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TRAUMA TABLE OF CONTENTS:

1. Lacerations

2. Nasal Bone Fractures

3. Mandible Fractures

4. Midface Fractures

5. Frontal Bone Fractures

6. Orbital Fractures

7. Penetrating Neck Trauma

8. Temporal Bone Trauma

TRAUMA ON-CALL CONSULT PODCAST EPISODES:

1. Sinonasal Trauma

2. Dentoalveolar Trauma

3. Temporal Bone Trauma

4. Perichondritis and Auricular Hematoma

Link to instructional video on suture technique. 

Overview
The care of head and neck soft tissue wounds including lacerations, avulsions, and abrasions is a crucial skill for the Otolaryngology resident to maximize functional and aesthetic outcomes. General principles of facial laceration and avulsion repair include detailed physical exam for additional injuries and damaged critical structures (e.g., facial nerve, salivary ducts, etc.), copious irrigation and cleaning of wounds, minimal tissue debridement or removal in the acute period, and closure as soon as possible after injury (i.e., at least within 24 hours for grossly non-contaminated wounds). While typically ordered by the Emergency Department provider, always ensure tetanus and rabies vaccinations are given when indicated. Antibiotics are not routinely prescribed for head and neck lacerations but should be considered in immunosuppressed patients, in ear or nasal lacerations with exposed cartilage, any open fracture, through and through lip lacerations or any laceration crossing mucosal barriers, and grossly contaminated wounds or bite wounds. Common mistakes to avoid during laceration repair are inadequate irrigation of wounds, failure to meticulously remove foreign debris, inadequate exam of wound extent especially in puncture wounds, wound closure under tension, and assumption of missing tissue in widely gaping or macerated lacerations.

Evaluation and Cleaning of Lacerations

Always begin with detailed history; important considerations include injury timing, any loss of consciousness, mechanism of injury, and social context (domestic abuse and assault are common causes of facial trauma making documentation especially important from a medicolegal standpoint). Physical exam as in all traumas should start with focus on the ABCs (Airway, Breathing, Circulation) and should then include a general head and neck physical exam avoiding the pitfall of concentrating on obvious or “distracting” injuries at the neglect of being thorough. Underlying bony injuries to the face, cervical spine, or skull as well as intracranial injuries should be ruled out by proper exam and imaging when indicated. After appropriate attention to more critical injuries, wounds should be thoroughly cleaned and assessed. Cleaning of wounds involves copious irrigation with saline, frequently 1-2 L depending on wound size and degree of contamination. In wounds with dry bloody crusts or hair throughout the wound, it may be necessary to add a small amount of hydrogen peroxide to aid in cleaning. Hydrogen peroxide is not routinely added to irrigation solutions due to concern of impaired wound healing but should be selectively used to facilitate wound inspection and closure. Similarly, antimicrobial cleansers such as povidone iodine and chlorhexidine are not necessary after irrigation in most facial wounds but should be used if the wound is contaminated or had a “dirty” mechanism.

Local Anesthesia

Local anesthesia of wounds allowing complete wound evaluation and relatively painless closure can typically be obtained by topical anesthetic, direct infiltration, or nerve blocks. While a wide range of local anesthetics are commercially available for any of these methods, the selection can typically be simplified to a few common choices. Topical anesthetic may make closure more comfortable in all patients but is commonly used only in cases where a patient is unable to tolerate injections, such as children or mentally disabled adults and usually is achieved through application of LET (4% lidocaine, 1:2,000 epinephrine, 1% tetracaine) or TAC (0.5% tetracaine, 1:2,000 adrenaline, 11.8% cocaine) directly in the wound bed with overlying occlusive dressing application. Downsides to topical anesthetics include time requirements (may take 30 minutes for full anesthetic effect), additional cost, and potential toxicity when additional local anesthetics are required given difficulty of calculating total dosage. The most common injectable anesthetic choices are listed below.

Direct infiltration of wounds with local anesthetic is an easy method for achieving sufficient anesthesia in small wounds but can distort local tissues or compromise macerated tissue with tenuous blood supplies if the solution contains epinephrine. In large wounds or wounds where tissue distortion is to be avoided, nerve blocks may provide anesthesia with decreased total anesthetic dosage and without the tissue distortion. There are eight primary blocks important in facial anesthesia: supraorbital, supratrochlear, infraorbital, dorsal nasal, mental, zygomaticofacial, zygomaticotemporal, inferior alveolar, and great auricular nerve blocks. The precise method to achieve these individual blocks is beyond the scope of this chapter but should be reviewed by residents as needed prior to complex laceration repairs. If patients remain combative or non-amenable to any of the methods discussed above, sedation may be required via monitored anesthesia care in the Emergency Department or occasionally in the OR with general anesthesia.

Suture Selection

The table below outlines the most commonly used sutures in facial laceration repair as well as possible options for suture selection based on subsite or structure. All closures should involve meticulous closure with minimal wound tension on the dermis/epidermis and eversion of the skin edges. Generally, deep sutures for approximation of subcutaneous tissue and reduction of surface tension should be placed any time a laceration is deep enough to allow them while still placing as few as necessary to relieve the surface tension to minimize the inflammatory reaction. Suture selection for the skin edges should be made with consideration of likelihood of patient follow-up and ease of removal; choose absorbable sutures if the patient is unlikely to return to care in a timely manner or unable to tolerate suture removal. Traditionally, it has been thought that non-absorbable suture with planned early removal leads to best aesthetic results, although many believe fast absorbing gut sutures yield comparable results and may be routinely used. The most important factors are optimal technique and minimizing skin tension with closure.

Key Supplies for Laceration Consultation

• Headlight

• Appropriate PPE including mask, eye protection, gloves, and gown

• Normal saline bottles for wound irrigation

• Iodine swabs

• 1% lidocaine 1:100,000 with epinephrine

• 18- and 27-gauge needles with 3 mL syringes

• 4x4 gauze

• Laceration tray with forceps, needle driver, and scissors

• Sutures or stapler

• 15-blade scalpel

• Vaseline® or bacitracin ointment

Abrasions

The management of the most superficial of these injuries, an abrasion, is thorough cleaning and light debridement (critical to avoid traumatic tattooing) followed by meticulous wound care while healing. Wound care for abrasions involves keeping the site moist with bacitracin or petroleum-based ointment and avoidance of drying/crusting of the surface and strict sun avoidance or protection.

Specific Facial Subsite Considerations

These subsites outline basic closure with the expectation that a comprehensive history and physical exam are completed prior to laceration closure with prioritization of more critical injuries first. The scope of the discussion herein is narrowed to lacerations typically closed by junior residents in the Emergency Department setting without significant loss of tissue or complexity requiring advanced reconstructive techniques.

Scalp

Unique to the scalp due to its distinctly layered anatomy is the propensity of lacerations to create large flaps or avulsion injuries that may require a drain/compression wrap to prevent hematoma formation. Recall the layers of the scalp with the S.C.A.L.P. mnemonic: Skin, Connective tissue, Aponeurosis, Loose areolar tissue, Periosteum. Scalp wounds also tend to collect debris and congealed blood in the tissue requiring a slightly more aggressive washout and manual debridement prior to closure.

Small lacerations of the scalp can frequently be closed with a quick staple or two without any local anesthetic as their rapid application is usually less painful and traumatic than an injection. Moderate sized lacerations involving multiple layers of the scalp should be closed in layers and a head wrap considered if concerned for hematoma formation. Very large lacerations to the scalp are frequently still closed at bedside with frequent drain requirements and may require large doses of anesthetic, making it critical to calculate maximum weight-based doses of local anesthetics before injection. Scalp wounds with tissue defects, especially defects that involve pericranium leaving a segment of calvarium exposed, should typically be closed in the OR with reconstructive techniques such as local flaps, grafts, and free flaps that are beyond the scope of this chapter.

• Gentle inspection of the wound and consideration for need to go to the OR for closure (severely contaminated or large macerated wounds, wounds requiring complex reconstructive methods, lacerations in patients unable to tolerate bedside closure, or patients with other injuries that require operative intervention).

• Anesthetize the wound (the scalp is highly vascular making anesthetic preparations that contain epinephrine especially beneficial) by injecting circumferentially into the tissue around the laceration.

• Slide the patient to the top of the bed or gurney and, while an assistant holds the patient’s head off the bed as well as a basin below, wash the wound out thoroughly while using one hand to gently scrub the wound, ensure all hematoma has been removed and no foreign bodies are present, may lightly paint the wound with iodine swabs if contaminated.

• Slide the patient back down the bed or gurney into a comfortable position with towels under the head and proper lighting.

• If a suction drain is needed, make a small stab incision with 11-blade scalpel 1-2 cm away from the posterior or most dependent portion of the laceration while the patient is supine. Push a Kelly or Mayo clamp through the incision and grasp the end of a 7 French Jackson-Pratt (JP) drain and pull through the incision into the wound bed. Cut the end of the drain so it is not coiled in the wound bed and secure drain with a 2-0 nylon suture.

• Close the laceration by layers. Use buried interrupted Vicryl® sutures to close the deep layers (being cautious not to suture through the drain), place your deep dermal sutures until the skin edges are well approximated and the drain holds suction. Close the skin with staples (hair bearing), Ethilon®, Prolene®, or fast absorbing gut suture, typically in a running or horizontal mattress fashion.

• Apply Vaseline® or bacitracin to the incision. If placing a head wrap, apply Xeroform® gauze to laceration, cover with fluffs, then wrap the head using Kerlix followed by Coban ensuring the wrap is appropriately tight. May need to wrap under the chin if the laceration is on the vertex of the scalp to apply downward pressure.

Ear

The blood supply to the ear is robust, but the cartilage derives its blood supply from the overlying skin and perichondrium and must be fully covered to survive. The cartilage is also fragile and easily torn if passing suture, especially with cutting needles. Because of the thin skin and easily distorted architecture of the ear, most lacerations of the ear are best anesthetized with a nerve block of the external ear as opposed to direct infiltration of wounds (although direct injection may be necessary for the concha cavum and tragus). The external auditory canal may be involved in some lacerations with the risk of scarring leading to canal stenosis. These lacerations can usually be managed with stenting of the canal during healing by use of an ear wick placed after detailed exam.

• Anesthetize the ear with a nerve block by injecting appropriate local anesthetic targeting the auriculotemporal (anterior superior course to the ear), the greater auricular (posterior inferior to the ear), and lesser occipital nerve (posterior mid ear).

• Thoroughly irrigate the wound with saline and meticulously remove any foreign bodies or debris.

• Ensure sufficient laxity in skin to close over the cartilage or judiciously trim small amount of exposed cartilage back to allow closure of skin.

• Complete the deep closure of the laceration using 5-0 Monocryl® or undyed PDS® interrupted deep sutures through dermis and perichondrium with sparing use of cartilaginous sutures.

• Close the skin with interrupted Ethilon® or fast absorbing gut sutures (5-0 or 6-0 typically).

• If there was significant separation of the skin/perichondrium from the cartilage or concern of auricular hematoma, an ear bolster dressing may be applied. Patients are often placed on a prophylactic antibiotic while the bolster is in place for 5-7 days.

• Consider fluroquinolone if dirty wound or significant cartilage exposure.

• Explain return precautions including warning signs of hematoma formation.

• Follow-up in 5-7 days for bolster and suture removal.

Periorbital

The skin around the eye is some of the thinnest skin in the body and is both aesthetically and functionally important especially when involving the eyelids, the lid margins, and the canthi. Closure of periorbital lacerations requires detailed orbital exam first and foremost ensuring no injury to the globe or lacrimal system while always maintaining a high level of suspicion for involvement of underlying structures and a low threshold for Ophthalmology consultation if suspected. The lids are comprised of the anterior lamella (skin and orbicularis oculi), middle lamella (orbital septum), and posterior lamella (tarsus, levator palpebrae superioris in the upper lid, and conjunctiva). The medial and lateral canthal tendons maintain the tension and position of the lids respective to the bony orbit and injury should be suspected with lacerations that pass through or near the canthi and when increased lid laxity is found on exam. The medial canthus attaches to the frontal process of the maxilla and lacrimal bones and surrounds the lacrimal sac, which is often injured concomitantly. If concerns for lacrimal system injury, Ophthalmology should be consulted. The closure of the eyelid margins with full thickness defects must be exact to prevent entropion or ectropion and is usually accomplished with a 3-suture technique where approximation of the meibomian glands, grey line, and lash line by individual sutures is used. The finding of ptosis in a patient with an upper eyelid laceration may indicate injury to the levator palpebrae superioris muscle and Ophthalmology should be consulted. Lacerations involving the lateral brow can involve the frontal branch of the facial nerve, which must be carefully examined prior to anesthetic injection. The eyebrow should be carefully reapproximated and should never be shaved as regrowth is unpredictable and can take 6 months or more. Additionally, minimal dermal sutures should be placed in the brow to minimize the risk of alopecia secondary to follicle damage, although this may be unavoidable, and patients should be warned of this possibility.

• Inject the tissue surrounding the laceration with local anesthetic.

• Thoroughly irrigate the laceration with saline.

• Consider applying eye ointment and corneal protector if suturing close to the globe to avoid corneal abrasion.

