ENT CASE PRESENTATION

CSU-PGI SPUP CLERKS

LACAMBRA, PHILDENCE JAI PAZZIGUAN,REYNEL
SUNNY,RIYA
UDARBE MARIE IRENE
 GENERAL DATA
PATIENT : R C
AGE/SEX : 25,Male
CITIZENSHIP :Filipino
RELIGION :Roman Catholic.
CIVIL STATUS : Single
DOB :15th February 1995
ADDRESS : Gadu, Solana
CHIEF COMPLAINT : Facial injury
 HISTORY OF PRESENT ILLNESS
NATURE OF INCIDENT : Motor Vehicular Accident
TIME OF INCIDENT : 12PM
PLACE OF INCIDENT : Solana
DATE OF INCIDENT : 15th october 2020

One hour prior to admission

• Patient was riding a motorcycle & got involved in motor vehicular accident
• He was hit by a speedy car coming from the opposite direction and was ejected
2 meters away during the collision.
• He fell on the road and hit his face on a concrete plant box and experienced :
– (+) Transient loss of consciousness lasting for 2 minutes(according to a witness)
– (+) Excruciating pain over the middle third of face(rated as 9/10)
– (+) Headache ( Bifrontal ;rated 5/10)
– (-) Nausea,(-) Vomiting ,(-) Blurry vision, (-) seizure (-) dizziness
• He was brought to the ER by a witness
 PRIMARY SURVEY

AIRWAY : Patent Airway.

BREATHING : RR- 20cpm , spo2=98%
: Symmetric chest expansion.
CIRCULATION: CRT< 2sec , BP:120/70mmHg, HR:85bpm
: Clotted nasal bleed
: No other active bleeding
DISABILITY/DEFORMITY:GCS -15/15 ,(E4 V5 M6)
:Pupil bilateral reactive(4/4)
EXPOSURE : Noted abrasions over face and body.
 SECONDARY SURVEY:

GCS :15/15 (E 4V 5M6)

VITAL SIGNS
Respiratory Rate : 20 /min
Blood Pressure : 110/70 mmHg(left Arm)
Pulse Rate : 85bpm
Temperature : 37.5°C
Oxygen Saturation :98%
 PAST HISTORY
Childhood illnesses :None
Adult illnesses
• Medical : None
• Surgical : None
• Psychiatric : None
Health maintenance : Complete vaccination .
Screening test : None.
 FAMILY HISTORY
• Father ,66years old , alive and well.
• Mother, 65 years old ,alive and well.
• The patient has 2 sibling : alive and well
• No family history of cardiovascular diseases ,Diabetes
mellitus, Bleeding disorders or other disorders
 PERSONAL AND SOCIAL HISTORY
• Born and raised in Solana.
• The educational attainment is grade five.
• The patient was working as a utility worker and currently he is
a farmer.
• Non-smoker and Non alcoholic beverage drinker.
• Caffeine intake - Occassional.
• Prefers vegetables and little meat in diet.
• Gets little exercise.
 REVIEW OF SYSTEMS

General : (-) fever, fatigue, weakness

Skin : No itch,rashes or colour change.

HEENT
Head : (-) Lightheadedness
Eyes : (-) pain, excessive tearing, double vision
Ears : No tinnitus ,vertigo and infections
Nose : No cold,hay fever,sinus trouble.
Throat:No bleeding of gums,sore throat.
REVIEW OF SYSTEMS
Neck: No lumps , pain , swollen glands and limitation of
movement
Breast : No pain , lumps ,discharge.
Respiratory: No Cough ,wheezing, shortness of breath
Cardiovascular : No known heart disease .No substernal pain ,
palpitations .
Gastrointestinal :No abdominal pain and tenderness
Urinary: No hesitance ,dysuria , hematuria ,or recent flank pain
REVIEW OF SYSTEMS
Genital :No Perineal pain or infection.
Musculoskeletal : No pain , stiffness ,joint swelling.
Neurologic : (-) memory loss, vertigo, tremors, changes in
attention or speech
Hematologic :Pallor or easy bruising.
Endocrine : (-)Polydypsia, polyuria, polyphagia, (-) heat or cold
intolerance
 PHYSICAL EXAMINATION
General Survey
• Patient is alert, conscious, coherent and not in
cardiorespiratory distress.

