Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4540_Библиотеки_им_академика_М_И_Перельмана.pdf
328
CHAP TER11 The upper jaw and midface
Figure11.2 Le F ort f rac ture patte rns.
Le Fort II (‘pyramidal’)
Star ting at the nasal bones, this fracture crosses the frontal processes
of the maxillae into the medial orbital walls. It passes through the lacrimal bones and crosses the inferior orbital margin near to the infraorbital foramen. It then continues downwards and back wards through
the lateral wall of the antrum below the zygomaticomaxillary suture.
Posteriorly the fracture passes midway through the pterygoid plates.
It also passes through the nasal septum and may involve the cribriform
plate of the anterior cranialfossa.
Le Fort III (‘high transverse’ or ‘craniofacial dysjunction’)
Star ting at the nasal bones, this fracture pa sses from the frontonasal
suture back wards through the ethmoid bone (and cribriform plate). It
passes laterally through the orbit below the level of the optic foramen
to reach the posterior aspect of the inferior orbital ssure. From here
the fr acture passes laterally through the lateral wall of the orbit and frontozygomatic process. Posteriorly it crosses the pterygoma xillary ssure
and the base of the pterygoids. This separates the entire facial skeleton
from the skullbase.
Both Le Fort II and III fractures involve the orbit (with risk to the eyes) and
potentially involve the anterior cranial fossa (with associated head injury/
CSF leakage)
FRAC TURES TO THE UPPER JAW AND MIDFACE
Clinical features
Consider multiple facial/ midface injuries in anyone with gross swelling. Clinical
features may be the result of the impact it self, or as a consequence of the
eects of this force on disr uption and displacement of the midfacial skeleton. Although this list is long it would be a very unlucky patient indeed
if they had all these ndings. Nevertheless many of them may be present:
• General features:
•
Airway compromise (uncommon).
•
Haemorrhage— associated with mucosal tears in the nasopharynx
or facial wounds/ lacerations. Rarely torrential, although may
require nasal packing or immediate manual reduction of the
fracture to stem the ow. If the patient is shocked, always consider
anothercause.
• Neurosurgical related:
•
CSF rhinor rhoea (anterior cr anial fossa#).
•
CSF otorrhoea (middle cranial fossa#).
•
‘Tramlining’ may be seen when blood mixes with CSF and leaks
from the nose or ear. Along the per iphery of this ow the blood
clots while the CSF washes it away centrally forming two parallel
lines:hence ‘tramlining’.
•
Complications of CSF leaks (meningitis, aerocoele or stula
formation with signicant CSFloss)
• Facial swelling— this can rapidly progress with high- energy impacts.
Consider early intubation.
• Abnormal mobilit y of the midface— checked by holding the anter ior
maxillary alveolus and gently attempting to mobilize the maxilla. Do
not attempt this if the patient has been bleeding signicantly from the
face— it may restart.
• Eye/ orbit related:
•
Bilateral periorbital ecchymoses (‘panda faces’ or ‘racoon eyes’).
These are often associated with a signicant degree of facial
swelling. Seen in any fracture that passes into theorbit.
•
Bilateral subconjunctival ecchymoses (bright red). This is bleeding
within the conjunctiva adjacent to an orbital fr acture.
•
Enophthalmos— this may initially be masked by oedema.
•
Diplopia— this ha s many causes and may be dicult to assess at an
early stage, unless it is obvious.
•
Traumatic mydriasis (dilated pupil)— spasm of dilator pupillae
secondary to a directblow.
• Features related to the displacement of the midface skeleton:
•
Obstructed airway — this results from a combination of soft palate
displacement, swelling, and bleeding.
•
Anterior open bite (see Figure 11.3 for lateral openbite).
•
Apparent restricted mouth opening caused by premature contact
in the molar region which result s in gag ging of the occlusion.
•
Lengthening of the face (longface).
•
‘Dishfaced’ deformity— comminution of the bones may result in
collapse of the centr al par t of the face, rather than displacement of
the wholeface.
329
330
CHAP TER11 The upper jaw and midface
Figure11.3 L ater al ope n bite i n a midf ace fr actu re. Note that the upper dental
midline doe s not cor respond with the lower, or th enose.
• Pain and crepitus.
• Upper buccal sulcus/ palatal bruising.
• Numbness— commonly in the distribution of the infraorbitalnerve.
Investigations
• CXR— remember the possibility of inhaled foreign bodies (e.g. from
dental trauma).
