Nasal and Facial fracture ( under graduate)

Dr. Srinivas Pennam
Nasal and Facial Trauma

AETIOLOGY
 Road traffic accidents
 Sports injuries
 Personal accidents
 War accidents
 Assaults & fights
 Birth injuries

Nasal and Facial Trauma
 Nasal trauma is extremely Common
 From birth onwards nose is assaulted
 Up to 20 % babies are found have Squashed noses
 Majority spring back, but about 1-2 % are left
with a permanent deviations
 Early detection of septal abnormalities and
correction with Gray’s struts prevents idiopathic
deviated septum

Emergency room management
 Air way maintenance by intubation or tracheostomy
 Hemorrhage : By packing, pressure, or ligation of blood
vessels
 Tetanus
 Associated major injuries to other regions like head,
chest, spine, abdomen, neck, larynx, orbit
 Soft tissues of face
 Facial nerve
 Salivary glands

Bone injuries
Divisions of the facial bone injuries
 Upper third – Above the level of supra orbital
ridge
 Middle third – Between supra orbital ridge and
upper teeth
 Lower third – Mandible and lower teeth

Structures involved
 Nasal bones and septum
 Naso orbital region
 Zygomatic arch
 Zygoma
 Orbital floor
 Maxilla
Fractures of middle third of face

Fracture of Nasal Bones
 Very common injury due to prominent
projection of nose on the face
 Direct blows or falls
 As a part of facio maxillary injuries
 Often associated injuries to septum like
dislocation, fracture, buckling, haematoma
formation

Fracture of Nasal Bones
 Injuries may occur to other surrounding
bony structures.
 3 types:
 Depressed
 Laterally displaced
 Nondisplaced

Pathogenesis
Variables-
 The patient’s age (tissue flexibility)
 The amount of force applied
 The direction of the force
 The nature of the striking object

Types
Type - I
 Frontal or fronto lateral
blow – Depressed nasal
bones. May be associated
with vertical fracture of
nasal septum
Type - II
 Lateral Blow – Angulated
deformity - deviation of
nasal bridge or depression
of nasal bone on injured
side

Frontal Impact
Plane I-
 Fracture of nasal tip
 Small dorsal hump with supertip
depression
Plane II-
 High fracture of nasal bones
 Dorsal depression
 Septal buckling with flattened appearance
of the nose

Frontal Impact (cont.)
Plane III-
 Fracture of nasal bones, frontal process and
anterior nasal spine
 Comminuted, lateralized
 Marked nasal depression
 Columellar retraction
 Medial canthal relaxation with
telecanthus

Lateral Impact
Plane I-
 Unilateral nasal bone depression
 Elevation of contralateral nasal bone
 Septal buckling
 C or S shaped deformity of nasal dorsum

Lateral Impact (cont.)
Plane II/III-
 Fracture extension to frontal process
 Marked displacement of septum and
dorsum
 Medial maxillary wall depression

Septal Fracture
 Horizontal with posterior
fracture (Jarjavay)
 Vertical with anterior
fracture (Chevallet)
 S and C shaped
deformities with healing
 Telescoping of segments
prevents closed reduction
Fracture of
Chevallet
Fracture of
Jarjavay

Nasal Fractures
 Clinical findings:
 Nasal deformity
 Edema and
tenderness
 Epistaxis
 Crepitus and
mobility

Clinical Features
 External deformity due to
 Fracture dislocation of
fractured bone fragments
 Odema of soft tissue
 Skin over the nasal bridge
discolored or lacerated
 Palpation over the bridge –
Tenderness or crepitus

Clinical Features
 Nasal obstruction – Due to Blood clots, septal
haematoma or septal deformity
 Peri orbital echymosis, sub conjunctival
haematoma
 Associated facio maxillary or head injury
 Watery nasal discharge - suspect CSF leak

