepitus, deformity and
auricular region, subcutaneous air.
associated with  Palpate the zygoma along its arch and its
temporal bone articulations with the maxilla, frontal and
fractures temporal bone. Tenderness along this area
indicates fracture
 Check facial stability.
NOSE:
 Inspect the nose for asymmetry, telecanthus,
widening of the nasal bridge.
 Measure the distance between the medial
canthi.
 In normal patients the distance is 35-
40mm. If it’s greater than 40 mm you
should suspect nasoethmoid-orbital
trauma.
Traumatic Telecanthus

MOUTH:
 Inspect the teeth for malocclusions, bleeding
and step-off.

 An important finding in naso-ethmoidal-orbital

(NEO) injuries
 When the distance between the medial ends of  Intraoral examination:
the palpebral fissures of both eye exceeds the  Manipulation of each tooth.
distance measured between the medial and  Check for lacerations.
lateral canthi of an individual eye  Stress the mandible.
 Tongue blade test.

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  Palpate the mandible for tenderness, swelling
and step-off. Areas of tenderness would
indicate the fracture site
EYES:
 Check visual acuity.
 Check pupils for roundness and reactivity.
 Examine the eyelids for lacerations.
 Test extra ocular muscles.
 Palpate around the entire orbits..
 Evaluate extraocular motions in all directions
while asking the patient about diplopia

 Check for bony crepitus since that would mean

that one of the sinuses is involved/violated

Marcus Gunn test: (Swinging Flashlight Test)

 In patients who suffer ocular trauma
 Perform the swinging flashlight test
 Swing the penlight back and forth between
the pupils
 If a pupil dilates when initially struck by
light, an optic nerve or retinal injury is likely.

 Anaesthesia or paresthesia would mean an

injury to the nerve (Mental nerve)

Drawer’s Sign
 Rocking of the palate, pathognomonic of Le Fort
fractures
 Grasp the anterior maxillary arch and then pull and
push firmly, keeping the opposite hand on the
patient’s forehead to prevent motion of the neck

 Examine the cornea for abrasions and

lacerations.
 Examine the anterior chamber for blood or
hyphema.
 Perform fundoscopic exam and examine the
Spatula test / Tongue Blade Test posterior chamber and the retina.
 Subconjunctival Hemorrhage is usually
 If no fracture is obvious, stress the mandible to
present in most maxillofacial injuries.
detect mobility or pain
This will usually end in 2-3 weeks
 Perform the with a tongue blade
 Have the patient bite down on the tongue blade
and twist forcibly. Patients with mandibular
fractures reflexively open their mouths, and the
tongue blade will not bend or break

Subconjunctival Hemorrhage

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EARS: MAXILLOFACIAL REGIONS
 Examine and palpate the exterior ears.
 Hematoma of the pinna cannot be
managed conservatively. It has to be
drained; otherwise, there is a high
probability of perichondritis occurring
(and much later  cauliflower ears)

 Upper face
 Where fractures involve the frontal
bone and sinus
Hematoma of the Pinna  Midface
 Upper Midface
 Examine the ear canals.  Is where maxillary Le Fort II
 Check neuro distributions of the supraorbital, and Le Fort III fractures,
infraorbital, inferior alveolar and mental nerves. fractures of the nasal bones,
 Check if the ear canals contain blood or if the nasoethmoidal or
tympanic membrane is perforated zygomaticomaxillary
 Hemotympanum (blood in the middle complex, and the orbital floor
ear) is considered if there is a occur.
bluish/blackish tympanic membrane.  Lower Midface
This is usually seen in temporal bone  Where Le Fort I fractures
fractures. This will usually present as a happen
triangular perforation plus you’ll notice  Lower face
that a part of the tympanic membrane o Where fractures are isolated to the
has been peeled off. Topical antibiotics mandible
will be given in these cases. If no
infection occurs within 2-3 weeks, then FRACTURES OF THE UPPER FACE
it heals spontaneously (usually in 6 FRONTAL BONES AND FRONTAL SINUS FRACTURES
months)

