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Overview

What is a broken jaw (mandibular fracture)?

A broken jaw (mandibular fracture) is the second most common facial fracture in sports

because of the anterior location on the skull. The mandible is the jawbone. Because the

mandible is exposed and not covered by most protective devices, it is susceptible to injury.

Symptoms

What are the signs and symptoms of a broken jaw?

The mandible usually fractures in more than one place and occurs on opposite sides of the

midline of the jaw. These fractures can either be displaced (more severe with bone ends

separated and moved apart) or nondisplaced (bone ends aligned).

The signs and symptoms of a displaced broken jaw include:

Gross deformity

Malocclusion (teeth do not align when jaw is closed)

Oral bleeding

Paresthesia or anesthesia of lower lip andchin

Changes in speech

Swelling

Bruising to the floor of the mouth

Mucous membrane tears

The signs and symptoms of a nondisplaced broken jaw include:

Oral bleeding oozing between the teeth

Point tenderness over the fracture site

Pain on opening and closing the jaw

Swelling

Discoloration


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Causes

Who gets a broken jaw?

A broken jaw is most often caused by a blow to the lower jaw from sports equipment (hockeystick, bat). Because of the length of a hockey stick and/or bat, it does not take as much force

from the opponent swinging the equipment to create enough force to fracture the jawbone.

Mountain biking is another sport with a high incidence of facial fractures. This type of injury

occurs when the athlete goes over the handlebars and falls directly onto the lower jaw or chin

hitting a hard surface.

Fighting sports in which direct blows are delivered as part of the sport (boxing, mixed martial

arts) also have a high incidence of jawbone fractures.

Treatment

What is the immediate treatment for a broken jaw?

If a broken jaw is suspected, emergency services should immediately be called. Initial

treatment should be focused on maintaining an open airway with the athlete in a sitting

position with the athletes hands supporting the lower jaw. This position will allow the blood

to flow forward and out of the mouth rather than back into the throat.

Because the amount of force required to fracture the mandible is significant, care must be

taken to evaluate the athlete for possible concussion and/or brain injury also.

To determine if the athlete has any signs and symptoms ofconcussion, check for the

following:

Dizziness

Headache

Confusion Nausea

Ringing in the ears

Inability to answer simple questions

If any of the above symptoms are present, assume that the athlete may also have a

concussion. An unconscious athlete or an athlete with a suspected concussion should be

placed on their side with head tilt and jaw support after the mouth has been cleared of any

broken or dislodged teeth.

The jaw can be immobilized using an ace bandage or roller gauze but care must be taken to

ensure that the jaw is not displaced posteriorly which may compromise the airway. Thebandages can be wrapped under the chin and over the top of the head.
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A crushed ice pack can be applied to the area to reduce the amount of swelling. However,

care must be taken that the weight of the ice pack does not displace the fracture.

More Information: Read aboutsports injury treatment using the P.R.I.C.E. principle-

Protection, Rest, Icing, Compression, Elevation.

Is surgery needed to repair a broken jaw?

If the athlete has sustained a nondisplaced jawbone fracture, the healing can be managed

conservatively with analgesia and rest. To allow the fracture to heal properly, the athlete

should only eat soft foods for up to four weeks or as long as recommended by the treating

physician.

Most displaced jawbone fractures will require closed reduction and internal fixation for four

to six weeks. While the athletes jaw is wired shut, the athlete should be consuming high -

protein, high-carbohydrate liquid diets. It is normal for an athlete to lose between 5% and

10% of his/her body weight during this time. If there is concern about the amount of weightlost, the athlete should consult with a nutritionist.

When is it safe to return to sports after a broken jaw?

Light activities such as stationary cycling, walking, and light resistance exercises can be

performed during the time of fixation to maintain muscle tone. Care should be taken not to

increase the heart rate to a level where increased oxygen is needed for the muscles because

the athlete is only able to breathe through his/her nose and not able to breathe through his/her

mouth to increase the oxygen uptake. It is recommended that the athlete should not return to

contact or collision sports until one to two months after the jaw is unwired.

If you suspect that you have a broken jaw (mandibular fracture), it is critical to seek the

urgent consultation of a local sports injuries doctor for appropriate care. To locate a top

doctor or physical therapist in your area, please visit ourFind a Sports Medicine Doctor or

Physical Therapist Near You section.

Related Articles

Broken Nose (Nasal Fracture)

Subdural Hematoma

Orbital Blowout FractureTraumatic Brain Injury (TBI)

References

Anderson, M.K., Hall, S.J., & Martin, M. (2009). Foundations of Athletic Training:

Prevention, Assessment, and Management. (3rd Ed). Lippincott Williams & Wilkins:

Philadelphia, PA

Bahr, R., & Maehlum S. (2004). Clinical Guide to Sports Injuries. Human Kinetics:

Champaign, IL.
http://www.sportsmd.com/SportsMD_Articles/id/347.aspxhttp://www.sportsmd.com/SportsMD_Articles/id/347.aspxhttp://www.sportsmd.com/SportsMD_Articles/id/347.aspxhttp://www.sportsmd.com/SportsMD_DoctorSearch/d/doctors.aspxhttp://www.sportsmd.com/SportsMD_DoctorSearch/d/doctors.aspxhttp://www.sportsmd.com/SportsMD_DoctorSearch/d/doctors.aspxhttp://www.sportsmd.com/SportsMD_DoctorSearch/d/doctors.aspxhttp://www.sportsmd.com/Articles/tabid/1010/id/25/Default.aspx?n=broken_nose_%28nasal_fracture%29http://www.sportsmd.com/Articles/id/7/n/subdural_hematoma.aspxhttp://www.sportsmd.com/Articles/id/26/n/orbital_blowout_fracture.aspxhttp://www.sportsmd.com/Articles/tabid/1010/id/28/Default.aspx?n=traumatic_brain_injury_%28tbi%29_the_high_price_athletes_pay_to_compete_in_high_risk_sportshttp://www.sportsmd.com/Articles/tabid/1010/id/28/Default.aspx?n=traumatic_brain_injury_%28tbi%29_the_high_price_athletes_pay_to_compete_in_high_risk_sportshttp://www.sportsmd.com/Articles/id/26/n/orbital_blowout_fracture.aspxhttp://www.sportsmd.com/Articles/id/7/n/subdural_hematoma.aspxhttp://www.sportsmd.com/Articles/tabid/1010/id/25/Default.aspx?n=broken_nose_%28nasal_fracture%29http://www.sportsmd.com/SportsMD_DoctorSearch/d/doctors.aspxhttp://www.sportsmd.com/SportsMD_DoctorSearch/d/doctors.aspxhttp://www.sportsmd.com/SportsMD_Articles/id/347.aspx


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Assessment & management of facial trauma injuries

Facial trauma can present some of the most challenging injuries that prehospital care

providers are called on to manage. Although most injuries to the face arent life-threatening,

some may compromise the patients airway or result in significant hemorrhage requiring the

providers immediate attention.

Facial trauma may also be associated with other injuries that place the patients life in

jeopardy. Finally, these injuries may be disfiguring, which may distract the novice provider

from recognizing and addressing more serious conditions.

