CHAPTER 82

MAXILLOFACIAL TRAUMA
Joshua J. Solano, MD, Ethan M. Ross, MD, and Carlo L. Rosen, MD

1. What are the facial bones?

The facial bones are the frontal, temporal, nasal, ethmoid, lacrimal, palatine, sphenoid bones,
vomer, zygoma, maxilla, and mandible.
2. What is the initial approach to a patient with maxillofacial trauma?
The initial management of patients with facial trauma should follow the ABCs (airway, breathing, and
circulation) of trauma resuscitation. The airway is the primary concern and can be challenging to
manage in these patients. Significant facial trauma may cause distortion of the airway as a result of
bleeding, swelling, loose teeth, or fractures. In patients with mandibular fractures, the tongue loses
its support and can occlude the airway.
3. How should the airway be managed in patients with maxillofacial trauma?
Early endotracheal intubation should be considered in patients with significant midface or
mandibular trauma, especially if they exhibit any signs of airway distress. Standard methods
of intubation, such as rapid-sequence intubation using direct or video laryngoscopy, should be
attempted first. However, airway distortion resulting from facial trauma may lead to a difficult
airway situation that necessitates a cricothyrotomy. All patients with facial and head trauma
should be assumed to have a cervical spine injury. In-line cervical spine stabilization should be
used during intubation. The incidence of cervical spine injuries in patients with facial trauma is
1% to 4%.
4. Which procedure is contraindicated in patients with maxillofacial trauma?
Nasogastric tube placement should not be performed because of the risk of inadvertent intracranial
placement through a fracture in the cribriform plate. The small size and flexibility of the nasogastric
tube allow it to be misdirected through such a fracture into the brain. There is also a concern about
placing a nasotracheal tube through the cribriform plate into the brain. However, an endotracheal
tube is larger and more rigid than a nasogastric tube. The literature suggests that the risk of
intracranial placement of a nasotracheal tube is extremely low.
5. What is a blow-out fracture, and what is the entrapment syndrome?
A blow-out fracture is a fracture of the orbital floor that results from a direct blow to the orbit. The
sudden increase in intraorbital pressure causes rupture of the floor of the orbit. The entrapment
syndrome is binocular diplopia and paralysis of upward gaze that results from entrapment of the
inferior rectus muscle in the orbital floor defect. Diplopia is noted by having the patient visually
follow and count fingers using an upward gaze. Other physical findings include infraorbital
anesthesia and enophthalmos (posterior displacement of the globe into the orbit). Patients may have
tenderness or palpable step-offs at the infraorbital rim or subcutaneous emphysema secondary to
a fracture into the maxillary sinus. Ophthalmologic evaluation for associated ocular trauma (globe
rupture, hyphema, retinal tear or detachment, blindness), despite an initially normal visual acuity
and funduscopic examination, should be considered.
6. What is a lateral canthotomy, and when is one necessary?
This is a procedure that involves incising the lateral canthal ligaments of the orbit. If a patient
sustains trauma to the orbit resulting in a retrobulbar hematoma, the buildup of pressure behind the
globe can lead to ischemia of the optic nerve and retina and permanent blindness. This complication
may occur in as little as 90 to 120 minutes after injury. Performance of a lateral canthotomy allows
the pressure to be relieved.
7. What findings indicate the need for a lateral canthotomy?
Patients with blunt trauma to the orbit who have proptosis, impaired extraocular movement,
decreased vision, and increased intraocular pressure are candidates for lateral canthotomy.

542
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82 Maxillofacial Trauma 542.e1

Abstract
This chapter summarizes the approach to patients with maxillofacial trauma, including choices for diagnostic imaging, safe
procedures for the patient with maxillofacial trauma, and treatment of these injuries.
Keywords:
Le Fort fracture, cerebrovascular injury, septal hematoma, frontal sinus fracture, zygoma fracture, tongue blade test, mandible
fracture, temporomandibular joint dislocation, Stensen duct, ear trauma

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82 Maxillofacial Trauma 543

Le Fort III
Le Fort II
Le Fort I

Figure 82-1. Le Fort classification of facial fractures. Le Fort I: palatofacial disjunction. Le Fort II: pyramidal disjunction.
Le Fort III: craniofacial disjunction. (From Cantrill SV: Face. In Marx JA, Hockberger RS, Walls RM, etal, editors: Rosens
emergency medicine: concepts and clinical practice, ed 5, St. Louis, 2002, Mosby, p 325.)