Clinical Features
 Bony injury will be obscured by the oedema
which sets after 4 -6 hours
 Exact bony deformity can be assessed
within 2 -4 hours of trauma (or) after 6-7
days when oedema subsides

Diagnosis
 Clinical examination
 X-ray of the nasal bones
 X-ray P.N.sinuses

X- Ray nasal bones showing fracture

Diagnosis
 X-ray or CT scan of brain if associated head
injury suspected
 Haemoglobin to assess blood loss, Blood
group & cross matching if Hb is low.
 Opthalmological examination

Treatment
 In major accidents exclude injuries to other regions
like Head, Chest, Abdomen, Spine, Neck & Larynx
 Epistaxis to be managed if necessary by nasal packing
 Lacerations of skin sutured
 Antibiotics, Anti inflammatory agents

Management of nasal bone fracture
Simple fracture without displacement of fractured
fragments - only conservative management
Fracture with displacement of fractured fragments
needs reduction
Best time to reduce the fracture is immediately after
injury before the appearance of oedema or after 5-7
days when the oedema subsides and exact deformity
is seen. If patient is seen 4 weeks after injury
malunion must have occurred – needs rhinoplasty.

Closed Reduction – Is usually done by
elevation of depressed fragments,
correction of laterally displaced bridge
with special forceps
- Septal dislocation and fracture corrected
- Septal haemotoma should be drained
Open reduction - very rarely done

Frontal Sinus/ Bone Fractures
Pathophysiology
 Results from a direct blow to the frontal
bone with blunt object.
 Associated with:
 Intracranial injuries
 Injuries to the orbital roof
 Dural tears

Clinical Findings
 Disruption or
crepitance orbital rim
 Subcutaneous
emphysema
 Associated with a
laceration

Diagnosis
 Radiographs:
 Facial views should
include Waters,
Caldwell and lateral
projections.
 Caldwell view best
evaluates the anterior
wall fractures.

Diagnosis
 CT Head with bone
windows:
 Frontal sinus fractures.
 Orbital rim and
nasoethmoidal
fractures.
 R/O brain injuries or
intracranial bleeds.

Treatment
 Patients with depressed skull fractures or with
posterior wall involvement.
 ENT or nuerosurgery consultation.
 Admission.
 IV antibiotics.
 Patients with isolated anterior wall fractures,
nondisplaced fractures can be treated
outpatient after consultation with
neurosurgery.

Complications
 Associated with intracranial injuries:
 Orbital roof fractures.
 Dural tears.
 Mucopyocoele.
 Epidural empyema.
 CSF leaks.
 Meningitis.

Naso-Ethmoidal-Orbital
Fracture
 Fractures that extend into
the nose through the
ethmoid bones.
 Associated with lacrimal
disruption and dural tears.
 Suspect if there is trauma
to the nose or medial orbit.
 Patients complain of pain
on eye movement.

Fracture
 Flattened nasal bridge or a saddle-shaped
deformity of the nose.
 Widening of the nasal bridge (telecanthus)
 CSF rhinorrhea or epistaxis.
 Tenderness, crepitus, and mobility of the nasal
complex.
 Intranasal palpation reveals movement of the
medial canthus.

Fracture
 Imaging studies:
 Plain radiographs are insensitive.
 CT of the face with coronal cuts through the medial
orbits.
 Treatment:
 Antibiotic
 Maxillofacial consultation.

Orbital Blowout Fractures
 Blow out fractures are
less common.
 Occur when the the
globe sustains a direct
blunt force
 2 mechanisms of injury:
 Blunt trauma to the globe
 Direct blow to the
infraorbital rim

Clinical Findings
 Periorbital tenderness,
swelling, ecchymosis.
 Enopthalmus or
sunken eyes.
 Impaired ocular
motility.
 Infraorbital anesthesia.
 Step off deformity

Imaging studies
 Radiographs:
 Hanging tear drop
sign
 Air fluid levels
 Orbital emphysema

Imaging studies
 CT of orbits
 Details the orbital
fracture
 Excludes retrobulbar
hemorrhage.
 CT Head
 R/o intracranial injuries

Treatment
 Blow out fractures without eye injury do not
require admission
 Maxillofacial and ophthalmology consultation
 Decongestants for 3 days
 Prophylactic antibiotics
 Avoid valsalva or nose blowing
 Patients with serious eye injuries should be
admitted to ophthalmology service for further
care.

