Oto Primary Care FINALhigh

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

maxillofacial trauma management

is secure the

irway,

reathing,

and

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.