8. What are Le Fort fractures?

The Le Fort classification is used to describe maxillary fractures (Fig. 82-1). Midface fractures can
often be diagnosed by grasping the upper alveolar ridge and noting which part of the midface
moves.
Le Fort I: A transverse fracture just above the teeth at the level of the nasal fossa; allows
movement of the alveolar ridge and hard palate
Le Fort II: A pyramidal fracture with its apex just above the bridge of the nose and extending
laterally and interiorly through the infraorbital rims; allows movement of the maxilla, nose, and
infraorbital rims
Le Fort III: The most serious of the Le Fort fractures; represents complete craniofacial disruption
and involves fractures of the zygoma, infraorbital rims, and maxilla
It is rare for these fracture types to occur in isolation; they usually occur in combination (one
type on one side of the face and another on the other side).
9. Is there a role for screening patients with Le Fort fractures for blunt
cerebrovascular injury?
Blunt cerebrovascular injury (BCVI) to the carotid or vertebral artery is becoming increasingly
recognized in blunt trauma and is found in nearly 1% of all blunt trauma patients when screening
protocols are used. Significant morbidity and mortality is encountered if these vascular injuries are
left untreated, and there is commonly a clinically silent period before symptoms occur. Although no
standard exists for screening, guidelines are being developed that suggest screening should be
undertaken with computed tomography angiography (CTA) in patients with signs or symptoms of
BCVI and patients at high risk. High-risk patients that should be screened include those with a
Le Fort II or III fracture, certain cervical spine fracture patterns (subluxation, fractures extending into
the transverse foramen, fractures of C1-C3), basilar skull fracture with carotid canal involvement,
diffuse axonal injury with Glasgow Coma Scale score lower than 6, or near hanging with anoxic
brain injury.
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544 XVI TRAUMA

10. When are nasal radiographs indicated?
Almost never; nasal fractures typically are a clinical diagnosis without the need for routine
radiographs. Physical examination may reveal swelling, angulation, bony crepitus, deformity, pain on
palpation, epistaxis, and periorbital ecchymosis. Nasal radiographs are neither sensitive nor specific
for fractures. The results do not alter management.
11. What is a septal hematoma, and why is it important?
All patients with nasal trauma and suspicion of a nasal fracture require inspection of the nasal
septum for a septal hematoma. This is a collection of blood between the mucoperichondrium
and the cartilage of the septum. It appears as a grapelike swelling over the nasal septum. If left
undrained, it may result in septal abscess, necrosis of the nasal cartilage, and permanent saddle
nose deformity. If a septal hematoma is identified, incision and drainage is indicated in the ED,
followed by nasal packing, antistaphylococcal antibiotics (prophylaxis for toxic shock syndrome), and
prompt referral to otolaryngology.
12. When should a consultation be obtained for a nasal fracture?
Most nasal fractures do not require immediate reduction unless there is significant deformity and
malalignment. After anesthetizing the nose with lidocaine or tetracaine-soaked gauze or pledgets,
early reduction of an angulated fracture is performed by exerting firm, quick pressure toward
the midline with both thumbs. However, reduction is associated with significant pain, and
systemic analgesia should be considered. Patients should be referred to an otolaryngologist or
a maxillofacial or a plastic surgeon for follow-up care in 4 to 7 days. Immediate consultation is
suggested for nasal fractures with associated facial fractures, cerebrospinal fluid rhinorrhea, and
sustained epistaxis.
13. How is a frontal sinus fracture diagnosed?
Frontal sinus fracture should be suspected in any patient with a severe blow to the forehead. There
is often an associated brain injury. The clinical signs include supraorbital nerve anesthesia, anosmia,
cerebrospinal fluid rhinorrhea, subconjunctival hemorrhage, crepitus, and tenderness to palpation.
The preferred diagnostic modality is computed tomography (CT) to determine whether there is
involvement of the anterior or posterior walls of the sinus or intracranial hemorrhage.
14. How are frontal sinus fractures treated?
After surgical consultation, patients with nondisplaced anterior wall fractures may be discharged on
prophylactic antibiotics, with instructions to avoid Valsalva maneuvers and to follow up in 1 week
with the surgical consultant. Patients with displaced anterior wall and sinus floor fractures require
surgical consultation, admission, and antibiotic therapy. Patients with posterior wall fractures require
antibiotics and immediate neurosurgical consultation.
15. What are the classic zygoma fractures?
The zygoma is the third most commonly fractured facial bone (after the nose and mandible).
Zygoma fractures are classified into three basic types:
1. Arch: The bone may be fractured in one or two places and may be nondisplaced or displaced
medially. Pain and trismus are caused by bony arch fragments abutting the coronoid process of
the mandible. Because the masseter muscle originates on the zygoma, any movement causes
further arch disruption. The fracture is diagnosed by the plain radiograph bucket-handle view
(submentovertex).
2. Tripod: Also termed a zygomaticomaxillary fracture, this is the most serious type of
zygoma fracture and involves the infraorbital rim, the zygomaticofrontal suture, and the
zygomaticotemporal suture. Clinical signs include deformity (flatness of the cheek), infraorbital
nerve hypesthesia, inferior rectus muscle entrapment, and diplopia on upward gaze. Although
these fractures may be detected on plain radiographs (Waters and Caldwell views), maxillofacial
CT is necessary to better define the extent of the fracture. For these fractures, admission and
consultation with a plastic or maxillofacial surgeon are required.
3. Body: Fracture of the body of the zygoma, which involves the clinical signs and symptoms of the
tripod fracture, results from severe force and leads to exaggerated malar depression.
16. What are the typical findings of a mandible fracture?
Patients with mandible fractures have mandibular tenderness and deformity, sublingual hematoma,
and malocclusion on physical examination. The jaw appears asymmetric, with deviation toward the
side of the fracture.
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82 Maxillofacial Trauma 545

