trauma in orltrauma in orl in orl.pdf · trauma in orltrauma in orl dr. saad al-muhayawi, m.d.,...

TRAUMA IN ORLTRAUMA IN ORLTRAUMA IN ORLTRAUMA IN ORL

DR. SAAD AL-MUHAYAWI, M.D., FRCSCAssociate Professor & ConsultantAssociate Professor & Consultant

ORL Head & Neck Surgery

TYPES OF TRAUMATYPES OF TRAUMA

EAR & TEMPORAL BONE TRAUMANOSE & FACIAL BONES TRAUMALARYNGEAL TRAUMALARYNGEAL TRAUMANECK TRAUMACAUSTIC INGESTION

PRIORITIES IN TRAUMAPRIORITIES IN TRAUMA

A – AirwayB – Breathing C CirculationC – Circulation

Priorities according to life threatening situation

AURICULAR HEMATOMAAURICULAR HEMATOMA

Blunt trauma – Shear injury – Contact sports / child abuseContact sports / child abuse

Hematoma – Between cartilage and perichondrium

Fluctuant anterior swelling g

TreatmentTreatment – Needle aspiration: inadequate – Incision & drainage: recommended – Compressive dressing p g– Antistaph antibiotics

Complications – Infection / abscess – Cauliflower earCauliflower ear

AURICULAR HEMATOMAAURICULAR HEMATOMA

TEMPORAL BONE FRACTURETEMPORAL BONE FRACTURE

Blunt > penetrating – MVA, fall and assault– Associated with life threatening conditions

EvaluationEvaluation – Trauma protocol / clear c – spine – Assess facial nerve function early

Immediate vs. delayed

– Ear examination: hemotympanum, csf leak, TM perforation. p

EvaluationEvaluation – Assess function: tunning forks, audiogram

di lRadiology– Head CT scan: evaluate for head injury j y

HRCT of temporal bone with bony windowE l t t t f th f t– Evaluate extent of the fracture

ManagementManagement – Facial nerve paralysis

Immediate: operative exploration and repairDelayed: observe, steroids, eye protection

– CSF leak Conservative management Bed rest vs. lumbar drain> 90 % resolve in 2 weeks

– Hearing lossSensorineural loss: hearing aidSensorineural loss: hearing aidConductive loss: ossicular reconstruction

V tiVertigo:– Treat symptomatically– Meclizine, physical therapy

Physical examination Physical examination

CT findings CT findings

NASAL FRACTURENASAL FRACTURE

Very commonM t f i l f t– Most common facial fracture

– 3rd most fractured boneHi h i d f i i f f tHigh index of suspicion for fracture– Mechanism, change in appearance

Epistaxis nasal obstruction– Epistaxis, nasal obstruction Examine and palpate nose carefully

I t bilit bilit it ti– Instability, mobility, crepitation – Fracture, septal hematoma


Management

ZYGOMA FRACTURE ZYGOMA FRACTURE

Signs and symptoms – Subconjunctival hemorrhage – Infraorbital hypesthesiaInfraorbital hypesthesia – Depressed malar eminence

T i / b t ff– Trismus / bony step off

E l iEvaluation – Facial CT – coronal cuts – Ophthalmology evaluation

Evaluate for ocular injuryEvaluate for ocular injury

Management– Open reduction / internal fixation ( ORIF)

ZYGOMA FRACTUREZYGOMA FRACTURE

ZYGOMA FRACTUREZYGOMA FRACTUREZYGOMA FRACTURE ZYGOMA FRACTURE

ZYGOMA FRACTUREZYGOMA FRACTURE

ORBITAL FLOOR FRACTURE ORBITAL FLOOR FRACTURE

ORBITAL FLOOR FRACTUREORBITAL FLOOR FRACTURE

MANDIBLE FRACTURE MANDIBLE FRACTURE

1/3– ½ facial fractures Signs and symptoms

Malocclusion step off– Malocclusion, step off– Floor of mouth hematoma – Chin ( V3) hypoesthesia

Evaluation– Secure airway – as neededSecure airway as needed – Rule out associated injury

Closed head injuryClosed head injury C – spine, facial fractureTooth aspirationTooth aspiration

– ( panarox, mandible series) plain x – ray– CT – scan

MANDIBLE FRACTUREMANDIBLE FRACTURE

ManagementManagement – Soft diet, severe fractures

P di i l l iPediatric, normal occlusion Non – displaced

Ramus subcondylar– Ramus, subcondylarClosed reduction

– Minimally displaced y pOpen reduction

Complications – Infection / non unionInfection / non union– Malocclusion

MIDFACE FRACTURES MIDFACE FRACTURES

Diagnosis– Malocclusion, depressed midface, open bite– Assess midface mobilityAssess midface mobility– CT scan – axial, coronal cuts

