Management of maxillofacial trauma in emergency: An update of challenges and controversies

Could mandibular fractures lead to obstructive sleep apnea?

OBJECTIVE

To detect and assess obstructive sleep apnea (OSA) before and after repair of different types of mandibular fractures.

METHODS

In patients with traumatic isolated mandibular fractures who were indicated for open reduction and internal fixation (OR/IF), polysomnography (PSG) was done before and 3 months after surgery.

RESULTS

Of 51 patients (80 mandibular fractures), fractures were unilateral in 29 patients (56.9%) and bilateral in 22 patients (43.1%). PSG was normal in 33 patients (64.7%), and OSA was detected in 18 cases (35.3%); all had bilateral fracture. Mild OSA was reported in 9 cases (17.65%), and moderate OSA was detected in 9 cases (17.65%). Three months after OR/IF of the fractures, successful reduction was obtained, and PSG was within normal limits in all patients.

CONCLUSION

Bilateral mandibular fractures often lead to OSA, which could be cured with proper OR/IF of the fractures. OSA is not encountered in unilateral fractures.

Temporal Bone Fractures and Related Complications in Pediatric and Adult Cranio-Facial Trauma: A Comparison of MDCT Findings in the Acute Emergency Setting

PURPOSE

The purpose of this study was to analyze the prevalence of and complications resulting from temporal bone fractures in adult and pediatric patients evaluated for cranio-facial trauma in an emergency setting.

METHODS

A retrospective blinded analysis of CT scans of a series of 294 consecutive adult and pediatric patients with cranio-facial trauma investigated in the emergency setting was conducted. Findings were compared between the two populations. Preliminary reports made by on-call residents were compared with the retrospective analysis, which was performed in consensus by two experienced readers and served as reference standard.

RESULTS

CT revealed 126 fractures in 116/294 (39.5%) patients, although fractures were clinically suspected only in 70/294 (23.8%); p < 0.05. Fractures were longitudinal, transverse and mixed in 69.5%, 10.3% and 19.8% of cases, respectively. Most fractures were otic-sparing fractures (95.2%). Involvement of the external auditory canal, ossicular chain and the osseous structures surrounding the facial nerve was present in 72.2%, 8.7% and 6.3% of cases, respectively. Temporal bone fractures extended into the venous sinuses/jugular foramen and carotid canal in 18.3% and 17.5% of cases, respectively. Vascular injuries (carotid dissection and venous thrombosis) were more common in children than in adults (13.6% versus 5.3%); however, the observed difference did not reach statistical significance. 79.5% of patients with temporal bone fractures had both brain injuries and fractures of the facial bones and cranial vault. Brain injuries were more common in adults (90.4%) than in children (63.6%), p = 0.001. Although on-call residents reliably detected temporal bone fractures (sensitivity = 92.8%), they often missed trauma-associated ossicular dislocation (sensitivity = 27.3%).

CONCLUSIONS

Temporal bone fractures and related complications are common in patients with cranio-facial trauma and need to be thoroughly looked for; the pattern of associated injuries is slightly different in children and in adults.

Delayed Surgical Intervention in Cranio-Maxillofacial Splinter Injury: Report of a Case and A Literature Review

Introduction

In the context of Indian combat scenario, maxillofacial injuries from gunshots are uncommon.

Methods

The first section of this study is a case report of a rare instance of metal foreign bodies that were lodged in the parapharyngeal space, deeper to the deep lobe of the parotid right next to the carotid space in the neck. The second section focusses on the unique treatment for blast injuries as well as the variety of imaging procedures that are readily available to assist with surgery, such as plain film, CT, angiography, and occasionally MR imaging.

Result and Conclusion

According to the study, understanding the pertinent anatomy, precise imaging of the penetrating object in relation to vital structures, meticulously planned and conducted surgical removal of the foreign body, and repair of damaged structures are the key elements of a successful treatment.

Comparison of different 3D printers in terms of dimensional stability by image data of a dry human mandible obtained from CBCT and CT

OBJECTIVES

To manage the mandibular traumas, for the expression of the complex anatomy or pathology in education of health sciences related branches, a model of the traumatized mandible is indispensable. For these, different 3D-print-technologies can be used. The aim of this study is, to measure how close these 3D-printed-models are to human-mandible (trueness) and the effectiveness of CT and CBCT at this point.

