Danger Triangle of the face involves the facial vein draining to the ophthalmic vein then to the cavernous sinus, allowing infections to spread to the brain.
Maxillofacial Anatomy
Lymphatics
Submental lymph nodes drain the chin, lower lip, and floor of the mouth.
Maxillofacial Anatomy
Lymphatics
Submandibular lymph nodes drain the medial face, nose, and upper lip.
Maxillofacial Anatomy
Foramina
Mandibular foramen is the entry point for the Inferior Alveolar Nerve (V3).
Topic
Category
Key Details
Initial Assessment
Priorities
Priorities of management follow: 1. Circulation/hemorrhage, 2. Airway, 3. Shock, 4. Life-threatening associated injuries, 5. Local injuries, 6. Triage.
Initial Assessment
Shock
Signs of shock include early hypertension followed by hypotension, increased heart rate, blurring of vision, syncope, and loss of consciousness.
Initial Assessment
Airway
Causes of airway problems include the tongue falling back, dentures/blood clots/aspiration, direct laryngeal trauma, and multiple facial fractures.
Airway Management
Procedures
Endotracheal Intubation is the fastest general procedure to secure an airway but is contraindicated by tumors or fractured mandibles where the tongue cannot be elevated.
Airway Management
Procedures
Cricothyrotomy is a temporary first-aid/emergency airway performed at the cricothyroid ligament; it is the "fastest" in a field/barrio setting to prevent hypoxic encephalopathy.
Airway Management
Procedures
Tracheostomy is the preferred definitive airway in a hospital setup and can be performed quickly (4 mins) in patients with tetanus (risus sardonicus) where ETT is impossible.
Topic
Category
Key Details
Nasal Bone Trauma
Features
Nasal bone fractures are the MOST frequently traumatized bones in the face due to their prominence.
Nasal Bone Trauma
Signs
Signs of nasal fracture include septal deviation, epistaxis, nasal obstruction, and crepitation.
Nasal Bone Trauma
Classification
Plane 3 Nasal Injury according to Stranc and Robertson involves a naso-orbitoethmoidal (NOE) fracture and the orbit.
Nasal Bone Trauma
Treatment
Closed Reduction is the gold standard for nasal bone fractures if performed within 2 weeks of injury.
Nasal Bone Trauma
Treatment
Open Reduction and Internal Fixation (ORIF) with titanium implants is required for nasal fractures >2 weeks old due to callus formation.
Nasal Bone Trauma
First Aid
Nasal packing serves to control bleeding and can temporarily elevate fractured bone, but must be removed within 24-48 hours to avoid SSI/Staphylococcal infection.
Topic
Category
Key Details
Mandible Trauma
Features
Mandibular fractures are the 2nd most common facial fractures and the most common case encountered by interns.
Mandible Trauma
Anatomy
Mandible parts include: Symphysis (midline), Parasymphysis (midline to canine), Body (canine to 3rd molar), Angle, Ramus, Coronoid, Condyle, and Alveolus.
Mandible Trauma
Nerve Injury
Mandibular body fractures are specifically associated with paresthesia of the lower jaw and numbness of the lower lip due to V3 (Inferior Alveolar Nerve) compression.
Mandible Trauma
Classification
Favorable mandibular fractures are those where muscle forces (Masseter) tend to keep bone fragments together.
Mandible Trauma
Classification
Unfavorable mandibular fractures occur when muscle pull separates the bone fragments, necessitating ORIF.
Mandible Trauma
Hallmark Sign
Sublingual hematoma is the most important sign to recognize in mandibular trauma as it indicates a pending upper airway obstruction.
Mandible Trauma
Signs
Trismus is defined as an inter-incisor distance of less than 1.5 cm (normal is ~3 cm or 3 finger breadths).
Mandible Trauma
Signs
Malocclusion is an abnormal bite; it is a clinical diagnosis where the patient cannot bite "normally."
Mandible Trauma
Signs
Otorrhagia can occur if a fractured mandibular condyle pierces the external auditory canal.
Mandible Trauma
Diagnostics
Towne’s view X-ray is specifically used to check the mandibular Condyle.
Mandible Trauma
Diagnostics
Panoramic X-ray is used to evaluate the Mandibular Body.
Mandible Trauma
Treatment
Erich Braces (Dental Arch Bars) are used for closed reduction in favorable fractures to lock the bite for 3-4 weeks.
