facial trauma and oroantral fistula
TRANSCRIPT
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BRIG ANWAR UL HAQ
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BRIG ANWAR UL HAQ
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Trauma may involve◦ Soft tissues
◦ Bones
◦ Cartilages
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General management
Soft tissue injuries and their management
Bony injuries and their management
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Airway◦ Injuries
◦ Blood
◦ Secretions
Haemorrhage◦ Pressure
◦ Ligation
◦ Coagulation
Associated injuries◦ Head, chest, neck, larynx, cervical spine
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Facial lacerations
Parotid gland and duct
Facial nerve
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UPPER THIRD
MIDDLE THIRD
LOWER THIRD
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Frontal Bone◦ Frontal Sinus
◦ Anterior wall
◦ Posterior wall
◦ Injury to nasofrontal duct
Supraorbital ridge
Frontal Bone
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Anterior wall of Frontal Sinus
◦ Depressed deformity
◦ Reduction through the wound
◦ Elevation though eye brow incision
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Posterior wall of Frontal Sinus
◦ Dural tear
◦ CSF Rhinorrhoea
◦ Temoralis Fascia Repair
◦ Obliteration of Sinus
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Frontonasal Duct◦ Obstruction of Sinus
◦ Mucocele
◦ Surgical Obliteration of Sinus
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MIDDLE THIRD
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Nasal bone and septum
Naso orbital fractures
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Nasal bone and septum
Naso orbital fractures
Fractures of zygoma
Fractures of zygomatic arch
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Nasal bone and septum
Naso orbital fractures
Fractures of zygoma
Fractures of zygomatic arch
Fractures of orbital floor
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Nasal bone and septum
Naso orbital fractures
Fractures of zygoma
Fractures of zygomatic arch
Fractures of orbital floor
Fractures of maxilla
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Most prominent part◦ More likely
Amount of injury◦ Magnitude of trauma
◦ Direction
Ant
lateral
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Depressed
Angulated
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Swelling
Periorbital echymosis
Tenderness
Crepitus
Nasal deformity
Epistaxis
Nasal obstruction
Lacerations◦ Internal
◦ external
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Physical examination◦ Inspection
◦ Palpation - crepitus
X-Ray - +/-
Waters’ view
Lateral - Rt + Lt
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No displacement - No treatment
Reduction◦ Closed
◦ Open
Timing◦ Immediately
◦ 5-7 days later
Children- early union - earlier reduction
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Depressed fractures◦ Straight elevation
◦ Digital manipulation
Laterally displaced fractures◦ Digital manipulation
In opposite direction
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Rarely required
Associated septal injuries
Late◦ Rhinoplasty
◦ Septorhinoplasty
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Direct force over the Nasion◦ Fracture nasal bone
◦ Ethmoids
◦ Cribriform plate
◦ Medial orbital wall
◦ Frontal sinus
◦ Fronto-nasal duct
◦ Exra occular muscles
◦ Lacrimal apparatus
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Telecanthus
Pig nose
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Telecanthus
Pig nose
Peri-orbital echymosis
Peri-orbital haematoma
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Telecanthus
Pig nose
Peri-orbital echymosis
Peri-orbital haematoma
Epistaxis
CSF rhinorrhoea
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Telecanthus
Pig nose
Peri-orbital echymosis
Peri-orbital haematoma
Epistaxis
Csf rhinorrhoea
Displacement of eye ball
Squint (mal alignment of eyes)
Diplopia (Double Vision)
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X rays◦ Various films
◦ Different angles
CT Scan ◦ Better option
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Close reduction◦ Uncomplicated fractures
◦ Ashes’ forceps
◦ Fixation
Steel wire
Fixed over lead plates
Intra nasal packing
◦ Splinting - 10 days
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Indications◦ Multiple communications
Nasal cavities
Frontal sinus
◦ Injuries
Lacrimal apparatus
Extra ocular muscles
Medial canthal ligaments
Frontal sinus
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H shaped incision
Nasal bones reduced under vision
Medial canthal ligaments fixed with wire
Repair of lacrimal apparatus
Preference ◦ Medical canthal ligament
◦ Lacrimal apparatus
Nasal bridge and shape◦ Can be corrected later
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Second most common
