Modern management of maxillofacial trauma in the emergency department

doi:10.5847/wjem.j.1920-8642.2026.003

Abstract

Abstract:

BACKGROUND: Maxillofacial trauma represents a significant challenge in emergency medicine, requiring both diagnostic accuracy and prompt intervention while balancing immediate life-saving interventions with preservation of function and aesthetics. The complex anatomy of this region, with its proximity to critical structures, demands a thorough understanding of assessment and management principles. This narrative review aims to provide evidence-based guidelines for emergency physicians managing maxillofacial trauma, with particular emphasis on early recognition of critical injuries, airway management strategies, and special population considerations.

METHODS: A narrative review was conducted via a comprehensive literature search of the PubMed and Scopus databases, which focused on maxillofacial trauma management in emergency settings. Articles were selected based on relevance to clinical practice, methodological quality, and current management guidelines. The review synthesized evidence from multiple study types, including original research, systematic reviews, and clinical practice guidelines, to provide practical guidance for emergency physicians.

RESULTS: Initial assessment following Advanced Trauma Life Support (ATLS) principles is crucial, with airway management being a primary concern due to the risk of dynamic obstruction. Critical time-sensitive emergencies include orbital compartment syndrome, trapdoor fractures (in pediatric patients), and facial nerve injuries. Computed tomography (CT) imaging remains the gold standard for diagnosis. Special considerations are required for pediatric patients, who present unique anatomical challenges and injury patterns, and for elderly patients, who often have complex medical comorbidities and increased complication risks. Management strategies range from conservative treatment to urgent surgical intervention, with decisions based on the injury pattern and associated complications.

CONCLUSION: Emergency physicians must maintain a structured yet flexible approach to maxillofacial trauma, focusing on early recognition of critical injuries, appropriate airway management, and timely specialist consultation. Understanding injury patterns and their potential complications allows for effective risk stratification and treatment planning, ultimately improving patient outcomes.

Key words: Maxillofacial trauma, Orbital fractures, LeFort fractures, Facial fractures

Gaia Bavestrello Piccini, Domenico Sfondrini, Silviu-Andrei Tomulescu, Ciro Esposito, Andrea Piccioni, Giorgia Caputo, Antonio Voza, Christian Zanza, Yaroslava Longhitano, Gabriele Savioli. Modern management of maxillofacial trauma in the emergency department[J]. World Journal of Emergency Medicine, 2026, 17(1): 15-27.

Figures/Tables 5

Table 1.

Table 2.

Frequent clinical examination findings and associated risks by fracture types

Fracture types	Clinical examination findings	Associated risks
Frontal	•Tenderness to palpation •Edema over the frontal bone	•Intracranial injury •Orbital injury •Basilar skull fractures •Temporal bone injury •Frontal sinus fractures •Intracranial and cervical spine injury due to high-energy mechanisms
Orbital	•Bony tenderness •Swelling and ecchymosis •Reduced visual acuity, blurry vision or diplopia •Enophthalmos or eye swelling •Periorbital emphysema •Limitations of ocular movement	•Orbital floor fracture with inferior rectus entrapment •Medial wall fracture with medial rectus entrapment •Lens dislocation •Retrobulbar hematoma with orbital compartment syndrome^[17,55] •Loss of sight (direct/indirect) •Oculocardiac reflex^[41,56-61]
LeFort I	•Movement of the maxilla •Floating palate •Mobility of toothbearing maxilla and hard palate •Malocclusion •Dental fractures	•Cervical spine, intracranial, and ocular injuries due to highenergy mechanisms
LeFort II	•Movement of nasal complex •Movement of maxilla (hard palate) •Malocclusion	•Extraocular muscle injury •Orbital hematoma •Globe rupture/impingement •Optic nerve damage •Epistaxis •Cerebrospinal fluid (CSF) rhinorrhea •Lacrimal system injury •Medial canthal tendon injury •Sinus drainage obstruction
LeFort III	•Craniofacial disjunction •Malocclusion •Movement of midface and orbital rims	•Orbital complications •Lacrimal system injury •Epistaxis •CSF rhinorrhea
Nasal	•External lacerations and tissue loss •Asymmetries and deviations of nasal dorsum •Periorbital ecchymoses •Septal hematoma	•Epistaxis •Septal cartilage avascular necrosis •Nasoorbitoethmoid fracture with intracranial injury
Mandibular	•Pain with jaw movement or trismus •Jaw malocclusion •Sensitive problems of lips and chin •Sublingual hematomas •Dental or alveolar ridge fractures •Loose fractured or displaced teeth	•Airway compromise from sublingual hematomas and posterior tongue displacement in bilateral fractures •Hemotympanum •Auditory canal lesions

Table 2.

Table 3.

Table 4.

Table 5.

