CASE: 3

MAXILLOFACIAL CASE
 ANTHONY NOYAL, LEENA ANGEL
GONUGUNTLA, VYSHNAVI

GROUP JOSEPH, EMMANUEL

MEMBERS
HASAN,SAMIM
KOHLI, YUVRAJ SINGH
MANDAL,DHANANJAY KUMAR
SAVIO BELO TOU PINTO, JELFY
THADURI, UMA
GENERAL DATA

JA, 21 Y/O M, single,

roman catholic, from
dagupan city,
pangasinan
Informant: sister
CHIEF COMPLAINT:
LOSS OF CONSCIOUSNESS
PRIMARY SURVEY
Primary survey
Standardized initial assessment of all trauma patients

Two goals

● Promptly identify life threats

● Provide immediate stabilization

Simultaneous assessment and treatment

Airway
Airway is not compromised
● Ensuring a patent airway is the first priority in the primary survey.

● This is essential, because efforts to restore cardiovascular integrity will be

futile unless the oxygen content of the blood is adequate.

● In general, patients who are conscious, without tachypnea, and have a

normal voice are unlikely to require early airway intervention.
Breathing
Equal chest expansion and clear breath sounds
● Once a secure airway is obtained, adequate oxygenation and ventilation must be
ensured.

● All injured patients should receive supplemental oxygen and be monitored by

pulse oximetry.

● The following conditions constitute an immediate threat to life due to inadequate

ventilation and should be recognized during the primary survey: tension
pneumothorax, open pneumothorax, flail chest with underlying pulmonary
contusion, and massive air leak
Circulation
BLOOD PRESSURE:120/80
HEART RATE:106
RESPIRATORY RATE : 22bpm
TEMPERATURE:37.2 C
● With a secure airway and adequate ventilation established, circulatory status is the
next priority.
● An initial approximation of the patient’s cardiovascular status can be obtained by
palpating peripheral pulses.
● In general, systolic blood pressure (SBP) must be 60 mm Hg for the carotid pulse to
be palpable, 70 mm Hg for the femoral pulse, and 80 mm Hg for the radial pulse.
Disability
GCS=12(E1V5M6)

● GCS 12 indicates minor brain injury with no neurological deficits.

Exposure
Remove all clothing to complete head to toe exam.

● Examine axillae and perineum

● Roll to examine back with maintaining C-spine immobilization.
● Check for head/back in collared patient

Caution: avoid hypothermia

 SECONDARY SURVEY
A-ALLERGIES: The patient is not allergic to any foods and drugs
M-MEDICATION: The patient is currently not taking any medication
P-PAST MEDICAL HISTORY:The patient does not have any history of surgeries or
medical illness

L-LAST MEAL: The patient had his last meal 8 hours prior to the admission
E-EVENTS SURROUNDING INJURY:Patient was intoxicated with alcohol, As he
was on his way home, riding his motorcycle, he was ran over by a speeding van.
E-EVENTS SURROUNDING THE INJURY
• DOI : 12/24/20

• TOI: 9:30PM

• POI: Lingayen, Pangasinan

• MOI: Patient was intoxicated with alcohol. As he was on his way home,

riding his motorcycle, he was ran over by a speeding van.

• (+) LOC, (-) vomiting

 History
• Past Medical: unremarkable

• Family Medical: unremarkable

• Personal / Social: + 5 pack years smoker, heavy alcoholic beverage

drinker, denies illicit drug use

PHYSICAL EXAMINATION

HEAD TO TOE EXAMINATION

HEENT:
● 4*3 cm open wound glabellar area with exposed frontal bone and oozing of clear fluid
● unable to open eyes with telecanthus
● (+)intact vision on the right eye
● (-)Vision in the left eye
● Pupils 2 mm BRTL in the right eye
● (+)ruptured globe in the left
● (+)movable depressed nasal bone segment
● (+)epistaxis
● (-)septal hematoma
● (+)malocclusion
● (-)trismus
● (+)anterior drawer’s sign
CHEST
● ECE
● CLEAR BREATH SOUNDS
● (-) WHEEZES
● (-) RALES
CARDIAC
● ADYNAMIC PRECORDIUM
● DHS
● (-) MURMURS
ABDOMEN
● NO NOTED BULGES
● SOFT
● (-) TENDERNESS
● NORMAL BOWEL SOUNDS
● NO BRUISES OR ERYTHEMA
● NO INFLAMMATION
● NO SCARS,STRIAE
NEUROLOGIC
● GCS 12 (E1V5M6)
● (-) SENSORIMOTOR DEFICITS
EXTREMITIES

● FULL AND EQUAL PULSES

● NO DEFORMITY
● NO COMPARTMENT
SYNDROME
● NO BRUISES
● NO FRACTURES
● NO EDEMA
● NO NOTED SWELLINGS
INITIAL IMPRESSION
Nasoorbitoethmoidal (NOE) Fracture
 ● Location of injury
● Degree of comminution

