A 35-year-old man has swelling and tenderness of the nose and deviation of the nose to the left after being accidentally struck in the face while playing squash. Intranasal examination shows a localized purple mass on the left side of the septum. A CT scan is shown on page 4. Which of the following is the most appropriate initial management?

(A) Immediate closed reduction and placement of an external splint
(B) Immediate open reduction of the nasal fractures
(C) Immediate incision and drainage of the septal mass
(D) Immediate submucous resection of the septal fracture

The correct response is Option C.

The most appropriate initial step in the management of this patient is immediate incision and drainage of the septal hematoma. If left untreated, septal hematomas cause fibrosis and narrowing of the nasal passages, distortion of the septum, and/or formation of an abscess. They can also cause pressure necrosis of the septum, leading to septal perforation and eventually to complete necrosis with formation of a saddle-nose deformity.

Fracture management is undertaken after the hematoma has been evacuated. In patients who have significant swelling obscuring the nasal structure, fracture reduction is delayed until the swelling resolves, typically within five to 10 days. If swelling is minimal, then reduction can be performed immediately after evacuation.

Although closed reduction is appropriate in most patients with nasal fractures, open reduction may be necessary to obtain anatomic reduction. If lacerations are present, they may be used as incisions for surgical reduction. However, it should be noted that open techniques have been associated with a small incidence of necrosis of the traumatized nasal mucosa. In addition, unsatisfactory results following surgery are likely to lead to severe injury of the nasal septum that may be difficult to correct. Formal rhinoplasty may be performed at a later date to resolve breathing difficulties or improve the aesthetic appearance of the nose.

References
1. Manson PN. Facial fractures. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith’s Plastic Surgery. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:383-412.
2. Rohrich RJ, Adams WP. Nasal fracture management: minimizing secondary nasal deformities. Plast Reconstr Surg. 2000;106:266-273.

A 25-year-old woman sustains a frontal sinus fracture in a motor vehicle collision. On physical examination, there is cerebrospinal fluid rhinorrhea. A CT scan of the head shows displacement of both the anterior and posterior walls and fracture lines extending through the nasofrontal ducts. Which of the following is the most appropriate management?

(A) Ablation
(B) Cranialization
(C) Exenteration
(D) Nasalization
(E) Obliteration

The correct response is Option B.

Cranialization of the frontal sinus is the most appropriate management of this patient who has a fracture of the posterior table of the frontal sinus with a concomitant cerebrospinal fluid leak. This procedure is often recommended for patients with severe comminution of the posterior table to resolve any cerebrospinal fluid leakage. Bifrontal craniotomy is performed first to repair the dura, and the posterior table of the frontal sinus and associated mucosa are removed. The nasofrontal duct is occluded with a pericranial flap, disrupting the communication of the duct with the frontal sinus. Following surgery, the brain gradually expands to fill the space previously occupied by the frontal sinus.

Ablation of the frontal sinus involves total removal of the anterior and posterior tables. This procedure is no longer performed due to its resultant cosmetic defects.

Exenteration involves removal of the anterior table of the frontal sinus only. Although it results in a cosmetic deformity, it may be considered in patients who have severe damage to the anterior table resulting from infection and who cannot undergo immediate reconstruction.

Nasalization is a technique in which the nasofrontal duct is either stented or enlarged to ensure adequate drainage of the frontal sinus. This procedure is typically used in patients with frontal basilar fractures involving the nasofrontal duct or floor of the sinus.

Obliteration of the frontal sinus is accomplished by removing all of the mucosa within the frontal sinus and allowing the nasofrontal duct to occlude. Graft material can be used for filling, or the space may remain open and eventually close through the process of spontaneous osteogenesis. This technique is recommended for patients in whom the patency of the nasofrontal duct is compromised.

References
1. Manson PN. Facial fractures. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith’s Plastic Surgery. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:383-412.
2. Rohrich RJ, Hollier LH. Management of frontal sinus fractures: changing concepts. Clin Plast Surg. 1992;19:219-232.

A 32-year-old man sustains a fracture of the mandible in a motor vehicle collision. The likelihood of concomitant cervical spine injury in this patient is closest to

(A) 10%
(B) 20%
(C) 30%
(D) 40%
(E) 50%

The correct response is Option A.

In patients who sustain facial fractures in motor vehicle collisions, the incidence of cervical spine injury has been shown to range from 5% to 15%, according to the results of multiple studies. Overall, multiple studies have reported the incidence of concomitant injuries associated with facial fractures sustained during motor vehicle collisions as ranging from 11% to 99%. These injuries are most likely to include closed head injuries, soft-tissue lacerations to the face, head, or other regions, and fractures of the ribs, pelvis, and lower extremities.

Because of the correlation between facial fractures and cervical spine injuries, standard Advanced Trauma Life Support (ATLS) protocols recommend that the cervical spine be immobilized until the absence of cervical spine injury can be documented definitively. These injuries can result in paresis, paraplegia, and even death; therefore, the surgeon must maintain a high index of suspicion in any patient who sustains a mandibular fracture in a motor vehicle collision. Even patients who have mandibular fractures resulting from physical altercations should be evaluated carefully, although the incidence of concomitant cervical spine injury is not as high as in those patients who are involved in motor vehicle collisions.

