FRCA Notes

Over 50% of facial injuries arise from inter-personal violence
Injuries may also arise from trauma due to sports (19%), RTC (16%), falls (11%) or industrial accidents (2%)
Facial injuries are more common in young (mean age 25yrs), male (2x) patients
There may be associated injuries, such as TBI (15 - 48%), soft tissue and dental injuries

The bony face

The inter-digitating suture lines between the bones of face act to dissipate energy transferred to the face during trauma, minimising damage to the brain
There are very strong, dense areas of bone called buttresses, yet also natural points of weakness, especially in the presence of foramina e.g. intra-orbital foramen
Fractures (unsurprisingly) typically occur at points of weakness
If buttresses break they typically do so cleanly; comminuted fractures imply a high energy transfer

The tongue

The tongue is tethered to the mandible via the paired genioglossi muscles
Bilateral, anterior mandibular fractures may therefore cause the tongue to fall backwards
The unconscious, supine patient may therefore develop (fatal) airway obstruction

Vasculature

The face is highly vascular
Facial fractures, particularly of the mid-face, can cause catastrophic haemorrhage
This may be occult, especially if the patient is supine, with blood accumulating in pharynx, larynx and stomach

Upper third

The upper third of the face consists of the frontal bone, sphenoid bones and upper half of the naso/orbito/ethmoidal complex
It houses the eyes and paranasal sinuses e.g. frontal, sphenoid and ethmoid

The frontal sinus is the weak zone in the frontal bone
Fracture through the frontal bone with a large frontal sinus can involve the anterior skull base, and associated:

Upper third facial fractures, if combined with anterior skull base fracture, will increase the risk of nasal catheters (nasal tubes, temperature probes, nasal ETT) ending in the frontal lobe

Middle third

The mid-face comprises the maxilla, zygoma and lower half of the naso/orbito/ethmoidal complex
It houses the eyes, nasal airway, maxillary sinuses and maxillary teeth
It acts as a crumple zone to protect the brain from injury

Brain injury
Significant haemorrhage requiring maxillary splinting and tamponade with rapid rhinos or bite blocks
Breathing difficulties due to loss of nasal airways

The Le Fort classification is used for mid-face fractures, although it was developed in vitro using cadavers (i.e. monsieur Le Fort smashed a load of decapitated or otherwise dead skulls)
There is increasing facial mobility with higher Le Fort number

Lower third

The lower third of the face comprises the mandible and teeth
The roots of the teeth are structural weak points and teeth are often displaced, loosened or avulsed

The mandible forms a ring structure with the TMJ and base of skull; as with other ring structures in the body, fractures typically occur in >1 place
Mandibular fractures are typically bilateral but in different places on each side

This causes minimal impact on the airway, unless there is gross displacement or the aforementioned bilateral, anterior fractures
Gross displacement can cause bleeding and large sublingual haematoma akin to a Ludwig's angina

Trauma patient

Assessment should follow a primary survey pattern and ATLS protocol, being mindful that facial fractures may distract from other injuries
Early intubation may be required as part of the resuscitative process
A group and save/cross-match should be taken owing to high risk of perioperative bleeding

Airway assessment

Airway compromise may be suggested by classical signs such as dyspnoea, stridor, drooling, odynophagia, subcut. emphysema, voice changes, trismus (which mayn't disappear post-induction if it is mechanical)
Airway assessment should include a review of pre-operative imaging and a discussion with the surgeon about their route of surgical access (e.g. intra-oral, subconjunctival, via scalp flap) as this will inform airway choice

Airway

Oral intubation is not appropriate for fixation of Le Fort fractures as dental occlusion must be checked at the end of the case
Options include:

Bleeding

Profuse bleeding from the mid-face can occur, risking airway obstruction
Bleeding is most commonly from the maxillary arteries
Management steps for bleeding intra-operatively include (in order of increasing desperation):

Bradycardia

Risk of bradycardia during zygomatic levering or manipulation of the mid-face
Cessation of the surgical stimulus can reverse the bradycardia, which should otherwise be managed as normal e.g. with anti-cholinergics

Associated care

Extubation

Extubation requires careful planning
The decision about extubation should be made on a patient-by-patient basis, involve surgical input and ideally follow the DAS Guidelines for the management of tracheal extubation (2012)
The surgical team should be present during extubation, and a period of in-theatre observation might be sensible prior to transfer to recovery

May require a higher care area for monitoring, especially as degree of oedema can worsen in 48hrs post-injury
Some patients may require prolonged I&V on ICU

Haematoma formation

An uncommon but airway-threatening complication
Removal of clips/sutures and manual evacuation of clot should be performed if so, may not alleviate obstruction arising from venous congestion and oedema

Facial Fractures