Mechanisms of InjuryAlthough injuries to the face are mostly the result of blunt trauma, they may also result from

penetrating trauma. The most common causes of blunt trauma to the face are motor vehicle

crashes and assaults. During a crash, an occupant may strike their face on hard surfaces inside

the vehicle, such as the steering wheel, dashboard or windshield, or on the roadway if theyreejected from the vehicle.

Assaults, another common cause of injuries, occur when the face is punched by a fist or

struck by an object. A minority of these injuries result from stab, gunshot or shotgun wounds.

Assessment: Primary SurveyThe primary survey is a rapid assessment of vital functions to identify life-threatening

conditions. The typical approach for performing the primary survey is through the standard

ABCsairway, breathing and circulationdisability and exposure (A-B-C-D-E).

Airway & breathing: The primary survey begins with an assessment of airway patency. Whenthe provider first sees the patient, numerous clues may point toward an inadequate airway.

When lying in a supine position, an unconscious patient is at risk for airway obstruction from

the tongue as it relaxes and falls back to block the airway. Noisy breathing, namely gurgling

or high-pitched noises, indicates partial airway obstruction. The airway may be compromised

by broken or avulsed teeth and fragments of bone, as well as blood or vomit. Because the

tongue is attached to the mandible, fractures of that bone may predispose the tongue to block

the airway, especially if its broken in two locations.

Facial fractures, such as injuries to the maxilla or mandible, may cause mechanical

obstruction or result in associated hemorrhage. Penetrating injuries, such as those caused by a

gunshot wound to the face, and severe facial fractures may disrupt blood vessels deep withinthe facial skeleton, resulting in hemorrhage that may pool in the airway. This blood may

drain externally through the nose and mouth, but it may also be swallowed by an unconscious

patient. Injuries to the arteries of the face can produce an expanding hematoma that may grow

to occlude the airway. Nasal flaring and the use of accessory respiratory muscles, such as the

strap muscles of the neck, indicate the patient is struggling to breathe.

Conscious patients with facial injuries will typically find a position that facilitates breathing

(often sitting up and leaning forward), and they may become combative if forced to lay

supine. With the exception of airway compromise, facial trauma doesnt impair oxygenation

and ventilation (breathing). Thus, when a patient with facial trauma is noted to have difficulty

in breathing but has an apparently patent airway, the provider should suspect either an occult


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airway obstruction (i.e., one they have not yet identified) or an associated thoracic injury,

such as a pulmonary contusion or pneumothorax.

Circulation:The face and scalp possess a high concentration of blood vessels, and even a

small wound can produce dramatic hemorrhage. More serious wounds can result in life-

threatening hemorrhage. A degloving injury of the scalp, in which a large portion of tissue ispeeled back off the skull, may result in significant external hemorrhage and decompensated

hypovolemic shock. As noted above, severe fractures to the midface may result in

exsanguinating hemorrhage.

Disability: Trauma to the face may be associated with traumatic brain injuries and injuries to

the spine and spinal cord. In the primary survey, the provider should assess the patients

Glasgow Coma Scale (GCS) score, making note of the eye, verbal and motor components. If

the patients GCS score isnt normal (i.e., less than 15), the provider next assesses the pupils

for symmetry and reaction to light. A depressed GCS score, combined with a unilateral

dilated pupil and lateralizing signs (weakness on one side of the body), is highly suggestive

of an intracranial hematoma (subdural or epidural). As with other vital signs, the GCS scoreshould be reassessed at five- to 15-minute intervals, depending on the severity of injury.

Exposure:In this step, all clothing is removed to allow for assessment of any other life-

threatening conditions that have yet to be noticed. Hats or caps should be removed from the

head so the entire scalp can be visualized and palpated.

Consider removing any protective gear (e.g., sports or motorcycle helmets) that may preclude

a thorough assessment of facial injuries.

Assessment: Secondary SurveyThe secondary survey is a complete head-to-toe assessment of the patient performed to

identify all obvious injuries. Its performed only after the primary survey is complete and any

life-threatening conditions have been ruled out or corrected. Conscious patients may also be

questioned about their injuries, including the mechanism of injury. Other important

symptoms to note include new onset of visual changes, double vision, hearing impairment or

numbness, location of pain, inability to open or close the mouth and a change in the

alignment of teeth (malocclusion).

The provider should inspect and palpate the face of all patients who have suffered facial

trauma. The face is inspected for any soft-tissue injuries. Any deviation of the nose or

asymmetry of facial structures, such as cheek bones and the mandible, is noted. Theoropharynx should be examined for evidence of broken teeth, foreign material or swelling of

the palate or floor of the mouth. Clear fluid draining from the nose or ear canals may be

cerebrospinal fluid and indicate a basilar skull fracture. The face is gently palpated, looking

for sites of tenderness, bony step-offs or crepitation.

In unconscious patients, a gloved flinger can be inserted into the mouth and the maxilla

gently pulled forward, looking for instability of the bones of the midface.

Extraocular movements can be tested by having the patient track a finger moving in different

directions. Deficits in EOMs may be the result of a nerve injury or entrapment of one of the

muscles that move the eye. The trigeminal nerves can be tested by lightly stroking theforehead, cheek and mandible and having the patient report any decreased sensation. The


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branches of the facial nerve can be tested by asking the patient to sequentially wrinkle their

forehead, raise their eyebrows, close their eyes tightly, puff out their cheeks, frown and smile,

showing their teeth.

Specific Injuries

Soft-tissue injuries of the face may include contusions, hematomas, abrasions, lacerations andavulsions, as well as stab and gunshot wounds. Because of the plentiful blood supply, wounds

that break the skin are often associated with hemorrhage, which is often brisk but rarely fatal.

Although many of these wounds are limited to the skin and subcutaneous fat, deeper wounds

may damage underlying structures, including muscles, nerves and salivary glands. Soft-tissue

injuries that overlie deformities and points of tenderness or crepitation may represent open

fractures of the facial skeleton.

The nasal bones are the most commonly fractured facial bones. Signs of a nasal fracture

include swelling, deformity and tenderness of the nose. Nasal bone fractures may be

associated with copious epistaxis (i.e., nosebleed). However, this bleeding is generally self-

limited. Squeezing of the nostrils just below the end of the nasal bones can assist withcontrolling persistent epistaxis.

One concerning complication of a nasal fracture is a septal hematomaa collection of blood

inside the nasal septum. The blood supply to the delicate, cartilaginous portion of the nasal

septum may be impaired by the hematoma, resulting in necrosis of the cartilage. Over time,

this cartilage collapses, and the nose develops a saddle deformity.

Another type of fracture is an orbital blowout fracture, which involves a direct blow to the

orbit. As the pressure in the orbit increases, the medial wall or floor may rupture, allowing

orbital contents, including fatty tissue and muscles, to herniate outward. A common fracture

pattern involves rupture of the orbital floor, resulting in entrapment of the inferior rectus

muscle of the eye. This prevents the affected eye from looking superiorly when EOMs are

examined. Because the eyes dont move in unison, the patient may complain of diploplia

when looking in certain directions.