• Repair the laceration deep to superficial typically avoiding suture placement in the septum or conjunctiva (risk of corneal abrasion from sutures).

• Approximate the tarsus with 5-0 PDS® or 6-0 Vicryl® simple interrupted sutures with the knot on the superficial side of the tarsus to avoid corneal irritation.

  • Place a vertical mattress suture with 7-0 Ethilon® or Prolene® through the meibomian gland line.

  • A 7-0 Ethilon® or Prolene® is then used to approximate the grey line with either a vertical mattress or simple interrupted.

  • A third margin suture in then placed at the line of the lash follicles with the 7-0 Ethilon® or Prolene® suture.

  • The remainder of the skin layer is closed with 6-0 fast absorbing gut suture.

  • Tuck the tails of the margin sutures away from the eye by passing the tails under a skin suture.

• Apply antibiotic ointment (typically erythromycin ointment) and remove the corneal protector if placed.

• Schedule follow-up 5-7 days after repair for suture removal.

Nasal

Injuries to the nose should be approached with consideration of its important form and function with the goal to restore these through appropriate management of wounds. Lacerations that extend fully through the nose and nasal mucosa are at higher risk of leading to collapse of the internal or external nasal valve and therefore are more likely to lead to nasal obstruction and future need for functional rhinoplasty or scar revision. The repair of nasal cartilage is critical to long-term functional and aesthetic results and is usually best accomplished with sutures such as an undyed PDS® or Monocryl®. The alar rim is frequently involved in lacerations and has a propensity to retract with healing leading to external nasal valve collapse or notching especially if the wound is not well approximated. These complications may be avoided by silastic stenting of the involved vestibule for 1 week following repair and meticulous re-approximation during closure.

• Thoroughly wash and inspect the laceration.

• Ensure no underlying nasal bone or septal fracture/hematoma.

• Achieve sufficient anesthesia either through direct injection or a nasal block based on location and size of laceration.

  • Injections to supratrochlear, infraorbital, and dorsal nasal nerves, inject the lateral nasal area, columella, and place intranasal pledgets soaked in anesthetic.

• Repair laceration deep to superficial.

  • Approximate skin of vestibule or nasal mucosa with 5-0 fast absorbing gut or chromic gut suture.

  • If the laceration involves the alar rim, consider first approximating the laceration at the rim with a vertical mattress 5-0 fast absorbing gut or nylon suture.

  • Selectively place 5-0 PDS® or Monocryl® sutures to approximate nasal cartilage.

  • Lastly close the skin with gentle approximation with 5-0 or 6-0 fast absorbing gut or nylon suture. (Sebaceous rich skin of the nose tears easily if using a cutting needle or if under any tension.)

  • If significant laceration involving alar rim or external nasal valve, consider placement of a silicone nasal splint sutured in place.

  • Apply bacitracin or Vaseline® ointment.

  • Schedule follow-up 5-7 days after repair.

Intraoral/Lip

Lacerations to the tongue, buccal mucosa, and wet lip are commonly caused by the teeth and are therefore frequently puncture wounds in nature. These lacerations, like all lacerations, should be thoroughly irrigated, which may be best accomplished with warm water and an angiocatheter on a 20cc syringe as well as by simply having alert patients gargle with water or chlorhexidine rinse. The buccal mucosa and lip have the tendency to swell more than other subsites leading small lacerations that would otherwise not need any closure to splay open and take longer to heal if not sutured. The long-term healing of oral lacerations left to heal by secondary intention is typically satisfactory, although hypertrophic scarring in the buccal vestibules can lead to chronic irritation from the occluding teeth and can be avoided by primary closure. The parotid and submandibular ducts are important structures to examine prior to any attempted closure. If in doubt, these ducts can be probed to ensure no injury. Chromic gut is a common absorbable suture with properties ideal for the oral environment as the chromium salts help maintain tensile strength for 5-7 days. Vicryl® may be used both for deep buried sutures as well as for mucosal surface closure if tensile strength is desired for a longer period (may take up to 4 weeks in the mouth for breakdown). Lacerations to the dry lip that extend through the vermillion border should be approximated starting with the vermillion border prior to local anesthetic distorting tissue followed with deep sutures to approximate the orbicularis oris, deep dermal sutures, and lastly skin closure usually with fast absorbing gut or Ethilon® suture. The vermillion border suture must be extremely precise as a 1 mm discrepancy in the approximation can be noticeable. Avulsion injuries with loss of up to one-third of the lip can be closed primarily with low risk of microstomia; any larger loss of tissue should lead to consideration of closure with local flaps (e.g., Abbe or Gillies flaps).

• Thoroughly clean all intraoral wounds by having conscious and alert patients gargle and rinse with chlorhexidine oral rinse (altered patients should be topically cleaned with syringe flushes or a toothbrush dipped in chlorhexidine with suction ready to prevent aspiration).

• Achieve local anesthesia, commonly with direct infiltration, although avoid direct infiltration with wounds crossing the vermillion border as can obscure this landmark.

• Ensure critical structures (e.g., Stenson’s and Wharton’s ducts) are not involved, look for dental fractures, and ensure no palate or alveolar ridge mobility.

• Close wound deep to superficial (if wound crosses the vermillion border consider first passing one suture through this border to mark exact location prior to additional layers).

  • Approximate orbicularis oris with 4-0 Vicryl® sutures.

  • Intraoral mucosa and wet lip closed with 4-0 chromic gut sutures.

  • Dry lip and external skin closed with interrupted 5-0 fast absorbing gut or Ethilon® sutures.

• Apply bacitracin to external wound.

• Chlorhexidine mouth rinses 3 times daily for 2 weeks for intraoral lacerations.

• Schedule follow-up 5-7 days after repair.

Cheek

Primary concerns with cheek lacerations are damage to the facial nerve, especially the buccal branch, as well as the parotid gland and duct. Lacerations to the lateral cheek or preauricular area that extend deep to the superficial musculoaponeurotic system are likely to involve the parotid gland and any clear fluid in the wound bed should be suspected to be saliva. These gland injuries can be closed primarily by layers with attention to close approximation with low risk of salivary fistula when well closed if no associated ductal injury. Injuries to the parotid duct or buccal branch of the facial nerve should be suspected when an injury crosses a line drawn from the tragus to the middle of the upper lip and should be thoroughly explored. Both these structures are most vulnerable as they cross the masseter superficially in the mid cheek. Repair techniques for the parotid duct are beyond the scope of this chapter. Facial nerve injury repair is similarly beyond scope, but the primary responsibility of the junior resident is a thorough facial nerve exam with documentation of the affected branches as well as quantification of the paresis with House-Brackmann grading system as well as ensuring protective measures for the eye if lagophthalmos is noted (moisture chamber, Lacri-Lube®, artificial tears, etc.). If the injury is medial to an imaginary line drawn from the lateral canthus inferiorly, exploration of the wound with intent to repair the nerve is not usually attempted. When lateral to the imaginary line from the lateral canthus, the wounds may be explored in the OR with attempt to locate and repair by primary neurorrhaphy or interposition grafting as soon as possible as Wallerian degeneration leads to poorly stimulating distal branches by 72 hours, rendering identification of the distal injured segment(s) challenging.

• Thoroughly irrigate and inspect the laceration.

• Detailed facial nerve exam, including all major divisions, prior to any local anesthetic injection and careful exam for any exposed parotid tissue or possible injury to parotid duct.

• Inject local anesthetic, commonly direct infiltration, although infraorbital blocks may be helpful or even sufficient if wound is medial.

• Close laceration from deep to superficial with special attention to approximation, especially if concern of parotid salivary gland tissue damage, with goal to decrease risk of salivary fistula.

• Approximate the facial muscles and subcutaneous tissue with 4-0 Vicryl® sutures.

• Deep dermal suture with buried 4-0 Vicryl® sutures.

• Close the skin surface with 5-0 fast absorbing gut, Ethilon®, or Prolene® sutures.

• Apply bacitracin or Vaseline® ointment.

• Schedule follow-up 5-7 days after repair.

Aftercare

Routine care after laceration repair includes petroleum-based ointment for 1 week to keep moist, prevention of drying and crusting, chlorhexidine rinse after meals for 1 week for intraoral lacerations, scar massage beginning at 3 weeks, and avoidance of sun exposure to the scar for a minimum of 6-12 months.

References
1. Forsch, R.T, Little, S.H., Williams, C. (2017). Laceration repair: A practical approach. Am Fam Physician. 95(10):628-636.
2. Hill, J.D., Stoddard Jr., D.G., Hamilton III, G.S. (2020). Facial Trauma: Soft Tissue Lacerations and Burns. In Flint, P.W., et al. (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 269-287). Philadelphia, PA: Elsevier.
3. Shadfar, S., Shockley, W.W. (2013). Management of Soft Tissue Injuries of the Face. In Johnson, J.J., Rosen, C.A. (Eds.), Bailey’s Head and Neck Surgery-Otolaryngology 5e (pp. 1108-1130). Baltimore, MD: Lippincott Williams & Wilkins.

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Overview
The most common facial fracture is a nasal bone fracture making these a frequent consultation from Primary Care as well as the Emergency Department. These fractures vary from subtle and incidentally found on CT to disfiguring with significant underlying septal fractures or skull base fractures and are commonly associated with concomitant facial fractures or lacerations that may be the primary presenting concern. Therefore, the acute management of nasal bone fractures is triaged according to priority when considering other potentially more urgent injuries the patient has sustained. Potential long-term effects of untreated nasal fractures include nasal obstruction, nasal deformity, chronic sinusitis, septal perforation, and midface and nasal growth retardation in pediatric patients. The risk of these poor outcomes can be mitigated by appropriate treatment. The septum must be evaluated in all patients to rule out a septal fracture or septal hematoma. If left untreated, cosmetic and functional sequelae of an untreated hematoma include septal abscess, perforation, and saddle nose deformity. If a patient presents immediately following injury and before significant facial swelling (typically within 2-4 hours) it is possible to set the fracture immediately. However, swelling is commonly present that complicates both the pre- and post-reduction evaluation making it advisable to delay approximately 5 days while swelling resolves. While closed reduction is most common, open reduction will be required in some patients with complicating factors such as bilateral fractures with severe displacement and comminution, complex septal involvement, or dislocation or disruption of the upper lateral cartilage or keystone or scroll area. Open reduction in appropriately selected patients decreases the likelihood of requiring a rhinoplasty in the future by allowing better visualization and appropriate management of cartilaginous injuries. Following reduction, proper splinting and care must be taken by the provider and patient to maintain the reduction and optimize the outcome.

Key Supplies for Nasal Bone Fracture Consultation

• Appropriate PPE including mask, eye protection, gloves, and gown

• Headlight

• Nasal speculum

• If considering closed reduction: Cotton pledgets, oxymetazoline, 1% lidocaine with 1:100,000 epinephrine, alcohol or iodine swabs, 10 mL syringe with 18- and 27-gauge needles, bayonet forceps, Boies elevator, Asch forceps, absorbable nasal packing (firm NasoPore®), Doyle Splints, mupirocin, 3-0 Ethilon® suture, and supplies for nasal cast: Mastisol®, Steri-Strips®, and thermoplastic splint

Management

• Complete history including mechanism of injury and past medical history.

• Comprehensive head and neck exam with attention to possible additional injuries; always palpate orbital rims and midface as high association with orbital and zygomaticomaxillary complex (ZMC) fractures.

• Exam should include anterior rhinoscopy and manual palpation of the septum to rule out septal hematoma.

• Urgently drain septal hematoma if present.

  • After injecting 1% lidocaine with 1:100,000 epinephrine to septum just caudally to the hematoma, make caudal septal incision through mucosa and perichondrium down to cartilage, express hematoma, flush cavity thoroughly with saline syringe with attached angiocath, place septal stent (Doyle splints) to prevent recurrence.

  • Antistaphylococcal antibiotics should be given while splints are in place (cephalexin or amoxicillin are reasonable options).

  • Follow-up in 2-3 days for bolster removal and to ensure no recurrence of hematoma.

• If significant swelling is present it is generally advised to wait until swelling has resolved before attempt at reduction.

• If minimal swelling, consider immediate reduction.

• If unable to reduce immediately after injury, bring patient back approximately 7 days after injury to reassess and consider in office versus OR reduction if patient unable to tolerate closed reduction in clinic or if need for open reduction.

• After reduction of the nasal bone fractures, an external nasal splint (typically made of Aquaplast®) is placed and kept in place for 7 days.

• Patients should be advised to avoid nasal trauma for 8-12 weeks (specially designed facemasks to avoid nasal trauma are available).

• If patient unhappy with appearance or has bothersome nasal obstruction, can consider rhinoplasty usually 6 months following injury.

Closed Reduction of Nasal Bone Fracture

• Obtain informed consent after discussion of risks (pain, bleeding, intranasal and external deformity, need for future procedures and surgery).

• If not performed under general anesthesia, consider a nasal block with bilateral packing of cotton pledgets soaked in 1% lidocaine with 1:100,000 epinephrine, tetracaine, or 4% cocaine (contraindicated in patients with cardiovascular disease) for 5-10 minutes followed by injection of 1% lidocaine with 1:100,000 epinephrine (infraorbital, supraorbital, supratrochlear, lateral dorsum, midline dorsum from rhinion to supratip region, columellar base, and nasal septum).