Patients with mandibular fractures often have other associated injuries, such as lacerations of the face and head and other associated facial fractures. These patients should also be evaluated for potential closed head injury, which is a life-threatening concern associated with high mortality rates.

References
1. Fischer K, Zhang F, Angel MF, et al. Injuries associated with mandible fractures sustained in motor vehicle collisions. Plast Reconstr Surg. 2001;108:328-331.
2. Freidrich KL, Pena-Velasco G, Olson RA. Changing trends with mandibular fractures: a review of 1,067 cases. J Oral Maxillofac Surg. 1992;50:586-589.

A 27-year-old man has malocclusion and tenderness around the orbits and bridge of the nose after sustaining facial injuries in a motor vehicle collision. A photograph and CT scan are shown above. The patient is to undergo open reduction and internal fixation of the fractures.

Which of the following is the most appropriate management of the lacrimal system?

(A) Observation
(B) Exploration of the lacrimal duct
(C) Placement of a silicone stent
(D) Immediate dacryocystorhinostomy
(E) Primary repair followed by dacryocystorhinostomy in three months

The correct response is Option A.

In this patient who has sustained a naso-orbitoethmoid fracture, the most appropriate management of the lacrimal system is observation. The incidence of injury to the nasolacrimal duct in patients who undergo open reduction and internal fixation of naso-orbitoethmoid fractures but have no overlying lacerations is fairly low. Although swelling or fracture may contribute to blockage of the duct at the time of the initial injury, approximately 90% of patients will experience improvement of symptoms with resolution of the swelling and reduction of the fracture.

Exploration and/or manipulation of the duct are not recommended if there is no obvious injury to the duct. These procedures may only result in further damage because of the edema and friability of the tissues. Immediate dacryocystorhinostomy is not warranted for the same reason.

Patients who have persistent epiphora after resolution of swelling should undergo further evaluation. Dacryocystography can be performed for assessment of possible nasolacrimal duct occlusion. If occlusion is present, dacryocystorhinostomy is indicated.

References
1. Crawley WA, Vasconez HC. Midface, upper face, and panfacial fractures. In: Ferraro JW, ed. Fundamentals in Maxillofacial Surgery. New York, NY: Springer-Verlag; 1997:203-214.
2. Gruss JS, Hurwitz JJ, Nik NA, et al. The pattern and incidence of nasolacrimal injury in naso-orbital-ethmoid fractures: the role of delayed assessment and dacryocystorhinostomy. Br J Plast Surg. 1985;38:116-121.
3. Manson PN. Facial fractures. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith’s Plastic Surgery. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:383-412.

The CT scans shown above are from a 25-year-old man who sustained facial injuries in a motor vehicle collision. In this patient, rigid fixation at which of the following points is most likely to result in stable reduction of the fractures?

(A) Nasomaxillary buttress, inferior orbital rim, and zygomaticomaxillary buttress
(B) Zygomatic arch, central fragment, and nasomaxillary buttress
(C) Zygomatic arch, inferior orbital rim, and zygomaticomaxillary buttress
(D) Zygomaticofrontal suture, inferior orbital rim, and zygomaticomaxillary buttress
(E) Zygomaticofrontal suture, orbital floor, and zygomaticomaxillary buttress

The correct response is Option D.

This patient has sustained a fracture of the zygomaticomaxillary complex, also known as a zygoma fracture. To ensure stable reduction of the fracture, rigid fixation is applied at the zygomaticofrontal suture, inferior orbital rim, and zygomaticomaxillary buttress. Partial relapse may occur without this three-point rigid fixation.

Central fragments are associated with naso-orbitoethmoid fractures, not zygomaticomaxillary complex fractures. This fragment is comprised of the ascending frontal process of the maxilla and the descending internal angular process of the frontal bone. It provides the bony support for the medial canthus.

The nasomaxillary buttress is comprised of the piriform rim and is osteotomized routinely during elective Le Fort I maxillary advancement procedures. This structure is typically involved in midface fractures and not in fractures of the zygomaticomaxillary complex.

The orbital floor is often involved in zygomaticomaxillary complex fractures but not in simple fractures of the zygoma. Therefore, open reduction and internal fixation of the orbital floor may not be necessary to ensure correction of the zygomaticomaxillary fracture.

The zygomatic arch is contained within a periosteal sleeve and is often reduced and fixed adequately with adequate reduction and fixation of the zygomaticomaxillary complex. Open reduction and internal fixation through a coronal approach may be required if the zygomatic arch is comminuted significantly, but this is rare.

References
1. Crawley WA, Vasconez H. Midface, upper face, and panfacial fractures. In: Ferraro JW, ed. Fundamentals of Maxillofacial Surgery. New York, NY: Springer-Verlag; 1997:203-214.
2. Manson P. Facial fractures. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith's Plastic Surgery. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:383.

A 25-year-old man has diplopia two days after sustaining an orbital fracture in a motor vehicle collision. On physical examination, he does not have enophthalmos; review of CT scans obtained immediately after injury shows no bony displacement or entrapment of the orbital contents within the fracture.