17. What is the tongue blade test?
The tongue blade test is performed by asking the patient to bite down strongly on a tongue
depressor and keep the tongue depressor clenched between the teeth. The tongue blade should
be twisted by the examiner. If there is no fracture of the mandible, the examiner should be able to
break the blade. In the presence of a mandible fracture, the patient opens his or her mouth because
of pain from the fracture, and the tongue blade remains intact.
18. Which imaging studies should be ordered to diagnose a mandible fracture?
Mandible fractures are the second most common facial fracture. Multiple fractures are common
(>50%) because of the ring structure of the bone. Always check for a second fracture site. If
available, the panoramic view is the most useful view for detecting mandible fractures. It provides a
180-degree view of the mandible and can detect fractures in all regions of the mandible, including
symphyseal fractures that can be missed with the other views. If a panoramic radiograph machine is
unavailable, maxillofacial CT is indicated to define fracture fragments.
19. What are the most commonly fractured areas of the mandible?
The most commonly fractured areas are the body, the condyle, and the angle of the mandible.
20. What is the mechanism for a temporomandibular joint dislocation, and how is it
treated?
Temporomandibular joint dislocation can result from blunt trauma to the mandible, but it also can
occur with exaggerated opening or closing of the jaw, such as after a seizure or with yawning.
Patients with a temporomandibular joint dislocation have jaw deviation away from the side of the
dislocation if it is a unilateral dislocation, or with the mandible pushed forward (underbite) if it is a
bilateral dislocation. After conscious sedation with benzodiazepine for masseter muscle relaxation
and a narcotic for pain relief, the emergency physician should place gauze-wrapped thumbs on the
posterior molars while standing above and behind the patient or by standing in front of the seated
patient. The mandible is then pushed downward and posterior. Another approach relies on the
application of rotational force on the mandibular ramus with both index and middle fingers applying
clockwise force on the molars and thumbs pushing clockwise on the mental portion of the mandible.
21. When is a CT scan indicated in the evaluation of maxillofacial trauma?
In patients with a history of facial trauma but with minimal physical findings consistent with
fractures or an equivocal examination, traditional plain radiography is used as a screening test,
although in many sites maxillofacial CT is the preferred modality because of its increased sensitivity.
The standard plain film series of the face includes a Waters (occipitomental) view, Caldwell
(occipitofrontal) view, submentovertex view, and lateral view. The Waters view visualizes the
orbital rim, infraorbital floor, maxilla, and maxillary sinuses and is useful as an initial examination
in patients with suspected orbital floor fractures. Performance of this view requires that the cervical
spine be clear, because the patient is in the prone position. Fluid in the maxillary sinus is indirect
evidence of fracture. The Caldwell view allows visualization of the superior orbital rim and the frontal
sinuses. The lateral view shows the anterior wall of the frontal sinus and the anterior and posterior
walls of the maxillary sinus.
In patients with physical findings that are highly suggestive of facial fractures (tenderness,
step-offs, crepitus, or evidence of entrapment), some authors recommend proceeding directly to CT
and avoiding the additional cost of the plain film studies. This allows appropriate surgical planning.
High-resolution, thin-cut CT scanning is the preferred modality for the elucidation of bony and
soft-tissue injury in maxillofacial trauma. This is the preferred test in any patient with suspected
tripod, orbital, or midface fractures. In patients with suspected orbital fractures, CT scan with
coronal and axial sections should be ordered (2- to 3-mm cuts).
22. How do I recognize an injury to the Stensen duct?
The Stensen (parotid) duct arises from the parotid gland and courses from the level of the external
auditory canal (superficial) through the buccinator muscle to open at the level of the upper second
molar (Fig. 82-2). Any laceration along this pathway may involve the parotid gland, parotid duct, or
buccal branch of the facial nerve. Laceration of the parotid system is recognized by a flow of saliva
from the wound or bloody drainage from the duct orifice. Careful exploration reveals whether the
flow is from the parotid gland or duct. In addition, the buccal branch of the facial nerve travels in
close proximity to the Stensen duct; injury to the nerve leads to drooping of the upper lip, which
indicates a possible parotid duct injury. To assess for parotid duct patency, the parotid gland should
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546 XVI TRAUMA