Another sign of a blowout fracture is enophthalmos, or sinking in of the eyeball in orbit,

although its often hard to appreciate in an acute injury. An orbital fracture may also be

associated with proptosis, or protrusion of the eyeball from its socket. Proptosis usually

results from a retrobulbar hematoma, a collection of blood behind the eyeball, and may

jeopardize sight by stretching the optic nerve.

Yet another type of facial fracture is to the zygomatic arch, or cheekbone. On each side of the

face, the zygomatic bone creates an arch where it connects to the temporal bone on the side of

the skull. This zygomatic arch provides structure to the cheek and is prone to fracture when

struck by a direct blow. Signs of a cheekbone fracture include swelling; bruising; facial

asymmetry, which is characterized by a depressed cheekbone on the injured side; and

trismus, or spasm of the muscles of mastication that impairs the ability to open the mouth.

For other types of fractures occurring to the bones of the midface, we can look to history.

More than a century ago, Rene LeFort studied facial fractures in an experimental fashion. He

noted three common patters of fractures involving the bones of the midface1 (see Figure 2,).

The following are called LeFort fractures:


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LeFort I:This injury involves a horizontal fracture of the maxilla from the remainderof the midface. The maxilla may be depressed downward toward the tongue and

compromise the airway because of the fracture and associated swelling.

LeFort II: This injury is also known as a pyramidal fracture because the fractureplane extends obliquely in an inferolateral direction. This type of midface fracture

may be associated with significant hemorrhage because the fracture extends throughthe highly vascularized sinus cavities.

LeFort III: This injury is also known as craniofacial dissociation because the bones of the

midface are fractured off from the remainder of the skull.

Fractures of the mandible are the second most common type of facial bone fracture. If

conscious, the patient often complains of jaw painespecially when clenching their teeth

and malocclusion. Malocclusion refers to a change in how the teeth come together with the

mouth. Signs of a mandibular fracture include tenderness, swelling and deformity of the

mandible. When examining the oral cavity, the provider might note tears in the mucosa of the

gums and broken teeth.

Midface fractures often dont fit perfectly into one of the three LeFort categories but may be

a combination of two types. These fractures can be suspected in an unconscious patient by

mobility, which can be noted when a gloved finger is inserted into the mouth and the hard

palate is gently pulled forward.

Finally, injuries to teeth are common in patients with facial trauma. The provider may note

that teeth are loosened, fractured or avulsed (knocked out) from their sockets. Fractured teeth

are often painful, and the pain may worsen when the tooth is exposed to air. Tooth fragments

and avulsed teeth may be found in the oral cavity and should be removed. Avulsed teeth may

be salvaged if re-implanted within a short time period. Table 1 (p. 54) describes the care of

avulsed teeth.

ManagementLike most other injuries, definitive diagnosis and management occur in the hospital setting.

In the prehospital setting, place emphasis on establishing and maintaining a patent airway and

controlling external hemorrhage. These actions can be lifesaving.(2)

When caring for a patient with facial trauma, the providers highest priority is to ensure a

patent airway. Some conscious patients with severe facial trauma may be able to successfully

manage their airway. Although potential spinal injury is a concern, these patients maybecome combative if forced to wear a C-collar or lie supine on a long backboard. Such

patients can be transported in a position of comfort, generally sitting up, and they may be

given a suction device and allowed to suction fluid from their airway as needed. If the patient

allows, use manual stabilization of the head and neck during transport.

For the unconscious patient, essential airway skills are initiated while another provider

applies manual stabilization of the head and neck. The mouth may be opened with a modified

jaw thrust maneuver. Teeth and regurgitated food particles are swept from the mouth and

suctioning is used to remove blood. If transport times are brief, the airway may be

successfully managed with insertion of an oral airway and ventilating via a bag-valve-mask

(BVM) device. Repeat suctioning is performed as needed.


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For longer transport times, the airway is placed or endotracheal intubation is performed. Use

of a BVM may fail to ventilate a patient with severe facial trauma because an adequate seal

may not be possible with severe soft-tissue injuries that involve the mouth. If you cant

ventilate via either approach, consider performing needle cricothyrotomy with transtracheal

ventilation or a surgical cricothyrotomy, if protocols allow.

The airway should be reassessed at frequent intervals because facial traumas may have occult

airway injuries or progressively develop an airway obstruction. They may also have

associated thoracic injuries that can also contribute to impaired oxygenation and ventilation.

Use pulse oxymetry (SpO2) and administer oxygen to maintain oxygenation at or above 95%.

Another priority is to maintain circulation. These patients with facial trauma frequently

experience external hemorrhage. Most bleeding from facial injuries can be controlled with

firm, direct pressure on the site of the bleeding. Extensive scalp bleeding may be controlled

with the application of a pressure dressing, created out of gauze sponges and an elastic

bandage. If protocols allow, use of a topical hemostatic agent may help slow vigorous

hemorrhage. Unlike with bleeding from the extremities, tourniquets arent used around theneck because tightening will result in impaired blood flow to the brain. (For more on caring

for hemorrhaging patients, see the continuing education article, Shock Sense,JEMSJune

2011 issue,p. 58)

If bleeding continues from the oropharynx after intubation or cricothyrotomy is performed,

the mouth can be gently packed with gauze from a roll. This may help tamponade bleeding

from the mouth. If significant bleeding is coming from the nasal openings (nares), packing

these may only result in blood pooling in the hypopharynx.

If signs of shock are present, IV volume resuscitation can be initiated. Titrate IV fluids

should to maintain a systolic blood pressure in the 8090 mmHg range. More aggressive

volume resuscitation with crystalloid solutions may worsen hemorrhage by disrupting blood

clots or diluting blood clotting factors. Transport must never be delayed simply to place IV

lines; IVs can be initiated during transport.

If transport is prolonged due to long distances to a medical facility, wounds can be irrigated

with saline. Gently brush dirt and other debris from a wound using a moistened gauze pad.

Because many patients with significant facial injuries have concomitant traumatic brain

injuries (TBIs), frequently reassess neurologic functioning (GCS score and pupillary

response). Avoid hypoxia and hypotension because these factors are known to worsen theoutcomes of patients with TBIs. Anemia can also contribute to secondary brain injury,

underscoring the need to control external hemorrhage.

Finally, although more minor facial injuries can be satisfactorily managed at most community

hospitals, definitive management of complex facial trauma often requires the skills of

numerous surgical specialties, including plastic surgery, maxillofacial surgery,

otorhinolaryngology and ophthalmology. Therefore, these patients are probably best managed

in Level I and II trauma centers.

Summary

Many victims of severe facial trauma may recover with cosmetically satisfying resultsbecause of the modern techniques of operative fixation and the use of bone grafts. The


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prehospital care provider should focus on ensuring a patent airway and controlling

hemorrhage and then transporting to a facility capable of managing the patients injuries.

Some facial injuries may appear gruesome, but the provider should not be distracted from

identifying and managing life-threatening conditions. JEMS

Acknowledgment:The author would like to thank Vincent J. Perciaccante, DDS, for hisinsightful review of the manuscript.

