CC
A 21-year-old male arrives via emergency medical services (EMS) responders to the emergency department (ED) after a high-speed motor vehicle collision.
HPI
The EMS personnel report that the patient was an unrestrained driver traveling at 60 mph through a red light at an intersection when he hit an oncoming vehicle. The driver’s side airbag did not deploy, resulting in the direct collision of the patient’s upper midface with the steering wheel, causing a positive “steering wheel deformity.” (The incidence of naso-orbital-ethmoid [NOE] fractures has decreased since the advent of airbags. However, the impact of the midface with the steering wheel continues to be a common cause of NOE fractures). The patient had a transient loss of consciousness but remained coherent, alert, and oriented during transport to the ED. He complains of a severe headache, poor vision, and pain in the midface. (A history of severe headache, loss of consciousness, or declining mental status should raise suspicion of intracranial injury or hemorrhage.) The trauma team has requested a consultation for management of the patient’s midfacial soft tissue lacerations and evaluation for facial fractures.
PMHX/PDHX/medications/allergies/SH/FH
The patient has a prior history of substance abuse (cocaine) according to the patient and telephone contact with a family member.
A history of cocaine abuse is important to reconstructive maxillofacial surgeons because it may imply previous nasal septal perforation or compromised local vasculature of the nasal structures caused by repeated episodes of vasoconstriction from nasal cocaine abuse. In addition, a chronic or recent history of cocaine abuse has cardiovascular implications, putting the patient at increased risk for coronary vasospasm and cardiac arrhythmias. Illicit drugs are commonly implicated in motor vehicle accidents.
Examination
The initial evaluation of a trauma patient should follow the Advanced Trauma Life Support protocol.
Primary survey
The patient’s primary survey is intact, and he has a Glasgow Coma Scale score of 15. The patient is alert and oriented to person, place, time, and event and has been able to easily maintain his airway. (Severe posterior nasal hemorrhage can compromise the airway and be a significant source of blood loss.)
Secondary survey
General. The patient is a well-developed and well-nourished male in moderate distress, requesting pain medications and supporting a partially soaked 4 × 4 dressing held over the bridge of his nose and right eye.
Vital signs. His blood pressure is 150/84 mm Hg (hypertensive), heart rate is 125 bpm (tachycardia), respirations are 16 breaths per minute, and temperature is 37.6°C.
Maxillofacial. There is significant bilateral midfacial and periorbital edema with a 10-cm horseshoe ( U )-shaped laceration to the frontal region down to bone. A second 8-cm horizontal laceration extends across the nasal bridge (nasion) and through both the right and left upper eyelids with no orbital fat herniation (open globe injury should be suspected with exposure of orbital fat) ( Fig. 55.1 ). There are several small arterial bleeders within each laceration. Facial abrasions extend over the left malar (zygoma) region. The patient exhibits a positive result on the bowstring test on the left (movement of bone fragment at insertion of medial canthal tendon upon lateral pull on the upper eyelid). The intercanthal distance is 42 mm (the distance between the left and right medial canthus may be increased in NOE fractures), and the interpupillary distance is 62 mm. (Normal intercanthal distance is race dependent and ranges from 28.6 to 33 mm for adult females and 28.9 to 34.5 mm for adult males.)
Nose. There is crepitus and tenderness of the nasal complex upon palpation (nasal bones are displaced and unstable), and movement with digital pressure over bilateral medial canthi (NOE complex instability requiring reduction and stabilization). There is a widened nasal bridge, upturned nasal tip, and depressed radix. Nasal speculum examination reveals bright red blood in the bilateral nares (epistaxis) and deviation of the nasal septum to the right with no evidence of a septal hematoma. (This requires urgent decompression.) Clear fluid was obtained from the right naris (rhinorrhea) and has been sent for laboratory evaluation for cerebrospinal fluid (CSF). (The β 2 transferrin test and occasionally glucose and chloride levels are used to confirm CSF rhinorrhea.)
Maxilla. Bilateral hypoesthesia of the infraorbital nerve distributions (cranial nerve V2) is present. The maxilla is nonmobile, and the patient’s occlusion is intact. The patient has a full complement of teeth, with no grossly carious teeth and no mobile dentoalveolar segments.
Eyes. There is severe bilateral chemosis and subconjunctival hemorrhage. The patient is unable to open either eye, and examination requires careful eyelid elevation. (A Desmarres retractor or disinfected paperclip retractor allows for gentle eyelid elevation.) There is blunting of the bilateral medial palpebral fissures. There is no obvious epiphora (excessive tearing from the eye), but no attempts are made at primary probing of any of the canaliculi. (The lacrimal drainage system is commonly injured with NOE fractures.)
Right eye (OD) examination reveals a reactive pupil with hyphema (blood in the anterior chamber of the eye). The OD pupil appears round, and visual acuity is limited to light perception. Left eye visual acuity is 20/200 with a round and reactive pupil and no hyphema. (Visual acuity should be tested with the patient’s corrective lenses whenever present.) Extraocular movements are intact bilaterally, and there is no enophthalmos. (Medial orbital wall fractures can cause enophthalmos in the setting of NOE fractures.)
The physical examination of suspected NOE fractures should be detailed and directed toward assessing the degree of telecanthus and early identification of concurrent ocular and neurologic injuries. Soft tissue intercanthal distances greater than 35 mm are suggestive of a displaced NOE fracture, and distances greater than 40 mm are diagnostic. Crepitus or movement upon palpation of the medial orbital rim indicates instability and the presence of a fracture; clinical bowstring examinations can demonstrate whether the canthal-bearing bone fragment is displaced and mobile. Other tests include the Furness test (the degree of displacement is assessed by grasping the skin over the medial canthus with tissue forceps) and the bimanual examination (with an intranasally placed instrument applying lateral pressure to the NOE complex, the medial canthal tendon is digitally palpated for movement).
Imaging
The imaging modality of choice in the diagnosis and evaluation of midface fractures is a noncontrast maxillofacial computed tomography (CT) scan of the face. Because of overlapping bony architecture, plain films fail to demonstrate the degree and location of bony disruption. Thin cuts (1–1.5 mm) are usually required to determine the extent of the NOE injury. Of surgical importance is the determination of the position and status of the frontal process of the maxilla because this region bears the insertion of the medial canthal tendon.
In the current patient, a facial helical CT scan without contrast was obtained. Axial bony windows showed bilateral fractures at the NOE region with avulsion of several bony segments and bilateral medial orbital wall fractures ( Fig. 55.2 A). The orbital floors appear intact bilaterally. There is evidence of a 1-cm punctuate subarachnoid hemorrhage in the left temporal lobe, with no midline deviation. A three-dimensional reconstruction view permits visualization of the lines of fracture ( Fig. 55.2 B and C).