Mandible Trauma
Treatment
Restoring occlusion (normal bite) is the most important goal in managing mandibular fractures.
Topic
Category
Key Details
Maxillary Trauma
Classification
LeFort I (Guerin fracture) is a horizontal fracture of the palate/maxilla.
Maxillary Trauma
Classification
LeFort II (Pyramidal fracture) separates the midface from the cheeks, passing through nasal and zygomaticomaxillary sutures.
Maxillary Trauma
Classification
LeFort III (Craniofacial dysjunction) separates the midface from the upper face/cranium.
Maxillary Trauma
Diagnostic Sign
Drawer’s sign is performed by pulling the dentition while stabilizing the face to check for movement at different LeFort levels.
Maxillary Trauma
Management
Nasogastric Tube (NGT) insertion is dangerous in LeFort III fractures because the tube may inadvertently enter the brain.
Topic
Category
Key Details
Zygoma Trauma
Features
Zygomaticomaxillary Complex (ZMC) Fracture (formerly Tripod fracture) involves 6 structures including the zygomaticofrontal, maxillary, temporal, and sphenoid sutures.
Zygoma Trauma
Diagnostics
Teardrop sign on Water’s view X-ray indicates orbital contents (fat/muscle) herniating into the maxillary sinus.
Zygoma Trauma
Signs
Limitation of eye motion and diplopia are the most critical functional findings in ZMC fractures.
Zygoma Trauma
Muscle
Inferior oblique muscle is the most common muscle entrapped in ZMC/orbital fractures, limiting upward/lateral gaze.
Zygoma Trauma
Nerve Injury
Infraorbital nerve (V2) injury in ZMC fractures causes numbness of the lateral nose, upper lip, and cheek.
Zygoma Trauma
Signs
Hypoglobus is the inferior displacement of the orbit, while Enophthalmos is the posterior displacement.
Zygoma Trauma
Treatment
Indications for ORIF in ZMC are functional: 1. Limitation of eye motion, 2. Diplopia, 3. Trismus.
Zygoma Trauma
Diagnostics
Forced Duction Test is used to differentiate muscle entrapment (eye won't move) from nerve paralysis (eye moves when grasped).
Differentiating Similar Entities for Exams:
Nasal Bone vs. Mandible: The Nasal Bone is the #1 most common facial fracture; Mandible is the #2 most common.
Cricothyrotomy vs. Tracheostomy: Cricothyrotomy is a temporary emergency first-aid; Tracheostomy is the definitive hospital-based airway.
V2 vs. V3 Nerve Injury: V2 (Maxillary) injury causes upper lip/cheek numbness (common in ZMC/Maxilla fractures); V3 (Mandibular) injury causes lower lip/chin numbness (common in Mandibular body fractures).
Favorable vs. Unfavorable Mandible Fracture: Favorable fractures are held together by muscle pull; Unfavorable fractures are pulled apart and require surgery (ORIF).
LeFort I vs. II vs. III: LeFort I is the palate only; LeFort II is the pyramidal/midface; LeFort III is the entire face separating from the skull.
Trismus (Mandible) vs. Trismus (ZMC): In Mandible fractures, trismus is due to pain/displacement; in ZMC fractures, it is often due to the zygomatic arch impinging on the Coronoid Process.
Hypoglobus vs. Enophthalmos: Hypoglobus is an "up/down" displacement (downward); Enophthalmos is a "front/back" displacement (sunken eyes).
Manual reduction vs. ORIF timing: Nasal fractures should be closed-reduced within <2 weeks; after 2 weeks, they require Open Reduction (ORIF).
Forced Duction Test Results: If the eye is restricted/cannot be moved manually, it is muscle entrapment; if the eye moves easily manually but not on its own, it is nerve paralysis.
Submental vs. Submandibular Drainage: Submental drains the chin/floor of mouth; Submandibular drains the medial face/upper lip.
Lateral Pterygoid vs. Other Masticatory Muscles: Lateral Pterygoid "Opens" the mouth; Masseter, Temporalis, and Medial Pterygoid "Close" the mouth.
Towne’s View vs. Panoramic X-Ray: Towne’s is best for the Condyle; Panoramic (Panorex) is best for the Mandibular Body.
Water’s View vs. Other X-rays: Water’s view is the specific X-ray used to see the Teardrop sign in orbital/ZMC fractures.
