**3.2 Clinical signs requiring a dynamic evaluation in the early stage of admission**

Some clinical signs are requiring recurrent analysis during the early time of admission of multiple trauma patients: state of consciousness or drowsiness, increase in facial hematomas, increase pressure in orbital hematomas, high fever, the appearance of CSF at the level of the nasal cavity or the external ear canal, double vision, aggravation of mastication impairment, and loss of sensitivity in trigeminal nerve territory [22].

#### **3.3 Treatment plan in craniofacial trauma cases**

This sequence of steps should focus on repairing all the lesions with full restoration of function and the esthetic aspect before the trauma. The therapy plan should focus initially on clinical signs and secondarily on the CT exam. Global management of the case should benefit from the input of various specialists such as ICU specialists, anesthesia specialists, and surgeons from all other backgrounds available in the healthcare unit on call. Recent photos of the patient along with dental X-rays before trauma may be useful in lesion assessment and clear future legal aspects. Surgical interventions may be postponed due to increasing facial hematomas, nasal CSF leak, high fever, and thoracic concussions [23].

#### **3.4 Specific considerations regarding the midface trauma**

In cases with severe deformity, our experience recommends avoiding a conservative approach via small multiple regional "conservative/cosmetic" incisions. For a successful outcome, it is best to achieve a complete regional exposure through a coronal or hemicoronal flap (**Figure 4**) combined with a lower eyelid or intraoral incision if necessary [24].

The reduction of the zygomatic bone is best achieved via an intraoral vestibular approach as opposed to a temporalis approach, due to the loosening of the periosteum over the anterior surface of the maxilla and zygomatic buttress. Also, it allows sinus cavity exploration, evacuation of the sinus hematoma with an antiseptic irrigation, and, if necessary, plating along the maxilla-zygomatic buttress [25].

In orbital floor reconstruction, the reconstruction material should extend posteriorly to the orbital ridge of the palatine bone with a slight upward contour. A short, inferiorly inclined plate leads to persistent hypoglobus. In large orbital floor defects, we believe that it is important to avoid using other alloplastic materials than titanium due to the risk of globe mispositioning and possible local inflammatory response due to lack of rigid fixation and mobility (**Figure 5**) [26].

Do not delay the surgical intervention for more than 14 days. Except in a few numbers of severe polytrauma cases, the general condition of the patient should be stabilized in this time frame, and definitive treatment should be undertaken. After 14 days the case must follow the protocol of secondary reconstruction, because of the consolidation of the fractures and the treatment is incomparably more difficult [27].

### **3.5 Nasal bone fractures**

These fractures require closure early within 24–48 hours except the cases with massive facial swelling and presenting nasal CSF leak. A clinical examination of the modified aspect of the nasal vault should be completed with plain X-ray of the nasal bones. Bear in mind the risk of secondary skull base fractures appearing during maneuvers for closing the nasal fracture. From the beginning of this chapter, we emphasized the importance of photos before and after the surgical procedure to prevent subsequent legal actions [28].

**91**

are as follows:

*Diagnosis and Treatment of Midface Trauma in the Context of Polytrauma: Characteristics…*

General anesthesia is compulsory to relax the muscles and gain comfort for both the patient and the surgical team. Performing any maneuver on a shocked patient is forbidden. In cases of multiple fractures, the surgery may be scheduled in 4–5 days to give time for all the edema to resolute. A nasal fracture forms a callus in 8–10 days, so closed reduction is viable because the bones are still mobile in the

*Clinical aspect before surgery in a case with trauma on the right side with unfunctional eyeball reconstruction of the orbit floor with a modified titanium mesh for sustaining the artificial eye prosthesis* 

Open reduction of the fractures is reserved only for specific cases such as open fractures with fragments penetrating the skin or in cases of animal attacks requiring rabies or antitetanic treatment. The surgical steps will focus on direct closure of the fracture site with or without metal plates, nasal packing, and the reconstruction of tissues and sutures. Preserving the fracture site is obtained by both internal nasal

These are overly complex fractures in the midface compartment with possible serious consequences from an esthetic and functional point of view. These cases frequently present a CSF leak. Clinically a quite easy assessment of the suspicion of a CSF leak is performed by observing the appearance of a pink hallow around the

Moreover, the persistent nasal bleeding should raise the question of a nasal CSF leak. Panda eyes sign of orbital hematomas is frequently associated with nasal CSF leak. In these cases, it is compulsory to perform a nasal endoscopy in the first

When suspecting a CSF leak, we must postpone surgical closure of the nasal vault fractures because the maneuvers can aggravate the lesions in the skull base. The CT scan confirms the fractures at the level of the nasal and ethmoid bones [33]. Consequently, imaging studies should gather data in all three axial planes with thin slices and 3D reconstructions (**Figure 7**). Particularly useful is close cooperation with the radiologist to perform serial images of the skull base and visualize the associated lesions of the lacrimal sack. In this type of fractures, open reduction after the resolution of edema under general anesthesia is recommended (**Figure 8**) [34].