Which of the following is the most appropriate next step in management?

(A) Observation
(B) Administration of a corticosteroid
(C) Administration of a diuretic
(D) MRI
(E) Immediate operative exploration

The correct response is Option A.

Conservative management is recommended in this patient who has diplopia after sustaining an undisplaced, stable orbital fracture without entrapment or enophthalmos. Diplopia often occurs following orbital trauma and may be caused by edema, neurovascular or muscle injury, or entrapment of surrounding structures within the fracture. If entrapment is the cause, surgical release should be performed within the first 24 to 48 hours after injury to prevent permanent muscle damage. However, if there is no entrapment, as in this patient, observation for 10 to 14 days is most appropriate. This will allow for resolution of any edema or temporary palsy. Repeat evaluation can then be performed at this time.

CT scan, not MRI, is most appropriate for evaluating the condition of the fracture site.

Corticosteroids or diuretics are not indicated in patients who have diplopia following orbital fracture.

Operative exploration is appropriate for reduction of bony fragments, release of entrapped, compressed, or prolapsed tissues, and accurate restoration of orbital volume, but is not the most appropriate next step in this patient.

References
1. Manson PN. Facial fractures. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith’s Plastic Surgery. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:383.
2. Smith ML, Williams K, Gruss JS. Management of orbital fractures. Operative Techniques Plast Reconstr Surg. 1998;5:312.

A 16-year-old basketball player is undergoing evaluation 12 hours after sustaining a nasal fracture in a basketball game. Physical examination of the fracture site shows marked edema. The radix is stable. A single fracture fragment is displaced from the bony nasal pyramid. Intranasal examination shows septal hematomas bilaterally.

Which of the following is the most appropriate management?

(A) Drainage of the septal hematomas followed by closed reduction and splinting in three days
(B) Immediate operative drainage of the septal hematomas, followed by closed reduction and splinting
(C) Drainage of the septal hematomas and intraoral open reduction and internal fixation of the nasomaxillary suture line in three days
(D) Closed reduction of the nasal fracture in three days, followed by submucosal resection and inferior turbinate infracture in six months
(E) CT scan of the face to rule out a naso-orbitoethmoid fracture, followed by open reduction and internal fixation of the fractures and septoplasty

The correct response is Option A.

In this patient who has sustained a nasal fracture with displacement of one fragment, intranasal examination shows septal hematomas bilaterally. Therefore, the most appropriate management is drainage of the hematomas, followed by closed reduction and splinting in three days. It is imperative to drain the hematomas immediately to prevent the development of complications, including thickening of the septum (ie, “cauliflower” deformity) or dissolution and collapse of the septum, which will ultimately result in a saddle-nose deformity. Because this patient has significant swelling, closed reduction should be delayed. After the swelling has decreased (typically at three to five days after injury), the septum and nasal pyramid should be reduced, and the nasal pyramid should then be splinted.

Immediate closed reduction is difficult in any patient with significant edema.

Internal fixation and/or septoplasty are not required for management of uncomplicated nasal fractures.

Submucous resection and turbinectomy are rarely necessary because most patients with nasal fractures do not experience airway compromise.

References
1. Dolezal RF. Fractures of the nose. In: Cohen M, ed. Mastery of Plastic and Reconstructive Surgery. Boston, Mass: Little, Brown & Co; 1994;2:1126-1135.
2. Manson P. Management of midfacial fractures. In: Georgiade GS, Riefkohl R, Levin LS, eds. Plastic, Maxillofacial and Reconstructive Surgery. Baltimore, Md: Williams & Wilkins; 1997:351-376.

A 23-year-old man is undergoing evaluation one week after sustaining a nasal fracture. Each of the following is appropriate management of this patient’s injuries EXCEPT

(A) closed realignment of the nasal fracture with forceps
(B) drainage of septal hematomas
(C) intranasal packing
(D) osteotomy and realignment of the nasal fracture
(E) use of a dorsal nasal splint

The correct response is Option D.

Complications associated with fracture of the nasal bones include hemorrhage and hematoma. Bleeding is common with nasal trauma because of the rich blood supply of the mucoperichondrium. Fracture of the nasal septum can lead to hematoma, which frequently occurs bilaterally, as septal fractures communicate between both sides of the nose. If untreated, a septal hematoma can become thick and fibrotic, obstructing the nasal passage, or can cause pressure necrosis of the nasal mucosa and cartilage, ultimately leading to septal perforation. Therefore, appropriate management involves incision along the base or most inferior portion of the hematoma, which will allow for drainage and prevent blood from refilling the cavity. In addition, closed reduction is appropriate for septal fractures and deviated nasal bones. Intranasal packing and dorsal nasal splints are typically used to aid in maintaining the reduction.

Osteotomy should not be performed in patients with acute fractures because nasal collapse may result. This procedure should be delayed until the fracture has healed significantly.

References
1. Manson PN. Facial injuries. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders; 1990;2:988.
2. Verwoerd CD. Present day treatment of nasal fractures: closed versus open reduction. Facial Plast Surg. 1992;8:220.