• Plain lms of the face. Plain lms of the face have no role in the
resuscitation room and add little diagnostic information in obvious
fractures where CT is clearly indicated. However, they may be
undertaken in the ‘walking wounded’ as a preliminary view, if
fractures are not obvious. One or two OM projections (15 and
30 degrees) together with a good clinical examination should be able
to exclude most frac tures. Atrue lateral projection may also show
displacement of the maxilla. It is also useful for assessment of the
frontal sinuses (uid levels, posterior wall fractures) and visualizing
the pterygoid plates. Specialist periapical and upper occlusal views
are useful in the assessment of dentoalveolar fractures. OP T is ver y
useful if a mandibular fracture is suspected. It may also show low-
level Le Fort Ifractures, dentoalveolar fractures, and dental injuries.
• CT scan. This is now the investigation of choice in obvious midface
fractures. MRI may be of value in the assessment of soft tissue
injuries, particularly to the brain, cervical spine, and orbit, but is
rarely undertaken urgently.
FRAC TURES TO THE UPPER JAW AND MIDFACE
Management
High- ener gy injuries should be initially assessed using ATLS® principles
(see E Chapter 2). Midface injuries not associated with airway obstruction
or major bleeding, should be only treated after the patient has been stabilized
and life- threatening injuries managed. Considerrst:
• Airway with cervical spine protection
• Breathing
• Circulation
• Head injuries
• Ocular injuries.
Beware the patient who keeps trying to sit up— they may be trying to clear
their airway.
First aid measures
• Le Fort fractures can present with signicant epistaxis. As a r st-
aid measure, nasal packs may tamponade the ow. Poster ior na sal
packing is discussed in detail in E Chapter 7. Custom- made devices
(or if necessar y urinary catheter s) may be inserted and the balloons
inated to sit in the nasopharynx. This facilit ates nasal packing with
ribbongauze.
• Replace lost uids— patients with midface fractures should have IV
access and appropriate uid resuscitation.
• Dentoalveolar fractures should be reduced and temporarily
stabilized. If teeth have been avulsed or subluxed they should ideally
be re- implanted or repositioned as soon as possible and then
splinted.
• Lacerations should be inspected for contamination and foreign
bodies (see E Chapter 2). If the patient obviously needs to go to
theatre then formal wound closure can be delayed. Afew tacking
sutures and a simple dressing should be placed.
• Prevent infection— Le Fort fr actures are almost always open
(compound) injuries via the sinuses or facial wounds. Antibiotics
should be commenced. Many regimens exist and include Augmentin®,
or benzylpenicillin + metronidazole. Consider tetanus prophylaxis.
• Analgesia— although often prescribed facial fractures are often not as
painful as one may think. Avoid opiates until the patient is cleared of a
headinjur y
• Advise the patient not to blow their nose. They are at risk of both
surgical emphysema and tension pneumocephalus.
Denitive management
Not all patients require immediate admission, depending on the sever ity
of their injury. Some minimally displaced upper jaw/ midface fr actures
are managed non- surgically, especially in children, the elderly, or those
patients without any teeth. The remainder usually require reduction and
repair, or intermaxillary xation.
331
332
CHAP TER11 The upper jaw and midface
cInfections
Infec tions conned exclusively to the upper jaw tend to be dental in origin and are described in E Chapter 13. Initially contained within the
supporting bone, these usually present as toothache. If left untreated an
infection may either spread into the surrounding soft tissue facial spaces,
or it may spontaneously discharge into the mouth through a sinus, with
minimal symptoms.
Fascial spaces related tothe upper jaw and midface
These are potential spaces between brous tissue planes and the adjacent muscles, which can become distended with serous uid, pus, blood,
or (rarely) tumour. These planes open up relatively easily and bacteria
can therefore spread quickly along them by breaking down the fr iable
connective tissue within. Many spaces are interconnected. They include.
Buccalspace
This is the most commonly aected space and often presents to casualt y
as a ‘fat face’. Infections can spread into it from both the mandibular and
maxillary teeth. It is bounded by the buccinator and the masseter muscle
medially. Laterally is the deep fascia from the parotid capsule and the
overlying platysma. The inferior boundary is the inser tion of the deep
fascia into the mandible, and it s superior boundary the zygomatic process of the maxilla. It cont ains the buccal fat pad. Posteriorly it is continuous with the pterygoidspace.
