🦷 Maxillofacial & Facial Trauma
Initial assessment, Le Fort fractures, mandibular fractures, orbital blowout, and chemical eye burns — airway first, always.
Initial Trauma Assessment — Facial Injuries
Facial injuries are rarely immediately life-threatening in isolation, but they can rapidly compromise the airway through haemorrhage, oedema, displaced fractures, and foreign bodies. Always follow ATLS principles: Airway with C-spine control → Breathing → Circulation → Disability → Exposure.
Airway is the Priority — Assume C-Spine Injury Until Proven Otherwise
All significant facial trauma must be treated as having an associated cervical spine injury until imaging excludes it. Maintain in-line cervical stabilisation throughout airway management. Massive midface trauma can cause posterior displacement of the midface, obstructing the nasopharynx. Haemorrhage into the oropharynx, fractured teeth, and disrupted bony architecture may all rapidly threaten the airway. Early anaesthetic involvement for airway control is essential.
Airway Management Considerations
- Orotracheal intubation: Preferred route. Can be performed with in-line cervical stabilisation.
- Nasotracheal intubation: Contraindicated in suspected cribriform plate fracture (Le Fort II/III, midface trauma, basal skull fracture) — risk of intracranial passage. Suspect cribriform plate fracture with: CSF rhinorrhoea, periorbital ecchymosis (panda eyes), Battle’s sign, anosmia.
- Surgical airway: Cricothyroidotomy or surgical tracheostomy if oral intubation fails or is contraindicated. Cricothyroidotomy landmark: midline depression between thyroid cartilage (above) and cricoid (below).
- Nasogastric tubes: MUST be placed orally (OGT) in any midface fracture — nasal placement risks intracranial passage through a cribriform plate defect.
Nasogastric Tube — Never Via Nose in Midface Trauma
Case reports document NGT placement into the cranial vault through a cribriform plate fracture. In any patient with significant midface or frontobasal skull trauma, insert all tubes orally. This includes NGT, gastric tubes, and nasopharyngeal airways. The same applies in any patient with suspected basal skull fracture — use an oropharyngeal airway instead of a nasopharyngeal airway.
Facial Oedema — Rapid Assessment Required
- Facial swelling progresses rapidly post-trauma — assessment window is narrow before oedema obscures anatomy
- Periorbital swelling can prevent adequate eye examination — document visual acuity, pupillary reflexes, and extraocular movements before swelling worsens
- Tense periorbital haematoma may cause orbital compartment syndrome — emergency lateral canthotomy and cantholysis if VA deteriorating, IOP >40 mmHg, or proptosis with afferent pupillary defect
Signs of Basal Skull Fracture
| Sign | Description | Mechanism |
|---|---|---|
| Panda eyes (periorbital ecchymosis) | Bilateral “raccoon” bruising around eyes | Anterior cranial fossa fracture → blood tracks into periorbital fat |
| Battle’s sign | Bruising over mastoid process | Middle cranial fossa / petrous temporal bone fracture → blood tracks along fascial planes |
| CSF rhinorrhoea | Clear fluid from nose — positive “halo sign” on paper, glucose-positive | Cribriform plate fracture → dural tear → CSF leaks through nose. Risk of ascending meningitis. |
| CSF otorrhoea | Clear fluid from ear | Petrous temporal bone fracture → CSF leaks via torn TM or through Eustachian tube |
| Anosmia | Loss of smell | Cribriform plate fracture → shearing of olfactory filaments (CN I) |
| Haemotympanum | Blood behind tympanic membrane | Middle cranial fossa / petrous fracture |
Haemorrhage Control in Facial Trauma
Severe midface fractures can cause life-threatening haemorrhage from branches of the maxillary artery (sphenopalatine, descending palatine, posterior superior alveolar). Initial management: direct pressure, anterior/posterior nasal packing (Foley catheter posteriorly), and correction of coagulopathy. Persistent haemorrhage requires: interventional radiology (selective embolisation) of internal maxillary artery branches, or external carotid artery ligation. NEVER overlook blood loss from facial fractures — up to 2 litres can be lost into the midface compartments.