AAO-HNSF Primary Care Otolaryngology Handbook

MAXILLOFACIAL TRAUMA

Generally, history, inspection, and palpation are the best ways to diag- nose a broken nose. Uncomplicated nasal fractures are treated with anti- biotics, pain medicine, a decongestant nasal spray, and a referral for reduction within three to five days. It is very helpful to compare the patient’s nose with pretrauma photos, but remember that nasal edema can mask bony deformities. Continuing with the exam, evaluate the stability of the maxilla by grasping the maxilla area just above the front teeth and applying a gentle rocking motion. If the maxilla is unstable, you will feel it move separately from the face. This is a Le Fort fracture and will require surgical plating . A complete bilateral Le Fort III fracture is rare, and involves massive trauma that disarticulates the face from the skull. It may be accompa- nied by spinal fluid leakage manifested by clear rhinorrhea. The remaining soft tissue attachments consist largely of the optic nerves; thus, the examiner must gently rock the maxilla and hard palate. A computed tomography (CT) scan will elucidate the situation if you are unsure. Check the patient for cerebrospinal fluid (CSF) rhinorrhea, since a basal skull fracture or temporal bone fracture can leak into the middle ear, which drains down into the Eustachian tube and out the nose. Alternatively, the site of the leak may be just above the cribriform plate. Remember that CSF mixed with blood produces a ring sign on the sheets or on filter paper (halo sign), and also that CSF has a measurable glucose concentration, while mere nasal secretions do not. Beta-2 transferrin is a protein found only in CSF, so a positive test is diagnostic of a CSF leak. Next, evaluate the mandible. Examine the patient’s occlusion and ask if his or her teeth fit together like they always have. Mandibular fractures are generally treated with a combination of intermaxillary fixation (also known as maxillomandibular fixation) and the surgical application of plates. On the rare occasion favorable mandibular fractures may be treated with a no-chew soft (or liquid) diet for four to six weeks. (Favorable versus unfavorable is discussed later in this chapter.) Trauma to the neck may injure the larynx or trachea. For example, blunt trauma from a steering wheel can cause fracture of the thyroid cartilage, cricoid, or both. A complete crush is nearly always fatal, unless someone handy with a knife is waiting to do an immediate cricothyrotomy. Lesser injury generally results in progressive hoarseness and stridor . The only initial physical finding may be cervical ecchymosis . Check for loss of cartilaginous landmarks, and feel for subcutaneous air (subcutaneous emphysema) . Any positive finding is an indication for further evaluation with flexible laryngoscopy; possible high-resolution, thin cuts CT of the

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