Masticatorspace
This is bounded laterally by the temporalis fascia, z ygomatic arch, and
masseter muscle and medially by the medial and lateral pterygoid muscles. The temporalis muscle and mandibular ramus further divide the
space into supercial and deep compar tments. The super cial compartment contains the submasseteric space below and the supercial
temporal space above. The deep compar tment contains the supercial
pter ygoid space (or pterygomandibular space) below and the deep temporal space above. The supercial pterygoid space communicates with
the deep pterygoid space. The super cial and deep temporal spaces
together are also known as the infratemporal fossaspace.
Parotidspace
This contains the parotid gland, the parotid lymph nodes, the facial
nerve, the external carotid ar ter y, and retromandibular vein. It is formed
by the splitting of the deep cervical fascia, to enclose the parotid gland.
The fascial covering is generally thin, but thickens to for m the stylomandibular ligament.
Upperlip
Infec tion here can result in severe swelling of the upper lip, usually deep
to orbicularis or is, dr aining into the mouth. It is usually secondary to
periapical infections of the upper incisorteeth.
Caninefossa
This is bounded by the muscles of facial expression around the orbicularis
oris (levator labii superioris, levator anguli oris, zygomaticus minor and
major) and the overlying skin. Infections usually originate from the upper
canine or r st premola r teeth. Dependi ng on the leng th of their roots and
their inclination, infections can spread either bet ween these muscles, or
it can track to the buccal sulcus within the mouth. Non- dental causes of
swelling include skin infections. If bilateral consider an allergic reaction.
Also consider sinusitis and nasolacrimal dacryocystitis— infection of the
tear drainage pathway.
Potentially infection can spread superiorly and then, via the ophthalmic veins,
intracranially (see E ‘Cavernous sinus thrombosis’, pp. 92–3). This israre.
cFacial space infection
This is usually due to a localized or spreading bacterial infection in one of
the fascial spaces. Most of ten the underlying cause is a dental infection.
However, be thorough and exclude all other possible causes. Although
initially mild, if left untreated, these can rapidly progress and in some cases
become life- threatening.
Spread of infection depends on the local anatomy, in which tooth
the infection originates in, and in which jaw. Virulence of the organism
and host resistance are also important factors. The face has a ver y rich
blood supply which helps in its resist ance to infection. However, the rich
venous drainage of the face also communicates with the cavernous sinus,
potentially draining infections intracranially. These veins are often valveless, allowing infection to pass in a retrograde direction. The communications are mostly around the or bit, the most import ant being between
the angular veins on the face and ophthalmic veins. These then pass
through the orbit into the cavernous sinus. Infected emboli can therefore
result in cavernous sinus thrombosis and intracranial abscesses.
Clinical features
Symptoms and s igns depen d on the severity of t he infection. Th is is determined by the health of the patient , the virulence of the micro- organism,
antibiotic sensitivity and the fascial space or spaces involved. Patients
usually present with a localized, or more commonly a diuse swelling
on the face. There may be cervical lymphadenopathy. If advanced they
are often unwell, feverish, with signs of systemic inammatory response
syndrome.
Investigations
• Usually the FBC will show an increasedWCC.
• Blood cultures and a raised ESR may indicate bacteraemia or
septicaemia.
• If the patient is very ill and dehydrated, the haematocrit will be raised
and the urea and creatinine will be elevated.
• Never forget to take a random serum glucose sample— the patient
may be an undiagnosed diabetic.
• Depending on the extent of infection and the suspected source
imaging will be required (OPT/ OM/ CT). US will of ten determine if a
swelling is oedematous only, or containspus.
INFECTIONS
333
334
CHAP TER11 The upper jaw and midface
Management
Not all fascial space infections require admission. If minor they can be
prescribe d antibiotics and referred to their ow n dentist for assessment of
the teeth. Treatment depends on the extent of the infection, its location,
the patient’s general health, and the response to previous treatments.
Presentation varies from the ambulant patient with mild cellulitis to the
severely ill, toxic, and bed- bound individual requiring urgent admission
and drainage of infection. Keep the following principles inmind:
• If in doubt, refer oradmit.
• Screen for diabetes (random blood sugar) and
immunosuppression(WCC).
• Never underestimate a fascial space infection. In fact, never call it a
‘dental abscess’ as this terminology will put you, the anaesthetist, and
theatre sta in the wrong state of mind and a lower gear of aler tness.
It is a ‘fascial or cer vical space infec tion’.
• Do not underestimate the rapidity with which these infections can
spread. If you suspect the airway may potentially be threatened, do
not ‘wait and see’ by treating with antibiotics. Electively secure the
airway with endotracheal intubation and drain the abscess.
• Never treat a fascial space infection of an identiable cause with
antibiotics alone, try to remove thecause.
