Trauma of the midface

Abstract

Fractures of the midface pose a serious medical problem as for their complexity, frequency and their socio-economic impact. Interdisciplinary approaches and up-to-date diagnostic and surgical techniques provide favorable results in the majority of cases though. Traffic accidents are the leading cause and male adults in their thirties are affected most often. Treatment algorithms for nasal bone fractures, maxillary and zygomatic fractures are widely agreed upon whereas trauma to the frontal sinus and the orbital apex are matter of current debate. Advances in endoscopic surgery and limitations of evidence based gain of knowledge are matters that are focused on in the corresponding chapter. As for the fractures of the frontal sinus a strong tendency towards minimized approaches can be seen. Obliteration and cranialization seem to decrease in numbers. Some critical remarks in terms of high dose methylprednisolone therapy for traumatic optic nerve injury seem to be appropriate. Intraoperative cone beam radiographs and preshaped titanium mesh implants for orbital reconstruction are new techniques and essential aspects in midface traumatology. Fractures of the anterior skull base with cerebrospinal fluid leaks show very promising results in endonasal endoscopic repair.

Keywords: ESS; midface fractures; orbit; rhinology; trauma.

Table 1. Surgical approaches to the facial skull, modified according to [13]

Table 2. Low-grade head injuries [38]

Table 3. Classification according to Markowitz [91]

Table 4. Fluorescein application for detection of CSF leaks

Table 5. Patterns of injury of the optic nerve according to Walsh [263]

Table 6. Possible clinical symptoms in cases of fractures of the zygomatic bone complex

Figure 1. Course of the vertical and horizontal trajectories of the midface

Figure 2. Le Fort fractures

Figure 3. Surgical approaches to the midface. The definitions of the incisions are listed in Table 1. Modified according to [13].

Figure 4. Frontal sinus fracture. From left to right, the arrows mark: the central fragment with base of the canthal ligament and the trochlea, involvement of the drainage, posterior wall of the frontal sinus.

Figure 5. Lateral transorbital osteotomy of the frontal sinus

Figure 6. Frequent locations of fronto-basal fractures with CSF leak (green) and medial orbital fractures (blue)

Figure 7. Pneu-encephalon with Mount Fuji sign in the axial CT scan

Figure 8. Rhinobasal fractures. Coronal CT scan, CSF leak (fluorescein stain), cartilaginous underlay, mucosal transplantation.

Figure 9. Cartilage chip as underlay, bone chip as underlay, during insertion. Covering with collagen patch.

Figure 10. Avulsion injury. MRI: The arrows indicate bleeding into the location of rupture of the optic nerve (contralateral most severe contusion injury of the bulb).

Figure 11. Foreign body of the orbit. In the CT scan the biological material is detected as gap. The foreign body caused a minimal wound when penetrating (arrow in the left image). It was stopped in the orbital tip. Removal via an endonasal approach.

Figure 12. Tripoid fixation of a zygomatic bone fracture in combination with a titanium mesh for stabilization of the fracture of the orbital floor

Figure 13. Transcutaneous approaches by the lower eyelid (A: subciliary incisin; B: incision in the middle of the lower eyelid; C: infraorbital incision)

Figure 14. Classical transconjunctival approaches with pre- and postseptal dissection