Functional vs. Cosmetic Indications: In ZMC fractures, diplopia and trismus (functional) are primary indicators for surgery, while enophthalmos (cosmetic) is secondary.
Cricothyrotomy Tube vs. Method: Cricothyrotomy is performed between the thyroid and cricoid cartilages; Tracheostomy is performed lower in the neck (tracheal rings).
List the Priorities of management in order (6). | 1) Circulation/hemorrhage 2) Airway 3) Shock 4) Life-threatening associated injuries 5) Local injuries 6) Triage
What is the first (1st) priority in Maxillofacial Trauma management? | Circulation/hemorrhage.
What is the second (2nd) priority in Maxillofacial Trauma management? | Airway.
List the Signs of shock in maxillofacial trauma. | Hypertension then hypotension. Includes tachycardia, syncope, and loss of consciousness.
List the Causes of airway problems (4). | 1) Tongue falling back 2) Dentures/clots/aspiration 3) Laryngeal trauma 4) Multiple facial fractures
(Approach) History and PE account for 90% of diagnoses in patients presenting with a Thyroid mass.
(Approach) A Thyroid mass is clinically identified because it characteristically moves during deglutition (swallowing).
(Approach) If a neck mass does not move with deglutition, the Differential Diagnosis should include lymph nodes, esophageal masses, or schwannomas.
(Approach) A Thyroid panel typically includes FT3, FT4, and TSH; elevated TSH indicates hypothyroidism while decreased TSH indicates hyperthyroidism.
(Approach) Perform a Metastatic work-up (liver UTZ, CXR, Thyroid Body Scan) prior to operation if cancer is diagnosed.
(Approach) DO NOT perform FNAB if you suspect a Toxic thyroid state/Hyperthyroidism as puncturing the mass can leak hormone and exacerbate the condition.
(Approach) The TI-RADS (Thyroid Imaging Reporting & Data System) scale for ultrasound ranges from 1 (Benign) to 5 (Highly suspicious).
(Approach) The definitive diagnosis for a thyroid mass is obtained via Fine Needle Aspiration Biopsy (FNAB).
(Approach) According to the lecturer, FNAB becomes optional if History, PE, Thyroid Panel, and Bilateral Ultrasound are already strongly indicative of cancer.
(Approach) Surgery is indicated for a Thyroid mass if there is obstruction of breathing/swallowing, if it is refractory to medication, if it is malignant, or per patient choice.
(Approach) A Unilateral solitary nodule has a higher chance of being malignant compared to a diffusely enlarged or toxic goiter.
(Approach) Philippine Guidelines for Total Thyroidectomy mandate the procedure for cancerous nodules > 1 cm, whereas US Guidelines suggest > 4 cm.
(Approach) Filipino thyroid cancers are considered among the most aggressive types and are likely to recur, justifying more aggressive management.
(Goiter) Levothyroxine is used for thyroid suppression therapy in non-toxic goiters < 3 cm to provide negative feedback and reduce TSH production.
(Goiter) Suppression therapy/Levothyroxine for a Goiter is a preventive measure and does not typically make the existing nodule disappear.
(PTC) At the board exams, use Orphan Annie eye nucleus as the specific histological marker for Papillary Thyroid Carcinoma, as Psammoma bodies are only present in 40% of cases.
(PTC) Papillary Thyroid Carcinoma spread is primarily lymphatic, usually involving Level VI or central neck nodes.
(PTC) Radioactive Iodine (RAI) is indicated for Papillary Thyroid CA if the tumor is > 1 cm (PH guidelines), is an aggressive type, has lymph node metastasis, or extra-thyroidal invasion.
(PTC) Extra-thyroidal invasion of Papillary Thyroid Carcinoma often involves the "S-O-T-S" strap muscles: Sternohyoid, Omohyoid, Sternothyroid, and Thyrohyoid.
(FTC) Follicular Thyroid Carcinoma spread is primarily hematogenous, often resulting in metastases to the lungs, liver, and brain.
(MTC) Medullary Thyroid Carcinoma is the only thyroid CA type that does not develop in a thyroglossal duct cyst or lingual thyroid.
(MTC) Pre-op and post-op work-up for Medullary Thyroid Carcinoma must include monitoring levels of Calcitonin, Calcium, and CEA.
(MTC) If Medullary Thyroid Carcinoma is associated with Parathyroid hyperplasia, it is classified as MEN 2A; if not, it is MEN 2B.