• Ensure nasal septum integrity or attempt to reduce septal fracture with use of Asch forceps with an arm in each nostril along dorsal septum, elevate the septum with force directed away from face while simultaneously attempting to realign septal fragments by pushing with the ends of the arms.

• After septal reduction, introduce Boies elevator intranasally with tip at the premeasured distance from nasal tip to intercanthal line.

• Elevate depressed portion of fracture using Boies elevator in one hand with other hand palpating externally during reduction or attempting to simultaneously reduce the contralateral side if it is outfractured.

• Once adequate reduction is achieved, consider placing absorbable intranasal packing (Bactroban® coated NasoPore®) high in the nasal vault under the nasal bones to support them, then place trimmed Doyle splints and suture in place with 3-0 nylon.

• Apply external nasal splint (clean skin with alcohol swabs, apply Mastisol® followed by Steri-Strips®, then apply prepared splint with careful application taking care not to depress any fragments).

Example Procedure Notes
Procedure: Closed reduction of nasal bone fractures under general anesthetic
The risks, benefits, and alternatives to treatment were discussed with the patient who elected to proceed with the procedure. Written informed consent was obtained. The patient was brought to the OR and identified by name and medical record number. After an adequate plane of general anesthesia was obtained by the Anesthesiology team, the patient’s airway was secured with a Down RAE endotracheal tube that was taped to the chin. Lacri-Lube® ointment was placed in the eyes followed by Tegaderm® dressing to protect the eyes during surgery. The nasal cavity was carefully examined with a nasal speculum and headlight and Afrin® pledgets were placed in bilateral nasal passages. The patient was prepped and draped in the standard fashion. Pledgets were removed and nasal cavities were re-examined. No obstructing fractures or septal hematomas were noted. The nasal bones were palpated. The right nasal bone was noted to be fractured medially and the left nasal bone laterally. A Boies elevator was inserted intranasally on the right with tip at the premeasured distance from nasal tip to intercanthal line and used to out-fracture the nasal bone into alignment. Manual digital pressure against the left nasal bone reduced it medially into alignment. The nose was carefully examined, and nasal bones were deemed to be straight. An external Aquaplast® nasal cast was applied. This completed the procedure. The patient was extubated and transferred to the PACU in stable condition. No complications. Minimal blood loss.

Procedure: Nasal bone reduction with local anesthetic
The risks, benefits, and alternatives to treatment were discussed with the patient who elected to proceed with the procedure. Written informed consent was obtained. Local anesthetic was injected, 1% lidocaine with 1:100,000 epinephrine, to bilateral V2, supratrochlear, supraorbital, lateral and midline dorsum, and the internal septum. After local anesthetic was applied, the Boies elevator was used to manipulate the nasal bones bilaterally. Reduction was achieved and confirmed by visual inspection and palpation. The patient was satisfied and there was minimal epistaxis following the reduction. External thermoplastic splints were applied. The septum was inspected after the procedure with no sign of a septal hematoma or fracture. The patient tolerated the procedure well.

References
1. Chegar, B.E., Tatum, S.A. (2020). Nasal Fractures. In Flint, P.W., et al. (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 457-469). Philadelphia, PA: Elsevier.
2. Gillman, G.S., Rivera-Serrano, C.M. (2013). Nasal Fractures. In Johnson, J.J., Rosen, C.A. (Eds.), Bailey’s Head and Neck Surgery-Otolaryngology 5e (pp. 1241-1254). Baltimore, MD: Lippincott Williams & Wilkins.
3. Fusetti, S., Cornelius, C.P., Gellrich, N., et al. Treatment of Nasal Bone. AO Foundation Surgery Reference, https://surgeryreference.aofoundation.org/cmf/trauma/midface/nasal-bone.

Overview
As the second most common facial fracture behind nasal bone fractures, the basics of the workup and management of mandible fractures must be understood by the junior Otolaryngology resident early in training. Mandible fractures are commonly classified according to anatomic location: condyle/subcondyle, coronoid, ramus, angle, body, parasymphysis, symphysis, and alveolus. Appropriate management reduces long-term morbidity from these injuries, including malocclusion, trismus, infection, nerve injuries, temporomandibular joint ankylosis, malunion/nonunion, and dental injuries. Initial exam should focus on airway status as, while relatively rare, bilateral body fractures or other concomitant injuries can lead to acute airway obstruction. The overlying soft tissue should be examined closely for associated injuries and crepitus with documentation of patient reported occlusion and inferior alveolar nerve anesthesia if present. Detailed intraoral exam is crucial including dental health, missing or fractured teeth, occlusion class, and any intraoral lacerations. Non-contrast maxillofacial CT is used in most centers for diagnosis due to availability, high sensitivity, and ability to detect additional facial injuries, although panoramic films can be helpful at times for increased visualization of dental fractures, root health, and alveolar ridge details. The favorability of fractures may also be used to classify the fracture and influence the treatment approach. This chapter is meant to aid in the initial evaluation of these patients; the AO Foundation Surgery Reference provides an excellent review of management techniques according to fracture subsites.

Determining Favorability of a Fracture

Classifying mandible fracture “favorability” is mainly applicable to angle and body fractures and is related to the angulation of the fracture line. Favorability is evaluated in both the horizontal and vertical dimensions. When a fracture is considered favorable, the muscles attached to the mandible are holding the fracture into anatomic reduction (often contracting perpendicular to the fracture line), compared to an unfavorable fracture where muscle attachments will pull fragments apart. Generally, the origin and attachment of the musculature on the mandible pull the anterior fragments inferior and posterior (digastrics, genioglossus, geniohyoid, mylohyoid), while posterior mandibular fragments are pulled superior and medial (masseter, medial pterygoid, temporalis). A quick method of remembering favorable versus unfavorable fracture patterns is: When viewed in a sagittal or axial plane, unfavorable fractures “stink” – that is they point toward the nose.

Occlusion and Dental Numbering

Determining the occlusive status is crucial both in the initial exam as well as during management. This begins with careful exam of cuspal interdigitation as well as the location and contact of the wear facets. Normally the maxillary arch of dentition is outside of the mandibular arch. The anterior sextant of maxillary dentition is also wider than the mandibular dentition. Angle’s classification divides occlusive relationship of the maxillary and mandibular teeth into three categories based on the 1st molar relationship. Angle Class I (normal occlusion) indicates that the mesiobuccal cusp (anterior/lateral cusp) of the maxillary 1st molar interdigitates with the buccal groove of the 1st mandibular molar. Even with Class I occlusion, malposed teeth or other discrepancies may still exist. In Class II malocclusion (or retrognathism), the maxillary 1st molar mesiobuccal cusp is more mesial (anterior) to the buccal groove. In Class III malocclusion (prognathism) the cusp is more distal (posterior). In additional to the class of occlusion, evaluate for premature contact, open bite, cross bite (maxillary buccal cusps fall lingual to the mandibular), and chin deviation. Subcondylar fractures tend to cause shortening of the mandible with early contact of molars leaving an anterior open bite. Fractured or dislocated teeth or alveolar ridge fractures may also lead to early contact and open bite. During the exam, it is beneficial to ask patient how their occlusion feels as subjective reporting is usually quite accurate. The universal dental numbering system begins with the right maxillary 3rd molar as tooth #1, tooth #16 is the left maxillary 3rd molar, it then drops to left mandibular 3rd molar for tooth #17 and finishes with right mandibular 3rd molar as tooth #32.

Unique Patient Considerations

• Unerupted teeth leading to areas of weakness in the pediatric mandible and concerns surrounding future mandibular growth complicate screw and plate placement if open reduction is undertaken. Fortunately, most pediatric fractures can be managed with soft diet and observation or closed reduction with orthodontic brackets with guiding elastics for maxillomandibular fixation (MMF). If severe comminution or displacement is present, open fixation or rigid closed reduction may be necessary. When open reduction is required, inferiorly placed monocortical screws and absorbable plates are frequently used to minimize risk to unerupted dentition and long-term effects on bony facial growth. Early mobilization remains paramount for all pediatric patients to prevent temporomandibular joint ankylosis and resultant facial height asymmetry.

• Edentulous patients present a unique challenge due to inability to set occlusion and mandibular atrophy that is commonly present. If the patient has dentures, they may aid in judging the occlusion and proper reduction and may be used as a splint to attempt management with closed reduction. Open reduction internal fixation after anatomic reduction is most commonly used to repair mandible fractures in edentulous patients.

Key Supplies for Mandible Fracture Consultation

• Appropriate PPE including mask, eye protection, gloves, and gown

• Headlight

• Tongue depressors

• Flexible endoscope

• Antifog solution (Fred)

Management

• Ensure no acute airway concerns, assess ABCs (Airway, Breathing, Circulation) with attention to potential additional injuries which may require more acute management.

• Full history with attention to mechanism of injury, patient reported malocclusion or facial numbness, past medical history, surgical history, personal or family history of problems with anesthesia, and timing of last meal (if planning for surgery the same day).

• Detailed head and neck physical exam, cranial nerve exam with documentation of inferior alveolar nerve/mental nerve anesthesia, low threshold for nasopharyngeal endoscopic airway exam, intraoral exam including state of dentition and occlusion, inspect for floor of mouth hematoma. A full head and neck trauma exam should be performed in any patient with a mandible fracture, as the mechanism of injury often predisposes to additional facial fractures.

• Recommend basic labs including CBC and CMP; consider coagulation panel if planning for surgery.

• Imaging:

  • Non-contrast maxillofacial CT is preferred in most cases, providing fast, highly sensitive imaging and the potential for 3D reconstruction (helpful if severely displaced or comminuted, may need to call Radiology to ask for 3D formatting).

  • Panoramic films have advantage over CT of improved alveolar ridge and dental details but less sensitivity for fracture identification, do not assess for other concomitant craniofacial trauma, and do not show condylar malposition as well as CT.

  • Mandibular series plain films with Townes view are of historical relevance and are rarely used in U.S.

  • For patients with loss of consciousness and missing teeth, consider chest x-ray to rule out tooth aspiration.

• Surgical timing whether open reduction internal fixation (ORIF) or closed reduction is generally non-emergent and can be delayed and completed the following morning or within a few days as an outpatient. Delaying increases patient discomfort, and there appears to be a gradual trend toward increased infection if delayed beyond a few days. If a delay in treatment is anticipated, temporary stabilization of a fracture with Ivy loops or circumdental wires can be considered to reduce fracture bleeding and improve patient comfort.

• Antibiotics:

  • Antibiotics to cover oral flora in select cases – in adults most commonly amoxicillin-clavulanate, ampicillin-sulbactam, or clindamycin for penicillin allergic patients.

  • Oral antimicrobial rinse such as chlorhexidine can also be considered and is generally used for open fractures as well as postoperatively.

• Start antibiotics with continuation through surgery for open fractures (fracture through tooth bearing mandible is considered open in most cases even if no apparent laceration through skin or mucosa).

• Intraoperative antibiotics are routine in all cases.

• Postoperative antibiotics typically reserved for cases with severe comminution, contamination, or “dirty” mechanism of injury such as gun shot.

• Consider tetanus prophylaxis for contaminated wounds.

• Keep patient NPO if surgery is planned for same day.

• Admission if plan for immediate surgery, if pain is uncontrollable, or if any airway concerns, otherwise may discharge to home after reviewing with the team.

• If discharging with plan for surgery in following days: Consider starting a no chew diet, chlorhexidine oral rinse after each meal, ice to jaw 20 minutes of every hour while awake, and analgesics.

General Management Strategies by Subsite

• The first step in ensuring appropriate reduction for any approach is establishing at least temporary rigid fixation of normal occlusion using maxillomandibular fixation (Erich arch bars, intermaxillary fixation screws, or hybrid systems) or interdental fixation. This allows reduction of fractures in a way that will ideally result in ultimately normal occlusion.

• Parasymphysis/Symphysis: ORIF with intraoral approach, two mini plates or two lag screws (consider submental approach).

• Alveolar Ridge: Stabilize segment with arch bars or interdental wiring and follow-up with endodontist.

• Body: Intraoral approach, often with percutaneous screw placement, options include rigid fixation with two miniplates, inferior bicortical plate, and superior border monocortical tension-band plate.

• Angle: Rigid MMF for 6 weeks or ORIF with transoral placement of a Champy plate (may still need MMF), single mini-plate along superior border, two mini-plates or strut/ladder plate. For displaced or trigone fractures with bone loss, consider external approach with inferior border recon plate.

• Ramus: MMF for 6 weeks, if open repair is required, external approach or intraoral with trocar.

• Subcondylar/Condylar: “Closed reduction” with short duration (around 2 weeks) of rigid MMF transitioning to elastics and early mobilization to avoid temporomandibular joint ankylosis. Absolute indications for ORIF (Zide and Kent) are: (1) condyle displaced into the external auditory canal or the middle cranial fossa, (2) foreign body or open temporomandibular joint, (3) inability to obtain occlusion with MMF, and (4) lateral extracapsular displacement of the condyle. Relative indications include ability to achieve reduction, bilateral fractures, and other contraindications for MMF. ORIF usually requires pre-auricular, submandibular, or combined approaches with trans-parotid dissection (consider nerve monitoring) versus endoscopic trans-oral approach with percutaneous access.