STUDY DESIGN

One-dry-human-mandible and 10-models manufactured by five different 3D-printers in four different-kinds of additive-manufacturing technology (Fused-Deposition-Modeling (FDM), Stereolithography (SLA), Binder-jetting (BJ), Polyjet (PJ)) were used, five-anatomic-landmarks and eight-distances were measured and evaluated. Mandible's data were constructed based on DICOM-3.0 data from CBCT and CT scans. Images were opened in MIMICS (software-program).

RESULTS

Study compared the devices that produced models with the same dry human-mandible. It was seen that the model with the highest margin of error (132.5 mm) was manufactured by Fused-deposition-modeling device using CT-data. In terms of distance to real-data, the model with the lowest error was generated by Binder-Jetting (ZCorp) with CBCT-data. Models produced with CBCT-data are closer to dry-human-mandible than models with CT-data.

CONCLUSION

The current study shows that CBCT generates significantly better data than CT in producing mandibular models. The first choice for manufacturing of human mandible is BJ and the second choice is the technology of SLA.

Peculiarities of treatment of maxillofacial polytrauma during wartime

OBJECTIVE

Aim: Analyzing of the last-time papers in this subject in organizing, diagnostic and surgery tactic is the aim of this work.

PATIENTS AND METHODS

Materials and Methods: The study analyzed the experience of treating patients with maxillofacial polytrauma before and after February 24, 2022. Research methods: bibliographic, systematic, comparative, general clinical, radiological and retrospective analysis.

CONCLUSION

Conclusions: Tactic of the multidisciplinal team should based on the principles of damage control, which involves the initial performance of manipulations and surgical interventions that ensure the patient's survival. Modern strategies for infusion-transfusion therapy play a significant role in severe trauma cases. Choosing the rational management of this therapy for severe trauma remains an important issue. Reconstructive surgeries are recommended to be performer deferred, after surgical wound management, neurosurgical interventions and stabilization of the patient common status. Patients with maxillofacial polytrauma needs in specialized medical care at all the levels. Active wound management aimed at creating favorable conditions for healing, comprehensive medical treatment, prevention, early detection and timely treatment of complications.

Chondrocytes supplemented to bone graft-containing scaffolds expedite cranial defect repair

Critical maxillofacial bone fractures do not heal spontaneously, thus, often there is a need to facilitate repair via surgical intervention. Gold standard approaches, include the use of autologous bone graft, or devices supplemented with osteogenic growth factors and bone substitutes. This research aimed to employ a critical size calvaria defect model, to determine if the addition of chondrocytes to collagen-containing bone graft substitute, may expedite bone repair. As such, using a critical size rat calvaria defect, we implanted a collagen scaffold containing bone graft substitute (i.e., Bone graft scaffold, BG) or BG supplemented with costal chondrocytes (cBG). The rats were subjected to live CT imaging at 1, 6, 9, and 12 weeks following the surgical procedure and sacrificed for microCT imaging of the defect site. Moreover, serum markers and histological evaluation were assessed to determine osseous tissue regeneration and turnover. Live CT and microCT indicated cBG implants displayed expedited bone repair vs, BG alone, already at 6 weeks post defect induction. cBG also displayed a shorter distance between the defect edges and greater mineral apposition distance compared to BG. Summerizing, the data support the addition of chondrocytes to bone substitute, accelerates the formation of new bone within a critical size defect.

Diagnostic accuracy of physical examination findings for midfacial fractures: a systematic review and meta-analysis

Objectives

To conduct a systematic review and meta-analysis to assess the diagnostic accuracy of physical examination findings and related clinical decision aids for midfacial fractures in comparison to computed tomography and cone beam computed tomography.

Material and methods

A systematic review was performed by searching the MEDLINE, Cochrane, EMBASE, and CINAHL databases. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Pooled sensitivity, specificity, and diagnostic odds ratios with the corresponding 95% confidence intervals were calculated for each physical examination finding and reported clinical decision aids.

Results

After screening 2367 records, 12 studies were included. High risk of patient selection bias was detected in three studies (25%). Additionally, high concerns regarding applicability were found for the patient selection in five studies (41.7%), and for the reference standard in eleven studies (91.7%). Of the total 42 individual physical examination findings, only 31 were suitable for a meta-analysis. High specificity and low sensitivity were found for most findings. The pooled diagnostic odds ratio ranged from 1.07 to 11.38. Clinical decision aids were reported by 8 studies, but none were constructed specifically for midfacial fractures.

Conclusion

Based on the current available evidence, the absence of physical examination findings can successfully identify patients who do not have a midfacial fracture, but the presence of individual findings does not necessarily mean that the patient has a midfacial fracture. Although various clinical decision aids were presented, none focused on exclusively midfacial fractures.

