Chapter 8. Maxillofacial Trauma

Patients with maxillofacial trauma are seen everyday in emergency rooms throughout the United States. The cause of the trauma can be quite variable, ranging from industrial and motor vehicle accidents to interpersonal trauma involving either fists or weapons. It is common for trauma to be related to substance abuse or to behavior that can be linked to substance abuse. Sometimes trauma is related to sports activities or simply to accidental or work-related occurrences. The principles of management are directed at stabilizing a patient's medical condition and providing safe reconstruction to maximize both functional and aesthetic rehabilitation.

The ABCs of Trauma

It can be disconcerting when a patient is brought into the emergency room with severe craniofacial trauma. Patients may be covered with blood and have distorted anatomy that may divert attention from the initial principles of Advanced Trauma Life Support (ATLS). In these circumstances, it is critically important to follow the basic tenets of initial trauma stabilization, also known as the ABCs of trauma:

• Airway management and assessment
• Breathing
• Circulation

Tamponade of bleeding and C-spine clearance are also critical factors when the patient initially presents to the emergency room. In the initial management period, even occurrences of severe craniofacial trauma may be examined after cases of abdominal, thoracic, and—at times—limb trauma. A neurosurgical examination and clearance are frequently desirable in severe high-velocity injuries. When ocular injury is suspected, an examination by an ophthalmologist can be indispensable. Patients on the most severe end of the injury spectrum often require airway control via orotracheal intubation or, in certain cases, via cricothyroidotomy or tracheotomy.

Most attempts to repair maxillofacial trauma will be considered after the patient is stabilized. Almost all skeletal trauma repair is guided by the information provided by fine-cut computed tomography (CT) scans. Fine-cut scans take more time and require more medical condition stability than the initial screening provided by head and brain CT scans, which are often obtained to rule out suspected neurological injury during the initial, acute evaluation period. In contrast, soft-tissue injuries are often repaired as soon as it is practically possible. Low-velocity injuries, such as isolated nasal and mandible fractures, do not usually require the same highly consultative and collaborative team approach, especially if no other injuries are found or suspected. With isolated injuries, which tend to be more minor than multisystem injuries, treatment can be better directed; it can proceed on a pace both commensurate with and concentrated upon the direct injury.

Essentials of Diagnosis

• Obtain hemostasis
• Tetanus prophylaxis
• Irrigate/clean wound
• Meticulous layered closure

Treatment