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ABSTRACT: Background : Traumatic craniofacial and skull base injuries require a multidisciplinary team approach. Trauma physicians must evaluate carefully, triage properly, and maintain a high index of suspicion to improve survival and enhance functional recovery. Frequently, craniofacial and skull base injuries are overlooked while treating more life-threatening injuries. Unnoticed complex craniofacial and skull base fractures, cerebrospinal fluid fistulae, and cranial nerve injuries can result in blindness, diplopia, deafness, facial paralysis, or meningitis. Early recognition of specific craniofacial and skull base injury patterns can lead to identification of associated injuries and allow for more rapid and appropriate management.
Conclusion : Early detection and treatment of craniofacial and skull base traumatic injuries should lead to decreased morbidity and mortality. This review discusses the most common of these injuries, their possible complications, and treatment.
In the United States in 1999, there were over 6 million automobile crashes. Over 2 million crashes resulted in injuries and over 37,000 deaths. 1 Over 75% of these injuries have craniofacial or cervical spine injuries. 2 With the advent of ever-increasing sophistication in computed tomographic (CT) imaging, trauma surgeons can rapidly diagnose small facial fractures and intracranial hemorrhages. However, despite imaging improvements and more thorough physical examination, subtle complex facial fractures with cerebrospinal fluid (CSF) leaks, temporal bone fractures, and cranial nerve injuries can remain undiagnosed. Unfortunately, delayed or missed diagnoses can lead to significant morbidity (blindness, diplopia, deafness, facial paralysis, and meningitis) or death. Greater awareness of potential cranial injuries is needed to facilitate more rapid diagnosis and appropriate treatment.
A careful history and physical examination are paramount for accurate diagnosis of craniofacial injury. After performing the primary survey outlined by Advanced Trauma Life Support, a more thorough secondary survey should proceed systematically. The clinical examination of the craniofacial skeleton begins with inspection for localized tenderness, numbness, bleeding, asymmetry, deformity, ecchymosis, periorbital edema, otorrhea, and rhinorrhea. All bony surfaces should be palpated, including the superior and inferior orbital rims, zygomatic arches, nose, maxilla, mandible, and both alveolar ridges. Even if the eye is swollen shut, both eyes should be examined closely; examination should include visual acuity and extraocular muscles. Midface stability should be appraised. Alveolar ridges and teeth should be examined for dental trauma and occlusion should be assessed. 3,4
In the conscious and cooperative patient, a detailed cranial nerve (CN) examination should be performed. The optic nerve, CN II, is assessed by visual field acuity. Extraocular movements test the integrity of CN III, IV, and VI. 5 Hypoesthesia of the face suggests CN V injury. Facial nerve injury, CN VII, produces paresis or paralysis of the muscles of facial expression.
The cranial nerve examination of the comatose patient is slightly more difficult and relies on testing of brain stem reflexes. 6 In the comatose patient, assessing vision can be difficult; even with complete unilateral visual loss, pupils can remain equally reactive as long as the efferent pathway of CN III is intact. 7 The optic and oculomotor systems should be evaluated by the swinging flashlight test. The test requires an intact afferent CN II pathway and an intact efferent CN III parasympathetic pathway. 7 Testing patients with unilateral afferent CN II damage reveals bilateral, equal pupillary constriction when light is directed toward the eye with vision. However, when light is directed toward the eye with diminished vision, bilateral pupils will dilate. The phenomenon is referred to as the Marcus Gunn pupil. 7 In the comatose patient, extraocular movements can be tested with the oculocephalic (or doll's-eye) reflex. The corneal reflex consists of touching the cornea with a piece of cotton; afferent fibers of CN V send the message to the brain and CN VII responds by eyelid closure. CN VIII is assessed with the cold-water caloric test, in which ice water is injected into the ear and elicits nystagmus. Testing of the gag reflex evaluates CN IX and CN X. After careful physical examination, the trauma surgeon should focus on specific areas of common craniofacial injuries.
The Journal of Trauma and Acute Care Surgery. 04/2003; 54(5):1026-1034.