Clinical relevance

The diagnostic accuracy of physical examination findings can be used to diagnose a midfacial fracture so as to reduce unnecessary imaging, health care costs, and exposure to ionizing radiation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00784-022-04423-y.

Cervical Spine Injuries and Maxillofacial Trauma: A Systematic Review

OBJECTIVES

Identify specific maxillofacial trauma patterns associated with cervical spine injuries.

METHODS

The protocol was developed according to (PRISMA-P) and was admitted to PROSPERO under accreditation code #CRD42020177816. Furthermore, the reporting of the present SR was conducted based on the PRISMA checklist.

RESULTS

Of the 1,407,750 patients recorded, a total of 115,997 patients (12.13%) had MFF with an associated CSI with a gender proportion (M:F) of 3.63:1 respectively. Motor vehicle accident was the most common cause of the combined Maxillofacial Trauma (MFT) and CSI. The most common CSI location was at the C2, followed by the C5 cervical spines. The most common location of a maxillofacial fracture resulting in a CSI was the mandible.

CONCLUSION

The incidence of the association of CSIs with MFT has been low (12.13%). Nevertheless, in cases of an isolated mandibular trauma due to a severe blow presenting with a low Glasgow Coma Scale, maxillofacial surgeons should be at a high alert of an associated CSI.

Airway management in maxillofacial trauma

Airway management of patients with maxillofacial trauma remains a challenging task for an anesthesiologist in the emergency and perioperative settings due to anatomical distortion. Detailed knowledge of maxillofacial and airway anatomy is desired for the correct diagnosis of extent and severity of the injury. Basic principles of advanced trauma life support protocols should be followed while managing such patients. Establishing unobstructed airway remains the top priority while maintaining C-spine immobilization and preventing aspiration. Although multiple options exist for securing the airway, a universal technique of airway management may not be applicable to all the patients. Hence, a high index of suspicion along with timely and skillful management is warranted. In this brief review, issues affecting the airway management in cases of maxillofacial trauma are addressed with the possible uses of a wide range of airway management devices available in emergency and elective scenarios.

The management of ocular and peri-ocular trauma needs to be co-ordinated according to ATLS principles and requires multi-disciplinary collaboration

INTRODUCTION

This project set out to focus on ocular (globe) and peri-ocular trauma and to describe the spectrum of injuries seen in a busy South African trauma unit and to document their management and outcome.

RESULTS

During the period November 2012 to April 2020, a total of 12 115 patients were managed by the Pietermaritzburg Metropolitan Trauma Service (PMTS) at Greys Hospital in Pietermaritzburg, South Africa. Of these 2194 (11%) sustained ocular or peri-ocular injury. Of these 2194 patients, 1069 (83%) were male. 83% of injuries (n=1076) were classified as primarily blunt injury and 17% as a primarily sharp/penetrating mechanism. A substantial number of patients required a life-saving emergency intervention. These included resuscitation in 242 cases (19%) and active airway intervention was in 290 (22%). In total 919 (71%) patients required urgent surgery to the peri-ocular region. Slightly over half (55%) of these the surgery was performed by a single discipline. The rest needed procedures by two or more disciplines. The disciplines involved included ophthalmology, maxillofacial, plastic, ENT and neurosurgery. Plastic surgery was involved in 683 cases (53%). A total of 341 distant surgeries were required - These included orthopaedic operations, laparotomy and vascular operations. Of the 1294 cases in this study, 42 (3%) died before discharge and 99 (8%) were discharged with a GCS lower than 10. The primary skill set for management of these injuries is identified.

CONCLUSION

Although the management of immediate life and organ threatening injuries takes priority, ocular and peri-ocular trauma may damage a number of important structures and their comprehensive management requires a multi-disciplinary team of specialists or, in austere environments, a font-line medical team with a diverse skill set.

Management of intractable oronasal bleeding using Sengstaken-Blakemore tubes in patients with facial trauma: a case series and technical notes

Objective

Intractable massive oronasal bleeding can become a life-threatening condition. The success rate of conventional bleeding control methods other than transarterial embolization (TAE) is not expected to be high. We investigated the efficacy of Sengstaken-Blakemore tube (SBT) balloon tamponade in patients with sustained and intractable oronasal bleeding secondary to facial injury.

