**2. Principles of diagnosis in craniofacial trauma in cases with multiple trauma**

The diagnosis must be correct and complete without the pressure of emergency, life-threatening bleeding, or from the patient's relatives or even other surgical specialties. After stopping any nasal bleeding and securing airway patency, perform head and neck computed tomography (CT) scan [6].

While performing the clinical examination in head trauma cases, pay attention to important nasal pyramid deviations, abnormal motility of the maxillary, trismus, facial hematomas surrounding both orbital regions, and exophthalmia. Especially important is vision assessment performed by the ophthalmologist. The clinical examination should be performed in a gentle but secure fashion with a predefined succession of maneuvers from the upper third of the face downward and ending with visualizing the nasal and oral cavities [7].

Do not forget to assess the presence of blood in the ear canal because it could be a sign of skull base fracture. ENT endoscopy should be reserved for the 24- to 48-hour follow-up to confirm the presence of a nasal cerebrospinal fluid leak. CSF leak is confirmed also through a lab workup by collecting the seeping clear fluid in a sterile recipient and looking for beta-transferrin levels [8].

Head CT scan in axial and coronal sections is compulsory, but frequently sagittal section reconstructions offer useful data about the anterior segment of the skull base and orbital floor. 3D reconstructions are useful for surgical planning and even explaining the patient the complexity of the trauma and improve informed consent (**Figure 1**) [9].

While formulating the complete diagnosis of cranial and facial trauma, one must take into consideration the various classification systems, imaging data, and even the cause and mechanism of trauma production. There are still limitations in

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

prediction with high accuracy of the functional and esthetic outcomes of the case.

In 1901 LeFort described the midfacial fracture types I, II, and III after previous experimentally induced models. This classification is in use even nowadays because it is practical in nature and enables a common language between the trauma specialists. Often fracture lines are not complete bilaterally but still enable correct assess-

Low-transverse fracture LeFort type I has a direct mechanism of production through frontal and lateral impact or indirect by applying pressure in the mental region with the mouth closed. Fracture lines begin in the lower third of the nasal vault, above the dental roots through the canine fossa, along the zygomatic ridge through the maxillary tuberosity, and the lower third of the pterygoid. Also, there

The clinical facial exam is scarce. The oral cavity presents chemosis in the labial groove and oral vestibule with dental occlusion dysfunctions and specific paintriggering points behind the third molar teeth on the external pterygoid plate. In the case of a mobile fractured fragment, there is a supplementary fracture line in the vomer bone. Therefore, the physical examination will record the upper mobile

Middle-level transverse fracture LeFort type II presents a direct mechanism of production through a frontal impact in the middle vault of the viscerocranium. Fracture lines begin in the middle third of the nasal opening through the nasal bones bilaterally, the ascending arch of the maxillary bone, the lacrimal bone, the ethmoid bone, the floor of the orbit till the spheno-maxillary junction, the anterior

wall of the maxillary sinus, and the middle third of the pterygoid plate [14]. The physical examination is marked by the presence of marked swelling of the face, inferior eyelid chemosis with epiphora, depression of anteroposterior facial landmarks with preservation of the zygomatic bones, depression of the nasal bones, nasal

Afterward, perform a complete inventory of the other trauma lesions [10].

**2.1 Classification of midfacial fractures according to LeFort**

*CT scan with a complex maxillary-orbital-zygomatic fracture on the left side.*

could be two possible scenarios with fixed or mobile fragments [12].

ment of middle vault head trauma [11].

**Figure 1.**

alveolar bone along with the hard palate [13].

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

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

**Figure 1.** *CT scan with a complex maxillary-orbital-zygomatic fracture on the left side.*

prediction with high accuracy of the functional and esthetic outcomes of the case. Afterward, perform a complete inventory of the other trauma lesions [10].

#### **2.1 Classification of midfacial fractures according to LeFort**

In 1901 LeFort described the midfacial fracture types I, II, and III after previous experimentally induced models. This classification is in use even nowadays because it is practical in nature and enables a common language between the trauma specialists. Often fracture lines are not complete bilaterally but still enable correct assessment of middle vault head trauma [11].

Low-transverse fracture LeFort type I has a direct mechanism of production through frontal and lateral impact or indirect by applying pressure in the mental region with the mouth closed. Fracture lines begin in the lower third of the nasal vault, above the dental roots through the canine fossa, along the zygomatic ridge through the maxillary tuberosity, and the lower third of the pterygoid. Also, there could be two possible scenarios with fixed or mobile fragments [12].

The clinical facial exam is scarce. The oral cavity presents chemosis in the labial groove and oral vestibule with dental occlusion dysfunctions and specific paintriggering points behind the third molar teeth on the external pterygoid plate. In the case of a mobile fractured fragment, there is a supplementary fracture line in the vomer bone. Therefore, the physical examination will record the upper mobile alveolar bone along with the hard palate [13].