Endoscopic Balloon catheter repair
 Wide MMA
 Insert Foley and
inflate
 Leave in place for
7-10 days
 Broad spectrum
antibiotics

Fracture of middle third of the face
It is the fracture of facial bones, supra orbital ridge and upper
teeth
Types :
Depending on the site
 Central (Naso
maxillary bones)
 Lateral (Malar
maxillary bones)

Maxillary Fractures
 High energy injuries.
 Impact 100 times the force of gravity is
required .
 Patients often have significant multisystem
trauma.
 Classified as LeFort fractures.

Clinical Features
 Le forte –I (Transverse) – Transverse fracture of
maxilla involving palate only
 Le Forte –II (Pyramidal) – Fracture enbloc of the
palate and middle third of the face
 Le Forte –III (Cranio facial dysjunction) Involves
complete disruption of the attachment of the
facial skeleton from the cranium

Le Fort I (Guerin fracture)
Transverse fracture of
maxilla involving palate
only
Allows motion of the
maxilla while the nasal
bridge remains stable.
 Facial edema
 Malocclusion of the
teeth
 Motion of the maxilla
while the nasal bridge
remains stable

Maxillary Fractures
LeFort I
 Radiographic findings:
 Fracture line which
involves
 Nasal aperture
 Inferior maxilla
 Lateral wall of maxilla
 CT of the face and
head
 coronal cuts
 3-D reconstruction

Le Fort II (Pyramidal)
Fracture enbloc of the
palate and middle third of the
face
 Pyramidal fracture
 Maxilla
 Nasal bones
 Medial aspect of the orbits
 Marked facial edema
 Nasal flattening
 Traumatic telecanthus
 Epistaxis , CSF rhinorrhea
 Movement of the upper jaw and
the nose.

Maxillary Fractures
LeFort II
 Radiographic imaging:
 Fracture involves:
 Nasal bones
 Medial orbit
 Maxillary sinus
 Frontal process of the
maxilla
 CT of the face and
head

Le Fort III (Craniofacial disjunction)
Complete disruption
of the attachment of the
facial skeleton from the
cranium
 Fractures through:
 Maxilla
 Zygoma
 Nasal bones
 Ethmoid bones
 Base of the skull

Clinical Features
 Nose
 Collapse of nasal bridge
 Oedema of soft tissues
 Epistaxis
 Septal haemotoma
 Nasal obstruction
 C.S.F Rhinorrhoea

Maxillary sinus
 Step deformity of infraorbital margin due
to fracture
 Oedema of soft tissues
 Infra orbital involvement – Anaesthesia or
numbness over cheek

Face
 Flattening of face – Dish
faced deformity
 Mal occlusion of jaws
Eyes
 Epiphora
 Sub conjunctival
haemorrhage
 Diplopia
 Enophthalmos

Lateral Type - Zygoma Fractures
Malar maxillary complex fracture due to blow
from the side of the face
 Two types of fractures can occur:
 Arch fracture (most common)
 Tripod fracture (most serious)

Zygoma Arch Fractures
 Can fracture 2 to 3 places along the arch
 Lateral to each end of the arch
 Fracture in the middle of the arch
 Patients usually present with pain on opening their
mouth.