References1. LeFort R: Etude experimentale surgery les fractures de la marclioire superieure, Parts I, II ,

III. Paris, 1901. Rev Chir.

2. Salomone JP, Pons PT, McSwain NE, et al, Eds.: Prehospital Trauma Life Support. 7th

Edition. St. Louis: Elsevier, 2011.

Recommended Reading>> Seyfer AE, Hansen JE. Facial Trauma. In: Moore EE, Feliciano DV, Mattox KL, Eds:

Trauma. 5th Edition. New York: McGraw Hill, 2003.

Facial AnatomyA provider called to treat a patient with a facial injury must understand the anatomy of the

face. A number of bones fuse together to form the facial skeleton (see Figure 1,). The

forehead is supported by the broad fontal bone, the lower portion of which forms the superioraspect, or roof, of the orbit (eye socket). Two maxillary bones comprise much of the

midfaces support. A small pair of nasal bones attaches superiorly to the frontal bone and

laterally to the maxillary bones, providing structure to the nose. The zygomatic bones, or

zygoma, lie between the maxillary bones and the temporal bone of the skull, supporting the

cheeks. Portions of the maxilla and the zygoma form the inferior aspect (or floor) of the orbit.

The frontal bone and each maxilla contain hollow cavities, the frontal and maxillary sinuses.

The arch-shaped mandible provides structure to the jaw. Additional bones form the deep,

internal structure of the face.

The structures of the head are highly vascularized, providing a rich blood supply to the facial

tissue and nerves. On each side of the neck, the common carotid arteries travel from the

thorax up toward the head. Near the angle of the jaw, each carotid artery bifurcates (divides)

into the internal and external branches. The internal carotid artery then travels deep in the

head and enters the cranial vault to supply blood to the brain.

The external carotid artery has numerous branches that supply blood to the face and scalp.They are the occipital artery, which supplies the occipital scalp; the posterior auricular artery,

which supplies the ear and adjacent scalp; the lingual artery, which supplies the tongue and

the floor of the mouth; the facial artery, the chief artery of the face; and the two terminal

branches of the vessel, the maxillary artery and superficial temporal artery.

Each facial artery crosses over the mandible near its angle and then traverses superomedially

across the face toward the medial corner of the eye. The maxillary arteries have many

branches that supply the deep structures on the sides of the face. The superficial temporal

arteries emerge from behind the parotid glandthe large salivary glands located over the

angle of the mandibleand track superiorly just anterior to the ear, supplying the superior

portion of the scalp. Because there are many interconnections between these arteries, woundsto the face often result in copious hemorrhage.


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Virtually all the important facial nerves arise from the cranial nerves, which are paired nerves

that originate directly from the base of the brain. The optic nerves (cranial nerve II) connect

the light-sensing retina of the eye to the brain. Cranial nerves (CNs) III, IV and VI control the

muscles that move the eye. The movement of each eye comes from six muscles: the superior

oblique; the inferior oblique; and the superior, inferior, medial and lateral rectus muscles. Thetrochlear nerves (CN IV) innervate the superior oblique muscles, and the abducens nerves

(CN VI) stimulate the lateral rectus muscles. The oculomotor nerves (CN III) innervate the

superior, inferior and medial rectus muscles and the inferior oblique muscles, and control

pupillary dilation. Injury to any of these nerves or muscles will impair extraocular

movements (EOMs) and result in binocular diploplia (double vision when looking out both

eyes) and disconjugate gaze (eyes pointing in different directions).

Sensation of the face comes from the trigeminal nerves (CN V), each of which split into three

branches. The ophthalmic nerves (often abbreviated V1) provide sensation to the upper eyelid

and the forehead. The maxillary nerves (V2) provide sensation to the midface, from the lower

eyelid to the upper lip. The mandibular nerves (V3) provide sensation from the ear downacross to the lower lip and jaw. The mandibular nerve also controls the muscles of

mastication (chewing). The facial nerves (CN VII) supply the platysma (a superficial muscle

in the neck), as well as the muscles of facial expression. As the facial nerves pass through the

parotid gland, they divide into five branches: temporal, zygomatic, buccal, mandibular and

cervical. Injury to any of these branches results in an inability to move the muscles they

innervate.

This article originally appeared in April 2011 JEMS as The Face of Trauma: Assessment &

management of facial trauma injuries.

Comprehensive Airway Management of Patients with Maxillofacial

TraumaRobert M. Kellman,M.D.

1andWilliam D. Losquadro,M.D.

1

Author informationCopyright and License information

Go to:

Abstract

Airway management in patients with maxillofacial trauma is complicated by injuries to routes

of intubation, and the surgeon is frequently asked to secure the airway. Airway obstruction

from hemorrhage, tissue prolapse, or edema may require emergent intervention for which

multiple intubation techniques exist. Competing needs for both airway and surgical access

create intraoperative conflicts during repair of maxillofacial fractures. Postoperatively, edema

and maxillomandibular fixation place the patient at risk for further airway compromise.

Keywords: Airway obstruction, facial injuries, intubation, jaw fractures, laryngeal masks, mandibular

fractures, maxillary fractures, maxillofacial injuries, tracheostomy
http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=PubMed&term=%20Kellman%20RM%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=PubMed&term=%20Kellman%20RM%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=PubMed&term=%20Losquadro%20WD%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=PubMed&term=%20Losquadro%20WD%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=PubMed&term=%20Losquadro%20WD%5Bauth%5Dhttp://void%280%29/http://void%280%29/http://void%280%29/http://void%280%29/http://void%280%29/http://void%280%29/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052732/#ui-ncbiinpagenav-2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052732/#ui-ncbiinpagenav-2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052732/#ui-ncbiinpagenav-2http://void%280%29/http://void%280%29/http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=PubMed&term=%20Losquadro%20WD%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=PubMed&term=%20Kellman%20RM%5Bauth%5D


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Patients with maxillofacial trauma present unique airway management challenges in theemergent, operative, and postoperative settings. The craniomaxillofacial surgeon is often

asked to secure the airway in patients with severe facial injuries, and familiarity with

available techniques allows for the most expedient and least morbid means of success.

Orotracheal intubation remains the primary method of securing the emergent airway.

Fiberoptic-assisted nasotracheal intubation has gained popularity in managing difficultairways despite traditional concern for intracranial penetration in patients with severe skull

base injuries. Temporizing measures such as the laryngeal mask airway and

esophageal/tracheal combination tube provide ventilation until a definitive airway can be

obtained. When other measures fail, cricothyroidotomy is an expedient means of tracheal

intubation.

Intraoperative maxillomandibular fixation often necessitates nasotracheal intubation. When

nasoorbitoethmoid (NOE) fractures coexist with mandibular fractures, the nasotracheal tube

interferes with operative correction. Tracheostomy and intraoperative exchanges between

naso- and orotracheal intubation have traditionally been used in this subset of patients, yet

surgeons have sought other methods to avoid the associated morbidity of these maneuvers.Submental and retromolar intubation maintain oral and nasal access while simultaneously

avoiding tracheostomy.