Pathophysiology
Hemotympanum:  Results from a direct blow to the frontal bone
Blood in the middle ear causes a bluish discoloration of the with blunt object
drum  Associated with:
 Intracranial injuries
 Injuries to the orbital roof
 Dural tears

Clinical Findings
 Disruption or crepitance of orbital rim
 Subcutaneous emphysema – in patients with
frontal sinus violation
 Associated with a laceration
 CSF rhinorrhea
 Supraorbital nerve anesthesia
 Depressed frontal region
 Subconjunctival ecchymosis (Raccoon’s Eyes)
Tympanic Membrane Perforation with bleeding

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Imaging Studies Complications
 Radiographs:  Associated with intracranial injuries:
 Facial views should include Waters,  Orbital roof fractures
Caldwell and lateral projections.  Dural tears
 Caldwell view is the most helpful and  Mucopyocoele – most of the bone fractures
best evaluates the anterior wall are prone to develop with this kind of
fractures. complication later on especially if surgery
was not done
 There is not enough drainage in
the nasofrontal gap
 Epidural empyema
 CSF leaks
 Meningitis

FRACTURES OF THE MIDFACE

NASAL FRACTURES

 Most common of all facial fractures.

Fracture inside the red oblong via a radiograph
 Injuries may occur to other surrounding bony
structures.
 CT Head with bone windows:  3 types:
 HIGHLY RECOMMENDED  Depressed
 Frontal sinus fractures.  Laterally displaced
 Orbital rim and nasoethmoidal  Non-displaced
fractures.  Ask the patient:
 Helpful in R/O brain injuries or  “Have you ever broken your nose
intracranial bleed before?”
 “How does your nose look to you?”
 “Are you having trouble breathing?”
 MOST IMPORTANT: if he doesn’t
have any difficulty, then
interventions with regards to the
nasal cartilages is not necessary
Imaging Studies
 History and Physical exam.
 Soft tissue Lateral X-ray  BEST IMAGING
STUDY
 Lateral or Waters view to confirm your
diagnosis: for confirmation, or to see if your
patient has an isolated nasal fracture

Treatment
 Patients with depressed skull fractures or with
posterior wall involvement.
o ENT and neurosurgery consultation
o Admission
o IV antibiotics
o Tetanus
o ORIF if necessary The black silhouette on the right in this picture is the patient’s
 Patients with isolated anterior wall fractures, face. The one on the red circle is the nasal alae, with the
non-displaced fractures can be treated fracture
outpatient after consultation with neurosurgery Treatment
 Control epistaxis
 Drain septal hematomas
 Consevative management
 Open/Close Reduction

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OPEN REDUCTION
Open reduction of nasal bone fracture using an Ash forcep. The
forcep is inserted into the nostril, and fractured fragment is lifted.
 The fractured nasal bone is left with no treatment for
one month
 The treatment of choice in cases with extensive
fracture dislocation of the nasal bone and septum or
if a deformity still persists after an attempted closed
reduction
CLOSED REDUCTION
 Reduction would require elevation of the nasal bones
anteriorly and repositioning of the frontal processes
medially
Indications for repair
Just follow the outlines
 abnormal nasal function (difficulty in breathing
through the nose)
 abnormal appearance (dents)
 presence of early post-injury complications
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NASO-ETHMOID-ORBITAL (NEO) FRACTURES
 One of the most complex fractures in the
maxillofacial area
 May be misdiagnosed as simple nasal fracture
 May occur as isolated injury
 May be part of more complex (Le Fort) facial
fractures
 Produce disruption of critical aesthetic and
functional area
 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.
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 (disrupted medial canthal
ligament)
 Intraorbital air  orbit is soft to touch: absence
of Bowstring’s Sign
 “pig snout ” deformity  tip of the nose is tilted
upward; nose appears shortened; dorsum is
flattened between canthi
 Telescoping of ethmoid sinuses as the nasal
bones are pushed posteriorly
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Imaging studies
 Plain radiographs are insensitive: DO NOT
ORDER RADIOGRAPHS. You won’t see
anything
 CT of the face with coronal cuts through the
medial orbits. (BETTER IMAGING STUDY)
Clinical Findings
 Periorbital tenderness, swelling, ecchymosis
(these signs indicate fracture).
 Enopthalmus or sunken eyes  this is because
the floor has collapsed and they eye descends
to the maxillary area