A

Parotid gland
Parotid duct
Masseter
muscle

Branches of
facial nerve
A
Figure 82-2. Parotid gland and parotid duct with nearby branches of the facial nerve. Line B demonstrates approximate
course of the parotid duct from the parotid gland, entering the mouth at the junction of lines A and B. (From Cantrill SV:
Face. In Marx JA, Hockberger RS, Walls RM, etal, editors: Rosens emergency medicine: concepts and clinical practice,
ed 5, St. Louis, 2002, Mosby, p 323.)

be milked to see if saliva is expressed from the intraoral opening of the parotid duct. Damage to the
duct requires consultation with a plastic surgeon and repair over a stent.
23. When should closure of a facial laceration be deferred?
Closure of facial lacerations in the ED depends on the severity of facial and systemic injuries.
Complex lacerations in patients needing operative intervention should be cleansed with normal
saline, covered with moist gauze, and deferred for intraoperative closure. Closure of the highly
vascular tissues of the face may be delayed for up to 24 hours. Wounds involving the facial nerve,
lacrimal duct, parotid duct, and avulsions should be referred on presentation to the appropriate
surgeon for definitive care.
24. What deformity may arise from blunt trauma to the ear?
An acute auricular hematoma is a collection of blood separating the perichondrium from the
underlying cartilaginous layer that may develop after a blow to the ear. If a hematoma is left
undrained or an auricular compression is dressing not applied after incision and drainage of a
hematoma or repair of a pinna laceration secondary to blunt trauma to the ear, necrosis of the
cartilage may develop with resultant deformity, known as cauliflower ear.
25. How is the ear anesthetized?
A subcutaneous circumferential injection of plain lidocaine should be placed at the base of the
pinna. Lacerations in the external auditory canal require topical anesthesia with 4% lidocaine or
local injection.

KEY PO I N T S : M A X I L L O F A C I A L T R A U M A
1. Concern for facial fracture is a contraindication to nasogastric tube placement.
2. Always make sure to check extraocular movements in patients with facial trauma.
3. CT scan has largely replaced plain films in diagnostics for maxillofacial fracture.

