Acute life-threatening conditions
Maxillofacial (MFR) injuries are fraught with the rapid development of severe pathologies requiring emergency care:
- Asphyxia. Naturally occurs during the destruction of laryngeal and nasopharyngeal structures, as well as bilateral mandibular fractures (dislocation asphyxia).
- Massive hemorrhage. A hidden threat lies in wounds of the floor of the mouth: even with a small external defect, bleeding can become fatal due to rich vascularization.
- Traumatic shock. Closely associated with polytrauma. Facial injuries (especially of the maxilla) are accompanied in a significant number of cases by cerebral contusions, skull base fractures, and the formation of intracranial hematomas.
- Rapid dehydration. Compromised oral seal, profuse salivation, and swallowing disorders lead to rapid fluid loss by the body, which is especially critical in hot climates.
Infectious complications and secondary injuries
The wound process in the facial region is inextricably linked with the risk of purulent-inflammatory diseases, facilitated by anatomical specifics.
- Spread of infection. Infection can penetrate deeply via the venous bloodstream. There is a real danger of phlebitis and thrombophlebitis with the subsequent spread of the purulent process into the cranial cavity or mediastinum.
- Severe phlegmon. Blind wounds, where fragments embed into the deep tissues of the tongue, retropharyngeal, or parapharyngeal spaces, provoke rapid suppuration. Foreign bodies in these zones are removed on an emergency basis.
- Aspiration complications. Tooth fragments play a dual role. During trauma, they turn into secondary wounding projectiles, and when entering the respiratory tract, they act as conductors of infection, inevitably leading to the development of a lung abscess.
Functional and clinical paradoxes
Facial injuries are characterized by a pronounced clinical paradox: the frightening appearance of the wounded person does not always correspond to the true severity of the injuries. However, extensive disfigurement causes deep psycho-emotional trauma.
In addition to aesthetics, vital functions are lost:
- Loss of voice. Due to the inability to speak, the patient cannot call for help. On the battlefield, an unconscious and speechless wounded person may be mistakenly pronounced dead.
- Inability to eat and provide care. Mastication and swallowing disorders lead to severe emaciation.
- Inapplicability of protective gear. About 17% of patients with facial injuries are physically unable to put on a standard military gas mask.
Biophysics of complications: how tissues are destroyed
The severity of maxillofacial gunshot wounds directly depends on the kinetic energy of the projectile released in the tissues:
- "Interstitial explosion". As a bullet or fragment passes, a temporary pulsating cavity forms. The hydrodynamic shock transmits energy through major blood vessels directly to the brain, causing a concussion.
- Deviation of the wound channel. The channel is rarely straight. Upon collision with facial bones, the bullet deflects (primary deviation), and due to the uneven spasm of torn muscles, the wound tract curves even further (secondary deviation).
- Anatomical specifics of bones. Blind shrapnel wounds of the mandible end in fatality 2.5 times more often than similar wounds of the maxilla. At the same time, through-and-through bullet wounds of the maxilla kill 7 times more often than shrapnel wounds.
Briefly: answers to topical questions
What types of asphyxia exist in maxillofacial injuries besides dislocation asphyxia?
Besides dislocation asphyxia, four types of asphyxia are distinguished in maxillofacial injuries.
- Obstructive — closure of the upper respiratory tract by a blood clot or foreign body.
- Stenotic — compression of the trachea due to edema, hematoma, or emphysema.
- Valvular — closure of the laryngeal inlet by a soft tissue flap.
- Aspiration — aspiration of blood, vomitus, or soil into the respiratory tract.
Through which venous anastomoses does infection from the maxillofacial region penetrate into the cranial cavity?
Infection from the maxillofacial area can penetrate into the cavernous sinus (sinus cavernosus) of the dura mater via retrograde blood flow through the following venous anastomoses:
- Anastomosis of the facial vein (v. facialis) with the superior ophthalmic vein (v. ophthalmica superior) in the area of the medial angle of the eye (via the nasofrontal vein — v. nasofrontalis).
- Anastomosis of the facial vein (v. facialis) with the deep pterygoid venous plexus (plexus venosus pterygoideus) at the level of the nasal ala or lower.
- Anastomosis of the inferior ophthalmic vein (v. ophthalmica inferior) and the pterygoid venous plexus (plexus venosus pterygoideus).
What methods of temporary hemostasis exist for maxillofacial injuries?
The following methods are used for temporary arrest of hemorrhage:
- Digital pressure on the artery — compression of the vessel at points where it lies superficially and close to bone.
- Wound tamponade and pressure bandage application — tight insertion of a gauze tampon into the wound followed by fixation with a pressure bandage; used for bleeding from veins, small arteries, and soft tissues covering skull bones, elbow, and knee joints.
- Load pressure and cooling — application of a sandbag and/or ice pack for interstitial hemorrhages and for the prevention of postoperative hematomas.
- Tourniquet application — the most reliable method of temporary hemostasis; used mainly in the area of the extremities.
For quick memorization of key complications, use the acronym ASHOK: Asphyxia, Shock (due to concomitant brain injuries), Odehydration (Dehydration), Kraemmorrhage (Hemorrhage).
Class and exam questions
Why do blind wounds of the tongue require emergency intervention?
The localization of foreign bodies in the deep muscles of the tongue, as well as in the parapharyngeal or retropharyngeal spaces, creates an extremely high risk of developing life-threatening phlegmon, which is a direct indication for emergency surgery.
What is the essence of "clinical mismatch" in facial injuries?
The true severity of trauma often diverges from the external picture. Massive disfigurement may be observed with relatively minor injuries, while a fatal hemorrhage may be hidden behind a tiny through-and-through opening on the floor of the mouth.
What is the reason for the high probability of shock in injuries of the maxilla?
Injuries to the maxilla are often combined in nature. They are accompanied by cerebral contusions, intracranial hematomas, and skull base fractures, which provokes the development of severe traumatic shock.
What else to study on this topic
- Morphological zones of a gunshot wound (zones of primary and secondary necrosis, zone of parabiosis)
- The rule of entry and exit openings in through-and-through wounds
- Classification of maxillofacial injuries by localization and projectile nature
- Phases of the general body response to traumatic impact
- Features of the microbiological landscape of penetrating and non-penetrating wounds
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Other topics in the section "Chapter 11. Non-ballistic and ballistic facial injuries. Thermal and radiation lesions of the maxillofacial region (V.V. Afanasyev)"
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