(ATC) Anaplastic Thyroid Carcinoma has a mortality rate of over 90% and may transform from a long-standing papillary thyroid carcinoma.
(Staging) For Thyroid Cancer Staging in patients < 45 years, Stage I includes any size/local nodes, and Stage II includes distant metastases.
(Staging) For Thyroid Cancer Staging in patients ≥ 45 (or 55) years:
Stage I: ≤ 2 cm.
Stage II: 2-4 cm.
Stage III: > 4 cm (within thyroid) OR any size with spread to local tissues (not nodes).
Stage IV: Spread to trachea, esophagus, larynx, or distant organs.
(Staging) In the Thyroid N-staging, N1a refers to Level VI (central) nodes, while N1b refers to levels I-V (lateral) or superior mediastinal nodes.
(Salivary) The Rule of Salivary Glands states: the smaller the gland, the higher the chance of malignancy (Parotid 70% benign, Sublingual 70% malignant).
(Salivary) The Most common parotid tumor in the pediatric population is a Hemangioma.
(Pleomorphic) Pleomorphic Adenoma can transform into the aggressive "Carcinoma Ex Pleomorphic Adenoma" in 1.5% of cases within 5 years, and 10% after 15 years.
(Pleomorphic) The four red flags for Pleomorphic Adenoma malignancy transformation are: Facial Nerve Paralysis, Cervical Lymphadenopathy, Rapid Growth, and Involvement of the Deep Lobe.
(Parotid) The Facial Nerve (CN VII) passes between the superficial and deep lobes of the parotid gland.
(Parotid) Superficial Parotidectomy is performed if the tumor is in the superficial lobe, while Total Parotidectomy is required if the tumor involves the deep lobe to preserve nerve branches.
(Parotid) A Deep lobe parotid tumor may present with bulging of the lateral pharyngeal wall; bimanual palpation is used if no bulging is visible.
(Facial Nerve) The five branches of the Facial Nerve within the parotid are: Temporal, Zygomatic, Buccal, Marginal Mandibular, and Cervical.
(Facial Nerve) The Zygomatic branch is the most important as it supplies muscles for eye closure; the Cervical branch is the first that may be sacrificed.
(Warthin’s) Warthin’s tumor, or Papillary Cystadenoma Lymphomatosum, arises from cystic changes in parotid lymph nodes and is the only tumor that can be treated by simple excision.
(MEC) In Mucoepidermoid Carcinoma, a higher ratio of squamoid cells compared to mucous cells indicates a higher histological grade.
(Acinic) Acinic Cell Carcinoma is often mistaken for normal salivary tissue on FNAB; a second opinion or MRI/PET scan is recommended to avoid medico-legal issues.
(Adenoid Cystic) Adenoid Cystic Carcinoma is notorious for perineural invasion, allowing it to travel along axons to the skull base or brain.
(Salivary Staging) Salivary Tumor T-Staging:
T1: ≤ 2 cm.
T2: 2 - 4 cm.
T3: > 4 cm or extraparenchymal extension.
T4a: Invades skin, mandible, ear canal, or facial nerve.
T4b: Invades skull base, pterygoid plates, or carotid artery.
(Salivary Staging) Salivary Tumor N-Staging:
N1: Single ipsilateral ≤ 3 cm.
N2a: Single ipsilateral 3-6 cm.
N2b: Multiple ipsilateral ≤ 6 cm.
N2c: Bilateral/Contralateral nodes ≤ 6 cm.
N3: > 6 cm.
(Complications) Frey’s Syndrome (Gustatory Sweating) is caused by aberrant reinnervation between the auriculotemporal nerve (parasympathetic) and sweat glands (sympathetic).
(Complications) The Starch-iodine test (Minor test) is the diagnostic PE for Frey’s Syndrome, where a positive result (sweating while eating) turns the area bluish.
(Complications) Treatment for Frey's Syndrome includes anti-perspirants (Rexona), Botox, or Scopolamine ointment.
(Complications) Sialolithiasis is most common in the submandibular gland because its saliva is more mucoid/viscous compared to the serous saliva of the parotid.
(House-Brackmann) The House-Brackmann Scale grades facial nerve injury:
Grade I: Normal.
Grade II: Mild; complete eye closure with minimum effort.
Grade III: Moderate; complete eye closure with effort.
