4/25/2014 1 Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA Maxillofacial Trauma Eric W. Wang, MD Center for Cranial Base Surgery University of Pittsburgh Medical Center Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA Disclosure • None Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA Learning Objectives • Review the anatomy and common fractures of the maxillofacial skeleton • Understand the indications for intervention in bony maxillofacial trauma • Overview the surgical approaches to the maxillofacial skeleton
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Maxillofacial Trauma and CSF Leak - entpa.org Head _ Neck Trauma - Wang.pdfTraumatic CSF Leak • 18 year old male s/p ATV accident • Continuous rhinorrhea and headache • Cognitive
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4/25/2014
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Maxillofacial Trauma
Eric W. Wang, MD
Center for Cranial Base SurgeryUniversity of Pittsburgh Medical Center
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Disclosure
• None
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Learning Objectives
• Review the anatomy and common fractures of the maxillofacial skeleton
• Understand the indications for intervention in bony maxillofacial trauma
• Overview the surgical approaches to the maxillofacial skeleton
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Maxillofacial Trauma
• Mandible
• Maxilla
• Zygomaticomaxillarycomplex
• Orbital floor
• Nasal Bone
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Initial Evaluation
• ABC’s
– Possible sublingual hematoma
• Cervical spine and other associated injuries
• Identify the mechanism of injury
• PMH: bony growth abnormalities, osteoporosis
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Key Questions
1. Do you see “double?”
2. Are there any areas of numbness on your face?
3. Does your bite feel “normal?”
4. Which areas of your face hurt?
5. Does it hurt when you open your mouth?
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Clinical Examination
1. Soft tissues
2. Nerves
3. Facial Skeleton
– Inspection
– Palpation
4. Dentition
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Work‐Up
• Maxillofacial CT without contrast
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Mandible Anatomy
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Anatomy
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Mandible Fractures
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Common etiologies: Mandible Fracture
• Motor Vehicle Accident
• Altercation
• Work related accidents
• Fall
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Clinical Examination
• External skin lacerations, hematoma
• Oral mucosal lacerations, hematoma
• Deviation of the mouth
• Occlusion
• Palpate contour, TMJ
• Assess mobility
• Lip/Chin Numbness
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Occlusion: Angle ClassificationThe mesiobuccal cusp of the upper first molar should align
with the buccal groove of the mandibular first molar
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Imaging
Panorex CT maxillofacial s contrast
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Surgical Indications: Mandible
• Surgical Goal: To maintain stability– Restoration of occlusion and facial contour
– Prevent infection, osteomyelitis
• Malocclusion
• Open Fractures
• Coronoid fracture: No intervention needed
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Closed Treatment: MMF
• Unilateral condyle fracture
• Severely comminuted fractures
• Children
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
ORIF Mandible
• Unfavorable fractures
• Fractures open to skin
• Multiple facial fractures
• Nonunion
• Malunion
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Approach: Intraoral
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Approach: External Risdon Incision
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
External Access
Risdon Incision Retromandibular incision
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
ORIF Mandible: 2 Point Fixation
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Two Point Fixation: Plate and Arch Bar
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Mandible Fracture
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Post‐Operative CT
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Gunshot wound to the Mandible
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
ORIF Mandible
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Primary Closure
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Post‐Operative CT Reconstruction
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Maxilla Anatomy
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Maxilla: Le Fort Fractures
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Le Fort Fractures
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Common etiologies: Maxilla Fracture
• Motor Vehicle Accident
• ATV Accidents
• Altercation: Usually with a weapon
• Work related accidents
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Clinical Examination: Le Fort Fx
• Oral mucosal lacerations, hematoma
• Midface widening
• Occlusion
• Midface/Palate mobility
• Cheek or teeth numbness
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Imaging
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Le Fort I Fracture Patterns
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Surgical Indications: Maxilla
• Surgical Goal: To maintain stability
– Restoration of occlusion and facial contour
– Prevent infection, osteomyelitis
• Prevent malocclusion and palate mobility
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
ORIF LeFort I: Intraoral Approach
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Zygomaticomaxillary Complex (ZMC) Fractures
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
ZMC Fractures
Four Fractures of ZMC
1. Zygomatic Frontal
2. Inferior Orbital Rim
3. Zygomatic Arch
4. Lateral Maxillary Buttress
Previously misnamed Tripod Fracture
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Common etiologies: ZMC Fracture
• Altercation: Usually with a weapon
• Falls
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Clinical Examination: ZMC Fx
• Trismus
• Facial Symmetry
• Cheek numbness
• Palpate orbital rims and zygomatic arch
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Imaging
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Zygomatic Arch Fracture
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Surgical Indications: ZMC
• Surgical Goal:
– Restoration of facial contour and symmetry
– Trismus
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
ZMC: Multiple Approaches and Plating
Options
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
ZMC: Multiple Approaches and Plating Options
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
ZMC: ORIF Repair
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Orbital Fractures
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Orbital Anatomy
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Common etiologies: Orbital Fracture
• Falls
• Altercation
• Motor Vehicle accident
• Sports related accident
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Clinical Examination: Orbital Fx
• Decreased Eye Motion
– Entrapment
• Globe Injury
• Cheek numbness
• Visual Acuity
• Forced Duction Test
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Imaging
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Early Therapy
• Avoid Nose blowing
• ? Antibiotic Therapy
• Ice to face, Raise head of bed
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
• Weight loss– Gastric bypass reduced CSF pressure from 35.3 to 16.8 cm H20 Sugerman Ann Surg 1999
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Case Reports
• Spontaneous CSF leak after VP shunt failure that resolved after shunt revision Ransom et al Clin Neurosci 2006
• 3 separate case reports of cessation of CSF leaks after gastric bypass surgery and weight loss for IIH Rudnick Otol Neurotol 2005; Stangherlin Acta Chir Belg 2008; Sugerman Ann Surg 1999
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Case Example
• 62 year old female with moderate obesity presents with the acute onset of left sided watery rhinorrhea two weeks ago.
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Spontaneous Encephalocele
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Nasoseptal Flap Reconstruction
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Spontaneous CSF Leak: Endoscopic Repair
• 53 yo obese female initially admitted for meningitis with pansinusitis
• After resolution of meningitis, she reports a history of right sided clear rhinorrhea for 3‐4 years
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Encephalocele of the Lateral Recess of the Sphenoid
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Spontaneous CSF Leak: Endoscopic Repair
• 43 yo obese female who presents with watery rhinorrhea
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Left trans‐pterygoid approach to middle fossa
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Does decreasing ICP improve outcomes of endoscopic repair of spontaneous CSF leaks?
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Perioperative Concerns
• After repair and no further CSF diversion, ICP increase to 27‐32.5 cm H20