2017 NOTS Trauma Symposium

Maxillofacial Trauma: From Field to Finish

2017 NOTS Trauma Symposium

FREEDOM JOHNSON, MD, FACSDirector - Oncologic, Reconstructive and Cranial Base Surgery

Depts. of Otolaryngology – Head and Neck SurgeryMetroHealth Medical Center & CWRU

Disclosures

• None

Disclaimers

In this talk I:• WILL

- Provide an overview of Maxillofacial Trauma- Focus on major facial trauma- Share my approach

• Will NOT

- Review Definitive Management- Review Neck Trauma

Learning Objectives

At the conclusion of this talk participants shall:

1. Understand the signs of a potentially life-threatening maxillofacial injury

2. Understand workup and timing issues

3. Understand the long-term sequelae of facial trauma

Outline• Anatomy

• In the Field

• Acute Evaluation & Management

• Subacute/Long-term Management

• Case Examples

Background/Practice• Birth through Medical School - California

Background/Practice

• 2004 - Present: Cleveland!

• Residency @ CWRU/UH

• Fellowship @ Vanderbilt

• Started at MetroHealth 2009

• Practice about equally split:• Oncologic Ablative• Oncologic Reconstructive• Trauma Reconstructive

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Outline• Anatomy

• In the Field



• Case Examples

Anatomy

• Soft tissue envelope

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Anatomy

• Bony

Copyright © Pearson Education Inc, publishing as Benjamin Cummings

Anatomy

• Vasculature & Airway

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Outline• Anatomy

• In the Field



• Case Examples

In The Field

• Triage: Is this life threatening?

• Airway Compromise?

• Bleeding?

• Associated Injuries?

In The Field

• Airway Compromise

In The Field

• Bleeding• External bleeding

• Direct pressure if possible

• Hematoma/Internal bleeding• Control Airway

In The Field

• Associated Injuries• Intracranial• Cervical

In The Field

• Stabilize and Transport• Secure C-Spine• Secure Airway• Direct pressure for external bleeding

In The Field

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Outline• Anatomy

• In the Field

• Acute Evaluation &

Management


• Case Examples

Acute Eval & Management

• Events On Arrival• History• Workup• Treatment & Timing


• On Arrival• Standard ATLS• C-Spine

• Secure/Clear• Airway

• Intubate/Surgical airway• Bleeding

• Pressure/Pack/IR


• History• Mechanism

• Energy: Low vs. High

• Associated Injuries• Team Sport

• Social Circumstances

Acute Eval & ManagementHistory

• Mechanism: Energy• Low energy

• Blunt vs Penetrating• Limited/Predictable tissue injury

• “What You See is What You Get”• Typically single stage

• May 2 stage if extensive

Acute Eval & Management• Low Energy Examples

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• Mechanism: Energy• High Energy

• Penetrating (GSW)

• Unpredictable tissue viability

• Typically multiple stages


• High Energy: almost always GSW- Ballistic penumbra- Tissue necrosis evolves with time

Acute Eval & Management Ballistic Injury

• Damage to hard and soft tissue• projectile design• distance• velocity

• Trajectory can change

• Transfer of energy/deceleration

Acute Eval & ManagementBallistic Injury

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Acute Eval & ManagementBallistic Injury

Attribution unknown


• Associated Injuries• Airway

• Direct involvement vs supraglottic obstruction

• Vascular• intracranial vs extracranial• immediate vs delayed

• CNS/C-Spine

• Ophthalmologic


• Social Circumstances• Sets context of recovery

• Support network• Ability to get to rehab• Reliability

Acute Eval & ManagementWorkup/Planning

• Examination• Soft tissue envelope

• Imaging• High Resolution CT• 3D reconstructions• Virtual Surgery• Pre/Custom Bent plates

• Consultation• Gather all experience and resources

Acute Eval & ManagementWorkup/Planning

• Have a Team– Surgical

• Oto-HNS/Plastics• Neurosurgery• OMFS• Ophtho/Oculoplastics

– Non-Surgical• PM&R• Mental Health• Social Work

Acute Eval & ManagementTiming – Low Energy

• Soft Tissue/Composite• Address soft tissue within 24 hrs

• Bone• ~2 - 3 week window for adults• 5 - 7 days for children

Acute Eval & ManagementTiming – Low Energy

• Special cases for early intervention

• CSF Leak

• Flail Mandible

• Orbital entrapment or globe rupture

Acute Eval & ManagementEarly Intervention

• CSF Leak


• Flail Mandible

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• Orbital Entrapment

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Acute Eval & ManagementTiming – High Energy

• Immediate (hours to day 1)• stabilization• airway management (trach)• debridement

• Early (days 1 - 7ish)• local wound care• imaging• surgical planning

Acute Eval & ManagementTiming – High Energy

• Intermediate (week 1 - 2)• repeat EUA/Debridement• definitive reconstruction

• Delayed (months to years)• settle in for the long haul• anticipate many operations• “fine tuning” of soft tissue envelope• don’t forget about psychiatry

Outline• Anatomy

• In the Field


• Subacute/Long-term

Management

• Case Examples

Subacute/Long-Term

• Manage healing phase• Staged procedures• Wound complications• Trach/Peg weaning

• Begin rehabilitation phase

Subacute/Long-Term

• Plan additional procedures

• Manage psychiatric/psychological sequelae

• The underlying cause• The resultant issues

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Outline• Anatomy

• In the Field



• Case Examples

Case Examples

• #1 Self inflicted GSW

• #2 Shotgun Blast



Case Examples: Case #1

• 42 y/o woman self inflicted GSW




• Self Inflicted GSW x 3– Emergent Craniectomy– Immediate Tracheostomy– Temporary ORIF Mandible to Hold Position– Ex-Fix after Osteo of Mandible– Congentially Absent Posterior Tibial aa bil








• Self Inflicted GSW Submental– Military Rifle– Immediate Tracheostomy– Temporary Wire Mandible to Hold Position– Temporary Close Soft Tissue Envelope– Type I Diabetic














Conclusion

• Maxillofacial injury may be associated with life-threatening events• Airway• Bleeding• Associated Injuries

• Workup and timing impact outcome• Available resources and expertise

• These injuries often leave long-term sequelae in part due to disfigurement

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Questions?

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2017 NOTS Trauma Symposium

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