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priority imaging in maxillofacial trauma

C-spine a priority


history with facial issues

1. What happened and when
a. Fall? (why fell?), MVA? Assault?

2. LOC? Vomiting? Can’t walk?

3. Visual symptoms?

4. Facial anesthesia/paresthesia?
--> The amt of nerves in your face are no joke

5. Condition of teeth, bite, blown nose?

6. PMH, meds (on Coumadin?), tetanus

7. Police report made?

8. Domestic Violence? Child abuse?


PE for facial injury -ORAL

1. -Full, gloved exam
2. -Lips - lacs, hematoma,
3. Thru/thru, vermillion
4. -Trismus or can’t close?
5. -Teeth present and intact?
6. Where are they?

7. -Alveolar ridge, frenulum attachment
--> need to see if this is stable b/c it is differnt than a maxilla fracture
if that is moving get a CT
8. -Bleeding in mouth?
9. -Tongue - lacs? Bleed A LOT!!



• Look from above/below/side for asymmetry
• Whistle, smile, wrinkle forehead
• Eyes
Visual acuity (Rosenbaum card – near card; if they can stand do Snellan)
Periorbital - edema, crepitus, lacerations
Pupils, conjunctiva and anterior chamber
Symmetry, subconjunctival hemorrhage (blood vessel breaks between conjunctiva and sclera, hyphema (blood in ant. Chamber)



1. -Locate, control bleeding

2. -Nasoseptal hematoma?

3. -Palpate medial canthus for mobility (worried about sinuses)


PE- ears

1. Drainage (blood, CSF?)
2. Ear lac?
3. Auricular hematoma, Battle sign (ecchymosis behind the ear – basal skull fx)
4. TM’s - hemoptypanum, rupture


what do you need to palpate in facial trauma

how to assess for mandible fracture

how to check maxillary arch

Palpate entire face, both hands
Look for tenderness, bony crepitus, subcutaneous air, flattening, anesthesia
Palpate entire orbital rim

check if anterior maxillary arch is stable - if it moves at all, stop
• Intraoral palpation of zygomatic arch

• Tongue blade test for mandible Fx- bite down, twist
If can hold on, likely no Fx


systems you should not forget in ENT assessment

1. Scalp, Neck, Neuro exam, CN exam, Chest wall, lungs, heart, abdomen, extremities, pelvis


what should be done

what needs to be administered
what should you avoid

What imaging do you need for the mandible

1. ABC’s first - suction
2. Consider IV - pain control, Abx; TETANUS

3. Pain control

a. IM/IV or topical (eyes, nose) - AVOId po’s

4.Imaging - CT preferred over plain film
a. Panorex for mandible

before you call a surgeon have a dx


MOA of frontal sinus fx

right above the eyebrows you will have penetration into the brain

1. Significant mechanism-MVA
a. Common prior to seat belts

may have forhead lacs
high risk for intracranial injury and bleeding in the brain


sxs with frontal sinus fx

Bony crepitus, deformity, subcutaneous air, limited upward gaze, ptosis, sensory deficit forehead

need to het the bony windows in a CT


frontal bone injury is common in what do we worry about in these populations


much higher incidence of intracranial truama

Higher incidence of intracrainial trauma with frontal bone Fx - consider CT head

Frontal bone trauma – worry about the kid’s neck

Upper cervical spine injury more common than lower in kids

worry about to abuse


Nasoethmoidal-orbital fractures occurs form trauma to this

associated with these type of injuries

Small NEO Fx’s easy to miss
Trauma to bridge, medial orbits

Associated with lacrimal injury and dural tears (encephalities or brain infection)


sxs asscoaited with nasoethmoidal-orbital fractures

4. Pain at medial bridge, w/ EOM’s
5. Maybe crepitus, telecanthus


mnmgnt of Nasoethmoidal-orbital fractures

(if eyes are further apart than they should be)
6. CT, Abx, OMFS, admit


Orbital Floor – Blow out fx

what do you need to document

you can have this without entrapment but if you have entrapment of this muscle it needs to be repaired
this is when the muscle of the eye does not work

you say look up and one moves and the otherone does not (tethered and stuck)

IS THERE DBL vision on upward gaze*


Orbital Floor – Blow out fx how many have globe rupture

c. 30% have globe rupture


mngmt of orbital floor fx PE and imaging

CT maxillo-facial and orbits (head? If LOC)

Check eye: vision, hyphema, pressures, subconjunctival hemorrhage, subcutaneous emphysema (air b/c maxillary sinus has ruptured and the air escapes)


who do you call and what do you do for orbital floor fx

c. Check infraorbital anesthesia
d. OMFS, ophtho (since there is entrapment) consult
e. Pain control, tetanus; admit?


telecanthus means

if eyes are further apart than they should be)


lateral canthomotomy -when would this be indicated and what is it

Orbital Compartment Syndrome

need to cut the lateral canthus to allow more room for the globe

this can be a site saving procedure


RF with retrobulbar hematoma

vision loss, pupil irregular, papilledema, IOP up, field deficit = optic neuropathy


limbus in retrobulbar hematoma

Limbus – where the conjunctiva ends (around the pupil)


what does periorbital, Orbital Cellulitis entail

1. Unilateral infection around or around and behind orbital structures


sxs of periorbital, Orbital Cellulitis

2. Fever, red, swelling
3. EOM’s painful
4. Proptosis if orbital


tx of orbital and periorbital

a. Abx, +/- admit

Orbital Cellulitis-vision and life threatening need to admit


imaging for periorbital cellulitis

CT orbits all, ULS useful


questions you want to ask with nasal fx

Prior nasal trauma, deformity?
2. -Can you breathe thru your nose?
3. -Blow nose = face swelling?


nasal fx secret

What do you NEED in your chart

Check for nasal-septal hematoma**
a. -If present, must I&D or necrosis of septum ensues

if you see this it is a ENT emergency that needs to be drained or else you will have necrosis of the septum



ENT f/u with nasal trauma

-“Reduction”- specific cases only
8. -ENT f/u 5-7 days after edema subsides