Clinical Findings
 Palpable bony defect
over the arch
 Depressed cheek with
tenderness
 Pain in cheek and jaw
movement
 Limited mandibular
movement

Imaging Studies & Treatment
 Submental view
(bucket handle view)
 Treatment:
 Consult maxillofacial
surgeon
 Ice and analgesia
 Possible open elevation

Zygoma Tripod Fractures
 Tripod fractures
consist of fractures
through:
 Zygomatic arch
 Zygomaticofrontal
suture
 Inferior orbital rim and
floor

Clinical features:
 Periorbital edema and ecchymosis
 Hypesthesia of the infraorbital nerve
 Concomitant globe injuries are common
 Flattening of malar prominence
 External swelling
 Step deformity of infra orbital ridge
 Enopthalmos
 Trismus
 Diplopia

Imaging Studies
 Waters, Submental and
Caldwell views
 Coronal CT of the
facial bones:
 3-D reconstruction

Treatment
 Nondisplaced fractures without eye involvement
 Ice and analgesics
 Delayed operative consideration 5-7 days
 Decongestants
 Broad spectrum antibiotics
 Displaced tripod fractures usually require
admission for open reduction and internal
fixation.

Investigations
 Radiography
 CT – If necessary in cases of CSF rhinorrohoea

Treatment
 Reduction of fractures, under GA
 Reduced fragments are maintained in place
by use of steel wires,splints, rods and
traction

C.S.F Rhinorrhoea
It is the flow of cerebrospinal fluid from the nose
Sites of CSF Leak
 Cribriform plate of Ethmoid
 Frontal sinus
 Ethmoidal sinus
 Sphenoid sinus

C.S.F Rhinorrhoea
Aetiology
 Congenital – Congenital Dehiscence of
Nasal roof
 Traumatic
 Head Injury – Fracture of floor of anterior
cranial fossa

Iatrogenic
 Functional endoscopic sinus surgery (FESS)
 Ethmoidectomy, sphenoidectomy
 Trans nasal hypophysectomy
 Frontoethmoidal mucocele surgery
 SMR / Septoplasty

C.S.F Rhinorrhoea
 Spontaneous
 Raised intracranial tension
 Hydrocephalus
 Destructive bony lesions like granulomas
 Tumors

Clinical Features
 Rhinorrhoea – Unilateral, clear, watery, dripping
on looking downwards, increase on coughing,
sneezing, and on exertion
 History of Trauma - Accidental or operation on
nose or PNS
 Head Ache
 Meningitis – Rarely the presenting feature

Diagnosis
 To be differentiated from nasal discharge
 History
 Collection of fluid in test tube, allowed to stand
 CSF – Remains clear
 Nasal discharge – forms sediment
 Handkerchief test for nasal discharge – Handkerchief
stiffens

Double ring sign or halo sign
 Traumatic cases
 Discharge collected on a
tissue paper
 Central spot of blood, CSF
spreads as halo around it
 DIAGNOSTIC
NASAL
ENDOSCOPY

Diagnosis
 Fluorescein dye test
 Endonasal endoscopic evaluation following
lumbar intrathecal administration of sodium
fluorescein.
 Using flurescein blue light filter system coupled
to cold light source the site of leak is assessed
accurately
 Β2 TRANSFERIN PRESENT IN CSF

RADIOLOGICAL
 X-Ray skull bones
 CT Scan or CT Cisternography
 MRI or MRI Cisternography

TREATMENT
 Complete bed rest with raised head end
 Avoid blowing nose, sneezing or straining
 Avoid nasal packs or nasal drops
 Antibiotics
 Mannitol and acetazolamide to reduce intracranial
pressure
 Treat the cause

SURGICAL REPAIR
 External ethmoidectomy approach
(Rarely done now a days)
 Nasal endoscopic approach
 Intracranial of approach

Marquis Alfonso Corti worked on the mammalian auditory system at
the Koelliker Laboratory in Wurzburg (Germany). In 1851, he
published a paper describing a structure located on the basilar
membrane of the cochlea containing hair cells that convert sound
vibrations into nerve impulses: the organ of Corti

Nasal and Facial fracture ( under graduate)

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