• Anatomy
• Lateral orbital wall made up of zygoma and greater wing of sphenoid; medial of ethomid and palantine
• Seven bones comprise the orbit: ethmoid, frontal, lacrimal, maxilla, palatine, and greater and lesser wings of the sphenoid.
• Facial buttresses:
• Vertical: nasomaxillary, zygomaticomaxillary, pterygomaxillary, condyle, posterior mandibular ramus
• Horizontal: frontal, zygomatic, maxillary, mandibular buttresses -mandibular arch
• Ocular parasympathetic nerve injury: dilation of pupil, not responsive to light stimulation, no consensual response to light
• Travel within oculomotor nerve and inferior oblique muscle –> can be injured during reduction or fixation of fractures in region of orbit and zygoma
• Topical epinephrine can also result in this
• Optic nerve: marcus gunn pupil (consensual light response intact) (affected eye will still constrict somewhat)
• Can be caused by central retinal artery occlusion
• The flashlight shone into the left eye causes consensual constriction, and then both eyes dilate when the light is shone in the right eye, can also see color perception abnormalities
• Can also be caused by shear force injuries of the optic nerve (most common in the trauma setting)
• Cribiform plate: horizontal component of ethmoid bone, fracture may cause tear of meninges and allow leakage of CSF
• Supports olfactory bulb and creates passage way for olfactory nerves
• Nasal innervation:
• Anterior ethmoid-nasal tip
• Infratrochlea/infraorbital-nasal sidewalls
• Lateral branch of pterygopalantine- upper/middle turbinates, medial branch, septum
• General Trauma Principles
• Higher risk of mortality in older patients (>60), longer hospital stays, more severe injuries, higher incidence of midfacial fractures, orbital and condylar fractures. Also higher incidence of nonfacial trauma
• 5  criteria predictive of facial fracture: GCS <14, malocclusion, step offs, periorbital swelling/contusion, tooth absence
• Syndromes
• Superior orbital fissure syndrome: extension of fracture in sof, oculomotor, trochlear, abducens, ophthalmic division of trigeminal nerve through superior orbital fissure formed by greater and lesser wings (paralysis of EOM, and levator palp leading to ptosis, anesthesia of forehead, fixed pupil)
• Orbital apex syndrome: like superior orbital fissure syndrome plus blindness
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• Trauma
• Lacerations:
• Avulsions of scalp typically occur in loose areolar layer; galea is strength later, pericranium can accept skin grafts, SQ has nerves/vessels that supply scalp
• Canalicular injury: if identified intraoperatively then can place silicone stents and leave this in place for 3-6 months
• Mid cheek laceration: think buccal branch and stenson’s duct- cannulate, can close over stent
• Sialocele should be managed conservatively (pressure dressing, limited PO intake, aspiration, antisialogogues) –> most resolve 2-3 weeks
• Parotid duct injuries: manage with stent, ligation for extensive injuries, superficial parotidectomy for chronic fistulas
• Frontal
• Frontal sinus fracture carries 45-65% risk of intracranial injury like TBI
• Frontal sinus fracture: anterior table fracture with intact frontal sinus –> repair
• Obliteration if obstructed or nasofrontal duct involvement
• Cranialization if posterior table is comminuted or if there is posterior table and CSF leak (craniotomy, dural repair, pericranial flap for nasal duct obliteration)
• This entails removal of posterior table, closure of the dura, sinonasal tract, and obliteration of sinus mucosa
• In nondisplaced fs fracture with CSF leak- observe for 5-7 days with antibiotics, spinal drainage may be required after 4 days
• If sinus floor fractured medial to supraorbital foramen, NF duct may be injured
• Annual CT required for all FS fractures
• Glue fixation for AT fractures: thin bone fragments have same stability, same bone healing, less time, can be fixated in moist environments, inflammation rare
• NOE
• NOE fracture management: ORIF with immediate bone grafting, fractures of nasal bones, lacrimal, ethmoid bones (medial canthus and lacrimal system can be damaged)
• Telecanthus, impaction of nasal bridge, hematomas of eyelids
• Observe lacrimal system 90% will see improvement –> dacrocystography –> followed by dacryocystorhinostomy
• Transnasal canthopexy used for avulsions of medial canthal ligament with bone, if only partially detached use canthopexy
• Place wires posterior and superior! To insertion of medial canthal tendon (behind and above lacrimal nasal fossa)
• Bony intercanthal distance should be 16-23mm
• Fracture Patterns: Markowitz and Manson
• Five fractures must exist: nasal, inferior orbital rim, ethmoid, nasomaxillary buttress, maxillary frontal process
• Type I: single central fragment with minimal displacement and no disruption of medial canthus
• Management I and II: consider nasal dorsum support, plate fx (no need for medial reconstruction)
• Type II: comminution outside of medial canthus
• Type III: comminution including medial canthus
• Management: reconstruct medial orbital wall, bone graft to nasal dorsum; transnasal wiring of medial canthus (overcorrect)
• Need to support soft tissue s/p transnasal wiring
• (MCT) consists of three limbs: 1) a prominent anterior limb that inserts medially on the anterior lacrimal crest, 2) a thinner posterior limb that attaches to the posterior lacrimal crest, and 3) a vertical limb of fascia that inserts on the medial orbital rim inferior to the nasal frontal suture
• Nasolacrimal Duct