**3.7 Principles of osteosynthesis (internal fixation) in midface trauma**

The general principles of osteosynthesis were formulated in 1958 by the Association for Osteosynthesis (AO) and are the guidelines for osteosynthesis. The principles of osteosynthesis in midface trauma respect general principles, and they

*DOI: http://dx.doi.org/10.5772/intechopen.92862*

fracture site during this time frame [29].

**Figure 5.**

*introduced subsequently.*

packing and external metal splint placing [30].

**3.6 Nasal-orbital-ethmoid complex fractures**

nasal blood droplets collected on a clean tissue [31].

24 hours from the trauma to exclude CSF leak (**Figure 6**) [32].

**Figure 4.** *Coronal approach for a complex nasal-orbital-ethmoid fracture.*

*Diagnosis and Treatment of Midface Trauma in the Context of Polytrauma: Characteristics… DOI: http://dx.doi.org/10.5772/intechopen.92862*

**Figure 5.**

*Trauma and Emergency Surgery - The Role of Damage Control Surgery*

response due to lack of rigid fixation and mobility (**Figure 5**) [26].

incision if necessary [24].

**3.5 Nasal bone fractures**

prevent subsequent legal actions [28].

*Coronal approach for a complex nasal-orbital-ethmoid fracture.*

a successful outcome, it is best to achieve a complete regional exposure through a coronal or hemicoronal flap (**Figure 4**) combined with a lower eyelid or intraoral

The reduction of the zygomatic bone is best achieved via an intraoral vestibular approach as opposed to a temporalis approach, due to the loosening of the periosteum over the anterior surface of the maxilla and zygomatic buttress. Also, it allows sinus cavity exploration, evacuation of the sinus hematoma with an antiseptic irrigation, and, if necessary, plating along the maxilla-zygomatic buttress [25]. In orbital floor reconstruction, the reconstruction material should extend posteriorly to the orbital ridge of the palatine bone with a slight upward contour. A short, inferiorly inclined plate leads to persistent hypoglobus. In large orbital floor defects, we believe that it is important to avoid using other alloplastic materials than titanium due to the risk of globe mispositioning and possible local inflammatory

Do not delay the surgical intervention for more than 14 days. Except in a few numbers of severe polytrauma cases, the general condition of the patient should be stabilized in this time frame, and definitive treatment should be undertaken. After 14 days the case must follow the protocol of secondary reconstruction, because of the consolidation of the fractures and the treatment is incomparably more difficult [27].

These fractures require closure early within 24–48 hours except the cases with massive facial swelling and presenting nasal CSF leak. A clinical examination of the modified aspect of the nasal vault should be completed with plain X-ray of the nasal bones. Bear in mind the risk of secondary skull base fractures appearing during maneuvers for closing the nasal fracture. From the beginning of this chapter, we emphasized the importance of photos before and after the surgical procedure to

**90**

**Figure 4.**

*Clinical aspect before surgery in a case with trauma on the right side with unfunctional eyeball reconstruction of the orbit floor with a modified titanium mesh for sustaining the artificial eye prosthesis introduced subsequently.*

General anesthesia is compulsory to relax the muscles and gain comfort for both the patient and the surgical team. Performing any maneuver on a shocked patient is forbidden. In cases of multiple fractures, the surgery may be scheduled in 4–5 days to give time for all the edema to resolute. A nasal fracture forms a callus in 8–10 days, so closed reduction is viable because the bones are still mobile in the fracture site during this time frame [29].

Open reduction of the fractures is reserved only for specific cases such as open fractures with fragments penetrating the skin or in cases of animal attacks requiring rabies or antitetanic treatment. The surgical steps will focus on direct closure of the fracture site with or without metal plates, nasal packing, and the reconstruction of tissues and sutures. Preserving the fracture site is obtained by both internal nasal packing and external metal splint placing [30].

#### **3.6 Nasal-orbital-ethmoid complex fractures**

These are overly complex fractures in the midface compartment with possible serious consequences from an esthetic and functional point of view. These cases frequently present a CSF leak. Clinically a quite easy assessment of the suspicion of a CSF leak is performed by observing the appearance of a pink hallow around the nasal blood droplets collected on a clean tissue [31].

Moreover, the persistent nasal bleeding should raise the question of a nasal CSF leak. Panda eyes sign of orbital hematomas is frequently associated with nasal CSF leak. In these cases, it is compulsory to perform a nasal endoscopy in the first 24 hours from the trauma to exclude CSF leak (**Figure 6**) [32].

When suspecting a CSF leak, we must postpone surgical closure of the nasal vault fractures because the maneuvers can aggravate the lesions in the skull base. The CT scan confirms the fractures at the level of the nasal and ethmoid bones [33].

Consequently, imaging studies should gather data in all three axial planes with thin slices and 3D reconstructions (**Figure 7**). Particularly useful is close cooperation with the radiologist to perform serial images of the skull base and visualize the associated lesions of the lacrimal sack. In this type of fractures, open reduction after the resolution of edema under general anesthesia is recommended (**Figure 8**) [34].

#### **3.7 Principles of osteosynthesis (internal fixation) in midface trauma**

The general principles of osteosynthesis were formulated in 1958 by the Association for Osteosynthesis (AO) and are the guidelines for osteosynthesis. The principles of osteosynthesis in midface trauma respect general principles, and they are as follows:

