Resident Manual of Trauma to the Face, Head and Neck

y y If no saline is observed after irrigation, there is a complete blockage of the nasolacrimal system at some level, which should be obvious from the extent of the traumatic pathology. E. Isolated Orbital Fractures Typically, orbital fractures in NOE injuries are isolated to the region of the lamina papyracea and inferior-medial orbit. While medial orbital fractures can result in entrapment of periosteum, fat, and ocular muscle, it is not common because of the lack of gravitational force and because the ethmoid cells provide an additional support to the lamina. When entrapment does occur, it must be differentiated from a neuro- praxia of the oculomotor nerve to the medial rectus by forced duction testing. Like most patients with facial trauma, it is usually necessary for the trauma team to clear the patient from more serious injuries before the full evaluation and decision-making process on the facial trauma can take place. This includes the full-body trauma assessment, particularly of the circulation, airway, breathing, and neuro status, as well as the remainder of the bodily assessment. It is helpful for the otolaryngology resident to be present for this total body trauma assessment, as positive findings will impact the evaluation and treatment of facial fractures. Additionally, after the primary and secondary assessments, the otolaryngology resident will be able to focus specifically on a detailed head and neck examination. 2. Head and Neck Examination Particularly pertinent to NOE injuries, the head and neck examination should closely assess neurological status, nasal airway, vision (including pupillary examination and range of motion), CSF leak, epistaxis, nasal airway patency, and eyelid tension. Eyelid tension, when tested with the “bowstring test,” may demonstrate a laxity of the medial canthal tendon when the eyelid is grasped by eyelashes and pulled laterally. A normal attachment of the medial canthal tendon will demonstrate a firm resistance to distraction, while a disrupted attachment will feel lax. Since isolated NOE fractures are not common, but more often are a part of panfacial fractures, the entire facial skeleton must be adequately evaluated. 3. Ophthalmological Evaluation Any trauma at or around the orbit justifies an ophthalmological evaluation, preferably before any surgical procedure is planned. An F. Diagnostic Evaluations 1. Full-Body Trauma Assessment

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