Key considerations for pediatric and elderly population

Domain	Characteristics	Clinical implications
Pediatric population
Anatomical characteristics	•Larger skull-to-face ratio •Greater bone elasticity •Flexible suture lines •Smaller airways •Relatively larger tongue	•More cranial vs. facial injuries •Minimally displaced fractures •Lower threshold for airway intervention
Injury patterns	•More common superior orbital rim/frontal bone involvement •Greenstick fractures frequent •White eye syndrome •Minimally displaced fractures	•Need for careful orbital examination •Risk of trapdoor effect •Higher risk of muscle entrapment •Higher risk for oculocardiac reflex
Clinical assessment	•Challenging examination •Limited cooperation	•Calm, systematic approach •Distraction techniques •Parental presence •Appropriate pain control
Monitoring	•Rapid neurological deterioration possible •Close follow-up needed •Growth impact monitoring	•Essential neurological monitoring •Long-term growth consideration
Special considerations	•Growth and development impact •Excellent healing potential •Consider nonaccidental trauma	•Less likely to need surgery •Screen for abuse in suspicious cases
Elderly population
Risk factors	•Medical comorbidities •Decreased physiological reserve •Osteoporosis (especially women) •Polymedication •Anticoagulation	•Higher complication risk •Complex medication management •Increased fracture risk •Increased risk for retrobulbar hematoma with vision loss in orbital fractures
Injury patterns	•Midface fractures more common •Orbital floor/wall fractures (>75 years) •Less severe displacement	•Modified treatment approaches
Clinical concerns	•Risk of hemorrhage •Epistaxis •Intracranial bleeding •Thromboembolic events	•Mandatory head computed tomography •Anticoagulation management •Close monitoring
Hospital course	•Longer hospital stays •Higher surgical intervention needs •Immunosenescence •Increased nosocomial infection risk	•Extended care needs •Infection prevention crucial •Complex discharge planning

Table 5.