• Coronoid Process: Observation, soft diet.

General Management of Involved Dentition

• Avulsed tooth:

  • Place in milk – replace in socket as soon as possible (unlikely to survive if out longer than 2 hours) and splint in place with buddy wire or resin acrylic.

  • Follow-up with dentist or endodontist within 2 weeks, usually for root canal.

• Displaced or mobile tooth:

  • Document mobility with the Miller Classification: Class 1 denotes <1 mm horizontal mobility, class II denotes >1 mm horizontal mobility, and class III denotes >1 mm horizontal movement and vertical mobility.

  • Reposition and splint with acrylic resin or buddy wire.

• Indications for dental extraction:

  • Tooth preventing mandible fracture reduction.

  • Infected tooth within fracture line.

  • Tooth fracture with exposed pulp (although some fractured teeth with exposed pulp may be viable in young patients, consider dental evaluation prior to extraction if possible).

  • Tooth within fracture line interfering with occlusion.

• Follow-up with dentist for all dental injuries.

We recommend the AAPD Guidelines for the Management of Traumatic Dental Injuries for a more comprehensive review.

References
1. Ellis III, E., Schubert, W. Mandible. AO Foundation Surgery Reference, https://surgeryreference.aofoundation.org/cmf/trauma/mandible.
2. Diangelis, A.J., Andreasen, J.O., Ebeleseder, K.A., et al. (2012). Guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth. Dent Traumatol. 28:2-12.
3. Miles, B.A., Smith, J.E. (2013). Mandibular Fractures. In Johnson, J.J., Rosen, C.A. (Eds.), Bailey’s Head and Neck Surgery-Otolaryngology 5e (pp. 1195-1208). Baltimore, MD: Lippincott Williams & Wilkins.
4. Kellman, R.M. (2020). Maxillofacial Trauma. In Flint, P.W., et al. (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 286-310). Philadelphia, PA: Elsevier.
5. Zide, M.F., Kent, J.N. (1983). Indications for open reduction of mandibular condyle fractures. J Oral Maxillofac Surg. 41(2):89-98.

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Overview
Midfacial trauma describes hard and soft tissue trauma to the middle facial third, from nasion to subnasale. Midfacial fractures can include fractures involving any of the facial bones inferior to the frontal bone and superior to the mandible including nasal, zygoma, maxilla, ethmoid, sphenoid, vomer, palatine, and lacrimal.

The midfacial skeleton is organized into three complexes including the bilateral zygomaticomaxillary complex (ZMC), the unpaired naso-orbital ethmoid complex (NOE), and the bilateral nasomaxillary complexes. These skeletal complexes contribute to the vertical and horizontal buttresses of the midface, which provide structural support and protection to the cranium. The vertical buttresses of the midface are the nasomaxillary, zygomaticomaxillary, and pterygomaxillary buttresses, and the unpaired unnamed midline buttress. The midline buttress connects the palatine process of the maxilla to the frontal bone in the upper facial third, through articulation of the perpendicular plate of the ethmoid and the vomer. The most injured midfacial bones are the nasal bones, followed by fractures of the maxilla and zygoma. Fractures of the maxilla and zygoma may compromise their respective midfacial complexes and vertical buttresses. In this chapter, we provide a basic overview of assessment and treatment of the classic midfacial fracture patterns of Le fort fractures, ZMC fractures, and NOE fractures.

Key Supplies for Midfacial Fracture Consultation

• Appropriate PPE including mask, eye protection, gloves, and gown

• Headlight or pen light for checking ocular exam, including pupillary reflexes

• Snellen eye chart

• Tongue depressor to retract cheeks and perform thorough intraoral exam

• Nasal speculum for intranasal and septal exam (a cotton swab can be helpful to assess septal hematoma)

Management

• It is not infrequent that a midfacial trauma patient requires intubation on initial presentation for airway protection. Unstable midface fractures pose a risk of airway compromise, in addition to indirect risks posed by sequalae like expanding hematomas, or severe edema; in addition, many patients have concomitant facial or head and neck trauma, including mandible fracture(s).

• After ABCs (Airway, Breathing, Circulation) and primary survey, obtain basic history and past medical history when feasible based on patient condition and acuity.

• Complete head and neck physical exam with attention to signs of possible sequelae.

  • Hematomas: Midfacial trauma can result in retrobulbar hematomas, septal hematomas, or expanding hematomas of the palate. Failure to recognize a retrobulbar or palatal hematoma can result in blindness or airway compromise, respectively. Failure to recognize a septal hematoma can result in eventual ischemic necrosis of septal cartilage and a resultant collapse of vertical support termed “saddle-nose deformity.”

  • CSF leak: Injury to the NOE complex or skull base can result in an occult CSF leak, camouflaged by distracting epistaxis or heme in nares. Presence of watery discharge should raise suspicion for a CSF leak, which can be confirmed with a beta-2 transferrin assay.

  • Epistaxis: A common sequelae of midfacial trauma and may require intervention such as nasal packing. Most of the time significant bleeding is the result of lacerations/tears to the nasal or oral mucosa. Massive hemorrhage can occur after laceration or pseudoaneurysm of the sphenopalatine artery or other branches of the internal maxillary artery, requiring endoscopic clipping or Interventional Radiology consultation.

• An organized, sequential clinical facial assessment should be performed starting with the upper, then middle, and lastly the lower facial third, noting:

  • Presence of lacerations, documenting aesthetic subunits involved and depth of laceration.

  • Gross asymmetries of midfacial structures: Orbits, malar prominences, or maxillary occlusal plane (intraorally).

  • Presence of cranial nerve deficits.

  • Orbital exam: Assess proptosis, ptosis, and intraocular pressures if concern for retrobulbar hematoma, bowstring test to assess medial canthal tendon in an NOE, and forced duction test if concern for entrapment.

  • If patient is unconscious, intubated, and sedated, or uncooperative with exam, document inability to complete cranial nerve exam and prioritize exam at first opportunity.

  • Midfacial fractures commonly result in transient deficits (like hypoesthesia or dysfunction) to the V2 branch of the trigeminal nerve or the zygomatic branch of the facial nerve.

  • Hyposmia or anosmia from injury to cranial nerve I can be seen in NOE fractures.

  • Injury to cranial nerves II-VI is possible if a patient sustains midfacial fractures with significant orbital fracture components.

• Imaging: Thin slice, non-contrast maxillofacial CT is the gold standard.

  • Differs from CT head in extension of scan to include the entirety of the maxillary dentition and the entire mandible versus just the brain.

  • Cuts <1 mm allow for greater detail of fractures.

  • 3D reconstruction allows for more global assessment of complex and comminuted fracture patterns and assists with operative planning.

  • Assess midfacial complexes in axial, coronal, and sagittal views to allow for visualization of articulation points of the zygomas and maxilla that contribute to the vertical and horizontal buttresses.

  • Assess for associated orbital fractures.

  • Assess for evidence of disruption of the cribriform plate including pneumocephalus, nasofrontal outflow tract.

  • Assess for evidence of a displaced zygomatic arch fracture that may impede normal rotation of the mandibular coronoid process during mouth opening or entrap the masticatory muscle attachments to the coronoid process.

• Consider tetanus prophylaxis for contaminated wounds.

• Keep patient NPO if planning surgery for the same day.

• Likely best prognosis for functional and cosmetic rehabilitation if surgical intervention takes place on arrival, prior to edema progression. However, practically speaking, these patients may require prolonged resuscitation and interventions for other life-threatening injuries. Therefore, surgical intervention for midfacial fractures may be delayed by as much as 14 days.

• Admission if intubated or concern for airway compromise, plan for immediate surgery, or if pain is uncontrollable. Otherwise, after discussion with senior resident or attending, may consider discharge to home.

Discharge Recommendations

• Typically follow-up around 1 week for reassessment and surgical planning, or closed treatment and serial reassessments.

• For Le Fort fractures or severe ZMC fractures, recommend full liquid diet to avoid transmission of biting forces across unstable fracture lines.

• Sinus precautions for 2-4 weeks to prevent air emphysema (avoidance of nose blowing or sneezing with closed nostrils; “cough and sneeze with mouth open”).

• Adjunct recommendations to treat post-traumatic edema: Consider a short-course of steroids if not contraindicated, ice-soaked gauze to face every 2 hours for the first 48 hours, head of bed elevation >30 degrees, and lubricating eye-drops.

• The use of antibiotic prophylaxis in midfacial fractures is controversial as literature does not support routine antibiotic prophylaxis for facial fractures in the upper and middle facial thirds; however, practically speaking, many providers will still prescribe antibiotics depending on extent of mucosal trauma and other factors.

Classification and Assessment Specifics by Subtypes (Le Fort, ZMC, NOE)

Le Fort Fractures

Le Fort fractures are classified into three types, all of which include fracture of the pterygoid plates of the sphenoid bone. Le Fort I is a transverse fracture of the maxilla. Le Fort II is a pyramidal fracture of the maxilla with involvement of the nasal bones at the nasofrontal articulation. Le Fort III is a transverse fracture at the nasofrontal suture with lateral propagation through the medial and lateral orbits, finally coursing inferiorly through the zygomatic arches (i.e., craniofacial disjunction). Le Fort fractures commonly present in combinations or with variations in type between a patient’s right and left sides. For example, it is possible for a patient to have a right-hemi Le Fort III + a right-hemi Le Fort I + a left-hemi Le Fort II. Le Fort III fractures have the highest incidence, are typically caused by high-velocity blunt force traumas, and have the highest association with concomitant intracranial injuries.

Assessment of Le Fort Fractures

• Test for gross mobility of the maxilla with bimanual inspection, resting one hand on a stable, unaffected region (e.g., frontal bone).

  • A Le Fort III fracture pattern will result in craniofacial disjunction, best identified by lateral grasp of the lateral orbital rims and ZMC, checking for gross midfacial mobility. This exam is painful. If this fracture is clear on imaging, consider delaying this maneuver until under general anesthesia at the time of surgery.

• Intraorally:

  • Assess for concomitant dentoalveolar trauma: Avulsions or luxations of teeth, displaced dentoalveolar fractures associated with fractures of the maxilla.

  • Check for cant of maxillary occlusal plane, may indicate impaction of the maxilla.

  • Note presence of vestibular or palatal ecchymosis, may indicate underlying fractures.

  • Note deviation of the uvula or edema of palatal arches, rule out expanding hematoma, and secure airway if present. May need urgent surgical intervention and a CT angiogram for full evaluation of a rapidly expanding hematoma.

Zygomatico-Maxillary Complex (ZMC) Fractures

Although numerous ZMC classification systems have been proposed, no classification system has been universally adopted. ZMC fractures are typically described by the articulations involved, with acknowledgement of the presence or absence of an orbital floor fracture component. The zygoma articulates with the temporal, frontal, sphenoid, and maxillary bones with intraorbital and extraorbital extension of the zygomaticomaxillary suture. The zygoma’s contribution to multiple vectors of projection and five points of articulation makes achieving fracture reduction challenging. Given the zygoma’s propensity for rotational displacement, proper reduction and stabilization of the zygoma must be achieved to reestablish anterior-posterior projection, vertical height, and transverse width of the face.

Assessment of ZMC Fractures

• Carefully assess for concomitant orbital injury given the zygoma’s anatomic contribution to the orbital floor, inferior orbital rim, and the lateral wall of the orbit. Approximately 50% of ZMC fractures have an orbital component to the fracture.

  • Visual acuity.

  • Pupillary reflexes.

  • Relative afferent pupillary defect (RAPD) or Marcus Gunn pupil. Consensual light reflex is present in the affected eye, although the pupillary light reflex is absent if light is shown directly on the affected eye. RAPD may represent injury to the optic nerve or retina and warrants an Ophthalmology consultation.

  • Intraocular pressures.

  • Extraocular motility, and if concern, consider forced duction test.

• Zygomatic arch fractures can result in mechanical interference of the mandibular coronoid process, preventing mouth opening. This mechanical interference is typically the result of the displaced zygomatic arch fragment impinging upon the temporalis muscle, as is attaches to the mandibular coronoid process.

  • Check for reduced maximal inter-occlusal distance to confirm mandibular hypomobility.

    • Normal maximal inter-occlusal distance 40 mm or greater, although the maximal inter-occlusal distance may be reduced by approximately 1-10 mm due to generalized post-traumatic pain and myalgia.

    • A mechanical interference caused by a zygomatic arch fracture will usually result in a maximal inter-occlusal distance of 25 mm or less. The patient may maintain the ability to open approximately 20 mm because the first 0-20 mm of mouth opening is facilitated by rotation of the condyles and is unaffected by the zygomatic arch fracture. The second phase of mouth opening, translation of the condyles initiated by masticatory muscles like the temporalis, has the potential to be disrupted by the mechanical interference of a zygomatic arch fracture.

  • Evidence of mandibular hypomobility should be further characterized as a hard-stop (true hard-tissue mechanical interference) or hypomobility secondary to patient-guarding (splinting due to pain).

  • Palpate zygomatic arch for pain or fracture line.

