TRAUMATIC CONDITIONS OF THE FACE AND MOUTH432 Maxillofacial and Dental Emergencies
(iii) Request a computed tomography (CT) scan for more complex
injuries to the zygomaticomaxillary (malar) complex, or for an
associated ‘blow-out’ fracture of the orbital floor.MANAGEMENT
1 Advise the patient not to blow his or her nose, as subcutaneous emphysema
may develop if the paranasal sinuses are involved.
2 Commence amoxycillin 500 mg orally t.d.s. (or cefaclor 375 orally b.d. if the
patient is allergic to penicillin) for 5 days, as most fractures are compound
into the maxillary sinus, with an analgesic such as paracetamol 500 mg and
codeine phosphate 8 mg two tablets orally q.d.s.
3 Refer the patient to the maxillofacial surgery team within 24 hours for eleva-
tion of the depressed cheekbone within 7 days.‘Blow-out’ fracture of the orbital floor
DIAGNOSIS
1 This uncommon fracture is due to blunt trauma to the eye from a small
object about the size of a squash ball, that drives the eyeball backwards and
ruptures the weak bony f loor of the orbit.
(i) Orbital fat and occasionally the inferior rectus muscle herniate
through the defect into the maxillary sinus.
2 Exclude blunt trauma to the eye initially (see p. 415). The fracture itself
causes enophthalmos, which may be masked by periorbital oedema, infra-
orbital nerve loss to the side of the nostril and upper lip, and diplopia from
restricted upwards gaze due to trapping of the inferior rectus muscle or
orbital fat.
3 Request facial X-rays, although these may not show the fracture itself.
(i) This can be inferred from an opaque maxillary sinus or a fluid
level from bleeding, and a ‘tear drop’ soft-tissue opacity hanging
from the roof of the sinus.
4 Request a CT scan if there is doubt, as this demonstrates the fractures clearly.MANAGEMENT1 Refer a patient with blunt eye damage immediately to the ophthalmology
team.
2 Commence amoxycillin 500 mg orally t.d.s. and 1% chloramphenicol eye
ointment 4-hourly.
3 Refer the patient to the maxillofacial surgery team within 24 h.