VITAL SIGNS
• Respiratory Rate : 20 /min
• Blood Pressure : 120/70 mmHg(left Arm)
• Pulse Rate : 85bpm
• Temperature : 37.5°C
• Oxygen Saturation :98%
 PHYSICAL EXAMINATION
Skin
• Warm to touch , good skin turgor.
• Laceration : 2cm over nasal bridge
: 3cm over left maxillary region.
: 2cm - left upper arm,2cm-right hand
• Nail clubbing(-) , Cyanosis (-), jaundice(-)

HEENT
Head :(+)Ballooning of face or moon face
(+)Gross edema of middle third of face
Scalp without lesions .No lesions and tenderness
over frontal region.
Eyes : (+) Bilateral ecchymosis of the eyelids.
(+) Bilateral subconjuctival hemorrhage
(medially).
Symmetrical ,Pupils 2-3mm,round,equally reactive to
light and accomdation.
Extraocular movements intact.

Ears : Symmetrical with no external swelling , no redness ,no

visible discharge , no tenderness ,no lesions , hearing
grossly intact bilaterally ,Both ears: Normal cone of
light.
 PHYSICAL EXAMINATION

Nose
(+) mobility of nose,(+) Depressed nasal bridge
(+) tenderness over nasal region

Mouth
(+)hematoma in upper buccal mucosa
(-)No malocclusion
(-) No ecchymosis of palate
Tongue and uvula in midline ,Tonsils not enlarged.
Neck : No cervical spine tenderness, Neck supple ,Trachea
midline. No palpable lymph nodes.

Thorax and lungs

Inspection- Thorax symmetric with good excursion.
Palpations-No tenderness.
Auscultation- Breath sounds vesicular with no added sounds . No
rales or wheezes.
Percussion- Lungs resonant.

Cardiovascular
Inspection- Adynamic precordium
Palpation -PMI at 5th ICS left MCL.
Auscultation - No abnormal murmurs felt.
Breast : Symmetric ,No masses
Abdomen
Inspection- No visible masses or lesions.
Palpation - No tenderness or masses .Spleen and kidneys not felt.
Auscultation- Normoactive Bowel sounds
Extremities
Inspection- warm and without edema.CRT<2sec
Palpation - No tenderness over upper extremities
and right lower extremity
Musculoskeletal :No joint deformities . Good
range of motion in hands ,wrists , elbows, shoulders ,
spine.
Neurologic : Alert , cooperative. Oriented to person ,
place and time.
• GCS: 15
• Motor :Muscle bulk and tone are normal , 5/5 in all limbs
• Sensory : Intact sensation
• Cranial nerve : All intact
I- smell
II- Pupils equally reactive to light and accommodation
III, IV, VI – Extra ocular muscles intact (able to follow objects without deviation)
V -corneal reflex
VII -facial symmetry
VIII-responds to sound
IX, X - Gag reflex
XI -Symmetrical shoulders
XII- no tongue deviation
 DIAGNOSTICS
CT SCAN