Postoperative management of patients with maxillofacial trauma focuses on avoiding

reintubation of the difficult airway. Maxillomandibular fixation affects respiratory

parameters, and close monitoring of these patients is sometimes necessary. Efforts at

eliminating difficult airway reintubations have led some anesthesiologists to use pediatric

airway exchange catheters after extubation.

Go to:

EMERGENT MANAGEMENT

Airway maintenance is the first step in the American College of Surgeons Advanced Trauma

Life Support protocol.1In a review of 1025 patients with facial fractures by Tung and

colleagues, 17 (1.7%) emergently required establishment of a definitive airway secondary to

airway obstruction.2Thus, the majority of patients with maxillofacial trauma present with a

stable airway, and simple monitoring of oxygenation via pulse oximetry is often all that is

required. Although infrequent, the life-threatening nature of airway compromise mandates

early identification of the patient subset that requires emergent or prophylactic airway

control.

Guidelines for tracheal intubation issued by the Eastern Association for the Surgery of

Trauma identify cervical spine injury, severe cognitive impairment, severe neck injury,

severe maxillofacial injury and smoke inhalation as potential causes for airway obstruction.3

With regards to cognitive impairment, Advanced Trauma Life Support protocol recommends

intubation of all patients with a Glasgow Coma Scale score of 8 or less. Airway obstruction

directly related to maxillofacial trauma can be caused by tongue base or maxillary prolapse,

pharyngeal edema or hematoma, and severe hemorrhage. Patients with bilateral mandibular

body fractures are especially at risk for tongue base prolapse; tongue retraction with a heavy

suture or towel clamp will allow oxygenation until a definitive airway is secured. Le Fortfractures may cause airway compromise via maxillary prolapse, edema, or hemorrhage. Ng
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and colleagues reported establishing an emergency airway in 22 (34%) of 64 patients

presenting with Le Fort fractures; the severity of the Le Fort fracture also correlated with an

increased need for intubation.4

Often the status of the cervical spine is unknown in the acute setting, and care must be taken

to prevent inadvertent neurological injury.5

The incidence of cervical spine injury in theentire blunt trauma population is 1 to 3%.

6,7The exact relationship between maxillofacialtrauma and cervical spine injuries is disputed. Some authors have demonstrated an increased

risk of cervical spine injuries in patients with maxillofacial trauma compared with the entire

blunt trauma population,8whereas others have not.9,10Davidson and Birdsell reviewed 2555

patients presenting with facial fractures and found cervical spine injury in 1.3%.11When only

patients sustaining injury in motor vehicle collisions were examined, however, the rate of

concomitant cervical spine injury rose to 5.5%. Regardless, many level 1 trauma centers

immobilize the entire spine in all blunt trauma patients until spinal injury can be disproved

clinically and/or radiographically. The surgeon called on to emergently secure the airway

must be cognizant of the cervical spine during all intubation maneuvers.

No consensus regarding the best means of intubation in patients with cervical spine injuries

has been reached.7Reports of rapid sequence induction, manual inline stabilization of the

head, and orotracheal intubation via direct laryngoscopy have shown this to be a safe,

successful maneuver.12To attempt intubation via manual inline stabilization, the patient's

head is placed in a neutral position and grasped at the mastoid processes by an assistant (Fig.

1). This serves to limit the natural head movement that occurs during direct laryngoscopy.

Figure 1

Manual inline stabilization.

Other intubation tools that limit cervical motion include the Bullard laryngoscope (ACMI

Corporation, Southborough, MA) and the flexible fiberoptic endoscope. The Bullard is a rigid

laryngoscope (Fig.2)whose anatomic blade design allows insertion and fiberoptic glottic

visualization while maintaining a neutral head position. An attached stylet permits

concomitant endotracheal tube insertion while a separate port allows for lidocaine injection or

oxygenation. Improved ventilation provided by the larger port of the Bullard laryngoscopehas been used during intubation of patients with maxillofacial trauma and immobilized

cervical spines.13Another option to both minimize head movement and avoid unsuccessful

oral intubation in the sedated patient is fiberoptic nasotracheal intubation. Reports in patients

with maxillofacial trauma, however, are sparse.3
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Figure 2

Bullard laryngoscope.

The conscious patient presenting with severe hemorrhage often presents a treatment dilemma

with regards to cervical spine management. These patients will often struggle to sit up withtheir neck flexed and head down to clear blood and prevent aspiration.14In these situations,

the risk of airway compromise must be carefully balanced against the risk of spinal injury.

Efforts to clinically clear the spine and/or place the patient in a semirigid cervical collar may

hedge against potential neurological injury in these difficult circumstances.

Gunshot wounds to the face often present unique challenges in airway management due to

significant tissue loss and, less frequently, associated hemorrhage. The need for emergent

airway control in these patients ranges from 17 to 35% in recent reviews.15,16,17,18Many

authors recommend elective intubation even if the patient is initially stable to prevent delayed

airway compromise, especially in patients with mandibular injury, oral bleeding or edema,

and close-range shotgun wounds. Despite significant soft tissue loss, direct oral intubationcan frequently be accomplished. If unsuccessful, some authors recommend fiberoptic

nasotracheal intubation, cricothyroidotomy, and lastly, blind nasal intubation.19

Regardless of the associated injuries, the primary means of securing the airway in the vast

majority of acutely desaturating patients with maxillofacial trauma is orotracheal intubation

via direct laryngoscopy.3This has often already been performed by paramedics or emergency

department personnel. For patients with severe trauma such as gunshot wounds or in whom

attempts at intubation have failed, the surgeon may be called to intervene. Simple maneuvers

may improve the success of orotracheal intubation. Suction is often necessary to clear

pharyngeal secretions and bleeding. Visualization of the larynx may be improved with cricoid

pressure by an assistant. In patients where visualization of the true vocal cords is still

difficult, some have described the use of a gum elastic bougie (Fig.3).20This long introducer

has an angled tip that is inserted beneath the epiglottis and advanced blindly through the

glottis. Correct placement is confirmed by the distinctive feel of the tracheal rings; the patient

is then intubated over the bougie. Video laryngoscopes, such as the GlideScope (Verathon,

Inc., Bothell, WA), are promising new devices that allow visualization from the laryngoscope

blade on a separate monitor21,22;their use in trauma patients has not yet been described (Fig.

4).

Figure 3

Gum elastic bougie.
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Figure 4

GlideScope video laryngoscope. (Reprinted with permission from Verathon, Inc., Bothell, WA.)

In patients with significant trismus due to associated mandible fractures, laryngoscopy is

extremely difficult and other methods are necessary. Current widespread availability and useof fiberoptic endoscopes has made fiberoptic-assisted nasotracheal intubation a valuable asset

in airway management. Many prefer this method for patients who are maintaining their

oxygen saturation because it allows for awake intubation, thus avoiding potential airway

emergencies in the anesthetized patient. An endotracheal tube is placed over a flexible

fiberoptic bronchoscope and advanced to the handle (Fig.5). The bronchoscope, in contrast

to the nasolaryngoscope, provides the necessary length, a suction port to clear blood and/or

secretions, and a port for injection of topical anesthetic. After the bronchoscope is directed

through the vocal cords, the endotracheal tube is advanced into the airway over the scope.

