Developed by the Academy's Trauma Committee, this simple, concise, and easily accessible source of diagnostic and therapeutic guidelines for the examining/treating resident is an important tool, both educationally and clinically. It should be used as a quick-reference tool in the evaluation of a trauma patient and in the planning of surgical repair and/or reconstruction. This manual supplements, but does not replace, more comprehensive bodies of literature in the field. Use this manual well and often in the care of your patients.
Resident Manual of Trauma to the Face, Head, and Neck by Chapter
Because the otolaryngologist may not be present during patient arrival in the trauma bay, the patient assessment often begins with a call from a referring physician. Important information to retrieve includes the urgency of the patient's status, mechanism of injury, injury list, medical and demographic information, and, most important, airway status. It is important to review with the trauma team the potential for an unstable airway in any patient with craniofacial or neck trauma. When in doubt, the otolaryngologist should consider himself or herself the definitive airway expert. The importance of an ear, nose, and throat evaluation has been proven to be critical. Otolaryngologists have the airway, endoscopy, and neck exploration skills necessary to take care of the most critically injured patients.
Understanding the general principles of trauma repair in the face, head, and neck region is very important to achieving optimal outcome for the patient. Foundational is the knowledge of mechanisms of injury, tissue damage, and implications for surgical repair, based on the etiology of the trauma. Concomitant injuries of associated structures, such as the brain, spinal cord, and soft tissues, require a comprehensive knowledge of the anatomy, functional physiology, and potential risks and complications.
The implementation of the shoulder harness seat belt in motor vehicles has resulted in a much lower incidence of frontal sinus fractures. Because of the thick bone of the anterior wall of the sinus as well as its curved convexity, this first barrier to the effects of cranial trauma resists fracture. Fractures of the naso-orbital-ethmoid (NOE) region are typically due to blunt trauma injuries. Etiologies may range from motor vehicle accidents to falls and sports, but the force and focus of the blow determine the extent of the injuries to the structures located in this region of the face.
Fractures of the midfacial bones are most commonly due to blunt trauma from falls, altercations, and motor vehicle accidents. The aim of the treatment of midfacial trauma is to provide the patient afflicted with this injury the best aesthetic and functional result with a single procedure, if one is indicated. Nasal fractures are a commonly encountered, and often isolated, form of facial fractures. The prominence of the nose on the face makes it the common recipient of injury. Despite the frequency in which nasal fractures are encountered, the consulting surgeon may be confused regarding which approach is best applied to a given patient.
Mandible fractures are among the most common skeletal injuries in man due to blunt or penetrating trauma. They are often associated with other craniofacial, cervical, and systemic trauma. Mandibular fractures may destabilize the airway and may create malocclusion, joint dysfunction, pain, infection, and paresthesia. In facial trauma management, emergent consideration must be given to secure the airway and obtain hemostasis before initiating definitive treatment of any fracture.
Although temporal bone fractures are relatively uncommon, they present many complex diagnostic and therapeutic challenges. A large volume of force is required to fracture the temporal bone. These fractures rarely occur in isolation. Five percent of patients with significant head trauma will also sustain temporal bone fractures. Most often, treatment of temporal bone trauma can be delayed, after life-threatening injuries are treated.
Penetrating neck trauma has historically carried a high mortality rate, ranging as high as 16 percent during World War I when nonsurgical management was performed. During World War II, when mandatory
neck exploration was instituted, the mortality fell to 7 percent and remained 4–7 percent during the Vietnam War.Surgical management has evolved over the last two decades, based on the advent of advanced radiographic studies and endoscopic techniques. Most civilian centers currently practice selective neck exploration, with mortality rates ranging 3–6 percent for low-velocity penetrating neck trauma.
Traumatic injuries of the larynx are diverse, uncommon, and potentially life threatening. While each laryngeal injury is unique, an organized and appropriate management algorithm for the various types of laryngeal trauma results in increased patient survival as well as improved longterm functional outcomes. The management of laryngeal trauma can be complex, as the signs and symptoms are often variable and unpredictable, with severe injuries sometimes presenting with mild and innocuous symptoms. The immediate goal in managing laryngeal trauma is to obtain and maintain a stable airway for the patient. Once the airway is safely secured, the laryngeal injury is repaired in order to optimize the patient's long-term functional outcomes terms of breathing, speech, and swallowing.
Soft tissue wounding arises from myriad etiologies, from knife or gunshot wounds to animal injuries, and from assaults to motor vehicle accidents. As in all trauma cases, airway security, maintenance of breathing, and circulation are of primary concern. Thereafter, attention may be turned toward repair of facial trauma. A complete head and neck exam can often be accomplished in the emergency room or
outpatient surgery facility under local anesthesia with or without anesthesia monitoring. For difficult or complicated cases, operative intervention under general anesthesia, particularly in young children or in those patients with polytrauma or life-threatening injuries, may be considered. Surgical goals include functional and cosmetic restoration, while preserving tissue and preventing infection.Foreign body aspiration and caustic ingestion can be life-threatening emergencies. Rapid recognition, work-up, and treatment reduce the risk of complications and associated morbidity and mortality. Given the importance of endoscopy in these patients, a general understanding of the upper aerodigestive anatomy is critical in their management. This includes nares, nasopharynx, oral cavity, oropharynx, and larynx.
The clinical outcome for an individual patient after treatment for injuries to the face, head, and neck will depend upon a number of factors. Not all of these factors are under the direct control of the surgeon, especially where resources are limited and where the community has a high level of endemic noncommunicable diseases. The main factors under surgeon control are the extent of knowledge, experience, and competency of the surgeon. Patient outcomes after trauma care have a strong correlation with these factors. Therefore, throughout their career, otolaryngologists–head and neck surgeons must maintain interest in, and the practice of, modern trauma surgery.
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