References 161

1	Sethi RK, Kozin ED, Fagenholz PJ, Lee DJ, Shrime MG, Gray ST. Epidemiological survey of head and neck injuries and trauma in the United States. Otolaryngol Head Neck Surg. 2014; 151(5): 776-84. doi: 10.1177/0194599814546112 pmid: 25139950
2	Alvi A, Doherty T, Lewen G. Facial fractures and concomitant injuries in trauma patients. Laryngoscope. 2003; 113(1): 102-6. doi: 10.1097/00005537-200301000-00019 pmid: 12514391
3	Hogg NJ, Stewart TC, Armstrong JE, Girotti MJ. Epidemiology of maxillofacial injuries at trauma hospitals in Ontario, Canada, between 1992 and 1997. J Trauma. 2000; 49(3): 425-32. doi: 10.1097/00005373-200009000-00007
4	Zhang ZX, Xie L, Li Z. Global, regional, and national burdens of facial fractures: a systematic analysis of the global burden of Disease 2019. BMC Oral Health. 2024; 24(1): 282. doi: 10.1186/s12903-024-04048-5
5	Boffano P, Roccia F, Zavattero E, Dediol E, Uglešić V, Kovačič Ž, et al. European maxillofacial trauma (EURMAT) project: a multicentre and prospective study. J Craniomaxillofac Surg. 2015; 43(1): 62-70. doi: 10.1016/j.jcms.2014.10.011 pmid: 25457465
6	Scarfe WC. Imaging of maxillofacial trauma: evolutions and emerging revolutions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005; 100(2 suppl): S75-S96.
7	Bernstein SL, Aronsky D, Duseja R, Epstein S, Handel D, Hwang U, et al. The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med. 2009; 16(1): 1-10. doi: 10.1111/j.1553-2712.2008.00295.x pmid: 19007346
8	Mehta N, Butala P, Bernstein MP. The imaging of maxillofacial trauma and its pertinence to surgical intervention. Radiol Clin North Am. 2012; 50(1): 43-57. doi: 10.1016/j.rcl.2011.08.005
9	Sfondrini D, Marelli S. The “low preauricular” transmasseteric anteroparotid (TMAP) technique as a standard way to treat extracapsular condylar fractures. J Craniomaxillofac Surg. 2024; 52(1): 108-16. doi: 10.1016/j.jcms.2023.11.001 pmid: 38129188
10	Louis PJ, Morlandt AB. Advancements in maxillofacial trauma: a historical perspective. J Oral Maxillofac Surg. 2018; 76(11): 2256-70. doi: 10.1016/j.joms.2018.08.021
11	Gerbino G, Roccia F, Bianchi FA, Zavattero E. Surgical management of orbital trapdoor fracture in a pediatric population. J Oral Maxillofac Surg. 2010; 68(6): 1310-6. doi: 10.1016/j.joms.2009.12.037
12	Chen YH, Tsai YJ, Tzeng IS. Factors influencing surgical outcomes in orbital trapdoor fracture. Sci Rep. 2021; 11(1): 17547. doi: 10.1038/s41598-021-96920-5
13	Gooris PJJ, Mourits MP, Mensink G, Bergsma JE. Orbital fractures in the pediatric population in surgery in and around the orbit:CrossRoads. Cham: Springer International Publishing; 2023:245-57.
14	Barh A, Swaminathan M, Mukherjee B. Orbital fractures in children: clinical features and management outcomes. J AAPOS. 2018; 22(6): 415.e1-415.e7. doi: 10.1016/S1091-8531(18)30026-0
15	Erdmann D, Follmar KE, Debruijn M, Bruno AD, Jung SH, Edelman D, et al. A retrospective analysis of facial fracture etiologies. Ann Plast Surg. 2008; 60(4): 398-403. doi: 10.1097/SAP.0b013e318133a87b pmid: 18362568
16	Deana C, Biasucci DG, Aspide R, Bagatto D, Brasil S, Brunetti D Jr, et al. Non-invasive intracranial pressure assessment in adult critically ill patients: a narrative review on current approaches and future perspectives. J Clin Anesth. 2025;106: 111977.
17	Zanza C, Facelli V, Romenskaya T, Bottinelli M, Caputo G, Piccioni A, et al. Lactic acidosis related to pharmacotherapy and human diseases. Pharmaceuticals (Basel). 2022; 15(12): 1496. doi: 10.3390/ph15121496
18	Singaram M, G SV, Udhayakumar RK. Prevalence, pattern, etiology, and management of maxillofacial trauma in a developing country: a retrospective study. J Korean Assoc Oral Maxillofac Surg. 2016; 42(4): 174-81. doi: 10.5125/jkaoms.2016.42.4.174 pmid: 27595083
19	Tao YP, Zhao CH, Wu JG. Chinese and global trends in pediatric spinal cord injury burden (1990-2021) with projections to 2045. World J Pediatr. 2025; 21(12):1275-88. doi: 10.1007/s12519-025-00991-7
20	Boffano P, Roccia F, Zavattero E, Dediol E, Uglešić V, Kovačič Ž, et al. European maxillofacial trauma (EURMAT) in children: a multicenter and prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol. 2015; 119(5): 499-504. doi: 10.1016/j.oooo.2014.12.012