Level II, III, IV: Along the SCM (Oropharynx, Larynx, Thyroid).
Level V: Posterior neck (Nasopharynx).
Level VI: Central compartment (Thyroid, subglottic larynx).
(Neck Dissection) Therapeutic neck dissection is performed when neck nodes are clinically evident/positive.
(Neck Dissection) Elective neck dissection is performed in node-negative patients who have a > 20% risk of occult metastasis (e.g., Supraglottic CA).
(Neck Dissection) Radical Neck Dissection (RND) involves removal of Levels I-V plus the SCM, IJV, and CN XI.
(Neck Dissection) Modified Neck Dissection (MRND) involves removal of Levels I-V but preserves one or more of the three structures (SCM, IJV, CN XI).
(Neck Dissection) Selective Neck Dissection (SND) involves removing only a specific selection of nodal levels (e.g., Level VI for early thyroid CA).
(Neck Dissection) If an elective dissection reveals a positive node, the procedure must be converted to a Radical or Modified Radical Neck Dissection.
(Structures) The Sternocleidomastoid (SCM) is preserved to protect the carotid artery from rupture (carotid blowout) during radiation therapy.
(Structures) The Internal Jugular Vein (IJV) should not be removed bilaterally at once to prevent cerebral edema; the second IJV removal must wait 3 months for angiogenesis.
(Structures) The Spinal Accessory Nerve (CN XI) is preserved to maintain the ability to lift objects, carry items, and shrug shoulders (trapezius function).
(Drainage) The Thoracic Duct is located at Level IV on the left side; injury leads to a chyle leak (chylothorax).
(Drainage) Management of a Chyle leak involves a low-fat diet, as fatty acids worsen the leak and can lead to sepsis.
Papillary vs. Follicular Thyroid CA: Papillary primarily spreads through lymphatics (local nodes), whereas Follicular spreads hematogenously (distant organs like bone/liver).
Thyroid Node Staging vs. Other Head/Neck Staging: Thyroid N-staging is based on location (N1a central vs. N1b lateral), while Head and Neck N-staging is based on size/count (N1 <3cm, N2 3-6cm, N3 >6cm).
MEN 2A vs. MEN 2B: Both involve Medullary Thyroid CA, but MEN 2A includes parathyroid hyperplasia, and 2B does not.
Supraglottic vs. Glottic vs. Subglottic: Supraglottic = Dysphagia (swallowing), Glottic = Hoarseness (voice), Subglottic = Dyspnea (breathing).
Pleomorphic Adenoma vs. Warthin's Tumor: Pleomorphic is the most common and is "mixed" (solid/lobulated); Warthin's is cystic and frequently bilateral/associated with smokers.
Radical vs. Modified vs. Selective Neck Dissection: Radical removes 3 specific structures (SCM/IJV/CN XI); Modified saves them; Selective removes only specific levels (1-3 levels).
House-Brackmann Grade III vs. Grade IV: Grade III has complete eye closure with effort; Grade IV has incomplete eye closure.
Elective vs. Therapeutic Neck Dissection: Elective is for clinically negative (N0) necks with high risk; Therapeutic is for clinically positive (N+) nodes.
Thyroid vs. Salivary Staging (T2): For Thyroid, T2 is 2-4 cm; For Salivary, T2 is ≥2 cm to ≤4 cm. Both are identical in size range, but Thyroid Stage III starts > 4cm within the gland.
Submandibular vs. Parotid Salivation: Submandibular produces mucoid saliva (common for stones); Parotid produces serous saliva (active during eating).
Sublingual vs. Parotid Malignancy Rate: A sublingual mass is 70% likely to be malignant, whereas a parotid mass is 70% likely to be benign.
Planned vs. Salvage Neck Dissection: Planned is done regardless of response to radiation; Salvage is done for residual or persistent nodes that failed to resolve.
N2b vs. N2c Neck Nodes: N2b is multiple nodes on the same side (ipsilateral); N2c is nodes on both sides (bilateral) or the opposite side (contralateral).
Inspiratory vs. Expiratory Stridor: Inspiratory stridor usually points to a supraglottic obstruction; expiratory stridor must be differentiated from wheezing.
Filipino thyroid CA vs. Western Guidelines: PH surgeons perform total thyroidectomy at > 1 cm due to higher aggressiveness; Western surgeons often perform lobectomy up to 4 cm.