Primary Care Otolaryngology

Maxillofacial Trauma

You’ve gone through your checklist as above and have determined that the patient’s tongue is not the problem. You cannot perform an oral intubation (perhaps because the lateral C-spine film shows a broken neck), and you cannot perform a nasotracheal intubation (perhaps because the patient has profuse oral bleeding). You now know that the only option is a surgi- cal airway. The indication for an emergent (“bedside”) surgical airway, either cricothyroidotomy or tracheotomy, is in a patient who is unable to be intubated and unable to be successfully ventilated with a mask. The exception to this is a patient with severe laryngeal trauma, where mask ventilation or intubation could worsen the situation. The methods of choice are a tracheotomy and a cricothyrotomy. Which procedure is performed depends on the level of expertise available. In an emergency, cricothyrotomy may be chosen over tracheotomy, because it is quicker and is accomplished through the relatively thin and more superfi- cial cricothyroid membrane. You should learn to palpate and recognize the cricoid cartilage. Try it on yourself; the membrane is just above the cricoid cartilage and below the thyroid cartilage (the Adam’s apple). Other Aspects of Maxillofacial Trauma Management Anyone who has sustained enough trauma to break a facial bone should be assumed to have a C-spine fracture until this is ruled out. Rule #1 in

81

maxillofacial trauma management is secure the A irway, B reathing, and C irculation. Rule #2 is rule out a C-spine fracture, if it has not already been done. Rule #3 is eval- uate the patient completely. Look in the ears for hemotympanum, which can signify a temporal bone fracture. Check that the facial nerve works on both sides, since a complication of temporal bone fracture may be facial nerve paral- ysis (an otolaryngologist should be consulted for any temporal bone fracture). Next, palpate the orbital rims to ascertain whether or not a malar (tripod) fracture

Figure 12.2. Bilateral periorbital ecchymoses and sub- conjunctival hemorrhages. This may be due to soft tissue trauma only, or it may be a manifestation of an underlying fracture.

www.entnet.org