• (A) Coronal CT image shows fractures through the lateral maxillary walls,
inferior orbital rims , and across the medial orbital walls , creating a pyramidal
fracture characteristic of the Le Fort II pattern.
• (B)Coronal image posteriorly shows comminution of the pterygoid plates.
 SALIENT FEATURES
• 25 ,Male
• History of head injury
• Pain over middle third of face
• Ballooning of face or moon face
• Gross edema of middle third of face
• Bilateral ecchymosis of the eyelids
• Bilateral subconjuctival hemmorrhage
• Mobility of nose
• Depressed nasal bridge
• Tenderness over nasal region
• Hematoma in upper buccal mucosa
 INITIAL DIAGNOSIS
MIDFACIAL FRACTURE
DIFFERENTIAL DIAGNOSES
 DIFFERENTIAL DIAGNOSIS
Zygomatico-maxillary complex fractures
• Zygomaticomaxillary complex (ZMC) fractures, also known
as tripod, tetrapod, quadripod, malar or trimalar fractures, are seen
in the setting of traumatic injury to the face. They can account for 40%
of midface fractures.They comprise fractures of the: Zygomatic arch
,inferior orbital rim, and anterior and posterior maxillary sinus walls
lateral orbital rim
RULE IN RULE OUT
• (+)History of head injury. (-) Malar flattening
• (+)Gross edema of middle (-)Palpable periorbital step-off
third of face deformity
• (+)Bilateral ecchymosis (-) Blunting of lateral canthus.
of lower eyelids (-) Trismus
• (+)subconjuctival (-) Paresthesia of cheek
hemmorrhage (-) Enophthalmos
 DIFFERENTIAL DIAGNOSIS
Bifacial fracture Le fort I
Fractures extend from the nasal septum to lateral pyriform rims, and extend
horizontally above the teeth, crossing below the zygomaxillary junction, then
traversing the pterygomaxillary junction interrupting the pterygoid plates.

RULE IN RULE OUT

(+)History of facial injury. (-) Malocclusion

(+) Pain over middle third of face (-) Mobility of teeth
(+)Gross edema of middle (-) Mobility of maxilla
third of face. (-)Ecchymosis of palate (Guerin’s sign)
(+) Epistaxis
(+)Hematoma in upper buccal
mucosa
 DIFFERENTIAL DIAGNOSIS
Midfacial Fracture Le fort III
Also called cranial-facial separation, the fracture line in this injury passes
from the nasofrontal area across the medial, posterior, and lateral orbital
walls, the zygomatic arch, and through the upper portion of pterygoid
plates.
RULE IN RULE OUT
(+)History of Facial injury. (-)Tenderness and separation at
(+)Gross edema of middle third of face frontozygomatic suture.
(+)Bilateral circumorbital ecchymosis of (-) Enophthalmus
eyelids (-) Hemotympanum
(+)Bilateral subconjuctival hemorrhage (-) CSF otorrhea
(+)Mobility of nose (-) Ecchymosis of mastoid region
(+)Epistaxis
(+)Depressed nasal bridge.
(+)Tenderness over nasal region.
(+)CSF rhinorrhea
 DIFFERENTIAL DIAGNOSIS
NASO-ORBITO-ETHMOID FRACTURE
The classic NOE fracture involves fractures of the lateral nose, the inferior orbital rim,
the medial orbital ethmoid wall, the nasal maxillary buttress at the pyriform aperture,
and the junction of the frontal process of the maxilla with the internal angular
process of the frontal bone.
RULE IN RULE OUT
• (+)History of head injury. (-)Forhead paresthesia
• (+)Gross edema of middle third of (-)Forhead swelling
face (-)Epiphora
• (+)Bilateral ecchymosis of lower (-)Telecanthus
eyelids (-)Diplopia
• (+)Bilateral subconjuctival
hemorrhage
• (+)Mobility of nose
• (+)Depressed nasal bridge.
• (+)Tenderness over nasal region
• (+) CSF rhinorrhea
Embryology, Anatomy & Physiology
 Embryology
• Mesenchyme for formation of the head region derived
from
– paraxial and lateral plate mesoderm
– neural crest
– ectodermal placodes
• Somites and Somitomeres
– neurocranium (skull)
– all voluntary muscles of the craniofacial region
– dermis and connective tissues in the dorsal region of the
head
– meninges caudal to the prosencephalon.
 Embryology
Neural crest cells
• originate in the neuroectoderm
of forebrain, midbrain, and
hindbrain regions and migrate
ventrally into the pharyngeal
arches and rostrally around the
forebrain and optic cup into the
facial region
• In these locations, they form the
entire viscerocranium (face) and
parts of the membranous and
cartilaginous regions of the
neurocranium (skull)
 Embryology
First Pharyngeal Arch(5th -8th week)
• Maxillary process
– extends forward beneath the region of
the eye
– Mesenchyme of the maxillary process
gives rise to the premaxilla, maxilla,
zygomatic bone, and part of the
temporal bone