Naso-orbital Ethmoidal (NOE) Fractures

NOE fractures can involve complex, comminuted fractures of the nasal bones, frontal process of the maxilla, lacrimal bones, and lamina papyracea of the ethmoid bone. NOE fractures are commonly described by the Markowitz classification system, types I-III. A type I NOE fracture involves a fracture with a large fracture segment of the frontal process of the maxilla bearing the attached medial canthal ligament. Type II NOE fractures involve comminuted fractures of the frontal process of the maxilla, with maintenance of the medial canthal ligament attachment. Type III NOE fractures involve comminuted fractures with detachment of the medial canthal ligament.

Assessment of NOE Fractures

• Inspect for abnormal rounding of the medial orbital commissure to suggest medial canthal detachment. Follow the inspection with palpation. The eyelid traction test (or bowstring test) is used to identify abnormal canthal movement and diagnose canthal detachment.

• Measurement of inter-canthal distance can help distinguish true traumatic telecanthus from pre-morbid variations in anatomy. The average inter-canthal distance ranges from 35-40 mm, although can vary among different ethnicities. To roughly estimate the inter-canthal distance, draw a vertical line superiorly from the alar bases of the nose. This vertical line from the nasal ala should correspond with the medial canthal tendons of the orbit. Normal inter-canthal distance should also predict the intra-canthal distance from lateral to medial commissure of each orbit.

• Assess for presence of CSF leak or septal hematoma.

General Midfacial Fracture Surgical Management Strategies

Disclaimer
The Midfacial Fracture chapter of this Survival Guide was written with the intention of providing residents with a quick reference about evaluation and acute management strategies for midfacial fracture consultations. More detailed information regarding surgical approaches, surgical techniques, and long-term management strategies are beyond the scope of this chapter. Please refer to the referenced textbooks for a more comprehensive review of surgical management of midfacial fractures.

Surgical Timing

Ideally, midfacial fractures are repaired within hours if edema does not grossly distort access and repositioning. Alternatively, midfacial fractures can be fixated within 14 days of initial injury or may be deferred for a delayed secondary intervention in 3-6 months. The timing of repair may be influenced by the acuity of other significant injuries, timing of presentation, patient compliance and follow-up, among many other factors. Increased surgical difficulty in achieving mobilization and reduction increases as wound healing of the damaged hard and soft tissues progresses. Untreated comminuted fractures healing by secondary intention can result in the development of fibrosis and contracted soft tissues and callus maturation between the comminuted bony fragments. Creation of new, larger osteotomies may be required for adequate midfacial reduction if surgical intervention is delayed beyond 14 days of the initial injuries.

Surgical versus Non-surgical Management

Decisions about surgical versus non-surgical management of midfacial fractures are determined on a case-by-case basis, weighing the potential aesthetic and functional consequences of both closed and open treatment options. Several surgical approaches may be required for adequate access to involved fracture segment articulations. Objectives of operative management include reduction of displaced fractures or fixation of unstable facial fractures. Adequate reductions of midfacial fractures allow for return to pre-morbid masticatory function, restoration of anterior-posterior and transverse facial dimensions, and reinforcement of compromised vertical buttresses.

Maxillary impaction, of even a millimeter, represents compromised buttress support and displacement can worsen with masticatory forces and occlusal loading when the patient restarts a regular diet. For example, a non-displaced or minimally displaced Le Fort III may not require surgical intervention, while a minimally displaced hemi-Le Fort I may require surgical intervention if the amount of maxillary impaction results in the functional consequence of malocclusion. Next, imagine a patient presents with a mildly displaced ZMC fractures with a moderately displaced zygomatic arch component. While the minimally displaced fracture at the zygomaticomaxillary buttress may confer a clinically insignificant aesthetic deformity, the displaced zygomatic arch component would require open reduction if a mechanical obstruction caused by the displaced zygomatic arch results in the functional consequence of mandibular hypomobility.

Surgical Principles of Midfacial Fracture Treatment

These principles include protection of the globe during surgery, appropriate access to all fracture sites planned for open reduction, mobilization of impacted fracture segments, release of muscle impingements, removal of debris and bony fragments from the maxillary sinus prior to implant placement, and adequate reduction of fractures (starting from a top down or bottom up approach). Vertical and horizontal buttresses of the face are the regions prioritized when seeking reduction and attempting to fixate. Avoid aggressive stripping of periosteum, which is necessary for blood supply and eventual osseous healing of the thin and often comminuted bones involved in midfacial fractures. Adequate reduction is followed by proper adaptation of fracture plates to avoid untoward forces from hardware onto healing segments. Low-profile (1.3-1.7 mm) titanium plates with self-drilling, short-length (4-6 mm) screws are typically used to fixate larger fracture segments. Exploration of the orbital floor may be pursued after manipulation with fixation of a ZMC with a preoperative orbital floor component. Exploration and orbital implant placement may also be warranted after fixation of the zygomaticomaxillary suture at the inferior orbital rim, as orbital volume may increase and leave the periorbita and globe unsupported. In some cases, intraoperative imaging to confirm proper reduction and fixation is helpful as further mobilization of impacted segments or re-plating may be necessary. Follow with periosteal closure and re-suspension of canthal ligaments, malar fat pad, and superficial musculoaponeurotic system prior to skin closure. See the AO Foundation Surgery Reference for more detailed information regarding surgical planning.

Postoperative Care and Possible Complications

• Continued sinus precautions for length determined by injury extent.

• Soft or no-chew diet.

• Oral and nasal rinses.

• Ice-soaked gauze to face with head of bed elevation.

• Self-physiotherapy for mouth opening exercises.

• Counsel patients on possible short-term complications, including retrobulbar hematoma, extraocular muscle entrapment, diplopia, infection, and incisional dehiscence secondary to hematoma or seroma.

• Follow-up within 1 week for most patients. Long-term follow-up is advisable for complex midfacial injuries with attention to possible long-term sequelae including compromised facial form or masticatory function, occlusal disturbances, mandibular hypomobility, nasal obstruction, enophthalmos, persistent diplopia, plate extrusion or screw failure, and hardware infection.

References
1. Nam, A., Davidson, E.H., Manson, P.N. (2020). Assessment of the Patient with Traumatic Facial Injury. In Dorafshar, A.H., Rodriguez, E.D., Manson, P.N. (Eds.), Facial Trauma Surgery: from Primary Repair to Reconstruction 1e. (pp. 11-15). Edinburgh: Elsevier.
2. Cornelius, C.P., Gellrich, N., Hillerup, S., et al. (2009). Midface. AO Foundation Surgery Reference, https://surgeryreference.aofoundation.org/cmf/trauma/midface/.
3. Stack, B., Ruggiero, F. (2013). Midface Fractures. In Johnson, J.J., Rosen, C.A. (Eds.), Bailey’s Head and Neck Surgery-Otolaryngology 5e (pp.1209-1223). Baltimore, MD: Lippincott Williams & Wilkins.
4. Bevans, S., Malka, R. (2020). Midface Fractures: ZMC and LeFort Podcast Episode ENT in a Nutshell Published on Headmirror.com, www.headmirror.com/podcast/midface-fractures-zmc-and-lefort.
5. Milic, T., Raidoo, P., Gebauer, D. (2021). Antibiotic prophylaxis in oral and maxillofacial surgery: A systematic review. Br J Oral and Maxillofac Surg. 59(6):633-642.

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Overview
Fractures of the frontal bones can be broadly categorized based on sites of fracture, anterior or posterior table involvement, frontal sinus outflow tract involvement, and degree of displacement. When fractures involve the anterior table of the frontal sinus alone, the primary concerns relate to frontal sinus function and outflow as well as facial deformity secondary to a posteriorly displaced or impacted fracture. Chronic obstruction of the frontal outflow tract may lead to chronic sinusitis or mucocele formation, potentially with intracranial or intraorbital extension as late sequelae. These complications are avoided by careful exploration and management of the frontal sinus outflow tract. Fracture of the posterior table of the frontal sinus can affect not only sinus function if displaced but, as with any skull fracture, is frequently associated with intracranial injury. This type of fracture is usually managed in concert with Neurosurgery. Non-displaced posterior table fractures can be managed with observation alone, although herniation of brain or dura into the sinus or CSF leak should be ruled out before consideration of conservative management. Traumatic anosmia is also relatively common through shearing of the olfactory neurons as they pass through the cribriform plate. Various classification systems have been devised for fractures involving the frontal sinus including Stanley and Becker’s system for prediction of frontal sinus outflow tract obstruction, although no system is consistently used in clinical practice. Supraorbital rim involvement or orbital roof involvement of the fracture can present with various orbital concerns such as reduced ocular motility or injury to the supratrochlear or supraorbital nerves leading to forehead hypoesthesia. Additionally, fractures of the orbital rim as well as the nasoethmoidal complex have high association with lacrimal system obstruction.

Key Supplies for Frontal Bone Fracture Consultation

• Appropriate PPE including mask, eye protection, gloves, and gown

• Headlight

• Nasal speculum

• Flexible scope or rigid endoscope (with monitor and tower, if possible)

• Antifog solution (Fred)

• Oxymetazoline

• Flashlight for pupil exam (or can use headlight)

Management

• Full head and neck exam beginning with ABCs (Airway, Breathing, Circulation) and with attention to associated lacerations, sensation to forehead, presence of bony step off along orbital rims/frontal sinuses, facial contour over the frontal sinuses and glabella, extra ocular movements and visual acuity, presence of rhinorrhea or post nasal drip (may indicate CSF leak especially if clear and salty) and consideration of sinus evaluation with rigid endoscopy.

• High resolution maxillofacial CT is the imaging modality of choice with attention to involvement of the anterior and posterior tables, frontal sinus outflow tract, intracranial findings (pneumocephalus, epidural/subdural/subarachnoid hemorrhage, meningocele, or encephalocele), fracture extension into the naso-orbito-ethmoidal (NOE) complex, supraorbital rims, or anterior skull base.

• Make recommendation for appropriate consultations to include Ophthalmology if orbital involvement and Neurosurgery for significant posterior table fractures with associated pneumocephalus or intracranial injury or hemorrhage.

• Antibiotics are often considered for all posterior table fractures with coverage of common sinus organisms (e.g., amoxicillin/clavulanate or clindamycin), although their usage is not uniform.

• Initial non-operative CSF leak management options:

  • Over 50% of traumatic CSF leaks will spontaneously resolve in 1 week with conservative management.

  • Less likely to spontaneously resolve if posterior table displaced >5 mm.

  • Conservative management: Bedrest, head elevation, stool softeners, avoid Valsalva and nose blowing.

  • CSF diversion (lumbar drain or external ventricular drain) may be added through Neurosurgery if conservative management is not effective.

  • Antibiotics: Prophylactic antibiotics have not been shown to reduce risk of meningitis; data suggest surgical repair after 7 days without spontaneous resolution minimizes risk of meningitis.

• Isolated anterior table fracture without high risk of outflow obstruction or facial contour deformity can be managed conservatively with observation and radiographic follow-up. If forehead contour deformity is appreciated once the overlying soft tissue edema dissipates, this can be repaired secondarily.

• Depressed anterior table fracture with high risk of frontal sinus outflow tract obstruction (NOE fractures, fontal sinus floor fractures, inferior medial anterior table displaced fractures) or forehead contour deformity are usually managed with surgery.

  • For contour deformity, open reduction internal fixation (ORIF) with plates, autologous bone from the outer table of the calvarium or iliac crest, mesh, or a custom implant.

  • Most common approach is the coronal incision while other options include extension of an existing overlying laceration, bilateral brow incision (mid-forehead, pretrichial, etc.), or less commonly an upper blepharoplasty incision or gullwing/spectacle incision.

  • For sinus outflow tract obstruction, this can be managed with functional endoscopic sinus surgery or frontal sinus obliteration if severely comminuted (see the AO Foundation Surgery Reference for management specifics).

    • If sinus outflow obstruction occurs without CSF leak, most can be managed with endoscopic sinus surgery. Cranialization is rarely indicated and obliteration is rarely, if ever, used due to the high risk of late sequelae as outlined below.

• For isolated anterior table fractures that may impinge on the frontal outflow tract without cosmetic deformity, consideration may be given to observation with serial imaging. If obstruction develops radiographically, endoscopic management may be considered to re-establish normal outflow and preserve sinus function. This is often accomplished via a unilateral Draf IIB or Draf III frontal sinusotomy.

• Displaced posterior table fractures or patients with persistent CSF leak through the involved sinus are usually managed with cranialization of the sinus; frontal sinus obliteration has fallen out of favor at most centers secondary to the risk of late complications including mucocele formation, mucopyocele formation, and chronic infection of obliteration material.

  • Usually approached jointly with Neurosurgery with a coronal incision and frontal craniotomy.

  • Posterior table bony fragments are removed.

  • Dura is inspected and any tears repaired primarily or with a fascia lata graft sutured to dura.

  • Removal of all sinus mucosa including mucosal invaginations into the remaining bone (this is vital to reduce the risk of mucocele development as a late complication) smoothing of the bony surface of the frontal table (brain gradually fills the void left in the anterior cranial fossa).

  • A pericranial flap is often used as a second layer over the repaired dura or fascia lata graft.

Follow-up

• Short- and long-term follow-up is important because complications can develop; there is no strong consensus on timing of follow-up.

• CT can be used for surveillance unless the frontal sinus is obliterated, in which case MRI is needed.

  • Fat: T1 bright, T2 dark.

