Residency · Residency · Otolaryngology
Facial Fractures: Evaluation and Repair
Introduction
Facial fractures are among the most common injuries encountered in trauma settings, frequently resulting from motor vehicle collisions, assaults, sports injuries, and falls. The otolaryngologist must be proficient in the systematic evaluation of the traumatized face and the principles of open reduction and internal fixation (ORIF). Timely and accurate management minimizes long-term functional and aesthetic sequelae.
Initial Evaluation
Primary Survey and Stabilization
Follow Advanced Trauma Life Support (ATLS) protocols. Secure the airway; be prepared for emergent surgical airway if severe midface or mandibular injuries compromise the oropharynx. Control hemorrhage with direct pressure, nasal packing, or angiographic embolization. Assess for cervical spine injury (present in 1-10% of facial trauma patients). Evaluate for associated intracranial injuries.
Secondary Survey of the Face
Systematic examination from superior to inferior and lateral to medial. Palpate the orbital rims, zygoma, nasal bones, maxilla, and mandible for step-offs and crepitus. Assess ocular function: Visual acuity, pupillary reflexes, extraocular movements, enophthalmos. Evaluate dental occlusion: The most reliable indicator of maxillary and mandibular fracture reduction. Test cranial nerve function: Especially V2 (infraorbital nerve) and VII (facial nerve). Inspect for CSF rhinorrhea or otorrhea (suggestive of skull base fracture).
Imaging
CT with fine cuts (1-1.5 mm) is the gold standard for facial fracture evaluation. Axial and coronal reconstructions; 3D reconstructions aid surgical planning. Panorex (panoramic radiograph) useful for mandibular fractures and dental evaluation. Plain films have largely been replaced by CT but may be used for isolated nasal fractures.
Nasal Fractures
Most common facial fracture. Diagnosis is primarily clinical (edema, deviation, crepitus, epistaxis). Closed reduction performed within 7-10 days of injury (before bony union). Assess for septal hematoma; drain immediately to prevent septal abscess and saddle nose deformity. Delayed rhinoplasty/septorhinoplasty for persistent deformity after 3-6 months.
Orbital Fractures
Orbital Floor (Blowout) Fractures
Caused by direct force to the globe increasing intraorbital pressure. Symptoms: Diplopia (especially upgaze), enophthalmos, infraorbital hypoesthesia. Indications for repair: Symptomatic diplopia persisting >2 weeks, significant enophthalmos (>2 mm), large floor defect (>50% of floor), entrapped muscle on CT. Repair with titanium mesh, porous polyethylene (Medpor), or autologous bone. Forced duction test performed intraoperatively to confirm release of entrapped tissue.
Medial Wall Fractures
Often associated with floor fractures (combined inferomedial blowout). Risk of damage to the medial rectus and lacrimal system. Repair via transcaruncular or combined approaches.
Zygomaticomaxillary Complex (ZMC) Fractures
Involve four articulations: Zygomaticofrontal suture, infraorbital rim, zygomaticomaxillary buttress, zygomatic arch. Clinical findings: Malar flattening, trismus, periorbital ecchymosis, step-off at the infraorbital rim. ORIF with miniplate fixation at 2-3 points of articulation. Accurate reduction assessed by alignment at the zygomaticosphenoid suture (most reliable landmark). Approach via existing lacerations, subciliary, transconjunctival, upper buccal sulcus, or coronal incisions.
Mandible Fractures
Classification
By anatomic site: Symphysis/parasymphysis, body, angle, ramus, condyle, coronoid process. Angle fractures are most common in dentate adults. Bilateral condylar fractures cause anterior open bite.
Management Principles
Champy's ideal line of osteosynthesis guides miniplate placement. Load-bearing fixation: Reconstruction plates spanning the fracture for comminuted or atrophic mandibles. Load-sharing fixation: Miniplates along Champy's lines for simple fractures. Maxillomandibular fixation (MMF) used to establish preinjury occlusion before plating. Condylar fractures: Closed treatment with MMF for most; ORIF for severely displaced or dislocated condyles.
Complications
Malocclusion: Most significant complication; requires re-reduction. Infection (higher risk at the angle due to third molar involvement). Inferior alveolar nerve injury, Nonunion or malunion.
Le Fort Fractures
| Le Fort Type | Fracture Pattern | Clinical Finding |
|---|---|---|
| I | Horizontal through maxilla above dental apices | Floating palate; mobile upper dentition |
| II | Pyramidal through nasofrontal junction, medial orbit, infraorbital rim | Mobile midface pyramid; periorbital ecchymosis |
| III | Craniofacial dysjunction (midface separated from skull base) | Entire mobile midface; dish-face deformity |
Le Fort I: Horizontal fracture through the maxilla above the dental apices (floating palate). Le Fort II: Pyramidal fracture through the nasofrontal junction, medial orbit, and infraorbital rim. Le Fort III: Craniofacial dysjunction separating the midface from the skull base. All produce malocclusion and midface mobility. Management: MMF to restore occlusion followed by ORIF at the buttresses. Assess for associated injuries: CSF leak, optic nerve injury, carotid injury.
Frontal Sinus and Naso-Orbito-Ethmoid Fractures
Frontal sinus fractures: Addressed in Lecture 65. Naso-orbito-ethmoid (NOE) fractures: Disruption of the central fragment bearing the medial canthal tendon. Classified by Markowitz and Manson (Types I-III based on central fragment integrity). Telecanthus (widened intercanthal distance >35 mm) is the hallmark finding. Type I: Single central fragment; plate fixation restores anatomy. Types II-III: Comminuted; require transnasal wiring for canthal repositioning.
Key Clinical Pearls
Always assess occlusion in facial trauma patients; malocclusion is the most sensitive indicator of mandibular or maxillary fracture malposition. Septal hematoma must be drained emergently to prevent septal necrosis and saddle nose deformity. The zygomaticosphenoid suture is the most reliable landmark for assessing ZMC fracture reduction. Orbital floor fractures with evidence of muscle entrapment on CT, especially in children (trapdoor fracture), should undergo urgent repair to prevent muscle necrosis. Le Fort fractures are bilateral by definition, though the pattern may differ on each side.
References
- Kellman RM, Losquadro WD. Comprehensive management of facial fractures. In: Flint PW, et al., eds. Cummings Otolaryngology. 7th ed. Elsevier; 2021.
- Ellis E III, Zide MF. Surgical Approaches to the Facial Skeleton. 2nd ed. Lippincott Williams & Wilkins; 2006.
- Markowitz BL, Manson PN, et al. Management of the medial canthal tendon in nasoethmoid orbital fractures. Plast Reconstr Surg. 1991;87(5):843-853.
- Champy M, Lodde JP, et al. Mandibular osteosynthesis by miniature screwed plates via a buccal approach. J Maxillofac Surg. 1978;6(1):14-21.