A Royal Pain in the Throat Tinnitus - ENT & Allergy Associates

St i c k s , St o n e s a n dB r o k e n Bo n e sM i c h a e l Sh o h e t , M.D., F.A.C.S.Fall is upon us. With that, we see anincrease in the incidence of pediatrictrauma. Since a high percentage ofthis involves the head and neck area, thismay be a worthy time to review some importantissues regarding facial trauma in theyounger population.Fortunately, craniofacial skeletal trauma isquite rare in children. This is due to therelative composition of cancellous to corticalbone, and to the high cranial to facial ratio.However, as children grow they become moresusceptible to injuries. In early childhood,there are few primary teeth and smallpermanent tooth buds. As a child growsinto the mixed dentition stage, the mandiblebecomes more susceptible to fracture due tomore teeth and developing tooth crypts.The development of paranasal sinuses atapproximately 5 years of age further weakensthe bones. This weakness allows for themidface to be fractured or separated from thebase of the skull with trauma. Increasingly,popular sports activities add to the numberof facial injuries. Children and teenagersnow drive multi-speed bicycles, dirt bikes,and off-road vehicles. This contributes tothe frequency of facial injuries.Reconstruction of pediatric facial fractures,including those involving the orbit, themidface, and the mandible, requires anunderstanding of craniofacial developmentas well as the consequence of injury on futuregrowth. The patterns of facial fracture notonly differ significantly between adults andchildren, but also among children of differentages. Some of the treatment strategies forfacial fractures in adults and children aresimilar. Some algorithms used in adultsadversely affect craniofacial development.There is also controversy regarding thetiming of repair in children. Nevertheless,intraoperative CT scanning, craniofacialexposure, bone grafting, stereotactic imageguidance and the advent of resorbable rigidhave advanced our ability to reconstructeven the most complex 3D disfigurements.These techniques have reducedthe late sequelae of severe facialfractures.Fractures of the nose are relativelycommon in children. Two-thirdsof nasal fractures are minimallydisplaced and do not requiresurgery. Other injuries aroundthe nose are possible and shouldnot be overlooked. A septalhematoma can cause septalnecrosis and perforation. Forthis reason, if a nasal fracture issuspected, a thorough examinationof the internal and external nasalstructures is warranted. In highimpact trauma with persistentrhinorrhea, cerebrospinal fluidfistula deserves consideration.CSF leaks can typically berepaired by minimally invasiveendoscopic techniques if they donot resolve spontaneously. As inadults, displaced nasal bone andseptal fractures are reduced andstabilized with splints, thoughreduction should be performedsooner in children than in adults.In order to treat lacerations, burns, andother soft tissue trauma properly, oneneeds knowledge of basic wound physiology.Many options for wound closure exist,and the option chosen depends on thetype of wound. The ultimate goal is to obtainthe ideal functional and cosmetic resultwithout complications. This can often beaccomplished without transcutaneous suturesthus obviating suture removal. Multilayeredclosure utilizing high retensionresorbable monofilaments with or withoutcyanoacrylate is one option for managing facialwounds of moderate depth. Meticuloushandling of the soft tissues with thoroughwound cleaning is essential.Tetanus prophylaxis must be considered.A wound is considered tetanus-prone if ithas any of the following features: age ofwound greater than 6 hours, stellate woundor avulsion, depth of wound greater than1 cm, missile, crush, burn, or frostbite injuries,presence of infection, devitalized tissue,or contaminants.If there is one message worthy of relaying,it is the importance of timeliness in thediagnosis and management of both softtissue and skeletal facial injuries. As bothwound healing and fracture fixation isaccelerated in youth, the negative impact oflate management is substantially magnified.Pediatricians and family practitioners aretypically the first line of care and should haveaccess to a facial plastic surgeon on a promptbasis. Most otolaryngologists are qualified toassess these injuries and can direct the mostappropriate care for the patient. Expertmanagement of even the most complexsituations is just a phone call away. •19