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Craniofacial dysjunction: Otolaryngological point of view

Since Le Forte's experiments in the 19th Century, craniofacial dysjunction (Le Forte III fracture) has been recognized as a serious facial injury. A multidisciplinary approach to the management of these patients is often required by concurrent injuries to the eye, brain, chest, abdomen and extremities. The otolaryngologist is particularly equipped to deal with the problems of hemorrhage and upper airway distress, as well as with the functional and cosmetic repair these injuries require. This paper reports the management of craniofacial dysjunction in 26 patients during a three‐year period. Facial damage in the majority of cases was more extensive than that originally described and classified by Le Forte as Type III. Most cases resulted from automobile collisions. Males in the third decade of life predominated. Four patients died before care could be instituted. All patients had severe epistaxis, midfacial flattening and malocclusion, and six required emergency tracheostomy. Marked comminution of the nasal bones and septum was present in all. Fractures of the maxillary sinus were common and 16 of 22 survivors sustained nasofrontal injury, with pseudohypertelorism noted in all. Abrasions and lacerations to the face occurred in 12. Frontal sinus fractures were present in 15 cases and mandibular fractures in six. Other findings included seven with skull fractures, eight with fractured teeth, three with lacrimal sac and duct tears, two with severe intraocular damage, six with CSF rhinorrhea and 15 with diplopia. Repair of the facial fractures was initiated within the first 10 days following injury. All patients required intermaxillary fixation of the dental arches. No instance of delayed malocclusion resulted. When feasible, internal cranial suspension was employed, but in three severely comminuted fractures, external traction utilizing a special head cap was necessary. Frontal sinus obliteration with fat by osteoplastic technique was necessary in 10 patients. Fifteen patients had orbital floor explorations. Delayed findings included epiphora in two cases, diplopia in one, pseudohypertelorism and a flattened nose in three; jagged facial scarring in one, and CSF rhinorrhea in one. Individual follow‐up periods varied from one year to three years. It is the management of these delayed findings during the long follow‐up period that this paper particularly emphasizes.