• If a collec tion has formed, it will never resolve with antibiotics alone,
but requires incision and drainage. The space containing it must be
incised and drained, with appropriate dr ains left insitu.
cOsteomyelitis ofthe upperjaw
Osteomyelitis of the jaws is uncommon and most commonly associated
with odontogenic infection (infections of the teeth). It can occur follow-
ing extractions, trauma, or irradiation to the mandible. It can also occur
in patients taking bisphosphonates (BRONJ). Infection is more common
in the lower jaw, as the upper jaw has a relatively better blood supply.
Before the antibiotic er a, however, it was frequently fatal. Acute osteo-
myelitis is less common than chronic osteomyelitis, with patients rarely
presenting with obvious suppuration. A small amount of pus exuding
from around a tooth is more likely to be a periodont al abscess, but if
multiple adjacent teeth are involved, mobile, and the overlying soft tissue are
inamed, there is probably acute osteomyelitis.
Clinical features
These depend upon the type and extent of infection and may include:
• Pain— in acute osteomyelitis, this can be severe, throbbing and deep
seated. Chronic infection has a less intense but still deep seated and
unremitting character.
• Swelling, erythema, and tenderness. Initially soft, swelling is
secondary to inammation and oedema. This may later progress to a
rm subperiosteal abscess.
• Tris m u s .
• Dysphagia.
• Cervical lymphadenopathy.
• Halitosis.
• Pyrexia, anorexia, and malaise.
• Friable granulation tissue, exposed necrotic bone, and sequestrum
formation are all common in chronic infection. It is important to make
sure these features are not those of a malignancy.
Usually there is an obvious cause such as a decayed tooth. This may be
tender and mobile. Most patients are either malnourished or immune
decient to some extent. This condition is therefore commonly seen in
smokers, diabetics, and alcoholics as well as other well- k nown at- risk
groups.
The infection is usually a polymicrobial in nature. It is caused by a mixture of streptococci and anaerobic bacteria, which pass into the bones
from the infected tooth. Haematogenous spread is r are. Osteomyelitis
may also arise in an infected frac ture. This tends to be chronic. Smokers
are at particularly high risk of this. Actinomycosis is an unusual but specic
infection, also known to occur. This result s in recurrent and chronic jaw
abscesses. These can discharge large amounts of pus, which often contains characteristically appearing bright yellow granules (referred to as
‘sulphur granules’). Consider actinomycosis in any patient with chronic bone
abscesses and discharging sinuses.
Management
Acute osteomyelitis needs urgent referral for admission, IV antibiotics,
and drainage of pus. Chronic osteomyelitis may be managed as an outpatient with appropriate long- term antibiotics. If so, close follow- up is
required. The decision to admit for IV antibiotics depends on a number
of factors including the severity of symptoms, signs of systemic involvement (which are usually rare), extent of the infection (patients require
CT) and patient compliance. Any associated contributing factors should
also be identied and treated if possible. Surgical debridement may be
required.
cParotid sialadenitis
Mumps is the commonest cause of parotid swelling, even unilaterally. It has
a peak incidence in childhood but can occur in adult s. In teenagers, coxsackieviruses and echoviruses can also cause acute parotid sialadenitis.
Clinically there is pyrexia and malaise. Pain is the most striking symptom. There is diuse swelling of the gland and of ten trismus. Treatment
is supportive.
‘Ascending’ infection, i.e. bacteria in saliva passing back along the ducts
into the gland, can involve the parotid (and submandibular) glands. In
such cases, predisposing conditions are often associated, e.g. dehydration, diabetes, or immunosuppression. Fibrosis following radiotherapy
or pre- existing obstruction from a calculus or stricture may also predispose to infection.
Clinical features include:
• Fever
• Pain
• Erythema
• Tender swelling
• Dischar ge of pus from theduct.
INFECTIONS
335
336
CHAP TER11 The upper jaw and midface
If the infection is not treated early, this may develop into chronic or
recur rent infection. Progressive destruc tion occurs that ag gravates the
situation resulting in a non- functionalgland.
Management
In the absence of an obvious abscess, management initially consists of IV
antibiotics, rehydration, analgesia, and correction of any systemic condi-
tions (e.g. diabetes). If an obstruction is found (e.g. stone), this needs to be
removed to enable drainage. Gland massage, especially after meals, and
‘lemon drops’ to stimulate salivary ow, help to maintain a ushing eect
and prevent stagnation of saliva. Abscesses need to be incised and drained
on an urgent basis. Ultrasound may help distinguish an abscess from swell-
ing. If infection persists or continues to recur, excision of the gland may be
necessary. This is best done when there is no active infection.
cFacialpain
See also E Chapter 3.