  • Scar: T1 and T2 intermediate to dark.

  • Mucosa/Mucocele: T1 hypo- to intermediate intensity and T2 intermediate to hyperintense (depending on the relative fluid content of the mucocele), but T1 gadolinium bright peripherally in surrounding mucosa but hypointense centrally within the mucocele.

References
1. Fokkens, W.J., Harvey, R. (2020). Management of the Frontal Sinuses. In Flint, P.W., et al. (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 719-732). Philadelphia, PA: Elsevier.
2. Fusetti, S., Hammer, B., Kellman, R., et al. Skull Base and Cranial Vault. AO Foundation Surgery Reference, https://surgeryreference.aofoundation.org/cmf/trauma/skull-base-cranial-vault.
3. Strong, E.B. (2013). Frontal Sinus Fractures. In Johnson, J.J., Rosen, C.A. (Eds.), Bailey’s Head and Neck Surgery-Otolaryngology 5e (pp. 1255-1271). Baltimore, MD: Lippincott Williams & Wilkins.

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Overview
Orbital fractures are the third most common facial fracture after nasal fractures and mandible fractures. They may be encountered in isolation or as a component of complex midfacial fractures. The bony orbital vault is comprised of seven bones (maxilla, zygoma, frontal, sphenoid, palatine, ethmoid, lacrimal) and provides support for the periorbita, which suspends the globe and insulates the extraocular muscles and suspensory ligaments. There are three important foramina of the bony orbit, including the optic canal, superior orbital fissure, and inferior orbital fissure. Traumatic orbital injuries can cause damage to the bones, globes, intimately associated cranial nerves (II, III, IV, V1, V2, VI), suspensory components of the periorbita, or the nasolacrimal system. Orbital fractures are typically described by the orbital walls involved in the fracture (i.e., orbital floor, lateral or medial walls, orbital roof). The management goal of these fractures is to preserve vision and maintain orbital volumes and contour to allow proper globe position and extraocular movements. Orbital fractures can result in emergent sequelae that require rapid identification and management to prevent long-term visual disturbances or blindness. Emergent sequelae include retrobulbar hematomas, optic nerve compression or transection, entrapment with strangulation of extraocular muscles, oculocardiac reflex, and other injuries intrinsic to the globe. There is a wide range of symptoms associated with these fractures, and symptoms can be as minimal as mild pain, periorbital swelling, or transient numbness of the cheek or maxillary teeth. Common visual changes associated with orbital fractures include blurry vision, diplopia, loss of color saturation, or decreased peripheral vision. Symptoms may not always correlate well with clinical findings and injury pattern; a comprehensive assessment of symptoms, physical exam, and imaging are often required to determine necessity of surgical intervention and plan surgical management.

Key Supplies for Orbital Fracture Consultation

• Appropriate PPE including mask, eye protection, gloves, and gown

• Headlight or pen light for checking pupils

• Snellen eye chart

• Tonometer to check intraocular pressure

• Anesthetic eye drops and fine-toothed forceps to perform forced duction testing

Unique Patient Considerations

Pediatric orbital fractures can be easily missed, as advanced imaging is frequently deferred in this population, the clinical exam may appear benign, and occult “green stick” fractures may be overlooked on imaging. Orbital fractures in children may result in the presentation of a “white-eye blow out,” a clinical constellation of a benign orbital appearance with a white sclera and radiographic evidence of a non-displaced orbital floor fracture, despite severe muscle entrapment and possible oculocardiac reflex. Classically, stimulation of the oculocardiac reflex results in bradycardia, syncope, and nausea and requires urgent surgical management to address. Clinical exam in children should prioritize testing the extraocular muscles. Presence of extraocular muscle restriction in superior gaze is an indication for surgical intervention to prevent muscle ischemia and or persistent stimulation of the oculocardiac reflex. In the absence of emergent sequelae, pediatric orbital fractures present a dilemma in treatment options given the developing facial skeleton and risk of growth-interference.

Management

• Full history with attention to mechanism of injury, visual symptoms or complaints such as double, blurry, or loss of vision, past medical history, surgical history, personal or family history of problems with anesthesia, and timing of last meal (if planning for surgery the same day).

• Detailed head and neck physical exam always starting with ABCs (Airway, Breathing, Circulation), detailed cranial nerve exam with documentation of V2 nerve anesthesia. A full head and neck trauma exam should be performed to assess for other injuries.

• Thorough ocular exam:

  • Ideally, patients with orbital injury should be co-examined by Ophthalmology and Otolaryngology.

  • Assess for periorbital injuries (lacerations, palpable fractures, ecchymosis, edema, emphysema), lid and canthal abnormalities (ptosis, entropion, ectropion, telecanthus) globe position (exophthalmos, enophthalmos, hypoglobus), ocular injuries (chemosis, conjunctival hemorrhage, epiphora, hyphema, open globe injuries).

  • Assess pupillary reflexes, extra-ocular movements, gross visual acuity, color vision, and peripheral vision.

  • Assessment of canthal attachments using bowstring test.

  • Midfacial sensory test with attention to V2 distribution.

  • Forced duction test with the use of anesthetic eye drops if concern for entrapment.

  • Tonometry to measure intraocular pressures, if not completed by ER provider or Ophthalmology.

• Maxillofacial CT imaging:

  • Assess orbital walls in axial, coronal, and sagittal views.

  • Assess for presence of retrobulbar hematomas, evidence of entrapment of the extraocular muscles, and estimation of percent of floor involved in the fracture (>50% frequently require surgical fixation).

  • Evaluate for associated fractures including naso-orbito-ethmoidal (NOE), zygomaticomaxillary complex (ZMC), or Le Fort.

• Consider tetanus prophylaxis for contaminated wounds.

• Consider antibiotics, especially if there is a significant amount of blood collected in the surrounding sinuses.

• Keep patient NPO if planning for surgery the same day.

• Admission if plan for immediate surgery if any concerns for increased intraocular pressures (may require serial pressure checks), or if pain is uncontrollable, otherwise may consider discharge to home.

• If discharging with plan for surgery in following days: Discharge recommendations for orbital fractures are targeted at reduction of periorbital edema and avoidance of progressive air-emphysema. Discharge recommendations may include a short-course of steroids, a short-course of prophylactic antibiotics, lubricating eye drops, ice-soaked gauze to face, head of bed elevation >30 degrees, sinus precautions for 2-4 weeks (avoidance of nose blowing or sneezing with closed nostrils to avoid emphysema), and follow-up within 1 week.

Best prognosis for functional and cosmetic rehabilitation usually if surgery is performed within 2 weeks of initial injury in cases where surgery is deemed appropriate.

Retrobulbar Hematoma/Hemorrhage

• A rapidly progressive, vision-threatening emergency that can cause increased intraocular pressure and stretching of the optic nerve due to collection of blood in the retrobulbar space. This is a possible sequalae of orbital fractures that usually requires immediate decompression with lateral canthotomy and inferior cantholysis if causing increased intraocular pressures.

• Clinical signs and symptoms include a proptotic tense globe, acute severe pain, progressive loss of vision, relative afferent pupillary defect, subconjunctival hemorrhage without a posterior limit, and periorbital edema.

• Intraocular pressures should be obtained but should not delay decompression if the globe is tense on exam as blindness can occur in as little as 90 minutes, normal intraocular pressure ranges from roughly 10-20 mmHg.

• Lateral canthotomy and inferior cantholysis is performed in a trauma bay or the Emergency Department to prevent delay of decompression.

Operative Management

• Indications for urgent orbital fracture repair:

  • Oculocardiac reflex.

  • Severe muscle entrapment posing risk of ischemic necrosis.

  • Bone fragments impinging globe or optic nerve.

  • Severe globe malposition into maxillary sinus posing a risk of strangulation of cranial nerves.

• Indications for routine orbital fracture repair:

  • Radiographic involvement of >50% of the orbital floor or >1 cm of displacement of periorbita into the maxillary sinus (predicts future globe malposition).

  • Clinical enophthalmos/hypoglobus that exceeds 2 mm (can be a later finding as edema will artificially disguise true globe position).

  • Persistent diplopia or gaze restriction.

• Relative contraindications to orbital fracture repair (discuss with your attending and Ophthalmology):

  • Traumatic optic neuropathy (this varies according to clinical context and provider preference; some literature suggests no worsened visual outcomes following fracture repair).

  • Open globe injuries.

  • Retinal detachment or tear.

  • Orbital compartment syndrome.

  • Only seeing eye.

  • Hyphema.

Common Surgical Approaches to Orbital Fractures

• Transconjunctival (preseptal or retroseptal), transcutaneous (subciliary, subtarsal, infraorbital, lateral brow), via existing lacerations, and transantral (Caldwell-Luc). Extensions can be added to the transconjunctival approach to gain additional access at lateral and medial aspects of the orbit. Decision for which approach is used is based on location of fracture(s), cosmetic considerations, and surgeon preference as well as presence of existing lacerations.

• See the AO Foundation Surgery Reference for more information regarding surgical approaches and steps. Principles of treatment include protection of the globe during surgery, appropriate access, complete elevation of periorbita from affected wall to reduce risk of tissue-impingement by implants, removal of debris and bone fragments from the maxillary sinus prior to implant placement, and re-suspension of periorbital ligaments and skin.

• Implant options available to restore the inferior orbital support: Titanium mesh or porous polyethylene (MEDPOR®) are used often. Other options include composite of titanium mesh with MEDPOR® coating, resorbable plates, and bone grafts. These plates are typically fixated to the inferior orbital rim using a couple of small screws. The small posterior ledge provided by the palatine bone is used as a guide for implant extension posteriorly. The optic nerve is expected approximately 42 mm posterior to the inferior orbital rim; hence, dissection or implant extension farther than 42 mm is typically avoided. Posterior implant extension and vertical position is ideally confirmed with intraoperative imaging, if possible.

Postoperative Complications

• Short-term: Retrobulbar hematoma, rectus muscle entrapment, inferior oblique muscle avulsion, diplopia, elevated intraocular pressures, corneal abrasion, infection, and incisional dehiscence.

• Long-term: Persistent diplopia, enophthalmos, hypoglobus, entropion, ectropion, lower lid lag, plate extrusion, and scarring of periorbital tissues to the reconstruction plate limiting ocular motility.

• Presence of postoperative complications may warrant Ophthalmology or Oculoplastics consultation to identify the underlying etiology and secondary reconstruction options.

References
1. Kachniarz, B., Grant, M., Dorafshar, A.H. (2020). Orbital Fractures. In Dorafshar, A.H., Rodriguez, E.D., Manson, P.N. (Eds.), Facial Trauma Surgery: From Primary Repair to Reconstruction 1e. (pp. 113-121). Edinburgh: Elsevier.
2. Cornelius, C.P., Gellrich, N., Hillerup, S., et al. Orbit, Orbital Floor Fracture. AO Foundation Surgery Reference, https://surgeryreference.aofoundation.org/cmf/trauma/midface/orbital-floor.
3. Krishnan, D., Ochs, M. (2011). Orbital and Ocular Trauma. In Miloro, M. Ghali, G.E., Larsen, P. et al. (Eds.), Peterson’s Principles of Oral and Maxillofacial Surgery 3e. People’s Medical Publishing House.

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Overview
Penetrating neck injuries of various mechanisms (e.g., high velocity or low velocity gunshots, stab wounds, shrapnel, etc.), whether isolated or in conjunction with additional injuries, require rapid evaluation to potentially address life-threatening airway or neurovascular injury. These injuries may involve any of the critical neck structures to include the laryngotracheal complex, pharynx, esophagus, carotid, jugular, other large vessels, the spinal cord, and numerous cranial nerves. The basic tenet in trauma care of first assessing and supporting the patient’s ABCs (Airway, Breathing, Circulation) are especially vital with these consultations, with airway compromise and hemorrhage leading to hypovolemic shock being among the most common causes of death in the acute phase. Pharyngo-esophageal injuries are additional important sources of late morbidity due to neck and mediastinum infection and resultant sepsis when unrecognized along with associated morbidity from damage to many of the critical neck structures. Penetrating neck injuries can be characterized by their depth of injury (injuries that do not penetrate the platysma in the anterior triangle are considered superficial and are generally treated conservatively) and location in the neck, with the traditionally described neck zones useful to describe injuries and to guide management. Consideration of the mechanism of injury is especially important with gunshot wounds, as the missile type and velocity of the round significantly impact surrounding tissue destruction. For example, a hollow point round designed to flatten on impact can lead to a large area of tissue necrosis well beyond the diameter of the original ballistic path secondary to the large temporary and permanent cavitation. Historically, nearly all penetrating injuries that breached the platysma were explored operatively; however, the increased use of adjuvant studies including CT, CT and conventional angiograms, endoscopy of the upper aerodigestive tract, and neck ultrasound have reduced the negative neck exploration rate and helped determine which patients require surgical management.

Key Supplies for Penetrating Neck Trauma Consultation

• Headlight

• Appropriate PPE including mask, eye protection, gloves, and gown

• Flexible endoscope (preferably videoendoscopy via portable unit or tower to record exam)

• Suction with Yankauer tip

• Airway cart, complete with cuffed endotracheal tube assortment, and tracheostomy tray

• Throat packing supplies (Kerlix rolls x4, Kelly/tonsil clamp)

Zone I

• From the clavicles to the cricoid cartilage. Structures include the thoracic duct (left side), common carotid artery, internal and external jugular veins, innominate artery, subclavian, trachea, lung apices, esophagus, thyroid gland, the vagus and recurrent laryngeal nerves, and brachial plexus.