The endotracheal tube does not always advance easily secondary to nasal and laryngeal

resistance. It is therefore important to maintain constant visualization of the trachea to

prevent inadvertent scope displacement and possible esophageal intubation. The presence ofan assistant to advance the endotracheal tube while the surgeon maintains tracheal

visualization is helpful. Fiberoptic intubation can be accomplished orally or nasally, although

the oral route requires greater skill in placement and is less well tolerated by the awake

patient. Injection of topical anesthetic onto the true vocal cords is often necessary in the

awake patient to prevent laryngospasm. If possible, having the patient sitting will result in

less tongue base prolapse and, consequently, better visualization of the larynx.

Figure 5

Fiberoptic bronchoscope with attached endotracheal tube.

Much controversy exists regarding nasotracheal intubation in the presence of skull base

fractures. Multiple reports of intracranial placement of nasogastric,23,24nasopharyngeal,25,26

and nasotracheal tubes27with subsequent severe neurological sequelae or death have led

many to condemn nasotracheal intubation in patients with extensive cribriform plate or

sphenoid sinus fractures. Intracranial penetration from attempted nasotracheal intubation hasalso been reported after trans-sphenoidal pituitary surgery.28All cases involved blind

insertion of the nasotracheal tube; no intracranial placement during fiberoptic intubation has

been reported. Despite these rare case reports, some authors continue to advocate blind

nasotracheal intubation in patients with skull base fractures.29For the surgeon attempting to

secure the airway in patients with maxillofacial trauma, it would seem the risk, albeit small,

of catastrophic, blind intracranial tube insertion is unnecessary when other options are

available. However, if blind nasotracheal intubation is attempted, it is essential to direct the

tube posteriorly along the nasal floor to avoid superior displacement. Placing a gloved finger

through the mouth into the nasopharynx allows palpation of the advancing tube and facilitates

proper pharyngeal positioning.
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Additional choices for managing the emergent airway include the intubating laryngeal mask

airway (LMA Fastrach, LMA North America, San Diego, CA), esophageal/tracheal double

lumen airway (Combitube, Tyco Healthcare Group LP, Pleasanton, CA), lighted stylet, and

retrograde intubation. The laryngeal mask airway is placed blindly through the mouth and

seals off the hypopharynx via a circumferential inflatable cuff; this design may prevent

aspiration of cephalad bleeding but not of gastric contents.30

Ventilation is accomplishedwithout actually intubating the trachea. The related intubating laryngeal mask airway (ILMA)

(Fig.6)is designed to allow subsequent passage of an endotracheal tube with detachable

anesthesia circuit connector (LMA ET Tube, LMA North America, San Diego, CA).

Successful emergent use of the ILMA has been described in a patient with maxillofacial

trauma.31Its ease of insertion and subsequent ability to blindly intubate the trachea may be

advantageous when direct laryngoscopic intubation fails.

Figure 6

Intubating laryngeal mask airway.

The esophageal/tracheal combination (ETC) tube is a dual lumen, dual cuff tube that is

blindly inserted into the esophagus (Fig.7). The distal, smaller balloon is inflated within the

esophagus and may prevent reflux of gastric contents. The proximal, larger balloon seals off

the oropharynx and allows ventilation via perforations between the two cuffs. Similar to the

ILMA, ventilation is accomplished without direct tracheal intubation. However, if the ETC is

inadvertently placed into the trachea, ventilation can still be performed via the second lumen.

Successful use of this device by paramedics has been described in patients with maxillofacial

trauma after unsuccessful attempts at endotracheal intubation.32,33Rare complications include

piriform sinus and esophageal perforations.34Disadvantages of the ETC compared with the

ILMA include an inability to perform definitive tracheal intubation without removal.

Nevertheless, it may provide a facile means of ventilation in patients with maxillofacial

trauma.

Figure 7

Esophageal/tracheal Combitube.

The lighted stylet represents another option for difficult intubations in patients with

maxillofacial trauma. The stylet is bent 90 to 120 degrees 3 to 6 cm from the distal end and

is then blindly introduced into the hypopharynx.35Correct positioning produces an ambient

glow in the midline at about the level of the hyoid bone; transillumination off the midline

signifies malposition within the piriform sinus. The endotracheal tube is then advanced,

sometimes employing a rocking motion to direct the tube beneath the epiglottis. A continuous
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glow accompanies tracheal intubation, whereas a brief interruption and subsequent recovery

indicates esophageal intubation. Although most often accomplished with the patient's head

extended, lighted stylet intubation can be performed in cervically immobilized patients. The

lighted stylet can also be used for nasotracheal intubation, and successful application in

patients with maxillofacial trauma has been reported.36

Yet another method of intubation that has been successfully employed in patients with

maxillofacial trauma is retrograde intubation.37,38A large bore Angiocath (14 to 18 gauge) is

inserted at an 45-degree angle through the cricothyroid membrane or the proximal trachea;aspiration of air confirms placement. The catheter is advanced and the needle removed. A

long guidewire is then inserted through the catheter and advanced out the nose or retrieved

from the mouth with Magill forceps. The endotracheal tube is advanced over the wire via the

side port, or Murphy's eye, or pulled by tying the tube to the wire's end. Decreased resistance

to intubation may be accomplished by first advancing a tube exchanger, removing the wire,

and then intubating over the exchanger.

When attempts at intubation or ventilation have failed, cricothyroidotomy is considered theprocedure of choice.3The relative ease in locating the cricothyroid membrane and its

proximity to the skin allow more expedient dissection compared with emergent tracheostomy.

In a review of 8320 trauma admissions, Salvino and colleagues reported performing 30

(0.4%) cricothyroidotomies for emergent airway control.39Studies requiring emergent

cricothyroidotomy or tracheostomy for patients specifically with maxillofacial trauma report

rates from 0.1 to 3.3%.2,40Often the decision to perform a cricothyroidotomy is made after

failure of previous attempts at oro- or nasotracheal intubation, although it may also be the

initial maneuver used to secure the airway. Studies reveal 15 to 23% of emergent

cricothyroidotomies as the first and only means of airway control.39,41Reported indications

include excessive emesis or hemorrhage, known cervical spine fracture, and inability to

visualize the vocal cords. Cricothyroidotomy is contraindicated in pediatric patients due to

anatomic constraints and in patients with suspected laryngotracheal separation.

Go to:

OPERATIVE MANAGEMENT

Intraoperative airway management of patients with maxillofacial trauma is complicated by

competing needs for airway and surgical access. Often, the preferred route for endotracheal

tube placement prevents or interferes with surgical intervention. For patients with severe

panfacial injuries, intraoperative endotracheal tube changes and tracheostomy remain

common means of managing the airway. However, techniques such as submental and

retromolar intubation have recently been espoused to eliminate the morbidity associated with

tracheostomy as well as the risk of intraoperative tube repositioning.