• Mandibular process
– contains Meckel’s cartilage
– Membranous ossification of
mesenchymal tissue surrounding
Meckel’s cartilage forms the mandible.
 Embryology
• Frontonasal Process
– Forehead, nose,
primary palate, nasal
septum, filtrum of
upper lip
• Nasal placode
– Becomes the nasal pit
– Divides into medial and
lateral prominences
 Embryology
• Medial nasal processes
– elongate, fuse (form philtrum
of upper lip) and will form
the intermaxillary segment of
the tip of the nose
• Lateral nasal processes
– will form the allae of the
nostrills and merge with
maxillary porminences to
form lateral part of upper lip
 Embryology
• Early development
– face of the embryo is
represented by an area
bounded cranially by the
neural plate, caudally by
the pericardium, and
laterally by the
mandibular process of
the first pharyngeal arch
on each side
–
 Anatomy
• Upper third
– Fontal bones
• Middle third (midface)
– Maxillae
– Zygomas
– Orbits
– Nasal bone
– Nasoethmoid complex
• Lower third
– Mandible
 Upper third structures
• Frontal bone
• Frontal sinuses
• Supraorbital roofs
and ridge
• Glabellar portion
 Middle third (midface)
• Zygomas
• Orbits
• Maxillae
• Nasal Bone
 Middle third (midface)
• Zygoma
– malar eminence, or
“cheekbone
prominences”
– zygomatic arches
– lateral and inferior
orbital rims and the
inferolateral orbital
walls.
 Middle third (midface)
• Maxillae
– medial portions of
the infraorbital rims
and anterior orbital
floors
– Maxillary dentition
– Anterior lacrimal
crest
– Infraorbital nerve
– Maxillary sinuses
 Middle third (midface)
• Nasal bone
– Most frequently
fractured bones in
human body
– Supported by frontal
processes of the
maxilla
 Middle third (midface)
• Orbits
– Frontal bone
– Zygomatic bone
– Maxillary bone
– Lacrimal bone
– Ethmoid
– Palatine bone
– Sphenoid
 Lower third
• Mandible
– Contains the mandibular dentition
– Temporomandibular joint
– Horseshoe-shaped bone
 Lower third
• Mandible
– Condylar head – Mental Foramen
– Condylar neck – Mandibular
– Ramus foramen
– Mandibular angle – Alveolar process
 Skin of the Face
• possesses numerous sweat and
sebaceous glands
• connected to the underlying
bones by loose connective tissue,
in which are embedded the
muscles of facial expression.
• No deep fascia is present in the
face.
• Surgical scars of the face are less
conspicuous if they follow the
wrinkle lines.
 Sensory Nerves of the Face
• branches of the three divisions of
the trigeminal nerve
• except for the small area over the
angle of the mandible and the
parotid gland which is supplied by
the great auricular nerve (C2 and 3)
• not only supply the skin of the face,
but also supply proprioceptive fibers
to the underlying muscles of facial
expression.
• sensory nerve supply to the mouth,
teeth, nasal cavities, and paranasal
air sinuses.
 Sensory Nerves of the Face
Ophthalmic Nerve
• The ophthalmic nerve supplies the
skin of the forehead, the upper eyelid,
the conjunctiva, and the side of the
nose down to and including the tip
• Five branches of the nerve pass to the
skin
– Lacrimal nerve
– Supraorbital nerve
– Supratcohlear nerve
– Infratrochlear nerve
– External nasal nerve
 Sensory Nerves of the Face
Maxillary Nerve
• supplies the skin on the posterior
part of the side of the nose, the
lower eyelid, the cheek, the upper
lip, and the lateral side of the
orbital opening.
• Three branches of the nerve pass to
the skin.
– Infraorbital nerve
– Zygomaticofacial nerve
– Zygomaticotemporal nerve
 Sensory Nerves of the Face
Mandibular Nerve
• supplies the skin of the lower
lip, the lower part of the face,
the temporal region, and part
of the auricle. It then passes
upward to the side of the scalp.
• Three branches of the nerve
pass to the skin.
– Mental nerve
– Buccal nerve
– Auricotemporal nerve
 Arterial Supply of the Face
• Facial artery
– Submental artery
– Inferior labila artery
– Superior labial artery
– Lateral nasal artery
• Superficial temporal
artery
– Transverse facial artery
• Ophthalmic artery
– Supraorbital artery
– Supratrochlear artery
 Venous Drainage of the Face
• Facial vein
– formed at the medial angle of the eye by
the union of the supraorbital and
supratrochlear veins
– connected to the superior ophthalmic
vein directly through the supraorbital
vein.
– crosses superficial to the submandibular
gland and is joined by the anterior division
of the retromandibular vein.
– ends by draining into the internal jugular
vein.
• Tributaries
– deep facial vein
– transverse facial vein
 Lymph Drainage of the Face