Zone II

• From cricoid cartilage to mandibular angle. Structures include the common, internal, and external carotid, jugular veins, trachea, larynx, supraglottis, esophagus, hypopharynx, and pharynx.

Zone III

• From mandibular angle to skull base. Structures include the internal carotid and vertebral arteries, jugular vein, pharynx, sympathetic chain, and cranial nerves IX-XII.

Management

If patient has a compromised airway, is actively hemorrhaging, or in shock

• Upon arrival, assess patient status and ABCs (Airway, Breathing, Circulation). An underappreciated assessment that should always be completed in this situation with a conscious patient is simply asking how they are doing and if they are having difficulty breathing. Their response – full sentences, only head shakes, hoarse voice, incomplete sentences – can reveal many aspects of the airway status and help guide the next steps.

• Airway securement takes precedence.

  • Evaluation should include endoscopy by the best endoscopist in the room for decision on next step in airway management.

  • Airway securement preferably occurs in the OR whenever possible. (If intubated or surgical airway obtained prior to the OR, should still consider going to the OR for airway exam or tracheostomy conversion as indicated.)

  • Beware of laryngotracheal separation or fracture distraction/displacement during endotracheal intubation in patients with suspected tracheal injury.

  • If suspected laryngotracheal injuries, awake tracheostomy should be performed if possible.

• If active bleeding intraorally:

  • Set up two large bore suctions.

  • Arrange for airway securement as above.

  • Ensure airway cart is available and stays with patient.

  • Ensure patient is positioned upright with suctions to aid in protecting airway.

  • Maintain cervical spine neutrality and protection if possible if cervical spine injury status is known.

  • Once airway is secured, consider placing a throat pack to compress bleeding source.

• If bleeding externally:

  • Compression to stop bleeding while arranging for definitive treatment, may be best accomplished by a gloved finger with precise pressure as indiscriminate pressure with dressings may simply hide the bleeding; avoid indiscriminate clamping.

  • Ensure large bore IV lines are in place.

  • Treat hypotension with Emergency Department and Trauma providers; may require IV blood products, crystalloid, colloid, or vasopressors.

  • Have a colleague work on arranging for immediate OR or Interventional Radiology transfer if injury is a high zone III and not suspected to be surgically amenable.

• Labs:

  • CBC to assess hemoglobin and platelet count.

  • Consider type and cross or activate the massive transfusion protocol as indicated.

  • Obtain coagulation panel, correct anticoagulant status if indicated and possible.

  • Consider TEG (thromboelastogram) or ROTEM (rotational thromboelastometry) to guide resuscitation based on facility capabilities.

  • CMP with attention to renal function.

If patient is asymptomatic or minimally symptomatic

• Obtain relevant history including mechanism, timing, and additional comorbidities as time and situation allows; if gunshot wound try to obtain additional information including caliber, shotgun, handgun, rifle, shot distance, etc.; if time allows review of intake trauma notes from police, emergency medical services, or bystanders in the chart may contain valuable information not known to the patient.

• Detailed head and neck physical exam looking for entrance/exit sites (exit sites are generally larger and more traumatic than entrance sites), detailed cranial nerve exam, basic neurological exam, and consider nasopharyngoscopy for all patients if the situation allows.

• Palpate the neck with attention to wounds, crepitus, or hematoma (may be difficult to thoroughly inspect while patient is in C-collar; may consider having assistant hold patient’s head stable while C-collar is removed for thorough exam).

• Look for Horner syndrome (ptosis, miosis, anhidrosis; suggests sympathetic plexus injury and carotid sheath violation).

• If stab wound with the object still in place: Do not remove as may tamponade bleeding; remove only in the OR or in a controlled environment where you are able to control significant bleeding (ideally after CT angiogram when possible).

• If gunshot wound with large clot over entrance or exit wound: Do not probe wound and consider leaving clot in place as difficult or uncontrollable bleeding may follow clot removal.

• Auscultate ensuring bilateral breath sounds, listen for crunching sound with heartbeat (Hamman’s sign is suggestive of pneumomediastinum and esophageal perforation).

• Labs:

  • CBC with consideration of type and screen if indicated.

  • CMP with attention to renal function.

Imaging

• Chest x-ray: For all patients, evaluate for pneumothorax, hemothorax, and pneumomediastinum.

• CT: Practically speaking, CT is obtained in nearly all cases in the Emergency Department if time allows prior to surgical exploration (path of projectile through tissue may be indicated by bubbles or scattered radiodense foreign bodies or bone fragments).

• CT angiogram: Considered for most cases with risk of large vessel injury if not immediately undergoing neck exploration.

  • Evaluate for evidence of vascular injury including wall irregularity or stenosis, air around the vessels, foreign bodies or bullet fragments adjacent to the vessels, and active contrast extravasation.

  • Large metallic fragments may cause artifact necessitating catheter angiography for better visualization.

  • Relative contraindication of renal insufficiency and contrast allergy.

• Contrast Esophagram or swallow study: Consider after initial stabilization and exploration if indicated.

  • Gastrografin: Thinner, less sensitive than barium for small injuries.

  • Barium: Thicker and may identify small injuries missed by Gastrografin but more likely to cause massive irritation/reaction in the neck if leaked and necessitate immediate washout.

• CT esophagram: Combines CT and contrast esophagram for improved visualization and sensitivity, consider based on institutional capabilities, pre-test probability, and clinical scenario.

Management of PO Status and Enteral Access

• Keep all patients NPO during medical trials and until cleared of esophageal or pharyngeal injuries. The responsibility of determining appropriate studies and need for esophagoscopy for “clearance” of these injuries is often multidisciplinary with Trauma Surgery, Gastroenterology, and possibly CT Surgery, although Otolaryngology will often appropriately make final decisions and recommendations as the most comprehensive evaluators of the upper aerodigestive tract.

• Nasogastric tube placement only after evaluation for esophageal injury and may need to be placed in the OR after esophageal repair.

• Low threshold for General Surgery or Interventional Radiology consultation for gastrostomy tube placement for patients with anticipated extended need for NPO (although nasogastric tube may be helpful in patients with esophageal injuries to provide some level of stenting to prevent strictures).

Medications

• Prophylactic antibiotics should be considered in all cases and are recommended in cases with pharyngeal or esophageal injuries.

• If injury does not involve the aerodigestive tract, can consider more narrow antibiotic coverage of skin flora.

• If pharyngoesophageal injury is identified or suspected:

  • Consider weight-based ampicillin-sulbactam or piperacillin-tazobactam with or without clindamycin, options for patients with penicillin allergy include ceftriaxone/clindamycin/metronidazole or clindamycin/gentamicin.

  • Proton pump inhibitor or H2 blocker for all intubated patients or those with aerodigestive tract injuries; can consider pantoprazole.

Disposition

• Admit to ICU if any airway concerns, large vessel or esophageal involvement, or significant soft tissue destruction.

• Admit to the floor can be considered in select cases if low risk injury and no airway concerns.

• Most cases required hospitalization for minimum of 48 hours, although this varies based on the wide range of severity of these injuries.

Follow-up and Patient Instructions

• Close follow-up with Otolaryngology typically within 1 week for most patients.

• Discuss return precautions relevant to injury, usually airway symptoms including dysphonia, stridor, dyspnea, or signs of infection including redness, pain, swelling, dysphagia, or fever.

General Management Strategies by Zone for Hemodynamically Stable Patients

Zone I

• If symptomatic:

  • Vascular evaluation with CT angiogram of the chest and neck or surgical exploration.

  • If injury is identified, may require sternotomy or thoracotomy to control hemorrhage; consider multidisciplinary surgical approaches with Trauma, Vascular, or Cardiothoracic Surgery as indicated.

• If asymptomatic or once hemorrhage control obtained:

  • Esophageal evaluations should be performed on all patients with Zone I injuries with risk of esophageal injury (esophageal injuries may be silent in this level until mediastinitis and sepsis develop).

  • Esophagoscopy, flexible or rigid; consider if patient is already going to the OR.

  • Contrast Esophagram or swallow study:

    • Gastrografin: Thinner, less sensitive than barium for small injuries.

    • Barium: Thicker and may identify small injuries missed by Gastrografin but more likely to cause massive irritation/reaction in the neck if leaked and necessitate immediate washout.

Zone II

• If symptomatic:

  • Proceed to OR for neck exploration and usually direct laryngoscopy, bronchoscopy, and esophagoscopy.

  • Laryngeal and tracheal injuries may require repair with plating of the thyroid cartilage, keel or stent placement, etc.

  • Consider Vascular Surgery consultation to aid in optimal vessel repair if carotid artery injury is suspected (after discussion with your supervising senior resident as may not be required based on the attending Otolaryngologist’s vascular training).

• If asymptomatic:

  • Lower threshold for surgical exploration due to easier access and reduced morbidity of surgery.

  • Consider vascular evaluation with CT angiogram of the neck.

  • If large vessel injury is found, proceed to OR for neck exploration.

  • Perform detailed nasopharyngoscopy; immobile true vocal cord suggests vagus or recurrent laryngeal nerve injury (although rarely arytenoid dislocation could be the cause) and is an indication for early surgical exploration.

  • Consider direct laryngoscopy and bronchoscopy in the OR.

Zone III

• If symptomatic:

  • Consider Interventional Radiology consultation for catheter angiography.

  • Diagnostic and therapeutic angiography may be employed at discretion of the interventional radiologist.

  • Difficult surgical access in this zone; in cases of large volume hemorrhage where endovascular control is not possible, may require mandibulotomy or mandibular distraction techniques for access.

• If asymptomatic:

  • Cases with vascular injury may present without symptoms or with only symptom being corresponding cranial nerve deficits.

  • Low threshold for Interventional Radiology consultation for diagnostic four-vessel (bilateral carotid and vertebral arteries) catheter angiography with venous phase imaging. Obvious advantage of immediate treatment options being available if arterial injury is identified.

  • Pharyngeal evaluation: Detailed exam of the oral cavity, oropharynx, supraglottis, and larynx with direct visualization and nasopharyngoscopy. Low threshold for evaluation with swallow studies prior to diet initiation.

General Management Strategies by Injury Type and Involved Structures

Gunshot Wounds

Caliber and velocity of round are important as kinetic energy is related to the mass and velocity of the projectile. High speed rounds may cause significant tissue destruction beyond the immediate path of the projectile through cavitation. Distance of the shot is especially important with shotgun injuries due to rapid slowing of pellets and are thus frequently grouped into close range (around 3 meters or less) and long range. With close range shotgun injuries, superficial burns are possible, and the shell wad may embed in tissue and be a source of infection if not removed. Shotgun injuries with larger pellets such as buckshot or with slugs will not lose velocity as rapidly and should be considered in similar fashion to typical handgun or rifles injuries.

Stab Wounds

Stab wounds from assault, industrial accidents, large shrapnel fragments from blasts, or other mechanisms may penetrate the neck, damage structures in their path, and introduce foreign material. Due to the relatively low velocity, damage to tissue is through the direct passage of the object and more predictable paths and tissue injury are expected. Any patient who presents with a stab injury with the object still lodged should be evaluated with imaging prior to removal if possible due to the possibility of tamponade of large vessels by the object. If a large vessel is found to be involved in a hemodynamically stable patient, consideration for endovascular balloon placement proximal to the involved vessel or surgical access both proximal and distal should be obtained prior to removal or further exploration.

Esophageal and Pharyngeal Injuries

While some patients may show overt signs or symptoms of esophageal injury (dysphagia, hematemesis, neck crepitus, etc.) around half of cases present silently without frank symptoms. If unidentified, these patients may develop infection of the neck and mediastinum heralded by tachycardia with rapidly progressive sepsis and possible death. Fortunately, CT, contrast esophagrams, and esophagoscopy have a high sensitivity for esophageal injury detection, especially when combined modalities are used. Hypopharyngeal injuries above the level of the arytenoids and oropharyngeal injuries may be allowed to heal conservatively by secondary intention in some cases. Cervical esophageal injuries are usually managed surgically with water-tight closure in an open approach, although closed medical management with close observation may be cautiously considered in select cases. Low cervical and thoracic esophageal injuries carry increased risk of mediastinal and thoracic infections and thus usually necessitate more aggressive surgical management in conjunction with Cardiothoracic Surgery and Gastroenterology for endoscopic stenting or more commonly open approaches with closure in layers of the mucosa, muscle, and finally a third layer using nearby tissue such as pleura. All patients should be closely monitored, on GI prophylaxis with a proton pump inhibitor or antihistamine, on broad spectrum antibiotics, and kept NPO until cleared by appropriate studies.

Laryngotracheal Injuries

If concern for airway injury, the primary concern in the acute phase is obtaining a definitive airway as necessary, which may then be followed by detailed evaluation and classification of injuries in a controlled setting. Ballistic injuries or essentially any significant injury to the neck that presents with what appears at first to be a stable airway can rapidly decompensate secondary to bleeding, aspiration, hematoma, or edema. Laryngeal injuries are commonly classified according to the Schaefer classification system according to severity with prognostic and management implications.