21	Mohammadi H, Roochi MM, Heidar H, Garajei A, Dallband M, Sadeghi M, et al. A meta-analysis to evaluate the prevalence of maxillofacial trauma caused by various etiologies among children and adolescents. Dent Traumatol. 2023; 39(5): 403-17. doi: 10.1111/edt.v39.5
22	Liu FC, Halsey JN, Oleck NC, Lee ES, Granick MS. Facial fractures as a result of falls in the elderly: concomitant injuries and management strategies. Craniomaxillofac Trauma Reconstr. 2019; 12(1): 45-53. doi: 10.1055/s-0038-1642034 pmid: 30815215
23	Bettschen D, Tsichlaki D, Chatzimichail E, Klukowska-Rötzler J, Müller M, Sauter TC, et al. Epidemiology of maxillofacial trauma in elderly patients receiving oral anticoagulant or antithrombotic medication: a Swiss retrospective study. BMC Emerg Med. 2024; 24(1): 121. doi: 10.1186/s12873-024-01039-1 pmid: 39020294
24	Irgebay Z, Kahan EH, Park KE, Choi J, Zellner EG. Characteristics and patterns of facial fractures in the elderly population in the United States based on trauma quality improvement project data. J Craniofac Surg. 2022; 33(5): 1294-8. doi: 10.1097/SCS.0000000000008612 pmid: 36041136
25	Giacomin M, De Conto F, Siqueira SP, Signori PH, Eidt JMS, Sawazaki R. Elderly patients with facial trauma: a 10 year review. Rev Bras Geriatr Gerontol. 2017; 20(5): 618-23. doi: 10.1590/1981-22562017020.160183
26	Kloss FR, Tuli T, Hächl O, Laimer K, Jank S, Stempfl K, et al. The impact of ageing on cranio-maxillofacial trauma-a comparative investigation. Int J Oral Maxillofac Surg. 2007; 36(12): 1158-63. doi: 10.1016/j.ijom.2007.07.009
27	Chew DJ, Edmondson HD. A study of maxillofacial injuries in the elderly resulting from falls. J Oral Rehabil. 1996; 23(7): 505-9. pmid: 8814568
28	Shumate R, Portnof J, Amundson M, Dierks E, Batdorf R, Hardigan P. Recommendations for care of geriatric maxillofacial trauma patients following a retrospective 10-year multicenter review. J Oral Maxillofac Surg. 2018; 76(9): 1931-6. doi: 10.1016/j.joms.2017.10.019
29	Long S, Spielman DB, Losenegger T, Obayemi AA, Neuner R, Cosiano MF, et al. Patterns of facial fractures in a major metropolitan level 1 trauma center:a 10-year experience. Laryngoscope. 2021;131(7):E2176-80.
30	Kreidl KO, Kim DY, Mansour SE. Prevalence of significant intraocular sequelae in blunt orbital trauma. Am J Emerg Med. 2003; 21(7): 525-8. doi: 10.1016/j.ajem.2003.08.009 pmid: 14655229
31	Jia YJ, Zhang WD, Zhang JJ, Wang Y. The current situation and prospects of pre hospital blood transfusion for severe trauma. Chin J Emerg Med. 2025; 34(2): 158-62.
32	Dancey A, Perry M, Silva DC. Blindness after blunt facial trauma: are there any clinical clues to early recognition? J Trauma. 2005; 58(2): 328-35. doi: 10.1097/01.TA.0000135353.28388.B0
33	Magarakis M, Mundinger GS, Kelamis JA, Dorafshar AH, Bojovic B, Rodriguez ED. Ocular injury, visual impairment, and blindness associated with facial fractures: a systematic literature review. Plast Reconstr Surg. 2012; 129(1): 227-33. doi: 10.1097/PRS.0b013e3182362a6d pmid: 21915081
34	Sfondrini D, Marelli S, Patriarca R, Scribante A, Preda L, Savioli G, et al. Floor of the mouth hemorrhage following dental implant placement or guided bone regeneration (GBR) in the atrophic interforaminal mandible. Case Rep Dent. 2024;2024: 8413875.
35	Houck J, Mangal R, Vandillen C, Ganti L, Sleigh BC. Orbital compartment syndrome: how a young man’s vision was saved by the timely actions of an emergency medicine physician. Cureus. 2019; 11(7): e5057.
36	Greenspan J, Gartenberg A, Sofia Simich C, Halperin M. Atraumatic acute compartment syndrome secondary to prolonged intoxication induced recumbency: a case series. World J Emerg Med. 2025; 16(6):593-6. doi: 10.5847/wjem.j.1920-8642.2025.116
37	Peisah RI, Ostrowski K. Emergency management of orbital compartment syndrome: lateral canthotomy and cantholysis case series. Australas Emerg Care. 2025; 28(1): 67-71. doi: 10.1016/j.auec.2024.09.004
38	Murali S, Davis C, McCrea MJ, Plewa MC. Orbital compartment syndrome: pearls and pitfalls for the emergency physician. J Am Coll Emerg Physicians Open. 2021; 2(2): e12372.
39	Kumar S, Artymowicz A, Muscente J, Shinder R, Mostafavi D. Do not fall for this; diagnostic challenges in orbital floor fractures with extraocular muscle entrapment. Cureus. 2023; 15(2): e35268.