• submandibular lymph nodes

– forehead and the anterior part of the
face
• buccal lymph nodes
• parotid lymph nodes
– lateral part of the face, including the
lateral parts of the eyelids.
• submental lymph nodes
• central part of the lower lip and the
skin of the chin
 Muscles of the Face
Muscles of Facial Expression
• Orbicularis oculi
• Corrugator supercilii
• Compressor nasi
• Dilator naris
• Procerus
• Orbicularis oris

Nerve supply
– Facial nerve
 Muscles of the Face
Muscles of Mastication
• Masseter
• Temporalis
• Lateral pterygoid
• Medial pterygoid

• Nerve supply
– Mandibulardivision of
trigeminal nerve
 Muscles of the Face
Muscle of the Cheek
• Buccinator

• Nerve supply: Buccal

branch of the facial
nerve
• midface equates to a tent, where the
tent poles represent the bony midface
and the tarpaulin represents the
overlying soft tissues.
• vectors of the midface address all
three dimensions ie, vertical, sagittal,
and transverse
 Strong Areas of the Facial Bone

• Buttresses
– Support the anatomy and provide the strength
needed for masticatory function
– these areas are separated by weaker areas that
provide protection for important structures, such as
the eyes and the brain (Manson, Stanley)
Biomechanics of the midface

• midface equates to a tent, where the tent poles represent the bony
midface and the tarpaulin represents the overlying soft tissues.

• vectors of the midface address all three dimensions ie, vertical,

sagittal, and transverse,
 Strong Areas of the Facial Bone
a. Vertical Buttresses
• bilateral medial and
lateral buttresses
– extend from the dentition
superiorly
• posterior vertical
buttresses
– extend through the
pterygoid plates to the
skull base.
 Strong Areas of the Facial Bone
b. Medial Anterior
Buttresses
• extend from the alveoli
along the strong
pyriform aperture bone
superiorly along the
maxilla through the
nasal bone to the
frontal bone.
 Strong Areas of the Facial Bone
c. Lateral Buttresses
• extend from the
alveoli up along the
zygomaticomaxillary
junction and continue
through the lateral
orbital rim to the
frontal bone laterally.
 Strong Areas of the Facial Bone
d. Anterior-Posterior
Horizontal Buttresses
• extend from the
malar eminences
bilaterally posteriorly
along the zygomatic
arches to the
temporal bones.
 Strong Areas of the Facial Bone
e. Lateral-to-Lateral Horizontal
Buttresses
• Superior buttress
– extends from one malar
eminence to the other across
the inferior orbital rims and
nasal bones
• Inferior buttress
– extends across the inferior
maxillae from one side to the
other across the midline and
includes the palate for strength
extending posteriorly.
 Facial Crumple Zone
• “Crumple zone”
• “Shock absorber”
Maxillofacial
Trauma
Lefort II
Definition
Epidemiology
Classification
Pathophysiology
Diagnosis
 Maxillofacial Trauma
• Injuries to the facial skeleton
• Craniomaxillofacial trauma
• “Facial Orthopedics”
 Epidemiology
Study: Singaram Et al. J Korean Assoc Oral Maxillofacial
Surg. 2016 Aug (n=267)
• Most common cause for MFI- RTA (73.8%)
-Motorized two-wheelers (90.9%)
• Most common fractured structure- maxillary bone
(41.9%)
• Most common in males (74.5%)- M:F of 3:1
• Most common in ages 20 to 40 years
• Most common side fracture- Right side of face
• Intoxicated with alcohol- 3.88%
Classification
Frontal sinus
fracture:
•Gonty’s
classification