 Impaired ocular motility  an important sign

that involves your lateral rectus, inferior oblique
or inferior rectus muscle
 Infraorbital anesthesia (alam niyo na kung anong
Treatment nerve ang natamaan panigurado).
 Early treatment is much more effective than  Step off deformity
late  Restriction of eye movement  if you’re not
 Involves sure, you can do Forced Duction test using
 reduction of the impacted nasal bone forceps.
 medial canthal tendon repair
 Use of rigid fixation 1.2 or 1.5 mm microplates

This is Forced Duction Test using forceps.

PLEASE DO ANAESTHETIZE THE PATIENT PRIOR TO DOING
THIS. Horror

ORBITAL BLOWOUT FRACTURES

 Blow out fractures are the most common orbital

injuries.
 Occur when the the globe sustains a direct blunt
force
 2 mechanisms of injury:
o Blunt trauma to the globe
o Direct blow to the infraorbital rim

When you see your grades every evals

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 Imaging studies ZYGOMATIC ARCH FRACTURES
Radiographs:
 Paranasal Sinus X-
Ray (look for):

o Hanging tear
drop sign
o Open bomb bay
door
o Air fluid levels
o Orbital
emphysema
 If it’s pure arch fracture, we don’t usually do
 CT Head much reductions
o To R/o  Can fracture 2 to 3 places along the arch
intracranial o Lateral to each end of the arch
injuries o Fracture in the middle of the arch
 Patients usually present with pain on opening
their mouth (arch may have impinged the
temporomandibular joint)

Clinical Findings
 Palpable bony defect over the arch
 Depressed cheek with tenderness (if fracture is
 CT of orbits not displaced)
o Details the
orbital fracture
o Excludes
retrobulbar
hemorrhage

 Pain in cheek and jaw movement

 Depressed malar area
 Limited mandibular movement
Treatment
Imaging Studies
 ORIF
 Radiographic imaging:
 Goals of surgery o Submental view (bucket handle view)
o Elevate orbital contents out of fracture
site
o Release any adhesions between orbital
contents and fracture site
o Prevent any readhesion
o Restore orbital walls to normal shape
 Use of 1.2 or 1.5 microplates

Treatment
 Conservative management
o Minimal/Undisplaced fractures
o Patients with medical contra-indications
o The very elderly

FRACTURES OF THE ZYGOMA

 The zygoma has 2 major components:

o Zygomatic arch
o Zygomatic body
 Blunt trauma most common cause.
 Two types of fractures can occur:
o Arch fracture (most common)
o Tripod fracture (most serious) Temporal Fossa (Gillies) Approach: the following pictures
above are part of the Conservative Management

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Closed reduction if symptomatic  Flatness of the lateral cheek area
o Cosmetic deformity
o Impaired mandibular movement
o Diplopia
o Infraorbital para/anaesthesia

Intraoral Approach  pass through the gingiva until you reach

the zygomatic arch

 Diplopia on upward gaze – if there is a trapped

muscle

Eyebrow incison  done to hide scars

 Inferior displacement of ocular globe –

especially if floor of orbital floor is lost

ZYGOMATIC ARCH FRACTURES

 inability to open mouth

 Periorbital ecchymosis

 Repair with this kind of fracture is

MANDATORY
 Tripod fractures consist of fractures through:
o Zygomatic arch
o Zygomaticofrontal suture Imaging Studies
o Inferior orbital rim and floor  Radiographic imaging:
o Waters, Submental and Caldwell views
Clinical Features  Coronal CT of the facial bones( GOLD
 Periorbital edema and ecchymosis STANDARD):
 Hypesthesia of the infraorbital nerve o 3-D reconstruction
 Palpation may reveal step off

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Treatment Clinical findings
 Non-displaced fractures without eye  Facial edema
involvement  Malocclusion of the teeth
 Motion of the maxilla while the nasal bridge
remains stable

o Ice and analgesics

o Delayed operative consideration 5-7 Imaging Studies
days  Radiographic findings:
o Decongestants o Fracture line which involves
o Broad spectrum antibiotics o Nasal aperture
o Tetanus o Inferior maxilla
o You may send the patient home and let o Lateral wall of maxilla
the fracture heal by itself
 Displaced tripod fractures usually require  CT of the face and head
admission for open reduction and internal o coronal cuts
fixation using 1.2 or 1.5 microplates o 3-D reconstruction
 Incision may be done on infraorbital,
eyebrow or gingivobuccal area

Treatment
 ORIF
 Correction of malocclusion is main goal
MAXILLARY FRACTURES

 High energy injuries.