• Jones test: (first step)
• I: evaluates lacrimal outflow under normal physiologic conditions –> fluorescein dye is instilled in conjunctival cornice –> dye recovered 5 minutes by asking patient to blow their nose –> if no dye perform jones 2
• II: residual fluorescein flushed out from conjunctival sac–> asks patient to expel drainage from pharynx –> no dye means complete obstruction
• Post-operative obstruction of naso-lacrimal duct: dacryocysorhinostomy (for negative jones 1 and 2 which signifies distal obstruction past the lacrimal sac) and those not involving the proximal canalicular system 
• Obstruction at canalicular level or proximal obstruction= conjunctivodacryocysotostomy
• Obliteration of sac= conjunctivorhinostomy; intubation of tear sac= dacryocystostomy
• Conjunctivorhinostomy is used in patients who have obliteration or absence of the tear sac 

 

• Orbital Floor

• Surgical Approach: Subciliary approach has scar of orbital septum
• Preseptal transconj incision

• Incision is made through conjunctiva below tarsus of lower lid –> capsulopalpebral fascia is incised and plane between orbic and septum entered –> periosteum then exposed
• Trans caruncular approach: 
• Incision made between medial orbital septum and horner’s muscle; used for fractures of medial orbital wall

 

• Parasthesias of cheek after eye blowout fracture- injury to infraorbital nerve within the orbital floor

• Infraorbital nerve courses within the orbital canal along the floor of the orbit and exits body of zygoma through infraorbital foramen
• Orbital blow out fracture: indications for surgical management include floor defect >2cm or 50%, abnormally low vertical height of the globe, presence of other fractures, symptomatic diplopia and positive forced duction testing, entrapment, significant enophthalmos, lateral orbital wall displacement 
• Entrapment will often present with minimally displaced orbital fractures called (trapdoor fractures)
• Emergent (trapdoor- traps inferior rectus)- this will show minimal displacement, bradycardia, n/v,  
• urgent (persistent diplopia, early enopthalmos, vertical dystopia, large fracture size) –> should fix within 24 hours
• Clinically noticable enopthalmos occurs after 5% increase in orbital volume
• Soft tissue atrophy best served with fat grafting if no stepoffs etc
• Diplopia is common and should generally be observed as this should resolve with time (10-14 days if there is no entrapment)
• Orbital trauma with loss of globe and lids –> orbital prosthesis
• Ocular prosthesis requires a functional lid

• Nasal Bone
• Nasal fractures: drain septal hematomas immediately — if marked edema wait for closed reduction (3-5 days) and splint nasal pyramid
• Osteotomies should be delayed in acute fractures — nasal collapse may result
• Mucosal tear most significant sign of septal fracture followed by deviation

• Zygoma: 

• Gillies approach: technique for operative fixation of zygomatic fractures –> skin, sq, superficial, deep temporal fascia –> raise fractured arch (frontal branch lies under the superficial temp fascia)
• Coronoid process lies deep to temporalis muscle
• Displaced fractures of zygoma –> use lateral orbital rim (greater wing of sphenoid) as guide (least likely to be comminuted)
• Zygomatic osteotomies: indicated to provide increased malar projection in those who have scarring or inadequate vascularization of soft tissue (good for panfacial fractures); never indicated in acute injuries

 

• ZMC: Zygomaticomaxillary complex fractures: 4 buttresses zygomaticofontal, zygomaticomaxillary, ZT/ZS plus/minus infraorbital rim, 
• Use lateral orbital wall as set point for reduction (sphenoid)
• Stable fixation with ZF, ZM and inferior orbital rim
• Main width of the midface through the arch (projection of malar eminence)
• Orbitozygomatic complex: typically break in downward cant (depressed and rotated laterally) due to lateral canthus and unopposed pull of masseter
• Enophthalmos associated with inadequate reduction of ZM suture most frequently
• ZMC fractures without good reduction typically have concomitant NOE fractures that must be reduced first
• Larger than 2cm defect in orbital floor after reduction of ZMC necessitates repair
• 8 weeks out from ZMC fracture would require lefort 1 osteotomy and MMF to address malocclusion