40	Bora V, Sood G, Dunville LM, Kramer J. Oculocardiac reflex. Treasure Island: StatPearls Publishing; 2024: 205-17.
41	Kim BB, Qaqish C, Frangos J, Caccamese JF. Oculocardiac reflex induced by an orbital floor fracture: report of a case and review of the literature. J Oral Maxillofac Surg. 2012; 70(11): 2614-9.
42	Chukwulebe S, Hogrefe C. The diagnosis and management of facial bone fractures. Emerg Med Clin North Am. 2019; 37(1): 137-51. doi: 10.1016/j.emc.2018.09.012
43	Cornelius CP, Audigé L, Kunz C, Buitrago-Téllez CH, Rudderman R, Prein J. The comprehensive AOCMF classification system: midface fractures - level 3 tutorial. Craniomaxillofac Trauma Reconstr. 2014; 7(Suppl 1): S068-91.
44	Phillips BJ, Turco LM. LeFort fractures: a collective review. Bull Emerg Trauma. 2017; 5(4): 221-30. doi: 10.18869/acadpub.beat.5.4.499
45	Ikeda AK, Burke AB. LeFort fractures. Semin Plast Surg. 2021; 35(4): 250-5. doi: 10.1055/s-0041-1735816 pmid: 34819806
46	Bellamy JL, Mundinger GS, Reddy SK, Flores JM, Rodriguez ED, Dorafshar AH. LeFort II fractures are associated with death: a comparison of simple and complex midface fractures. J Oral Maxillofac Surg. 2013; 71(9): 1556-62. doi: 10.1016/j.joms.2013.04.007
47	Nahabedian MY. Michigan manual of plastic surgery. Ann Surg. 243(4): 567.
48	Ceallaigh PO, Ekanaykaee K, Beirne CJ, Patton DW. Diagnosis and management of common maxillofacial injuries in the emergency department. Part 1: Advanced trauma life support. Emerg Med J. 2006; 23(10): 796-7. doi: 10.1136/emj.2006.035931 pmid: 16988311
49	Son YK, Shin JM, An DA, Kim YH. Intrusive luxation of tooth due to bite block after oral endotracheal intubation. Korean J Anesthesiol. 2013; 65(3): 280-1. doi: 10.4097/kjae.2013.65.3.280 pmid: 24101969
50	No author listed. Management of severe hemorrhage from midface trauma. Available at https://www.northerntrauma.co.nz/adult_trauma/management-of-severe-haemorrhage-from-midface-trauma/
51	Ellis E, Moos KF, el-Attar A. Ten years of mandibular fractures: an analysis of 2,137 cases. Oral Surg Oral Med Oral Pathol. 1985; 59(2): 120-9. doi: 10.1016/0030-4220(85)90002-7
52	Champy M, Loddé JP, Schmitt R, Jaeger JH, Muster D. Mandibular osteosynthesis by miniature screwed plates via a buccal approach. J Maxillofac Surg. 1978; 6(1): 14-21. doi: 10.1016/s0301-0503(78)80062-9 pmid: 274501
53	Rozema R, Doff MHJ, El Moumni M, Boomsma MF, Spijkervet FKL, Diagnostic accuracy of physical examination findings for midfacial and mandibular fractures. Injury. 2021; 52(9): 2616-24. doi: 10.1016/j.injury.2021.05.037
54	Rozema R, Doff MHJ, Delli K, Spijkervet FKL, Diagnostic accuracy of physical examination findings for midfacial fractures: a systematic review and meta-analysis. Clin Oral Investig. 2022; 26(4): 3405-27. doi: 10.1007/s00784-022-04423-y
55	He D, Blomquist PH, Ellis E. Association between ocular injuries and internal orbital fractures. J Oral Maxillofac Surg. 2007; 65(4): 713-20. doi: 10.1016/j.joms.2006.09.006
56	Vasudev S, Reddy KS. Trigemino-cardiac reflex during orbital floor reconstruction: a case report and review. J Maxillofac Oral Surg. 2015; 14(suppl 1): 32-7.
57	Chesley LD, Shapiro RD. Oculocardiac reflex during treatment of an orbital blowout fracture. J Oral Maxillofac Surg. 1989; 47(5): 522-3. doi: 10.1016/0278-2391(89)90290-5
58	Robideaux V. Oculocardiac reflex caused by midface disimpaction. Anesthesiology. 1978; 49(6): 433. pmid: 727547
59	Loewinger J, Cohen M, Levi E. Bradycardia during elevation of a zygomatic arch fracture. J Oral Maxillofac Surg. 1987; 45(8): 710-1. doi: 10.1016/0278-2391(87)90315-6
60	Hirjak D, Zajko J, Satko I. Bradycardia after orbital injury: case report. Int J Oral Maxillofac Surg. 1993; 22(1): 26-7.
61	Bainton R, Lizi E. Cardiac asystole complicating zygomatic arch fracture. Oral Surg Oral Med Oral Pathol. 1987; 64(1): 24-5. doi: 10.1016/0030-4220(87)90110-1
62	Hollander JE, Singer AJ, Valentine S, Henry MC. Wound registry: development and validation. Ann Emerg Med. 1995; 25(5): 675-85. doi: 10.1016/s0196-0644(95)70183-4 pmid: 7741347
63	Peluso H, Vega K, Araya S, Talemal L, Moss C, Siegel J, et al. Incidence and characterization of facial lacerations in emergency departments in the United States. Craniomaxillofac Trauma Reconstr. 2024; 17(4): NP113-20. doi: 10.1177/19433875241257572