NOE: ZMC:
Markowitz Rowe & williams
classification classification

Mandible:
•Kruger’s
•Dingman- natwig
Le Fort
Classification
 Classification
• Le Fort Classification- Rene Le-fort in 1901
• Rowe and Williams Classification- 1985
• Erich Classification- 1942
• Modified LeFort Fracture Classification- 1993
-Marciani
 Le Fort
Classification
 Le Fort Classification
• Provides uniform method to describe the level
of major fracture lines
• Allows references regarding the probable
points of stability for surgical treatment
• Does not incorporate vertical or segmental
fractures, comminution or bone loss .
 Le Fort I
• Guerin’s Fracture
• Floating Fracture
• Pterygomaxillary Dysjunction
• Horizontal Fracture
• COMPLETE separation of dentoalveolar part
of maxilla
 LeFort 1
Horizontal maxillary fracture

Occurs above the level of

maxillary dentition,
separating the alveoli and
teeth from the remaining
craniofacial skeleton.
 Le Fort II
• Pyramidal
• Subzygomatic
• Separation of maxilla from skull base
Le Fort II
Starts on one side at the
zygomaticomaxillary buttress and
crosses the face in a superomedial
direction.
Fractures:
•Infraorbital rim
•Orbital floor
•Medial orbit
•Nasal root/ nasal bones
•Crosses contralateral side of facial
skeleton
 Le Fort III
• Transverse Fracture
• Suprazygomatic fracture
• High Level Fracture
• Cranio-Facial Dysjunction
 Le Fort III
Complete craniofacial separation

Occurs at the level of the skull

base, separating the zygomas from
the temporal bones and frontal
bones, crossing the lateral and
medial orbits and reaching the
midline at the nasofrontal junction,
also violating the nasal septum &
pterygoid plates.
Pathophysiology
 Clinical Manifestations
Le Fort I
Intra-oral manifestations Extra-oral manifestations
•Floating maxilla •Slight swelling and edema of the lower
•Impacted or Telescopic Fracture part of the mid face and the upper lip
•Anterior open bite •Epistaxis
•Disturbed occlusion •Pain and mobility
•Echymosis •Air emphysema in some cases
•Cracked pot sound
•Midpalatal split in some cases
•Damaged or subluxed teeth
•GUERIN’S SIGN
 Clinical Manifestations
Intra-oral manifestations
•Disturbed or Deranged
•Posterior Gagging of
occlusion with retro
positioning of maxillae with
Anterior open bite.
•Airway obstruction.
Le Fort III
Extra-oral manifestations
•Tenderness and separation at FZ suture
•Lengthening of the face One or other
•Zygomatic complex fracture with
•Displacement Flattening and a step deformity at the
Infra-orbital margin
•Movement of the entire facial skeleton as a single
block.
•Enoptholmos
•HOODING of the eyes
•Profuse CSF Rhinorrhea and CSF Otorrhea
•PANDA FACIES
•DISH FACE deformity
•BATTLE’S SIGN
•Haemotympanum Orbital dystopia with associated
Antimongoloid slant
•Flattening, widening and deviation of nasal bridge 
Pattern of trauma:
•Age
•Type of trauma/injury (HIGH vs. LOW Energy
trauma)
 Facial Soft Edema of
tissue middle third Moon Facies
damage offace
High
Damaged/ Leakage of
energy Ecchymosi Panda
burst blood blood
injury s (orbit) facies
vessels Under skin
to face
Subconjuntival
Eyes
hemorrhage
(medial)
Epistaxis
Damage to Nose Paresthesia of
Step infraorbital the cheek
deformity nerve Telescoping Dish face
@ IO fractures @ deformity
Facial midface
Depressed
fractures Nasal
Possible nose Face appears
malocclusion elongated
Ethmoid
(cribiform plate) CSF
Cracked pot sound (upper Rhinorrhea
teeth percussion)
 Clinical Manifestations
Le Fort II
Intra-Oral manifestations Extra-Oral manifestations
•Disturbed or Deranged Occlusion •BALLOONING or MOON FACE
•Airway obstruction •Bilateral circumorbital edema and
•Posterior Gagging of occlusion echymosis (Black eye)
with retro positioning of maxillae •Subconjunctival ecchymosis
with Anterior open bite. •Edema of the conjunctiva or chemosis
•Detection of a step deformity in the bone
of the Infra-orbital margin.
•Mobility of the midface
•Anaesthesia or parasthesia of cheek
•Possible Diplopia
•CSF Rhinorrhea
•NO tenderness over or disorganization
and mobility of Zygomatic bones and
arch.
•Nasal disfigurement
 Diagnosis
• History and PE
• Plain Radiograph
• CT-scan- Gold standard
 Stony Brook University
Physical Examination for
Facial trauma
 Wisconsin Criteria
•Reliable method to screen for facial fractures in trauma patients
•Guide to decision-making
•Avoid obtaining low- value imaging studies

