AAO-HNSF Primary Care Otolaryngology Handbook

MAXILLOFACIAL TRAUMA

You’ve gone through your checklist as above and have determined that the patient’s tongue is not the problem. You cannot perform an oral intu- bation (perhaps because the lateral C-spine film shows a cervical spine fracture), and you cannot perform a nasotracheal intubation (perhaps because the patient has profuse oral bleeding). You now know that the only option is a surgical airway. The indication for an emergent (“bedside”) surgical airway, either cricothyroidotomy or slash trache- otomy, is in a patient who is unable to be intubated and unable to be successfully ventilated with a mask. The exception to this is a patient with severe laryngeal trauma, where mask ventilation or intubation could worsen the situation. The methods of choice are a tracheotomy and a cricothyrotomy. Which procedure is performed depends on the level of expertise available. In an emergency, cricothyrotomy may be chosen over tracheotomy, because it is quicker and is accomplished through the relatively thin and more superficial cricothyroid membrane. You should learn to palpate and recognize the cricoid cartilage. Try it on yourself; the membrane is just above the cricoid cartilage and below the thyroid cartilage (the Adam’s apple). During emergent airway situations, otolaryngologists may preemptively palpate and draw landmarks (thyroid cartilage, cricothyroid membrane, cricoid, and tracheal rings) on the patient’s neck in case a surgical airway is needed urgently. Physical Exam of the Maxillofacial Trauma Patient Anyone who has sustained enough

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trauma to break a facial bone should be assumed to have a C-spine fracture until this is ruled out (Figure 11.1). Rule #1 in maxillofacial trauma management is secure the A irway, B reathing, and C irculation. Rule #2 is rule out a C-spine fracture, if it has not already been done. Rule #3 is evaluate the patient completely. Look in the ears for hemotympanum, which can signify a temporal bone frac- ture. Check that the facial nerve works on both sides, since a complication of temporal bone fracture may be facial nerve paralysis (an otolaryngologist should be consulted for any temporal bone fracture). Next, palpate the orbital

Figure 11.1. Bilateral periorbital ecchymosis and subconjunctival hemorrhages. This may be due to soft tissue trauma only, or it may be a manifestation of an underlying fracture.

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