 General Management Strategies by Schaefer Group

Group 1

• Flexible endoscopy or direct laryngoscopy if going to OR for other injuries (edema from inhalation injuries or blunt trauma may be expected to worsen for the first 24 hours and small hematomas may progress; maintain a low threshold for securing an airway).

• Medical management with consideration of steroids, antibiotics, proton pump inhibitors, humidification, and voice rest for injuries involving the vocal folds.

Group 2

• Consider direct laryngoscopy in the OR, esophagoscopy typically performed concomitantly.

• May occasionally require tracheostomy.

• Serial airway assessments if no tracheostomy is performed.

• Consideration of steroids, antibiotics, proton pump inhibitor, humidification, and voice rest for injuries involving the vocal folds.

Group 3

• Tracheostomy often required.

• Direct laryngoscopy and esophagoscopy for all patients (very limited circumstances where a Group 3 would not require direct laryngoscopy).

• Surgical management usually required, especially if anterior commissure injury, immobile vocal cord, arytenoid dislocation, recurrent laryngeal nerve injury, large lacerations with vocal fold involvement or cartilage exposure, or displaced fractures.

• Consideration of steroids, antibiotics, proton pump inhibitor, humidification, and voice rest.

Group 4

• Direct laryngoscopy and esophagoscopy for all patients.

• Tracheostomy for all patients.

• Surgical repair with plating or wiring of fractures, stents or keel placements, and repair of endolaryngeal injuries.

• Consideration of steroids, antibiotics, proton pump inhibitor, humidification, and voice rest.

Group 5

• Severe respiratory distress will be present in virtually all cases at presentation.

• Intubation may be impossible and up-front tracheostomy is usually required, although technically challenging secondary to edema, hematoma, and tracheal retraction possibly below the sternum.

• Early surgical repair pursued in most cases through various techniques beyond the scope of this chapter.

• Consideration of steroids, antibiotics, proton pump inhibitor, and humidification.

Following tracheostomy, large endolaryngeal and tracheal lacerations or those with cartilage exposure are usually managed with two-layer closure with mucosal closure with absorbable suture (usually Vicryl®) and an outer submucosal permanent suture layer from ring to ring. Some individuals repair the trachea primarily with permanent buried sutures, which can be useful, although they should be submucosal. Braided permanent sutures such as Tevdek® can be considered in these types of situations and can be commonly found in hospitals around the cardiothoracic surgical supplies. Approach for these repairs is occasionally endovascular or more often an open approach with midline thyrotomy with a horizontal cricothyroid membrane incision. Anterior commissure separations require meticulous reapproximation with sutures fixated to the external perichondrium of the thyroid cartilage. Immobile vocal folds may be secondary to arytenoid dislocation or subluxation from the injury itself or from traumatic intubations but more commonly is secondary to denervation from recurrent laryngeal nerve or vagus nerve injury. Blunt recurrent laryngeal nerve injuries are observed for at least a year after injury typically before intervention such as re-innervation due to the possibility of delayed spontaneous regeneration. Nerve injuries secondary to suspected nerve severing should be explored if the clinical situation allows with attempted primary repair to prevent vocalis muscle atrophy (mixed abductor and adductor nerve fibers prevent post-repair coordinated movement). Damage to the laryngeal cartilage framework may be managed with observation if non-displaced with the caveat that non-displaced fractures may gradually distract and lead to long-term voice consequences. Displaced fractures should be reduced and fixated with wires or preferably miniplates to maintain structural integrity and shape of the cricoid and thyroid cartilage (changes to the angle of the thyroid cartilage can have permanent voice implications). Laryngotracheal separation is rare but presents a very challenging clinical scenario where patients are typically in significant respiratory distress, are unable to be intubated, and have highly distorted neck anatomy with possible retraction of the trachea below the sternum making tracheostomy difficult. Pneumothorax may contribute to the respiratory distress and is common in patients with laryngotracheal or cricotracheal separation. These patients present a challenge for even the most experienced trauma teams and require a coordinated multidisciplinary approach.

References
1. Alao, T., Waseem, M. Neck Trauma. (2021). In: StatPearls. Treasure Island, FL: StatPearls Publishing; February 10.
2. Eller, R.L., Dion, G., Spadaro, E. (2015). Management of Acute Laryngotracheal Trauma. In Banks, D.E. (Ed.), Otolaryngology/Head and Neck Surgery Combat Casualty Care in Operation Iraqi Freedom and Operation Enduring Freedom (pp. 376-398). Office of The Surgeon General Department of the Army, United States of America.
3. Sniezek, J.C., Thomas, R.W. (2012). Laryngeal Trauma. In Resident Manual of Trauma to the Face, Head, and Neck (pp. 177-187).
4. Stewart, M.G. (2013). Penetrating Neck and Face Trauma. In Johnson, J.J., Rosen, C.A. (Eds.), Bailey’s Head and Neck Surgery-Otolaryngology 5e (pp.1131-1140). Baltimore, MD: Lippincott Williams & Wilkins.

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Overview
The temporal bone houses several important structures including the otic capsule containing the cochlea and vestibular labyrinth, facial nerve, ossicles, and carotid canal. Furthermore, its superior and medial boundaries comprise the dura of the middle fossa and posterior fossa, respectively. Thus, temporal bone fractures may result in temporary or permanent facial nerve injury, hearing loss (conductive, sensorineural, mixed), vertigo, CSF leak, or meningitis. Fractures of the temporal bone typically require significant force and therefore frequently occur in association with other significant maxillofacial, skull base, or cranial injuries. Diagnosis is made most often following emergent head or maxillofacial CT in the trauma bay. Typically, head CTs have thick cuts that may not adequately capture small structures in the temporal bone and additional imaging may be required.

 Evaluation and management of temporal bone trauma typically ensues following general trauma stabilization. Patient evaluation should assess for injuries involving the critical structures within the temporal bone. The most important information to document upon patient arrival to the hospital is facial nerve function. If a patient has facial nerve paralysis at the time of evaluation, it would be important to attempt to determine if this occurred immediately after the injury or in a delayed fashion. This may be challenging to elicit, because many patients experience polytrauma and facial nerve function is often not prioritized during an initial in-field assessment. Symptomatically, patients will most commonly experience conductive hearing loss secondary to hemotympanum, tympanic membrane tear, or external auditory canal occlusion from soft-tissue injury or debris. However, temporal bone fractures can violate the otic capsule and thereby cause sensorineural hearing loss. Although patients with major traumatic injuries may be intubated and sedated, effectively precluding a good facial nerve and audiological assessment, a 512-Hertz tuning fork exam in an awake patient can be helpful. Concomitant vertigo and associated nystagmus should also raise concern for otic capsule involvement.

As the consulting Otolaryngologist, a careful radiologic review of available temporal bone imaging should be performed. It is often helpful to review the scans with the Neuroradiology team if any questions arise. A systematic review of structures should include evaluation of the otic capsule, internal auditory canal, facial nerve path, ossicles, external auditory canal, middle and posterior fossa bony plates, temporomandibular joint, and vascular structures (carotid and sigmoid). Prognostically, otic capsule-involving fractures are more likely to have facial nerve injury, CSF leak, and sensorineural hearing loss. Identification of fluid signal in the mastoid, air in the labyrinth (i.e., pneumolabyrinth) and intracranial air (i.e., pneumocephalus) – fluid where air should be and air where fluid should be – offer immediate and reliable clues to injury of the respective regions. The astute resident should also use the contralateral ear as a “control” to ensure that normal sutures and other structures (e.g., singular canal, cochlear aqueduct) are not misinterpreted as fracture lines.

Classification Schema

Historically, temporal bone fractures were classified based on their relationship with the long axis of the petrous ridge. Under this classification, longitudinal fractures occurred in parallel to the petrous ridge whereas transverse fractures occurred in perpendicular orientation to the petrous ridge, most commonly traversing the foramen magnum. Transverse fractures are considered less common than longitudinal fractures but portend increased risk of facial nerve injury and otic capsule involvement. Fractures are now commonly classified as otic capsule sparing or violating.

Key Supplies for Temporal Bone Trauma Consultation

• Appropriate PPE including mask, eye protection, gloves, and gown

• Otoscope

• 512-Hertz tuning fork

• Cerumen curette

• Suction trap if fluid collection for CSF analysis is anticipated

• Ear wick

• If cleaning debris from the ear canal, will need operating microscope, size 3, 4, or 5 ear speculum, size 5 or 7 straight suction, and suction source

Complications and Management

Facial Nerve Injury

• Documentation of the timing and severity of facial nerve paresis is key. The House-Brackmann grading system is a convenient way to record facial nerve function.

• Facial nerve paresis (partial weakness) or delayed facial nerve paralysis carry a more favorable prognosis compared to immediate onset complete facial nerve paralysis.

• Facial nerve paresis or paralysis, regardless of timing, is typically treated with high-dose corticosteroids (such as oral prednisone) if not medically contraindicated.

• In the setting of significant facial weakness, careful attention must be paid to the patient’s eye closure.

• Patients with lagophthalmos should be given artificial tears, lubricating eye ointment, and precautions to avoid inadvertent corneal injury (e.g., moisture chamber at night while sleeping).

• In the setting of immediate complete facial nerve paralysis (House-Brackmann grade VI), surgical exploration with decompression may be considered, particularly when impinging bone fragments or clear radiological involvement of the fallopian canal can be seen on imaging. Although controversial, electroneuronography (EnOG) can be obtained if one is contemplating facial nerve decompression.

• Degeneration of >90% on EnOG and confirmation with electromyogram indicates more severe injury and further supports considering facial nerve exploration and decompression.

• Close follow-up to monitor facial nerve function and related complications.

Hearing Loss

• External auditory canal skin laceration is very common. Bedside debridement is recommended to allow for treatment with ototopical antibiotics. In some cases, circumferential lacerations may benefit from stenting with ear wick placement.

• In the acute setting, conductive hearing loss secondary to hemotympanum, tympanic membrane tear, or ossicular chain disruption is typically treated conservatively with observation.

• Sensorineural hearing loss stemming from an otic capsule-involving fracture can be treated with high-dose corticosteroids, although outcomes are variable. Patients with otic capsule involvement will also commonly have associated vertigo and nystagmus on exam.

• Early after the injury, a 512-Hertz tuning fork exam is important to perform. A Weber test (tuning fork placed firmly on midline, such as the forehead or central maxillary incisors) will lateralize to the size with better sensorineural function or the side with the greater conductive hearing loss. The Rinne test is used to distinguish sensorineural from conductive hearing loss for each individual ear. In a normal healthy ear, air conduction (tuning fork held 2-4 cm from the external auditory canal) should be greater than bone conduction (tuning fork firmly pressed on mastoid process). A person with temporal bone trauma and isolated conductive hearing loss will usually have a Weber that lateralizes to the affected ear, and on Rinne testing bone conduction will be greater than air. A crude bedside test using the phone dial tone can also be considered. An early audiogram with bone conduction thresholds should be obtained if sensorineural hearing loss is suspected.

• If only conductive hearing loss is suspected and imaging does not reveal otic capsule involvement, a formal audiogram is generally obtained about 8-12 weeks after injury to allow for resolution of middle ear fluid and inflammation. Surgical treatment may be indicated in large persistent conductive hearing loss.

CSF Leak

• While CSF leaks are relatively uncommon, patients should be evaluated for CSF otorrhea or rhinorrhea, especially in cases of otic capsule or skull base violation. Draining fluid suspected to be CSF can be tested for beta-2 transferrin, which is highly sensitive and specific for CSF. Notably, a halo or ring sign is not sensitive or specific for a CSF leak.

• Because most traumatic CSF leaks self-resolve, initial management is conservative and aims to reduce intracranial pressures with head of bed elevation to 30 degrees, limited activity, stool softeners, and avoidance of straining.

• Use of prophylactic antibiotics is controversial, although commonly administered.

• Lumbar drains are typically avoided in the early setting.

• Persistent CSF leak beyond 1-2 weeks may require surgical repair.

Others

• Persistent vertigo is uncommon but may be associated with posttraumatic benign paroxysmal positional vertigo, otic capsule fracture, or perilymphatic fistula.

• Fractures involving the carotid canal should be evaluated with CT angiogram to rule out internal carotid dissection with Neurosurgery consultation if carotid injury is found.

References
1. Wilkerson, B.J., Brodie, H.A., Ahmed, M.M. (2020). Management of Temporal Bone Trauma. In Flint, P.W., et al. (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 2207-2219). Philadelphia, PA: Elsevier.
2. Diaz, R.C., Kamal, S.M., Brodie, H.A. (2013). Middle Ear and Temporal Bone Trauma. In Johnson, J.J., Rosen, C.A. (Eds.), Bailey’s Head and Neck Surgery-Otolaryngology 5e (pp. 2410-2432). Baltimore, MD: Lippincott Williams & Wilkins.
3. Fusetti, S., Hammer B., Kellman, R., et al. (2011). Temporal Bone, Lateral Skull Base. AO Foundation Surgery Reference, https://surgeryreference.aofoundation.org/cmf/trauma/skull-base-cranial-vault/temporal-bone-lateral-skull-base.

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