MManagement – Secure airway ( oral intubation if possible )

C – spine injury or laryngeal fracture: surgical airway

– Avoid nasal instrumentation , cranial penetrationp

– Recognize and treat closed head injury Brisk epistaxis common posterior nasal– Brisk epistaxis common – posterior nasal packing S t CSF l k– Suspect CSF leak

– Open reduction and internal fixation

MIDFACE FRACTURESMIDFACE FRACTURES

MIDFACE FRACTUREMIDFACE FRACTURE

BLUNT LARYNGEAL TRAUMABLUNT LARYNGEAL TRAUMA

Mechanism: MVA,Sport,AssaultSigns and Symptoms

Hoarseness Voice change StridorHoarseness, Voice change, StridorSub-Q emphysema, Hemoptysis

Secure AirwayOral Intubation-problematicO pTracheotomy(not cricothyrotomy)


Flexible Fiberoptic Laryngoscopy

CT Scan- evaluate C Sca eva uateskeletal derangement

SurgicalSurgical Explporation/

iRepair

BLUNT LARYNGEAL TRAUMABLUNT LARYNGEAL TRAUMABLUNT LARYNGEAL TRAUMABLUNT LARYNGEAL TRAUMAEVALUATIONEVALUATION


Indications for CT scan Significant voice alteration Edema or hematoma on endoscopyEdema or hematoma on endoscopy Laceration or blood on endoscopy V l f ld l iVocal fold paralysis Palpation suspicious of fracture After tracheotomy- before definitive treatment

BLUNT LARYNGEAL TRAUMABLUNT LARYNGEAL TRAUMABLUNT LARYNGEAL TRAUMABLUNT LARYNGEAL TRAUMAMANAGEMENTMANAGEMENT

PENETRATING NECK TRAUMAPENETRATING NECK TRAUMA

Secure Airway, Clear C-spineAssume Multiple InjuriesX rays Neck and ChestX-rays Neck and Chest

Foreign bodies, PneumothoraxBony trauma


Weapons- Knife, GunDetermine Zone

1 below cricoid(16%)1- below cricoid(16%)2- cricoid to angle of mandible(78%)3- above angle of mandible(6%)

PENETRATING NECK TRAUMAPENETRATING NECK TRAUMAMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENT

PENETRATING NECK TRAUMAPENETRATING NECK TRAUMAPENETRATING NECK TRAUMAPENETRATING NECK TRAUMAPATTERNS OF INJURYPATTERNS OF INJURY

Vascular InjuryC tid i jCarotid injurySigns & Symptoms

Neurologic Deficit- ¼Neurologic Deficit- ¼Expanding Hematoma- 2/3Clinically silent- 15%

Arteriogram- 97% sensitiveEmbolization Possible-zone 1,3& vertebral artery

C li tiComplicationsStroke, ExsanguinationPseudoaneurysm, AV fistulay ,

PENETRATING NECK TRAUMAPENETRATING NECK TRAUMAPENETRATING NECK TRAUMAPENETRATING NECK TRAUMAPATTERNS OF INJURYPATTERNS OF INJURY

Pharynx& esophagus- 10%P i D h i H t iPain, Dysphagia, HematemesisBarium Swallow/ EsophagoscopyComplicationsComplications

Mediastinitis, Sepsis, Fistula

Larynx& Trachea-9%Larynx& Trachea 9%Hoarseness, Stridor, HemoptysisLaryngoscopy, BronchoscopyLaryngoscopy, BronchoscopyComplications

Laryngeal Dysfunction, Stenosis

CAUSTIC INGESTIONCAUSTIC INGESTION

Esophagus, pharynx, larynxBases

Drain cleanersDrain cleanersElectric dishwasher soapHair relaxant

AcidsBleaches


Alkalis – pH > 7Liquefaction necrosis

Acids – pH < 7Acids pH < 7Coagulation necrosis

Bleaches – pH = 7Irritants a


Children- most common, accidental

Adults- suicide attempt

Do not induce vomitingDo not induce vomitingDetermine- brand name, quantity ingested

Call poison control centerAlkali worse than acidsAlkali worse than acids


Examination not predictive of severityMost without oral lesions

Urgent speciality consultationUrgent speciality consultationFlexible LaryngoscopyEsophagogramEsophagoscopy- early

trauma in orltrauma in orl in orl.pdf · trauma in orltrauma in orl dr. saad al-muhayawi, m.d.,...

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