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82 Maxillofacial Trauma 547

KEY PO I N T S : C L I N I C A L S I G N S O F O R B I T A L F R A C T U RES
1. Eyelid edema
2. Enophthalmos
3. Proptosis
4. Limitation of upward gaze
5. Diplopia
6. Infraorbital anesthesia
7. Subcutaneous emphysema
BIBLIOGRAPHY
1. Cantrill SV: Face. In Marx JA, Hockberger RS, Walls RM, etal, editors: Rosens emergency medicine: concepts and
clinical practice, ed 5, St. Louis, 2002, Mosby, pp 314329.
2. Cothren CC, Biffl WL, Moore EE, etal: Treatment for blunt cerebrovascular injuries: equivalence of anticoagulation
and antiplatelet agents. Arch Surg 144:685690, 2009.
3. Druelinger L, Guenther M, Marchand EG: Radiographic evaluation of the facial complex. Emerg Med Clin North Am
18:393410, 2000.
4. Ellis E, Scott K: Assessment of patients with facial fractures. Emerg Med Clin North Am 18:411448, 2000.
5. Jones SE, Mahendran S: Interventions for an acute auricular haematoma. Cochrane Database Syst Rev
(2):CD004166, 2004.
6. Lowery LE, Beeson MS, Lum KK: The wrist pivot method, a novel technique for temporomandibular joint reduction.
J Emerg Med 27:167170, 2004.
7. MacLaughlin J, Colucciello S: Maxillofacial injuries. In Wolfson AB, Hendey GW, Hendry PL, etal, editors:
Harwood-Nuss clinical practice of emergency medicine, ed 4, Philadelphia, 2005, Lippincott Williams & Wilkins,
pp 928937.
8. Paul M, Dueck M, Kampe S, etal: Intracranial placement of a nasotracheal tube after transnasal trans-sphenoidal
surgery. Br J Anaesth 91:601604, 2003.
9. Rosen CL, Wolfe RE, Chew S, etal: Blind nasotracheal intubation in the presence of facial trauma. J Emerg Med
15:141145, 1997.
10. Bromberg WJ, Collier BC, Diebel LN, etal: Blunt cerebrovascular injury. Eastern Association for the Surgery of
Trauma guideline. J Trauma 68:471477, 2010.

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82 Maxillofacial Trauma 547.e1

QUESTIONS
1. A 25-year-old male comes to the ED after an altercation. He sustained multiple blows to the face and
has a swollen right eye and blood from both nares. His vital signs are temperature 98.7F (37.1C),
pulse 90 beats per minute, blood pressure 138/90, and respirations 16 breaths per minute. His
physical examination reveals no other injuries. He has a Glasgow Coma Scale score of 15, pupils are
equally round and reactive to light, extraocular movements are intact, and he is conversant. His
cervical spine is nontender. What is the next best step in management?
a. Assessment of visual acuity
b. Maxillofacial CT scan
c. Plain films of the face
d. Brain CT
The correct answer is a.
2. A 45-year-old male is intoxicated after an altercation. He sustained multiple blows to the face and
has a swollen left eye with a sunken appearance and blood from both nares. His vital signs are
temperature 97.4F (36.3C), pulse 110 beats per minute, blood pressure 133/75, and respirations 14
breaths per minute. His physical examination reveals no other injuries. He has a Glasgow Coma Scale
score of 15; pupils are equally round and reactive to light; and extraocular movements are intact,
except that he is unable to perform upward gaze of the left eye. His visual acuity is 20/20 in both
eyes. His cervical spine is nontender. What is the next best step in management?
a. Maxillofacial CT scan
b. Maxillofacial surgery consultation
c. Perform a lateral canthotomy
d. Ophthalmology consultation
The correct answer is b.
3. An 83-year-old male with atrial fibrillation on warfarin comes to the ED after he was the restrained
driver involved in a motor vehicle accident at highway speed. The airbag deployed, striking him in the
face. He has a swollen right eye with a proptotic appearance. His vital signs are temperature 97.8F
(36.6C), pulse 80 beats per minute, blood pressure 175/83, and respirations 16 breaths per minute.
His physical examination reveals no other injuries. He has a Glasgow Coma Scale score of 15, pupils
are equally round and reactive to light, extraocular movements are intact, and visual acuity is 20/20 in
the left eye but 20/200 in the right eye. His cervical spine is nontender. A focused assessment with
sonography for trauma (FAST) examination is normal. What is the next best step in management?
a. CT of the torso
b. Maxillofacial surgery consultation
c. Lateral canthotomy
d. Ophthalmology consultation
The correct answer is c.

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