64	Marks M, Polecritti D, Bergman R, Koch CA. Emergent soft tissue repair in facial trauma. Facial Plast Surg Clin North Am. 2017; 25(4): 593-604. doi: 10.1016/j.fsc.2017.06.010
65	Sabatino F, Moskovitz JB. Facial wound management. Emerg Med Clin North Am. 2013; 31(2): 529-38. doi: 10.1016/j.emc.2013.01.005
66	Tanner J, Melen K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev. 2021;8: CD004122.
67	Alexander JW, Fischer JE, Boyajian M, Palmquist J, Morris MJ. The influence of hair-removal methods on wound infections. Arch Surg. 1983; 118(3): 347-52. doi: 10.1001/archsurg.1983.01390030079013
68	WHO Team. Global guidelines for the prevention of surgical site infection. Available at: https://www.who.int/publications/i/item/9789241550475
69	Adeleye AO. Nonshaved cranial surgery in black Africans: technical report and a medium-term prospective outcome study. Neurosurg Rev. 2016; 39(3): 449-54.
70	Wulc AE, Arterberry JF. The pathogenesis of canalicular laceration. Ophthalmology. 1991; 98(8): 1243-9. pmid: 1923361
71	Drnovsek-Olup B, Beltram M. Trauma of the lacrimal drainage system: retrospective study of 32 patients. Croat Med J. 2004; 45(3): 292-4. pmid: 15185420
72	Rishor-Olney CR, Hinson JW. Canalicular laceration. Treasure Island: StatPearls; 2025: 326-39.
73	Al-Battashy A, Al-Mujaini AS. Canalicular lacerations: techniques used and timing to intervene. Oman J Ophthalmol. 2023; 16(2): 201-4. doi: 10.4103/ojo.ojo_101_23 pmid: 37602159
74	Sheth R, Smith RK, Lambert JS. Emergency department management of maxillofacial trauma. Emerg Med Pract. 2024; 26(suppl 10): 1-33. pmid: 39353207
75	Deliverska EG, Stefanov LP. Maxillofacial trauma management in polytraumatized patients-the use of advanced trauma life support (ATLS) principles. J IMAB. 2013; 19(2): 282-5. doi: 10.5272/jimab.
76	Perry M. Advanced trauma life support (ATLS) and facial trauma: can one size fit all? Part 1: dilemmas in the management of the multiply injured patient with coexisting facial injuries. Int J Oral Maxillofac Surg. 2008; 37(3): 209-14. doi: 10.1016/j.ijom.2007.11.003
77	Xu J, Cao W, Cao LJ, Bai XQ, Zhou YL, Xu XQ. One case of successful rescue of traumatic main airway rupture through extracorporeal membrane oxygenation. Chin J Emerg Med. 2024; 33(3):410-2.
78	Jose A, Nagori SA, Agarwal B, Bhutia O, Roychoudhury A. Management of maxillofacial trauma in emergency: an update of challenges and controversies. J Emerg Trauma Shock. 2016; 9(2): 73-80. doi: 10.4103/0974-2700.179456 pmid: 27162439
79	Krausz AA, El-Naaj IA, Barak M. Maxillofacial trauma patient: coping with the difficult airway. World J Emerg Surg. 2009;4: 21.
80	Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015; 115(6): 827-48. doi: 10.1093/bja/aev371
81	Mekkodathil A, El-Menyar A, Chughtai T, Abdel-Aziz Bahey A, Labib Shehatta A, Ayyad A, et al. Initial serum electrolyte imbalances and mortality in patients with traumatic brain injury: a retrospective study. World J Emerg Med. 2025; 16(4):331-9. doi: 10.5847/wjem.j.1920-8642.2025.064 pmid: 40708737
82	Bertuccio A, Marasco S, Longhitano Y, Romenskaya T, Elia A, Mezzini G, et al. External ventricular drainage: a practical guide for neuro-anesthesiologists. Clin Pract. 2023; 13(1): 219-29. doi: 10.3390/clinpract13010020
83	Jain N, Singh A. Videolaryngoscopy as the primary approach to emergency airway management in facial trauma: a case report. Cureus. 2024; 16(11): e74536.
84	Ahmad I, El-Boghdadly K, Bhagrath R, Hodzovic I, McNarry AF, Mir F, et al. Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia. 2020; 75(4): 509-28. doi: 10.1111/anae.14904 pmid: 31729018
85	Ayuningtyas LV, Mutiar A, Airlangga PS. Face-to-face awake intubation in an upright position in severe maxillofacial trauma. Turk J Emerg Med. 2024; 24(1): 58-61. doi: 10.4103/tjem.tjem_84_23 pmid: 38343521
86	Saraswat V. Airway management in maxillofacial trauma: a retrospective review of 127 cases. Indian J Anaesth. 2020;52: 311.
87	Zanza C, Piccolella F, Racca F, Romenskaya T, Longhitano Y, Franceschi F, et al. Ketamine in acute brain injury: current opinion following cerebral circulation and electrical activity. Healthcare (Basel). 2022; 10(3): 566.
88	Zanza C, Caputo G, Tornatore G, Romenskaya T, Piccioni A, Franceschi F, et al. Cellular immuno-profile in septic human host: a scoping review. Biology (Basel). 2022; 11(11): 1626.