Methods

This study is a retrospective chart review from traumatic patients with sustained and intractable oronasal bleeding who were admitted to the emergency center of Ajou University Hospital and Soonchunhyang University Bucheon Hospital from January 2014 to December 2016.

Results

Twelve patients were included in the study, of whom nine (75%) were male. The median age was 31 years (range, 20–73 years). Bleeding was controlled in 11 of the 12 patients (91.7%) either temporarily or definitively. One patient without hemostasis underwent TAE. TAE was performed in an additional three patients out of the 11 patients with hemostasis who experienced continued nasal bleeding after the removal of SBTs. There were no complications from performing the procedure.

Conclusion

Using SBTs as a hemostatic tool will aid patients with life-threatening intractable oronasal bleeding. Furthermore, this method may be used in patients with continual and intractable oronasal bleeding after facial trauma as a bridging procedure from the emergency department or the intensive care unit to the interventional radiology.

Management of Life-Threatening Hemorrhage from Maxillofacial Firearm Injuries Using Foley Catheter Balloon Tamponade

The aim of this study is to evaluate the efficacy of Foley catheter in the management of hemorrhage from penetrating maxillofacial injuries in austere environment. This retrospective cohort study evaluated all penetrating head and neck trauma caused by firearm injuries reported to a military hospital at a forward aid location during 2015-2017. Foley catheter was used in the emergency management of bleeding in 11 cases. The effectiveness of this technique in controlling hemorrhage, its indication, contraindications, and complications has been explained. Out of 26 penetrating injuries received during the time period, 11 patients underwent Foley catheter balloon tamponade for the control of hemorrhage. Ten out of 11 patients responded adequately to balloon tamponade. One patient with a bullet lodged inside the neck underwent immediate surgical exploration for its removal and repair of internal jugular vein. No neurological deficits or complications were noted in any of the patients. Foley catheter balloon tamponade is very effective in managing hemorrhage from head and neck penetrating injuries. It significantly reduces the mortality by controlling bleeding from the major vessels especially in a combat environment.

Substance Use and Maxillofacial Trauma: A Comprehensive Patient Profile

PURPOSE

Maxillofacial trauma confers an increased risk of long-term clinical sequelae with a substantial economic burden on the health care system. Substance use has long been correlated with an increased risk of trauma, yet to date, a comprehensive profile of substance users incurring facial fractures has not been established. We aimed to establish patterns and trends of substance use and specific substances in the setting of maxillofacial trauma.

PATIENTS AND METHODS

A retrospective chart review was conducted at our institution examining patients with maxillofacial fractures from 2016 to 2017. Information on age, gender, race, urine drug screen status, setting of presentation, mechanism of injury, trauma history, and injury severity was collected and examined for associations with particular substances.

RESULTS

We included 388 patients for analysis. Patients with positive urine drug screen results were significantly more likely to be men, present in an urban setting, incur poly-facial trauma, and have a history of facial trauma. In addition, alcohol use correlated significantly with injury severity in the context of polytrauma. Living in an urban setting and using phencyclidine were both significantly associated with a history of maxillofacial trauma.

CONCLUSIONS

Patients with comorbid maxillofacial trauma and substance use exhibit particular patterns in presentation and history. Establishing a profile for these patients allows for the development of prevention and rehabilitation programs.

Anesthetic Considerations for Oral, Maxillofacial, and Neck Trauma

Blunt, penetrating trauma to the ear, nose, and throat, and related structures are striking. Injuries may range from simple soft tissue wounds to complex injuries of the face, neck, and brain. Proximity of the cervical spine and airway complicate anesthetic management. A multidisciplinary approach is required. Airway control has highest priority in initial care. Management of airway, breathing, and circulation need to be tailored to the patient. Decisions regarding airway management, ventilation strategies, monitoring, and fluid and blood administration should be based on the patient's condition, clinical setting, and the available personnel, expertise, and equipment.

Predictive value of quick surgical airway assessment for trauma (qSAT) score for identifying trauma patients requiring surgical airway in emergency room

Background

A surgical airway is usually unpredictable in trauma patients. The aim of this study was to develop a predictable scoring system to determine the need for a surgical airway by using a database from a large multicenter trauma registry.

Methods

We obtained data from the nationwide trauma registry in Japan for adult blunt trauma patients who were intubated in the emergency department. Based on a multivariate logistic regression analysis in the development cohort, the Quick Surgical Airway Assessment for Trauma (qSAT) score was defined to predict the need for a surgical airway. The association of the qSAT with surgical airway was validated in the validation cohort.

