British Undergraduate Emergency Journal. 2012, 1.12
Considerations in Maxilliofacial Trauma
R. Adrian Scott MFDS RCSEd, Year 3 Medical Student, University of Glasgow
Maxillofacial trauma is a common presentation to the Emergency Department. Following injury, fragments of bone and teeth can displace into unusual sites of the neck, and consequently cause mortality or morbidity. These hard tissues are then a signiﬁcant risk to the airway, and act as foci for potential infection to develop. Radiographic investigations are essential to locate displaced bony fragments and teeth that are unaccounted for. Often, a chest radiograph is ordered. Yet, a foreign body may be displaced elsewhere on the journey from mouth to chest. It is possible that soft tissue neck views to locate an avulsed tooth would be justiﬁed. A case is presented of comminuted parasymphyseal fractures and avulsed teeth in a 13-year-old male, with extensive opening of cervicofascial spaces. Thorough assessment of pre-operative radiographs and exploration of the neck planes proved necessary in this unusual case.
A 13-year-old male presented to the Emergency Department (ED) with facial injuries. The patient fell from scaﬀolding of 2.5 metres in height, and hit their mandible oﬀ a brick wall before landing on a concrete surface. This resulted in a severely comminuted parasymphyseal fracture of the mandible, and avulsion of teeth into unusual places in the neck. (Figures 1 and 2) The young male was working on his parents’ farm when he became unbalanced and fell. No loss of consciousness or amnesia was evident from the history. He vomited several times in the ensuing few hours after the incident. No other injuries were sustained other than to the head/face. The patient had dysphagia, and developed large swelling of the ﬂoor of mouth and submandibular tissues. There was bleeding from his mouth, ﬁve lost teeth (none found at the scene or known to be ingested), and marked anaesthesia of the chin and lower lip. Clinically the patient could mobilise without pain along the spine, but was tender upon palpation. Radiographically, no fracture or signs of injury to the spinal cord were diagnosed and the spine was formally cleared in the ED. The patient had a high BMI (31.6), but was otherwise ﬁt and healthy. The anaesthetic team was informed early due to the patient’s obvious clinical features indicating an airway risk. Figure 1: Open comminuted fracture of the mandible with extensive opening of fascial planes
In maxillofacial trauma, the gold standard of care is in accordance with Advanced Trauma Life Support guidelines . The airway is a considerable risk in trauma involving facial fractures: there is risk of massive oedema, loss of tongue control and airway obstruction . With a comminuted and anterior fracture of the mandible as described, anatomically the tongue has poor support; and when combined with oedematous tissues and intraoral bleeding, the upper airway could readily occlude without proper management. This airway threat is well documented and requires urgent assessment by the ED staﬀ [3, 4]. Similarly, the incidence of associated head trauma, sight-threatening injuries, and involvement of various important neck structures R. Adrian Scott. Figure 2: PA radiograph with arrowed avulsed teeth. Note gross swelling of soft tissues is common with maxillofacial trauma and it is essential these are assessed and monitored. With the mechanism of injury in mind, the risk of cervical spine injury is signiﬁcant. The ED is required to assess and manage any potential spinal injury as a high priority. As the patient had lost teeth and had a badly comminuted fracture open to the mouth (and ergo the airway), these must be accounted for to avoid the risks of being lodged along the respiratory tract or elsewhere. Usually this will prompt the request of a chest radiograph; however, as could be seen in this case, the teeth may become lodged into unusual locations anywhere in the neck. Perhaps there is justiﬁcation for lateral soft tissue neck views in addition to mandatory chest and mandibular radiographs. Without a radiographic view of the entire neck, the clinicians cannot reliably account for all displaced hard tissues within the airway, nor those lodged within soft tissues anywhere between the mouth and chest. Referral to Oral and Maxillofacial Surgery was indicated for deﬁnitive treatment. The patient was taken to theatre as an urgent case on the same evening. The anaesthetist carried out a bronchoscopy initially, in order to rule out any fragments of bone or teeth that could be inhaled. Blood stained secretions were evident in the right main bronchus but no inhaled materials were found. Classically, an inhaled foreign body such as a tooth will preferentially become lodged within the right main bronchus due to the structural accessibility compared with the more acutely angled left main bronchus. Following ﬁbre-optic intubation, the intra-oral wounds and cervical spaces had to be formally explored. Four of the ﬁve avulsed teeth were located in various deep tissue spaces in the neck, as well as bony fragments. It was rare to observe the extent to which the planes of the neck were traumatically opened and along which hard tissues had become displaced and could readily be unaccounted for. The mandible required careful reduction and attempts to preserve as much of the patient’s bone as possible in order to facilitate future dental rehabilitation and aid ﬁxation. Osteosynthesis titanium plates were utilised to ﬁx the comminuted fracture. The traumatic wounds of the mucosa and skin were closed in layers, along with the intraoral surgical incisions. The issue of child abuse should be assessed in any young patient presenting with injuries [5, 6]. In this case, the history was carefully explored with the patient and parents individually, and compared against the ﬁndings from examination of the injuries. Their interactions and relationships were probed to exclude any suspicious signs indicative of neglect or abuse.
When a patient attends the ED with facial injuries and loss of teeth, it is essential that eﬀorts be made to account for the lost fragments due to the risks of inhalation or becoming displaced into the soft tissues. There is great potential for the avulsed teeth to act as foci for infection post-operatively, and there are well-documented risks that can threaten the airway. Appropriate radiographic views to account for avulsed teeth must be requested. This should include chest views, but additionally, soft tissue neck views may be required. This is often not carried out, and lost teeth in the cervical spaces cannot be conﬁdently ruled out. This case highlights the need for thorough investigation for teeth that may be displaced into unusual locations.
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