89	Muzzi DA, Losasso TJ, Cucchiara RF. Complication from a nasopharyngeal airway in a patient with a basilar skull fracture. Anesthesiology. 1991; 74(2): 366-8. doi: 10.1097/00000542-199102000-00026 pmid: 1990912
90	Iglesias J, Carrasco A, Catalán G, De la Fuente P, Gutiérrez R, Paternain C, et al. Intraventricular haemorrhage by nasogastric tube insertion into the brain after transsphenoidal surgery. A case report and review of the literature. Interdiscip Neurosurg. 2021;24: 101022.
91	Mittal G, Mittal RK, Katyal S, Uppal S, Mittal V. Airway management in maxillofacial trauma: do we really need tracheostomy/submental intubation. J Clin Diagn Res. 2014; 8(3): 77-9.
92	Arrowsmith JE, Robertshaw HJ, Boyd JD. Nasotracheal intubation in the presence of frontobasal skull fracture. Can J Anaesth. 1998; 45(1): 71-5. doi: 10.1007/BF03011998
93	Rhee KJ, Muntz CB, Donald PJ, Yamada JM. Does nasotracheal intubation increase complications in patients with skull base fractures? Ann Emerg Med. 1993; 22(7): 1145-7.
94	Zanza C, Longhitano Y, Planinsic R, Voza A, Tesauro M, Caputo G, et al. The immunomodulatory effects of nutritional supplements in traumatic brain injury. J Intensive Care Med. 2025: 8850666251337378.
95	Raval CB, Rashiduddin M. Airway management in patients with maxillofacial trauma - A retrospective study of 177 cases. Saudi J Anaesth. 2011; 5(1): 9-14. doi: 10.4103/1658-354X.76476 pmid: 21655009
96	Khan R, Sharma P, Kaul N. Airway management in trauma. Indian J Anaesth. 2011; 55(5): 463. doi: 10.4103/0019-5049.89870 pmid: 22174462
97	Athanassoglou V, Rogers A, Hofmeyr R. In-hospital management of the airway in trauma. BJA Educ. 2024; 24(7): 238-44. doi: 10.1016/j.bjae.2024.03.004
98	Gwyn PP, Carraway JH, Horton CE, Adamson JE, Mladick RA. Facial fractures-associated injuries and complications. Plast Reconstr Surg. 1971; 47(3):225-30. doi: 10.1097/00006534-197103000-00004 pmid: 5101680
99	Zanza C, Saglietti F, Tesauro M, Longhitano Y, Savioli G, Balzanelli MG, et al. Cardiogenic pulmonary edema in emergency medicine. Adv Respir Med. 2023; 91(5): 445-63. doi: 10.3390/arm91050034 pmid: 37887077
100	Thaller SR, Beal SL. Maxillofacial trauma: a potentially fatal injury. Ann Plast Surg. 1991; 27(3): 281-3. pmid: 1952756
101	Zhang Y, Di JZ. Management practice of optimizing blood transfusion process for emergency severe trauma patients. Chin J Emerg Med. 2024; 33(12):1760-4.
102	Buchanan RT, Holtmann B. Severe epistaxis in facial fractures. Plast Reconstr Surg. 1983; 71(6): 768-71. pmid: 6344112
103	Imai T, Michizawa M, Yamamoto N, Oba J, Sawano H. Life-threatening oronasal hemorrhage managed by transcatheter embolization of bilateral maxillary arteries in an elderly patient with comminuted LeFort I fracture. Oral Surg Oral Med Oral Pathol Oral Radiol. 2014; 118(1): e6-e11.
104	Zhang L, Wang L, Lin YQ. Study on the correlation between cerebrospinal fluid glucose and lactate levels and post-traumatic epilepsy. Chin J Emerg Med. 2024; 33 (8): 1197-201.
105	Wang S, Yan DP, Wu ZJ, Zhang YK, Chen HT, Chen LN, et al. Optimal evidence summary of hemostatic measures for adult trauma patients with active hemorrhage in the emergency. Chin J Emerg Med. 2024; 33 (12):1781-7.
106	Bynoe RP, Kerwin AJ, Parker HH, Nottingham JM, Bell RM, Yost MJ, et al. Maxillofacial injuries and life-threatening hemorrhage: treatment with transcatheter arterial embolization. J Trauma. 2003; 55(1): 74-9. doi: 10.1097/01.TA.0000026494.22774.A0
107	Kim J, Park SK, Chung J. Role of transarterial embolization in the treatment of life-threatening hemorrhage in patients with maxillofacial injury. Korean J Neurotrauma. 2022; 18(2): 178-87. doi: 10.13004/kjnt.2022.18.e37 pmid: 36381464
108	Yu J, Choi JW, Whang K, Oh J. The role of angiographic interventions in life-threatening traumatic maxillofacial bleeding. J Neurointensive Care. 2023; 6(1): 35-41. doi: 10.32587/jnic.2023.00612
109	Shi B, Lyu CJ, Le ZK, Ji HS, Xiao Y, Zhang YY, et al. NLRP 3 activation in macrophages promotes acute intestinal injury in neonatal necrotizing enterocolitis. World J Pediatr. 2024; 20(2):153-64. doi: 10.1007/s12519-023-00727-5