Anatomy and physiology oforofacialpain
The upper cer vical nerves carr ying pain impulses from the back of the
head and the neck converge with trigeminal sensor y neurons in the dor-
sal hor n— the ‘tr igeminocervical complex’. This convergence is the basis
for referred pain from the neck to the face and head. Facial sensation
is principally from the trigeminal nerve, although there is some contri-
bution from the facial and vagus nerves. The posterior aspect of the
tongue, tonsils, tympanic cavity, and the pharynx are innervated by the
glossopharyngeal nerve. The cornea and dental pulp are predominately
innervated by pain bres. There is a large representation of the orofacial
region in the cerebral somatosensor y system, accounting for the exqui-
site sensibility of the orofacial tissues.
Types ofpain
• Somatic pain is pain arising from structures which one is generally
aware of (skin, oral mucosa, joints, etc.). This pain often subsides
following healing. It is usually described as sharp orsore.
• Neuropathic pain is due to injury to the nociceptive (pain) pathway
and may persist long after healing has taken place. It is often
described as burning, shooting, or like an electric shock. Injur y may
occur peripherally or centrally, any where along the neural pathway.
This can occur for example, following herpes zoster infection— ‘postherpetic neuralgia’.
• Deaerentation. This refers to par tial or total loss of sensation in a
localized area following loss or interruption of sensory bres. Instead
of a decrease in pain sensation in the aected area, spontaneous pain
may develop. This is referred to as ‘dysaesthesia’. It is occasionally
seen following inferior alveolar or lingual nerve injury (e.g. after
wisdom tooth removal).
• Allodynia is pain caused by stimuli that would nor mally not produce
pain, e.g. bedclothes producing a burning sensation or shaving causing
severe facialpain.
OROFACIAL PAIN SYNDROMES
cOrofacial pain syndromes
Trigeminal neuralgia and atypical facial pain are among the most challenging pain conditions in the orofacial area. It is not always easy to distinguish
between these and other possible diagnoses, although it is import ant to
do so as treatments and prognoses dier. All forms of idiopathic facial pain
syndromes should be regarded as a ‘diagnosis of exclusion’, that is, all other
causes of facial pain should be considered and if necessary, investigated
for. Every now and then patients with odd symptoms turn out to have
signicant underlying disease, notably tumours.
Idiopathic facialpain
This makes up a signicant propor tion of outpatient attendances. Four
symptom complexes are commonlyseen:
• Facial ar thromyalgia (FAM or TMJ dysfunction syndrome)
(see E Chapter 12)
• At ypical facialpain
• Atypical odontalgia
• Oral dysaesthesia (bur ning mouth) (see E Chapter 13).
It has been suggested that these symptoms may form part of a wholebody pain syndrome, involving the neck, back, abdomen, and skin.
Adverse life events and impaired coping ability are well- known associations. The precise aetiology of idiopathic facial pain is still unknown. It has
been suggested that stress- induced neuropeptide inammation within
the tissues (e.g. TMJ) causes pain and local production of free r adicals.
Eicosanoids have been suggested as responsible for unexplained pain in
non- joint areas including theteeth.
cAtypical odontalgia
This is a severe throbbing pain in the tooth and jaw without signicant
pathology. Often described as severe continual throbbing pain, it may
vary from mild to intense pain, especially with hot or cold stimuli. It may
be widespread or well localized, frequently precipit ated by a dental procedure and may move from tooth to tooth. It may last a few minutes
to sever al hours. This is often a symptom of hypochondriacal psychosis
or depression and there is often excessive concern with oral hygiene.
Treatment involves counselling, avoidance of unnecessary pulp extirpations and extractions, antidepressants, and phenothiazines.
cHerpes zoster (shingles)
This is an acute herpetic infection in any dermatome, commonly the fth
(V)cranial nerve. It commonly involves the side of the face or forehead,
presenting with burning or a tingling pain in the skin with skin eruptions.
These are conned to the distribution of a nerve. If near the orbit, involve-
ment of the eye is possible and requires urgent referral to ophthalmology.
Post- herpetic neuralgia is chronic pain with skin changes following acute
herpes zoster. There may be burning or tearing sensations, or itching
and crawling dysaesthesias in skin. In the acute phase, stellate ganglion
block s using local anaesthetic such as bupivacaine, may help for severe
pain. Transcutaneous nerve stimulation, capsaicin cream, and tricyclic
antidepressants are also useful.
337