Maxillomandibular fixation is often employed intraoperatively when correcting both

mandibular and maxillary fractures, and, therefore, nasotracheal intubation remains the

preferred technique in these patients. Preformed curved nasotracheal tubes may be used to

minimize operative field interference but vary in their degree of protrusion from the nose

depending on the patient's anatomy. More precise methods of tube placement use curved,

metal anesthesia circuit connectors. After successful nasotracheal intubation, the plasticconnector is removed and the endotracheal tube grasped with hemostats at the naris. The tube
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is then cut 1 cm above the hemostats and a curved 60- to 90-degree connector is attached

(Fig.8). The airway circuit is then supported on the forehead and fixed with tape and/or a

circumferential head dressing. This results in minimal intrusion of the tube into the operative

field.

Figure 8

Curved endotracheal tube connector.

Patients with coexisting jaw and NOE fractures present additional challenges, and,

consequently, various airway management techniques have been employed. A nasotracheal

tube interferes with correction of septal and NOE fractures and may be breeched duringsurgery on the midface.42One solution is to simply switch from nasal to oral intubation

intraoperatively. After completion of internal fixation of jaw fractures and release of

maxillomandibular fixation, the patient is nasally extubated and reintubated orally. Multiple

creative methods of switching from naso- to orotracheal intubation without actual extubation

have also been described.43,44,45None of these maneuvers is ideal because they all interrupt

the surgical procedure and risk the loss of a previously secure airway. As a result, many

surgeons advocate tracheostomy before correcting extensive panfacial fractures.

Before the widespread application of rigid plating techniques, postoperative

maxillomandibular fixation was frequently necessary to ensure proper occlusion.

Maxillomandibular fixation combined with severe edema in patients with extensive panfacialinjuries necessitated tracheostomy to protect against postoperative airway compromise. The

advent of rigid internal fixation often allowed the release of maxillomandibular fixation

before extubation and, consequently, avoidance of tracheostomy in more patients.46

Nevertheless, a standard tracheostomy before surgery provides a safe, stable airway that does

not interfere with the operative field and protects against postoperative airway obstruction

secondary to surgical manipulation. Possible intraoperative airway compromise during

endotracheal tube exchanges is avoided. In the presence of severe neurological and/or

cardiopulmonary injury, which will result in the need for continued ventilatory support after

surgery, elective tracheostomy certainly provides the safest means of airway maintenance

with the least morbidity. Yet for patients with maxillofacial trauma who do not require long-

term ventilation, many surgeons continued to search for methods of avoiding tracheostomy.

Submental intubation was first described by Hernndez in 1986 and was designed to

eliminate the morbidity of tracheostomy in patients undergoing maxillofacial surgery.47The

patient is first intubated orally with a reinforced endotracheal tube. The original description

places an incision within the submandibular triangle (contrary to the name,submental

intubation), parallel to and one finger's breadth below the mandibular border (Fig.9). The

side opposite any body or angle fractures is chosen if possible. Incisions below the

mandibular angle48and within the midline49,50have also been described. Dissection is then

carried bluntly through the mylohyoid and along the inner mandibular cortex; subperiosteal

versus extraperiosteal dissection is debated. The floor of mouth mucosa is then incised over

the dissecting instrument. The pilot balloon and endotracheal tube without connector arepulled through the incision while the tube is stabilized to prevent inadvertent extubation.
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Some authors have advocated using endotracheal tubes with detachable connectors such as

that designed for the intubating laryngeal mask airway.51,52After reattaching the connector

and hooking up the anesthesia circuit, the tube is sutured to the skin. The endotracheal tube

can be brought back into the mouth before extubation, although extubation directly through

the submental incision has been described.49,52

Figure 9

Submental intubation.

Proponents of submental intubation cite more aesthetic scars, avoidance of morbidity

associated with tracheostomies, and minimal complications. In a review by Caron and

colleagues of 25 patients with maxillofacial trauma treated with submental intubation, 1 (4%)

patient developed cellulitis at the incision site.53Meyer and colleagues reported 1 (4%)

patient with hypertrophic scarring and 2 (8%) patients with floor of mouth abscesses in their

series of 25 patients with maxillofacial trauma.54Anwer and colleagues reported 2 of 14

(14%) patients with postoperative superficial skin infections.48Other possible disadvantages

include submandibular gland, Wharton's duct, lingual nerve injury, and orocutaneous fistula

formation. Additionally, increased sedation may be necessary due to the oral route of tubeplacement in patients who require long-term ventilation.

Perhaps the simplest and least morbid technique of avoiding tracheostomy in patients with

panfacial fractures is retromolar intubation. After oral intubation in patients with missing or

impacted third molars, a reinforced endotracheal tube can be passed through the retromolar

space and secured to an adjacent tooth with dental wire.55Patients who can close their jaws

after introducing an index finger into the retromolar space likely have adequate room for this

maneuver. Some authors have described concurrent third molar extraction56and bone

removal57to enable retromolar intubation, although the latter method seems to add further

morbidity to a technique designed to avoid it. Children are well suited for this method; Arora

and colleagues reported 79 of 80 (99%) pediatric patients could accommodate a retromolarendotracheal tube while maintaining centric occlusion.58No reports using retromolar

intubation indicate difficulty with placement of maxillomandibular fixation.

Go to:

POSTOPERATIVE MANAGEMENT

Patients with extensive maxillofacial trauma who are maintained in maxillomandibular

fixation after surgery should be carefully monitored while in the hospital. Studies have

predictably demonstrated increased respiratory obstruction in patients withmaxillomandibular fixation59,60and, therefore, they should be placed on continuous pulse
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oximetry. Steroids may be considered to decrease postoperative edema and improve

respiratory status. Wire cutters or scissors must be placed at the bedside and, more important,

ancillary staff should be taught which wires to cut if significant dyspnea or severe

nausea/vomiting develops.

A unique means of avoiding difficult postoperative reintubations is via placement of apediatric airway exchange catheter. Before extubation, this catheter is inserted through the

oro- or nasotracheal tube with care taken to ensure placement above the carina. Extubation is

then performed over the catheter, leaving it within the airway. It is then secured to the head

and used for oxygen delivery if necessary. Surprisingly, tolerance of the catheter is quite high

with reports ranging from 94 to 97%.61,62Reintubation is performed over the catheter and has

been uniformly successful in published accounts.

Go to:

CONCLUSIONSManagement of patients with maxillofacial trauma presents difficulties specific to injuries of

the upper airway. Multiple options exist for securing the emergent airway, and specific

interventions will depend on the availability of instruments and experience of practitioners in

each setting. Each technique has certain advantages and limitations; when properly applied,

the airway can be secured with minimal morbidity. The decision to perform

cricothyroidotomy must be made on an individual basis, and some patients may still require it

as the initial intervention. Intraoperatively, fracture patterns will dictate routes of intubation.

Newer options such as submental and retromolar intubation are gaining popularity.

Postoperative vigilance must be high for patients who are still in maxillomandibular fixation.