Results

Between 2004 and 2014, 17,036 trauma patients were eligible. In the development phase (n = 8129), the qSAT score was defined as the sum of the three binary components, including male sex, presence of a facial injury, and presence of a cervical area injury, for a total score ranging from 0 to 3. In the validation cohort (n = 8907), the proportion of patients with a surgical airway markedly increased with increasing qSAT score (0 points, 0.5%; 1 point, 0.9%; 2 points, 3.5%; 3 points, 25.0%; P <  0.001). Multivariate analysis revealed that qSAT score was an independent predictor of surgical airway (adjusted OR, 3.19 per 1 point increase; 95% CI, 2.47–4.12; P <  0.0001). The qSAT score of ≥1 had a had a good sensitivity of 86.8% for predicting the requirement for surgical airway; while qSAT score of 3 had a good specificity of 99.9% in ruling out the need for surgical airway.

Conclusions

The qSAT score could be assessed simply using only information present upon hospital arrival to identify patients who may need a surgical airway. The utilize of qSAT score in combination with repeated evaluations on physical finding could improve outcomes in trauma patients.

Associated head injuries and survival rate of patients with maxillofacial fractures in road traffic accident: A prospective study in Saudi Arabia

Background:

Every minute, an accident occurs in Saudi Arabia, causing 39,000 injuries and 7,000 deaths annually. Facial trauma or maxillofacial trauma (MFT) is a frequent presentation of road traffic accidents (RTAs), ranging from simple nasal fractures to gross or severe maxillofacial injuries.

Methods:

A total number of 237 patients were included in this prospective study from May 2013 to January 2018. The following medical details were recorded for each case, gender, age, fracture location, the presence of scalp laceration, the presence of brain damage, type of brain damage, shock degree, Glasgow Coma Scale (GCS), number of units used for blood transfusions for documentation of patient survival rate. We followed up the patients in their first appointment after 21 days of patient discharge from the hospital.

Results:

Majority of the patients were young male adults. A total of 59.1% of patients had cerebral damage, 38% (n = 90) of patients had at least, one scalp laceration, 43.5% (n = 103) of patients had some degree of shock, whereas 27.8% of the recruited patients needed at least 1 unit of blood transfusion. A total of 14.3% of the patients died as a result of their injuries, and the survival rate was 85.7%.

Conclusions:

Kingdom of Saudi Arabia (KSA) is having a high incidence of RTAs leading to high mortality rate. Therefore, it requires a sound evaluation of the risk factors for RTAs and establishment of guidelines to decrease the incidence of road traffic injuries and reduce health-care burden. Road safety campaigns focused on young population can help reduce RTAs and subsequent mortalities. Prompt arrival at the hospital, early diagnosis, and timely management of maxillofacial fractures and brain damages by skilled physicians will lower mortality rate in KSA..

Base of Skull Blocks for Open Reduction and Internal Fixation of Faciomaxillary Fractures

INTRODUCTION

Faciomaxillary fractures (FMF) occur in a significant proportion of trauma patients. Nearly all polytrauma patients and even those with isolated FMF are managed under general anesthesia for definitive management. We propose the use of regional nerve blocks as a safe and effective means for open reduction and fixation of isolated FMF.

AIM AND OBJECTIVES

The aim is to evaluate the feasibility, effectiveness and safety of base of skull maxillomandibular and distal trigeminal nerve blocks in the management of FMF.

MATERIALS AND METHODS

Ten young adults with fractures of the zygoma, mandible and Le Fort I/II injuries were included in the study. Patients with associated craniocervical and abdominothoracic injuries were excluded.

RESULTS

The patients' ages ranged from 21 to 40 years, with a mean time of onset of anesthesia being 5 to 12 minutes and total duration of 105 to 220 minutes. Supplementary block for patchy anesthesia was needed in three. All underwent unhindered surgery without complication.

CONCLUSION

Base of skull maxillary-mandibular and distal trigeminal blocks are an effective and efficient alternative to general anesthesia for the open reduction and internal fixation of FMF.

Facial injuries: Triage and applying damage control principles

Facial trauma varies widely in its severity and is also frequently associated with other injuries which can make prioritisation of injuries difficult. An effective method of triage is important to ensure this. This article describes one such approach and discusses the application of damage control principles to facial injuries. Both these issues commonly impact on the management of multiply injured patients with coexisting facial injuries during the initial stages of resuscitation or soon afterwards. Understanding facial trauma is based in part, on parallels with orthopaedic trauma.