Direct trauma
Lower segment pushed medially posteriorly◦ Flattening of malar prominance
◦ Zygoma – fractured -separated
Zygomatico frontal
Zygomatico maxillary- orbital floor
Zygomatico temporal
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Zygomatico frontalZygomatico temporalZygomatico maxillary - orbital floor
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Zygomatico maxillary - orbital floorOrbital contents - herniates – maxillary sinus
Tear drop sign
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Flattening of malar prominance
Step deformity of infra orbital margin
Trismus (inability to open mouth)
Oblique palpebral fissure◦ Displacement of LPL
Restriction of ocular movement – diplopia
Peri-orbital echymosis
Infra orbital anaesthesia
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Waters’ view (Occipito-Mental View)
Blood in maxillary sinus - opaque
CT scan – more beneficial
Fracture of zygoma (Tripode fracture)
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No displacemment - no treatment
Open reduction
Lateral brow incision
Reduction - putting elevator behind the zygoma
Fixation - wire
Transantral approach◦ Caldwell luc operation
◦ Intra nasal antrostomy
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Zygomatic arch fractures in two segments
Fractures at both ends
Depressed fracture
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Depression - Depressed fracture
Painful mastication
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Clinical examination
X ray sub mento vertical view
Waters’ view
DiagnosisFractures of zygomatic arch
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Incision - anterior to ear in the hair
Elevator◦ Deep to the temporalis fascia
Intra oral superior sulcus
Usually does not require fixation
TreatmentFractures of zygomatic arch
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Accompanies◦ Zygomatic fractures
◦ Maxilla fracture Le Fort II
Isolated blow out fractures◦ Large blunt object strikes globe
◦ Orbital contents herniate in the maxillary antrum
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Tear drop sign
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Echymosis of lid, conjuctiva and sclera
Enophthalmos
Diplopia
Infra orbital anaesthesia
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X ray PNS - Tear drop sign
CT Scan - 3D Reconstruction
Restricted eye movement◦ Inferior rectus
◦ Inf oblique
Cannot see up
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Surgical◦ Enophthalmos
◦ Diplopia
Infra orbital approach
Transantral approach
Repair◦ Nasal septal cartilage
◦ Illiac crest
◦ Silicon plate
Fractures of orbital floor
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Malocclusion
Elongation of midface
Mobility of maxilla
CSF rhinorrhoea◦ Le fort II & Le fort III
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X Ray◦Waters’ view
◦ Postro anterior view
◦ Lateral view
CT CSAN
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Complex
General management
Interdental wiring
Intermaxillary wiring Open reduction and fixation
Wire slings◦ Frontal bone
◦ Zygoma
◦ Infra orbital rim
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Mandible
Classified according to the location◦ Chondylar process
◦ Angle
◦ Body
◦ Symphysis
◦ Choronoid process
◦ Ramus
◦ Alveolar process
◦ Combination
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If not displaced◦ Pain
◦ Trismus
Inability to open
◦ Tenderness
If displaced◦ Malocclusion
◦ Deviation
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Palpation◦ Intraoral & extraoral
◦ Step deformity
Malocclusion
Tenderness
Crepitus
Echymosis of oral mucosa
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X RAY PA VIEW
OBLIQUE VIEW- RT/LT
Panoramic view
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Closed◦ Interdental wiring
◦ Inter maxillary fixation
◦ External pin fixation
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• Open reduction
◦ Interosseous wiring – figure of 8
◦ Compression plates
◦ Immobalization – prolonged avoided
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Communication◦ Oral cavity
◦ Maxillary Sinus
Location◦ Alveolus
◦ Gingivolabial Sulcus
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Dental Extraction◦ Second premolar
◦ Molars
Failure to heal Cald well Luc incision
Erosion by carcinoma
Penetrating injuries of Maxilla
Osteitis of Maxilla
Syphilus
Malignant Granuloma
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Regurgitation of food
Discharge
Inability to blow
Inability to suckNosesinus
Oralcavity
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Probing the fistula
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Conservative◦ Antibiotis
◦ Nasal Decongestants
Opturator
CaldWell Luc Operation
Antrostomy
Surgical repair◦ Labial Mucosal Flap
◦ Platal Falp
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