Difficult airways may benefit from placement of airway exchange catheters beforeextubation.

Jaw - broken or dislocatedEmail this page to a friendShare on facebookShare on twitterBookmark & SharePrinter-friendly

version

A broken jaw is a break in the jaw bone. A dislocated jaw means the lower part of the jaw hasmoved out of its normal position at one or both joints where the jaw bone connects to the

skull (temporomandibular joints).

Considerations

A broken or dislocated jaw usually heals completely after treatment. However, the jaw may

become dislocated again in the future.

Complications may include:

Airway blockage Bleeding Breathing blood or food into the lungs Difficulty eating (temporary)
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Difficulty talking (temporary) Infection of the jaw or face Jaw joint (TMJ)pain and other problems Problems aligning the teeth

Causes

The most common cause of a broken or dislocated jaw is injury to the face. This may be due

to:

Assault Industrial accident Motor vehicle accident Recreational or sports injury

SymptomsSymptoms of a dislocated jaw include:

Bite that feels "off" or crooked Difficulty speaking Droolingbecause of inability to close the mouth Inability to close the mouth Jaw that may protrude forward Pain in the faceor jaw, located in front of the ear on the affected side, and gets worse with

movement

Teeth that do not line up properlySymptoms of a fractured (broken) jaw include:

Bleeding from the mouth Difficulty opening the mouth widely Facial bruising Facial swelling Jaw stiffness Jaw tenderness or pain, worse with biting or chewing Loose or damaged teeth Lump or abnormal appearance of the cheek or jaw Numbnessof the face (particularly the lower lip) Very limited movement of the jaw (with severe fracture)

First Aid

A broken or dislocated jaw requires immediate medical attention because of the risk of

breathing problems or significant bleeding. Call your local emergency number (such as 911)

or local hospital for further advice.
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Hold the jaw gently in place with your hands while traveling to the emergency room. A

bandage may also be wrapped over the top of the head and under the jaw. However, such a

bandage should be easily removable in case you need to vomit.

If breathing problems or heavy bleeding occurs, or if there is severe facial swelling, a tube

may be placed into your airways to help you breathe.

DISLOCATED JAW

If the jaw is dislocated, the health care provider may be able to place it back into the correct

position using the thumbs. Numbing medications (anesthetics) and muscle relaxants may be

needed to relax the strong jaw muscles.

The jaw may need to be stabilized. This usually involves bandaging the jaw to keep the

mouth from opening widely. In some cases, surgery may be needed to do this, particularly if

repeated jaw dislocations occur.

After dislocating your jaw, you should not open your mouth widely for at least 6 weeks.

Support your jaw with one or both hands when yawning and sneezing.

FRACTURED JAW

Temporarily bandaging the jaw (around the top of the head) to prevent it from moving may

help reduce pain.

The specific treatment for a fractured jaw depends on how badly the bone is broken. If you

have a minor fracture, you may only need pain medicines and to follow a soft or liquid diet

for a while.

Surgery is often needed for moderate to severe fractures. The jaw may be wired to the teeth

of the opposite jaw to improve stability. Jaw wires are usually left in place for 6 - 8 weeks.

Small rubber bands (elastics) are used to hold the teeth together. After a few weeks, some of

the elastics are removed to allow motion and reduce joint stiffness.

If the jaw is wired, you can only drink liquids or eat very soft foods. Have blunt scissors

readily available to cut the elastics in the event of vomiting or choking. If the wires must be

cut, consult a health care provider promptly so they can be replaced.

DO NOT

Do NOT attempt to correct the position of the jaw.

When to Contact a Medical Professional

A broken or dislocated jaw requires immediate medical attention. Emergency symptoms

include difficulty breathing or heavy bleeding.

Prevention


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Safe practices in work, sports, and recreation, such as wearing a proper helmet when playing

football, may prevent some accidental injuries to the face or jaw.

Alternative Names

Dislocated jaw; Fractured jaw; Broken jaw; TMJ dislocation

Airway management after major trauma

1. Julius Cranshaw,MRCP FRCA PhD DICM EDIC1. Consultant in Anaesthesia and Critical Care Medicine, The Royal Bournemouth

Hospital Castle Lane East, Bournemouth, BH7 7DW

1. Jerry Nolan,FRCA FCEM+Author Affiliations

1. Consultant in Anaesthesia and Critical Care Medicine, Royal United Hospital CombePark, Bath BA1 3NG, UK Tel: 01225 825056 Fax: 01225 825061 E-mail:

[email protected](for correspondence)

Key points

The primary goal during early treatment of the severely injured patient is to provide sufficient

tissue oxygen delivery to avoid organ failure and secondary central nervous system damage.

212% of major trauma victims have a cervical spine injury; 714% of these are unstable.

Advanced airway interventions are associated with significant complications and have the

potential to cause harm and benefit.

Indications for immediate intubation are life-threatening hypoxaemia caused by airway

obstruction not relieved by simple means, and inadequate ventilatory support because of an

inadequate facemask seal.

In the emergency department, nearly 10% of intubations are described as difficult after rapid

sequence induction.

The primary goal in the early management of the severely-injured patient is the provision of

sufficient oxygen to the tissues to avoid organ failure and secondary central nervous system

damage. The first priority is to establish and maintain a patent airway. With the addition of

high-concentration oxygen and the presence of adequate tissue perfusion, this will enable

sufficient spontaneous breathing or assisted ventilation to oxygenate the patient.

The possibility of an unstable cervical injury exists in patients exposed to significant blunt

trauma; during airway interventions, neck movement must be minimized to avoid secondaryharm to the spinal cord. Depending on the series, 212% of major trauma victims have a
http://ceaccp.oxfordjournals.org/search?author1=Julius+Cranshaw&sortspec=date&submit=Submithttp://ceaccp.oxfordjournals.org/search?author1=Julius+Cranshaw&sortspec=date&submit=Submithttp://ceaccp.oxfordjournals.org/search?author1=Jerry+Nolan&sortspec=date&submit=Submithttp://ceaccp.oxfordjournals.org/search?author1=Jerry+Nolan&sortspec=date&submit=Submithttp://ceaccp.oxfordjournals.org/content/6/3/124.fullhttp://ceaccp.oxfordjournals.org/content/6/3/124.fullmailto:[email protected]:[email protected]:[email protected]://ceaccp.oxfordjournals.org/content/6/3/124.fullhttp://ceaccp.oxfordjournals

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Lbm 1 Kgd Sgd 12marlinca

pemicu kgd

KGD KARDIO

teori bljr kontruktivisme

Lbm 2 KGD SGD 8

Lawatan Sambil Bljr Sivik

Dian Ayu Lbm 3 Kgd Sgd 7

Satriya_lbm 5 Sgd 8 KGD

Lbm 6 Kgd Sgd 2 Fin

Motivasi bljr

CARA MUDAH bljr BHS INGGRIS.docx

Hubungan Gaya Bljr Dgn Pcapaian Baru

Lbm 1 Kgd Sgd 6

Documents

Bahan Bljr SGD KGD Lbm 1

Text of Bahan Bljr SGD KGD Lbm 1