CT SCAN
● Lacrimal fossa and
nasolacrimal duct
● Insertion of medial canthal
tendon

SOFT-TISSUE AND SKELETAL INJURIES OF THE

FACE -Grabb and Smith’s plastic surgery 7th ED

MANAGEMENT
Cranioplasty | Johns Hopkins Medicine
1st HD: Patient underwent
emergency cranioplasty
● Surgical repair of a bone defect
●
in the skull
Most involve lifting the scalp
and restoring the contour of the
skull with the original skull
piece or
 ● Custom contoured graft made
from materials such as:
○ Titanium (plate or mesh)
○ Synthetic bone substitute (in
liquid form)

MANAGEMENT ○ Solid biomaterial

(prefabricated customized
implant to match the exact
contour and shape of the
skull).
Cranioplasty | Johns Hopkins Medicine
 Intracranial repair of frontobasal
fracture

MANAGEMENT ● CSF rhinorrhea occur following

head trauma with fronto-basal
skull fracture leading to
spontaneous CSF leak

Ahsan.pdf (ayubmed.edu.pk)
 Cranialization of frontal sinus
fracture

MANAGEMENT ● Performed in patients with

frontal sinus fractures when the
frontonasal duct drainage is
interrupted

Frontal Sinus Cranialization | Plastic Surgery Key


MANAGEMENT
(PDF) Periosteal Pocket Flap for Horizontal Bone
Regeneration: A Case Series (researchgate.net)
Periosteal flap
● The flap design results in a
periosteal pocket
● Allows filling of bone-grafting
material
● Facilitating primary tension-free
soft tissue closure by splitting of
the mucosa
● The flap gives stability to the
augmented volume within the
pocket.
 Suturing of forehead laceration
under GA ℅ NSS.

MANAGEMENT Patient was referred to Plastic

Surgery for management of
maxillofacial fracture.
 ● Coronal and lower eyelid
incisions
● Reduction of fractures
SURGERY ● Internal fixation with titanium
plates
● Bone grafting
● Transnasal medial canthoplasty

SOFT-TISSUE AND SKELETAL INJURIES OF THE

FACE -Grabb and Smith’s plastic surgery 7th ED
 The majority of NOE injuries should
be exposed through both coronal

OPERATIVE
and lower-eyelid incisions

To improve visualization, it may be

TECHNIQUE helpful to score the periosteum in
the glabellar region to allow
expansion of the soft-tissue
envelope.

SOFT-TISSUE AND SKELETAL INJURIES OF THE

FACE -Grabb and Smith’s plastic surgery 7th ED
 Markowitz et al TYPE I

CLASSIFICATION ● Involve a large bone fragment

to which the medial canthal
based on the relation of the insertion tendon is inserted.
of the medial canthal tendon to the
fracture

SOFT-TISSUE AND SKELETAL INJURIES OF THE

FACE -Grabb and Smith’s plastic surgery 7th ED
 TYPE II

Markowitz et al ● Involve more extensive

CLASSIFICATION comminution; the medial

canthal tendon is still attached
based on the relation of the insertion to a bone fragment that can be
of the medial canthal tendon to the stabilized directly
fracture

SOFT-TISSUE AND SKELETAL INJURIES OF THE

FACE -Grabb and Smith’s plastic surgery 7th ED
 Markowitz et al TYPE III

CLASSIFICATION ● Involve avulsion of the medial

canthal tendon from its skeletal
based on the relation of the insertion insertion.
of the medial canthal tendon to the
fracture

SOFT-TISSUE AND SKELETAL INJURIES OF THE

FACE -Grabb and Smith’s plastic surgery 7th ED
 MANAGEMENT
● When transnasal medial canthoplasty is necessary, it must be performed so
that the direction of pall on the canthal tendon is posterior and superior.
● The procedure is performed by drilling from the contralateral side through the
ethmoid bones, with the exit point planned at approximately the level of the
superior aspect of the lacrimal fossa (vector for puU on the tendon).
● The medial canthal tendon is either grasped from the underside of the coronal
incision or looped from an anterior incision medial to the medial canthal angle.
● The wire or permanent suture is then placed through the drill hole using a
wire-passing drill bit toward the contralateral side.
● The suture or wire can be affixed to a SCKW placed on the contralateral side.
 MANAGEMENT
● A soft-tissue bolster over the medial canthal valley is also often necessary to
restore the normal contour to this region(usually left in place for 7 to 10 days. )
● The medial canthal valley is a unique region of the face where the skin is
intimately adherent to the underlying skeleton.
 MANAGEMENT
● The most common complication following NOE. fractures is telecanthus.
(difficult and sometimes impossible correct secondarily. )
● the area must be approached in a similar fashion, the scar contractures
completely released, bone grafts placed to reestablish contour, and transnasal
canthoplasties performed.
● The results of seamdary repairs are always disappointing when compared with
accurate acute repair.
THANK YOU