Maxillofacial Trauma
Case 1:
48y male, intoxicated
Fell striking cheek on the bar
Laceration to anterior cheek
Through-and-through
Case 2:
18y hockey player
“Too good” to wear a face mask
High stick to the face
Upper lip laceration
Crosses vermillion border
Involves muscular layer
Case 3:
25y female MVC, ejected
Intubated by STARS on scene
Swelling facial and periorbital
Extensive abrasions to forehead with gravel/glass in wound
Case 4:
It’s June 28, 1997
35y male boxer
Lac to right ear during fight
Through cartilage
Claims he was bitten
Opponent says it was a punch
Case 5:
12y female
Skateboarding for the first time
Fell
Caught tongue between teeth
Tongue laceration
Q: How to anesthetize?
Local infiltration
±Infraorbital nerve block
Q: How to repair?
1) Absorbable to buccal mucosa
2) Absorbable to muscle layer
3) Nonabsorbable to skin
Q: Antibiotics? No Yes
Q: How to anesthetize?
Infraorbital nerve block
(or mark vermillion border and locally infiltrate)
Q: How to repair?
Vermillion border first
Absorbable to muscle/lip mucosa
Q: Antibiotics? No Yes
Q: One bedside test you need to do?
Tonometry
Q: Management if test is abnormal?
Lateral canthotomy/cantholysis (IOP > 40)
Q: Treatment for her abrasions?
Vigorous scrubbing to avoid tattooing
Can use topical lidocaine (V1 block)
Q: How to anesthetize?
Ear field block
Q: How to repair?
6-0 absorbable to cartilage
5-0 nonabsorbable to skin
Compression dressing
Q: Antibiotics? No Yes
Q: Indications for tongue lac repair?
Q: How to anesthetize?
Inferior alveolar/lingual nerve block or 4% topical lidocaine
Q: How to repair?
4-0 absorbable or black silk
Q: Antibiotics? No Yes
Maxillofacial Trauma
Indications for tongue laceration repair (controversial)
(emedicine, EM Clinics of North America, Roberts & Hedges, Rosen)
· Midline
· Need hemostasis
· Large flap (>1cm or gaping)
· Avulsion/amputation
· Nonlinear laceration or U-shaped
Other questions to review if time permits:
Q) What are indications for abx in facial trauma
· Bite wound
· Devascularized tissue
· Through-and-through buccal mucosa
· Cartilage involvement (nose/ear)
· Extensive contamination
· Open #
· # into sinus
· # with CSF leak
Q) What is appropriate mgmt of pediatric peri-oral electrical burns?
Perioral burns
· Can result in severe cosmetic issues and microstomia
· Trivial looking initial wound may progress over days
· 5-21 days post-burn get eschar separation and can have lift-threatening labial artery bleeding
· NEED TO D/W plastics in the ED!
o Can d/c home with close watching and F/U ENT/plastics if not extensive initially
o Options: early surgery, oral splinting, delayed surgery
Q) Management of subperichondral hematoma?
· Risk factor for cauliflower ear
· Needs needle aspiration, compressive dressing and R/A in 24hrs to ensure hematoma has not re-accumulated
Q) Describe appropriate ED management of eyelid lacerations.
· Superficial lacs can be repaired with 6-0 Ethilon
· Lid margin, canalicular, lacrimal involvement need ophtho/plastics
Maxillofacial Trauma
Case 6:
It’s 0100
Dude and his girlfriend come in
She was “yawning” and mouth got stuck open
Case 7:
16y male
Tough guy
Punched in the nose
Swelling to nasal bridge
Crooked nose? Hard to tell…
Case 8:
22y female
Squash player
Hit in eye by ball
Diplopia on up-gaze
CT shows orbital floor blowout # without entrapment of EOM
Case 9:
Same polytrauma as Case 3
Still intubated
Bleeding into oropharynx & nasopharynx from ?
You think her face is mobile
Case 10:
35y female, fell down stairs
Teeth don’t fit right
Neck pain, no c=spine #
No other injuries
Q: What does she have?
TMJ dislocation
Q: How will you fix it?
Thumbs in buccal recess
Push down, rotate chin up, push mandible posteriorly
Q: F/U plans?
Oral surgery if recurrent
Q: One thing on physical exam that you need to rule-out?
Nasal septal hematoma
Q: Management of that thing if you find it?
Incision, expression of clot, anterior packing, R/A in 24hrs
Q: Investigations?
None (x-rays useless)
Q: ED management and F/U?
Analgesia, reduce if really crooked
F/U plastics in 7-10 days for R/A
Q: How does true EOM entrapment present?
Vagal tone, vomiting
Refusal to move eye
Q: Why does she have diplopia?
V2 neurapraxia, fat entrapment, intramuscular hematoma
Q: Mgmt of her fracture?
Analgesia (can D/W plastics)
F/U plastics in 7-10 days
Q: Describe the Le Fort classification system?
See next page
Q: Management of her bleeding?
Anterior packs
Pack naso/oro-pharynx around ETT
Reduce Le Fort
+/-Interventional radiology
Q: What % of mandible # have associated C-spine #?
10%
Q: Investigations?
Panorex or CT mandible
Q: Management/disposition?
Consult plastics or maxillofacial sx
Maxillofacial Trauma
LeFort
I – maxilla
II – nasal bridge, lacrimal bones, orbital floor, orbital rim, maxilla
III – craniofacial dysjunction (rare to get pure III); nasal bridge, ethmoids, maxilla, lateral orbital wall, zygomatic arch