For obtaining facial CT in multi-trauma patients. Any 1 of 5 criteria:

1.Bony step-off or instability
2.Periorbital swelling or contusion
3.GCS<14
4.Malocclusion
5.Tooth absence
 CT findings
CT vs. Radiograph
•Disadvantage of plain radiograph: Numerous
overlapping shadows make it easy to miss fractures
that would be found on CT.
•Exception simple nasal fracture (without evidence of
involvement of other facial bones)
 CT findings
• Axial CT vs. Coronal CT
Axial CT: Best for visualizing:
1. Frontal fractures
2. NOE fractures
3. Zygomatic arches
4. Vertical Orbital walls
Coronal CT: Best for visualizing:
4. Orbital roofs
5. Orbital floors
6. Pterygoid plates
 CT findings
• Upper third of face- High resolution axial CT
good for anterior and posterior wall
• Middle third: Coronal CT scan is best for
simple orbital floor blowouts; if extension to
medial wall- axial scan.
• Lower third- Plain radiographs, panoramic
tomography
Le Fort I

Le Fort I fracture
is confirmed by
noting other
expected
fractures in plane
of Le Fort I
fracture. Coronal
CT image shows
bilateral fractures
of pterygoid
Le Fort II
•Le Fort II fracture is confirmed by
noting other expected fractures in
plane of Le Fort II fracture.
•anterolateral margins of nasal fossa
(solid arrows) are intact, thus
excluding Le Fort I fracture. Inferior
orbital rims (open arrows) are
broken, indicating that Le Fort II
fracture is present.

• As expected in Le Fort II fracture,

lateral walls of maxillary sinuses
inferior in relation to the body of
zygomata are broken.
Le Fort III
• Axial CT image
shows fracture of
zygomatic arch on
left (arrow) at
zygomaticotemporal
suture; Le Fort III is
present on left.
TREATMENT AND MANAGEMENT
 MANAGEMENT

• Maintain patent airway

• Temporary cessation of bleeding
• Fluid replacement
• Antibiotic treatment
– most maxillofacial injuries are considered contaminated as a
result of communication with the nose, sinuses, and/or oral
cavity,
– penicillins, cephalosporins, or clindamycin
• Tetanus prophylaxis- ATS, TT
• Pain control
 MANAGEMENT
Maxilla-mandibular Fixation
Midfacial bones are repaired for two main
reasons:
1. to restore normal function and
2. to restore normal facial contour (cosmesis)
 MANAGEMENT

