Maxillofacial injury is a frequent
occurrence in the trauma setting. There are more than 3 million
incidences of facial trauma in the US each year - mostly resultant from motor
vehicle accidents and assault/battery type injuries. Upwards of 50% of
patients with maxillofacial injuries have multi-system trauma which requires a
coordinated effort between trauma surgeons, emergency physicians, and surgical
subspecialists in otolaryngology / plastic surgery / ophthalmology / oral and
maxillofacial surgery.
As surgical and emergency medicine residents on a
trauma service, it seems as though we frequently recommend these sinus
precautions for patients almost as an afterthought while trying to rush them
off the service and out of the hospital. What are these precautions?
Are they even important?
Injuries which frequently recieve sinus precautions
at our facility include fractures involving the
frontal, ethmoid,
and maxillary sinuses. These include frontal
bone fractures, orbital floor fractures, nasal fractures, nasoethmoidal
fractures, and maxillary fractures. (Or
any combination thereof).
Maxillary fractures themselves fall into one of
three categories, as outlined the in schematic below (LeFort type I, II, and
III). These
fractures seem to be of particular interest when
it comes to sinus precautions due to their frequent involvement of the
maxillary sinus.
http://commons.wikimedia.org/wiki/File:Clasificación_de_le_fort.png
According to the National Institutes of Health
(NIH) Sinus Precautions following oral surgery and traumatic facial injuries
include the following -
Patients should AVOID for a period of 2-4
weeks
- Nose Blowing- nasal secretions should be
wiped away gently
- Sneezing - keep mouth open if must
sneeze
-
Sucking- no drinking through straws, no smoking
-
Blowing- do not play wind instruments / blow up balloons
- Pushing / Lifting objects greater
than 20 lbs
- Bending
over- keep head above the level of the heart
In review of patient non-compliance with the
above sinus precautions the chief complications seem to deal with swelling and/or
hemorrhage. While these complications are infrequently life threatening
the healing of associated facial injuries and recovery time are impaired.
Extended hospital stays can result further need
for observation in a medical setting, pain control, or ongoing hemorrhage.
After a literature search of the topic there does
not seem to be an overwhelming body of evidence (if any) of proof regarding the
above recommendations.
These recommendations seem simple enough though-
don't do anything to increase your intracranial pressure / sinus pressure and
thereby aggravate a maxillofacial injury.
(Note: The reason for this post was a recent
patient with an orbital floor fracture who, minutes following discharge from
the hospital vigorously blew his nose.
The patient quickly returned to the trauma bay with marked edema around
the orbit and worsening of a subconjunctival hemorrhage. )
References:
http://emedicine.medscape.com/article/434875-overview
from Dr. Joshua Pratt
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