• LeFort: panfacial fractures carry the risk of concomittant cervical spine injury 10%
• LeFort: principle is establishing pre-traumatic maxillomadibular occlusion; if rigid fixation is applied prior to fracture site disimpaction, patient will have open bite on removal of maxillomandibular fixation –> impacted segments should be mobilized prior to application of rigid fixation 
• Panfacial fractures have 10% risk of concomitant cervical spine injury; mandibular fractures have 10% risk of concomitant cervical injury
• LeFort I: maxillary sinus fracture involving medial and lateral buttresses, pterygoid plate fracture
• LeFort II: NOE fractures (nasal bones, ethmoid, lacrimal), orbital floor and infraorbital rim, zygomaticomaxillary buttresses, posterior pterygoid
• LeFort III: NOE, orbital floor, zygomaticosphenoid articulation, lateral orbital wall, zygomaticofrontal buttresses and zygomatic arch, pterygoid plate
• In patients with panfacial fractures (maxillary and mandibular) –> reduce and fix mandible first to establish posterior height prior to ORIF of maxillary segments

 

• Complications

• Enophthalmos: posterior displacement of globe most commonly caused by increase in bony orbital volume, disruption of orbital ligaments can also cause (make sure they are intact)
• From inadequate fracture reduction most common
• Forced duction testing- can make sure no herniation/scarring
• Can be from ZMC, orbital floor, medial orbital wall
• Seen as shortening of palpebral fissure and deepening of tarsal fold
• Ectropion: caused by edema and scar contracture to the orbital septum (can be caused by sub ciliary incisions) –>incision into first eyelid crease is recommended to prevent this compication (preserves innervation to pretarsal portion of orbic)
• Ectropion: massage –> if persist more than 6 months –> kuhnt szymanowski procedure (horizontal shortening of lower lid), lateral canthoplasty, release of scar tissue and application of frost suture, nasal septal cartilage grafting to support posterior lamella
• Traumatic optic neuropathy:  can result from mechanical or ischemic  –> most likely from shear force on optic nerve
• Retrobulbar hematoma: lateral canthotomy and cantholysis (symptoms are pain and reducing visual acuity); therapeutic window of 90 minutes
• Delay of orbital floor fracture
• blindness with increased orbital pressure and proptosis
• Hyphema: urgent consult to ophthamology; blood in anterior chamber of eye –> can lead to glaucoma (blindness, blurred vision, eye pain, globe rupture, retrobulbar hematoma also emergent consults)
• Post-traumatic carotid-cavernous fistula: pulsatile proptosis, ocular/orbital erythema, chemosis, diplopia, headaches, visual loss 
• Abnormal connections between ICA and cavernous sinus
• Can lead to blindness, paralysis death –> associated with basilar skull fractures –> obtain cerebral angiography –> embolization
• Orbital roof fractures: can enter middle cranial fossa and allow for communication of cavernous sinus and carotid artery (may see associated bruit and ipsilateral blindness)
• Septal hematoma: can cause pressure necrosis of nasal mucosa and lead to septal perforation and saddle nose deformity if not treated –> should be immediately drained with 11 blade (incision preferred) or needle
• Develop between mucopericondrium and cartilage –> L incisions and abx
• In massive nasal/oral hemorrhage –> intubate –> anterior/posterior nasal packing
• Complications of frontal sinus fracture includes mucocele from undiagnosed nasal duct obstruction (others, sinusitis, mucocele, meningitis which are generally more acute)
• Mucocele will present with headache and frontal sinus pain
• Mucopyrocele is infected mucocele –> remove with diamond cut rotational burr, duct can be obliterated with fat or bone grafts or soft tissue flaps, (if infected use bone or soft tissue- preferred anyway over muscle and fat)
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• Teeth
• Tooth anatomy:
• Dentin protects pulp, visible part is crown, inner is root and consists of outer cementum, inner dentum and pulp

• Sensitivity to cold/pain is due to exposed dentin (can become infected) –> cap 
• Injury to pulp requires removing tooth
• Fracture to alveolar bone requires arch wiring
• Periapical cyst: most common odontogenic cyst- nonviable tooth becomes infected, necrosis of pulp, radiolucency on xray
• Dentigerous cyst: around the top unerupted tooth

 

• Cranioplasty
• Cranioplasty–> higher risk in those with large endocranial dead space and fronto-orbital decompressions 
• Hydroxyapetite contraindicated in radiated fields, not recommended in pediatric population, can use up to 25cm, wait 1 year, frontal area has more complications
• Methylmethacrylate has high compression strength;exothermic, low cost, does not ingrowth, more susceptible tin infection, can be prefabricated with planning (difficult)
• Skull fractures with dural lacerations in children –> can become growing skull laceration GSF, 

• Frontal sinus develops at 2 years
• Polylactic acid will give least amount of scatter on ct
• PEEK: (polyetheretherketone) infection is the most common complication

Miscellaneous

• Massive Transfusion Protocol: tranfusiong of FFP, PRBC at 1:1, discontinuing crystalloids

Beginning blood rather than crystalloid
FFP:PRBC 1:1
Delivery via rapid transfuser and blood warmer

• Treatment of tracheostomy scar includes scar excision and reapproximating of the strap muscles (staernohyoid and sternothyroid)