• Fractures that involve tooth-

bearing segments are first
stabilized at the level of the
occlusion.
• Repaired using 1.5- to 2-mm L and
J plates although other
combinations and sizes may be
used
• To fix the direction of the forces of
mastication
 MANAGEMENT
• Palatal splint- In cases of
severe disruption (alveolar
segments fracture and/or
the mandible disruption)
• The palate may be repaired
directly with a plate, or it
may be stabilized along the
premaxillary area, if the
occlusal stabilization is
adequate to prevent rotation
 MANAGEMENT

• Maxillary fractures at the Le

Fort II level are stabilized
using 1.5- to 2-mm plates,
ensuring that at least two
screws placed on either side
of each fracture plated
• A plate may be placed along
the infraorbital rim to
stabilize the upper portion of
these fractures
 MANAGEMENT

• When accessed, the

nasal root should be
rigidly fixated using very
small plates
• be certain that the
midface is not impacted
and rotated superiorly
before fixing the bones in
place
 MANAGEMENT

• Adams suspension wiring

- mainstay of treatment
- upper arch bar was wired to the zygomatic
arches to prevent facial elongation
- aggravated midfacial rotation and led to
foreshortening and anterior open bite
formation
 MANAGEMENT
• When bone is deficient along these
buttresses, it should be replaced
• A defect of less than 5 mm in a single
buttress can probably be safely
bridged with a plate

• Split calvarium
– common source of bone graft material
– can be stabilized under a plate, or it may
be used as a biologic plate and fixed to
the bone at each end using lag screws
 MANAGEMENT

• The amount of stabilization required for

fixation of zygomatic fractures and amount
of surgical exposure may vary depending on
the amount of instability and comminution
of the fractures.
• The severity of the injury is determined by
the amount of energy transmitted to the
bone at the time of injury
 MANAGEMENT
• Fixation along the infraorbital rim may be used
if needed
• Micro plates are best in this area to avoid
visibility and palpability in the lower lid region

• Fixation may be applied if needed and if

exposure has been performed at the
nasofrontal junction
 COMPLICATIONS
1. Malocclusion
- involves tooth-bearing bones
- may be corrected by adjusting the MMF
- if rigid fixation, removal and repositioning of the
2. Malunion
- bone heals in the incorrect position
- usually lead to facial asymmetries
3. Non union
- more serious complication
- associated with motion at the fracture site/ infected tooth
- may lead to osteomyelitis
 COMPLICATIONS
4. Scars – Hypertrophic, unsightly; may revise
5. Eyelid malpositions – Particular risk from repair of orbital floor
fractures; prevented by using a Frost stitch to stretch the lower
6. Lacrimal injuries– May be due to the trauma/ iatrogenic
7. Nerve injuries
8. Dental injuries
9. Missed fractures– NOE is most common.
10. Sinus problems–managed using rhinological techniques
11. CSF leaks/meningitis–managed aggressively to minimize risk
of significant neurologic morbidity
INDICATIONS FOR SURGICAL TREATMENT OF
FRONTOBASAL FRACTURES
Vital indications (operate immediately)
• Life-threatening rise of intracranial pressure due to intracranial
hemorrhage
• Bleeding from the nose or sinuses that is refractory to conservative
treatment
• Bleeding from an open skull injury that is refractory to conservative
treatment
Absolute indications (operate as soon as possible)
• Open brain injury
• Dural tear from an indirectly open head injury
• Penetrating foreign bodies and impalement injuries
• Early complications (e.g., meningitis, encephalitis, brain abscess)
• Late complications (e.g., meningitis, brain abscess, osteomyelitis)
• Orbital complications
Relative indications (operate in 1–2 weeks)
• Displaced bone fragments
• Fractures involving the drainage tracts of the paranasal sinuses
(“ostiomeatal unit”)
• Acute or chronic sinusitis at the time of the injury
• Post-traumatic sinus inflammation, mucopyocele formation
• Supraorbital nerve injury due to an adjacent fracture
 REFERENCE
• Flint, P. (2015). “ Maxillofacial Trauma”.
Cummings Otolarngology Head and Neck
Surgery 7th ed. Elsevier Inc, Philadelphia. Pp
295-310