 Impact 100 times the force of gravity is
required
 Patients often have significant multisystem
trauma.
 Classified as LeFort fractures.

MAXILLARY FRACTURES LEFORT I

MAXILLARY FRACTURES LEFORT II
Definition:
 Guerin’s Fracture Definition:
 Horizontal fracture of the maxilla at the level of  Pyramidal fracture
the nasal fossa. o Maxilla
 Allows motion of the maxilla while the nasal o Nasal bones
bridge remains stable (after Drawer’s Test) o Medial aspect of the orbits

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Clinical findings
 Marked facial edema
 Nasal flattening
 Traumatic telecanthus
 Epistaxis or CSF rhinorrhea
 Movement of the upper jaw and the nose after
Drawer’s Test
Imaging Studies
Dish-faced Deformity
 Radiographic imaging:
o Fracture involves: Imaging Studies
 Nasal bones  Radiographic imaging:
 Medial orbit o Fractures through:
 Maxillary sinus  Zygomaticfrontal suture
 Frontal process of the maxilla  Zygoma
 CT of the face and head  Medial orbital wall
 Nasal bone
 CT Face and the Head (GOLD STANDARD)

Treatment
 ORIF
 Correction of malocclusion is main goal

Treatment
 ORIF
 Correction of malocclusion is main goal

MAXILLARY FRACTURES LEFORT III

Definition
 Fractures through: FRACTURES OF THE LOWER FACE
o Maxilla MANDIBULAR FRACTURES
o Zygoma
o Nasal bones
o Ethmoid bones
o Base of the skull

Clinical findings
 Dish faced deformity
 Epistaxis and CSF rhinorrhea
 Motion of the maxilla, nasal bones and zygoma
after Drawer’s Test
 Severe airway obstruction

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Pathophysiology
 Mandibular fractures are the third most
nd
common facial fracture (2 most common is
orbital rim fracture right?).
 Assaults and falls on the chin account for most
of the injuries.
 Multiple fractures are seen in greater than 50%.
 Associated C-spine injuries – 0.2-6%.

Treatment
 ORIF
 If this is your management,
intermaxillary fixation (installation of
braces) is mandatory since the
mandible is an active (highly movable)
area of the face
 Correction of malocclusion is main goal
Clinical findings  Use 2.0, 2.4 or 2.5 mm plates
 Mandibular pain
 Malocclusion of the teeth
 Separation of teeth with intraoral bleeding
 Inability to fully open mouth
 Preauricular pain with biting.
 Positive tongue blade
 Anesthesia
 Swelling, hematoma
 Crepitus

Intermaxillary fixation

Imaging Studies
 Radiographs: Interosseous wiring
o Panoramic view (BEST VIEW) Old method: usually given if patients cannot afford titanium
o Plain view: PA, Lateral and a Townes view plates

Panoramic View
Lag screws

Titanium Plating/Rigid plates

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TEMPORAL BONE FRACTURES TRANSVERSE TEMPORAL BONE FRACTURE

 3 types
o Longitudinal
o Transverse
o Mixed

Battles’ sign

LONGITUDINAL TEMPORAL BONE FRACTURE  Less common

 Severe sensorineural hearing loss
 Loss of vestibular frunction
 Facial paralysis
 Hemotympanum

 Common
 Tympanic membrane Hemotympanum
 Roof of middle ear Treatment
 Ant. Petrous apex  Usually non-surgical
 Delayed onset VII paralysis  Supportive
 Disruption of ossicles
 Bleeding from the canal

Tympanic membrane
perforation and Bleeding
from the ear

CSF otorrhea

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