Thread by @drtintin99

Case study as #MorningPaper to start off the week. 27y cyclist vs car, GCS 15, CSF rhinorrhoea. CT attached. What are the steps of your management plan? What kind of injuries are you seeing?

My decision here: Lumbar drain initially for yeh CSF leak, Pneumovax but not antibiotics. Lefort III fracture and mandibular needs surgery so planned to cranialise frontal sinus at the same setting. Consent included fascia lata and calvarial grafts, just in case. 1/🧵

2/ #Submental intubation to gain better oral access: cut down onto inferior border of mandible, blunt dissection with artery clip through floor of mouth, dilators and then deliver ETT submetally and reconnect.

3/ Bicoronal incision with separate pericranial flap, preserving the temporal branch of facial nerves and supraorbital nerves. Expose down to ZF sutures, nasal bones and along orbital roof. I use a #Subfascial approach but you can do interfascial too.

4/ #Subconjunctival approach to the orbital floor and superior third of maxilla, taking care to preserve the infraorbital bundle to prevent gum necrosis and losing all the teeth. Then #sublabeal approach back up maxilla, allowing complete access. Separate approach to mandible.

5/ Now we're ready to fix the mandible, maxilla, zygoma and orbital floor. The frontal fractures were then hinged forwards to allow drilling off of the posterior wall of the sinus. Mucosa stripped and fronto-ethoid track packed. Frontal bones then fixed to the nasal bones.

6/ Finally, pedicled pericranial flap folds along the frontal bone and along skull base + #Tisseal and all the wounds closed. The only visible scar should be the parts of the bicoronal incision by the ears.

Ok took 6 hours...but it was worth it! I'll post the post-op scan soon!