Middle-level transverse fracture LeFort type II presents a direct mechanism of production through a frontal impact in the middle vault of the viscerocranium. Fracture lines begin in the middle third of the nasal opening through the nasal bones bilaterally, the ascending arch of the maxillary bone, the lacrimal bone, the ethmoid bone, the floor of the orbit till the spheno-maxillary junction, the anterior wall of the maxillary sinus, and the middle third of the pterygoid plate [14].

The physical examination is marked by the presence of marked swelling of the face, inferior eyelid chemosis with epiphora, depression of anteroposterior facial landmarks with preservation of the zygomatic bones, depression of the nasal bones, nasal

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

intoxication are mentioned [2].

the patient to an emergency tracheostomy [5].

head and neck computed tomography (CT) scan [6].

with visualizing the nasal and oral cavities [7].

sterile recipient and looking for beta-transferrin levels [8].

**with multiple trauma**

**2. Principles of diagnosis in craniofacial trauma in cases** 

patient's death [3].

hypothermia [4].

pathologies before trauma along with alcohol consumption and high-risk drug

Photographically documenting the case before and after surgical procedures with subsequent electronic storage for later use is particularly important. In each department, there should be a person assigned to archiving images in potential legal and scientific cases of interest associating tumors or deep neck infections with the

Patients with multiple trauma lesions admitted to the emergency department undergo assessment according to the ABCDE algorithm: A, airway plus spinal cord control; B, breath and ventilation; C, circulation and hemorrhage control; D, disability/neurologic status; and E, complete exposure but preventing

Facing a patient with multiple trauma lesions, a thorough head-to-toe lesion inventory with additional consults performed by the abdominal surgeon, thoracic surgeon, orthopedic surgeon, and others is necessary. For the head lesions, opinions from the neurosurgeon, ENT surgeon, OMF surgeon, ophthalmologist, and plastic surgeon should be gathered. The central pawn in this endeavor is the emergency specialist in the first stage and afterward the anesthesiologist supervising the case in the intensive care unit (ICU). Other lesions have a priority before facial fractures unless there is massive nasal bleeding with cerebrospinal fluid (CSF) leak or lesions hindering the oral intubation for general anesthesia. In the first case, the ENT surgeon must perform emergency nasal packing and in the other scenario must submit

The diagnosis must be correct and complete without the pressure of emergency,

While performing the clinical examination in head trauma cases, pay attention to important nasal pyramid deviations, abnormal motility of the maxillary, trismus, facial hematomas surrounding both orbital regions, and exophthalmia. Especially important is vision assessment performed by the ophthalmologist. The clinical examination should be performed in a gentle but secure fashion with a predefined succession of maneuvers from the upper third of the face downward and ending

Do not forget to assess the presence of blood in the ear canal because it could be a sign of skull base fracture. ENT endoscopy should be reserved for the 24- to 48-hour follow-up to confirm the presence of a nasal cerebrospinal fluid leak. CSF leak is confirmed also through a lab workup by collecting the seeping clear fluid in a

Head CT scan in axial and coronal sections is compulsory, but frequently sagittal

section reconstructions offer useful data about the anterior segment of the skull base and orbital floor. 3D reconstructions are useful for surgical planning and even explaining the patient the complexity of the trauma and improve informed consent

While formulating the complete diagnosis of cranial and facial trauma, one must take into consideration the various classification systems, imaging data, and even the cause and mechanism of trauma production. There are still limitations in

life-threatening bleeding, or from the patient's relatives or even other surgical specialties. After stopping any nasal bleeding and securing airway patency, perform

**86**

(**Figure 1**) [9].

**Figure 2.**

*Fracture LeFort type III—CT scan with 3D reconstruction, clinical aspect before surgery, and surgical reconstruction with titanium plates.*

bleeding, subcutaneous emphysema, and infraorbital grove numbness. The oral cavity exam shows swelling of the superior vestibule, dental occlusion difficulties in vertical and sagittal planes, maxillary depression, and lack of lateral teeth superposition [15].

High-level transverse fracture LeFort type III has a violent mechanism of production at the level of the glabella or from lateral. The trajectory of such a fracture passes through the vomer, upper third of the nasal bones, ascending arch of the maxillary, ethmoid bone, floor of the orbit, external orbital wall, upper third of the pterygoid plate, and zygomatic arch [16].

At physical examination, the case presents depression of the nasal vault, tumefaction around both orbits, blood in the anterior eye pole, nasal bleeding, double vision, and facial subcutaneous emphysema. The oral cavity exam shows an abnormal movement in vertical and transverse planes of the mandible with retrognate maxillary bone and abnormal teeth occlusion (**Figure 2**) [17].

An emergency CT scan is compulsory in both axial and coronal planes with 3D reconstructions extremely helpful in planning surgery [18].
