Facial Trauma – Zygoma

Overview

1. The clinical spectrum of facial trauma ranges from minimal soft tissue injuries to life threatening panfacial trauma.
2. This guide aims to outline basic assessment, management and referral pathways for the more common patterns of facial trauma namely:
   • Fractures of the mandible
   • Fractures of the zygomatic complex/arch
   • Orbital fractures
3. At presentation patients should be managed according to ATLS protocol so that life-threatening injuries/complications are prioritised.

Fractures of the Zygomatic Complex

1. Fractures of the zygomatic complex usually result from blunt trauma to the side of the face.
2. The zygomatic fracture is commonly pyramidal shaped and involves the zygoma and adjacent bones including the orbit. Isolated fractures of the zygomatic arch also frequently occur.

Clinical Features

1. Orbital involvement is common and an eye exam is vital to exclude retrobulbar haemorrhage, globe injury or a paediatric orbital floor injury. This will ensure that sight threatening injuries are not missed. Common eye examination findings would include:
   • Subconjunctival haemorrhage
   • Restriction of eye movement
   • Diplopia
2. A palpable step deformity (most easily felt at the inferior orbital margin)
3. Decreased mouth opening consequent to the zygomatic arch pressing on the temporalis muscle
4. Numbness in the distribution of the infraorbital nerve

Imaging

1. Occipitomental views (“facial views”). Often at 10 and 30 degrees
2. CT facial bones indicated if patient requires CT head or after discussion with OMFS

Must-Not-Miss Diagnoses

1. Retrobulbar haemorrhage: an unusual but significant complication where haemorrhage behind the globe of the eye causes compression of the optic nerve.
   • features include reduced visual acuity, a fixed and dilated pupil, a proptosed and tense globe, ophthalmoplegia and pain
   • management involves urgent discussion with local ophthalmology team and immediate lateral canthotomy and cantholysis with supplementary medical management including high-dose steroids
2. Paediatric orbital injuries:  Children are particularly at risk of extra-ocular muscle entrapment with orbital floor injuries. A “trap-door” defect may occur which can result in early necrosis of the trapped soft tissue.
   • classically present as the “white eye blow out fracture” where there is reduced ocular motility +/- features of an exaggerated oculo-cardiac reflex. These patients are often misdiagnosed with a head injury as they feel sick when opening the affected eye.
   • confirm diagnosis with CT orbits
   • require admission and urgent transfer to the Royal Hospital for Children Glasgow under OMFS surgical intervention to prevent muscle necrosis and permanent visual problems

Management

1. Any concerning eye signs (reduced visual acuity, globe injury, signs of retrobulbar haemorrhage, pain on upward eye movement, or signs of restricted eye movements in children) warrant urgent ophthalmology and OMFS referral
2. All patients with zygomatic complex fractures should be instructed not to blow their nose for 3 weeks due to the risk of surgical emphysema
3. In absence of the above concerning features patients can be reviewed in an OMFS outpatient clinic in 7-14 days. If the patient is being discharged please send a referral to OMFS secretary [email protected] with a copy of the discharge letter. If the patient is remaining an inpatient for another reason please refer in-hours to OMFS on-call in DGRI.
4. Antibiotics are not routinely required

Content by Lee Mackie, Updated by Gary Bell