110	Hutchinson AK, Morse CL, Hercinovic A, Cruz OA, Sprunger DT, Repka MX, et al. Pediatric eye evaluations preferred practice pattern. Ophthalmology. 2023; 130(3): P222-70. doi: 10.1016/j.ophtha.2022.10.030
111	Perry M, Moutray T. Advanced trauma life support (ATLS) and facial trauma: can one size fit all? Part 4: ‘can the patient see? ’ timely diagnosis, dilemmas and pitfalls in the multiply injured, poorly responsive/unresponsive patient. Int J Oral Maxillofac Surg. 2008; 37(6): 505-14. doi: 10.1016/j.ijom.2007.11.004
112	Perry M, Dancey A, Mireskandari K, Oakley P, Davies S, Cameron M. Emergency care in facial trauma—a maxillofacial and ophthalmic perspective. Injury. 2005; 36(8): 875-96. doi: 10.1016/j.injury.2004.09.018
113	Chen EJ, Fasiuddin A. Management of traumatic hyphema and prevention of its complications. Cureus. 2021; 13(6): e15771.
114	Gragg J, Blair K, Baker MB. Hyphema. Treasure Island: StatPearls Publishing; 2022:79-85.
115	Yurdakul NS, Uğurlu S, Yilmaz A, Maden A. Traumatic subconjunctival crystalline lens dislocation. J Cataract Refract Surg. 2003; 29(12): 2407-10. doi: 10.1016/S0886-3350(03)00332-8
116	Broadway DC. How to test for a relative afferent pupillary defect (RAPD). Community Eye Health. 2016; 29(96): 68-9.
117	Davis RE, Telischi FF. Traumatic facial nerve injuries: review of diagnosis and treatment. J Craniomaxillofac Trauma. 1995; 1(3): 30-41.
118	Gordin E, Lee TS, Ducic Y, Arnaoutakis D. Facial nerve trauma: evaluation and considerations in management. Craniomaxillofac Trauma Reconstr. 2015; 8(1): 1-13. doi: 10.1055/s-0034-1372522 pmid: 25709748
119	Hohman MH, De Jesus O. Facial nerve repair. Treasure Island: StatPearls Publishing; 2025: 169-90.
120	Mistry RK, Hohman MH, Al-Sayed AA. Facial nerve trauma. Treasure Island: StatPearls Publishing; 2025: 232-8.
121	Cho DY, Willborg BE, Lu GN. Management of traumatic soft tissue injuries of the face. Semin Plast Surg. 2021; 35(4): 229-37. doi: 10.1055/s-0041-1735814 pmid: 34819804
122	Gupta G, Mahajan K. Nasal septal hematoma. Treasure Island: StatPearls Publishing; 2024: 129-36.
123	Sanyaolu LN, Farmer SE, Cuddihy PJ. Nasal septal haematoma. BMJ. 2014;349: g6075.
124	Howell J, Costanzo RM, Reiter ER. Head trauma and olfactory function. World J Otorhinolaryngol Head Neck Surg. 2018; 4(1): 39-45. doi: 10.1016/j.wjorl.2018.02.001
125	Dalal PJ, Purkey MR, Price CPE, Sidle DM. Risk factors for auricular hematoma and recurrence after drainage. Laryngoscope. 2020; 130(3):628-631. doi: 10.1002/lary.28310
126	Tubbs RS, Shoja MM, Loukas M, Oakes WJ, Cohen-Gadol A. William henry battle and battle’s sign: mastoid ecchymosis as an indicator of basilar skull fracture. J Neurosurg. 2010; 112(1): 186-8. doi: 10.3171/2008.8.JNS08241
127	Myga-Porosiło J, Skrzelewski S, Sraga W, Borowiak H, Jackowska Z, Kluczewska E. CT Imaging of facial trauma. Role of different types of reconstruction. Part I - bones. Pol J Radiol. 2011; 76(1): 41-51.
128	Zanza C, Tornatore G, Naturale C, Longhitano Y, Saviano A, Piccioni A, et al. Cervical spine injury: clinical and medico-legal overview. Radiol Med. 2023; 128(1):103-12.
129	Marinaro J, Crandall CS, Doezema D. Computed tomography of the head as a screening examination for facial fractures. Am J Emerg Med. 2007; 25(6): 616-9. doi: 10.1016/j.ajem.2006.11.029 pmid: 17606084
130	Nair MK, Nair UP. Imaging of mandibular trauma: ROC analysis. Acad Emerg Med. 2001; 8(7): 689-95. pmid: 11435182
131	Roth FS, Kokoska MS, Awwad EE, Martin DS, Olson GT, Hollier LH, et al. The identification of mandible fractures by helical computed tomography and panorex tomography. J Craniofac Surg. 2005; 16(3): 394-9. pmid: 15915103
132	Wilson IF, Lokeh A, Benjamin CI, Hilger PA, Hamlar DD, Ondrey FG, et al. Prospective comparison of panoramic tomography (zonography) and helical computed tomography in the diagnosis and operative management of mandibular fractures. Plast Reconstr Surg. 2001; 107(6): 1369-75. pmid: 11335803
133	Goh SH, Low BY. Radiologic screening for midfacial fractures: a single 30-degree occipitomental view is enough. J Trauma. 2002; 52(4): 688-92.
134	Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med. 1998; 32(4): 461-9. pmid: 9774931
135	Michaleff ZA, Maher CG, Verhagen AP, Rebbeck T, Lin CW. Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: a systematic review. CMAJ. 2012; 184(16): E867-76. doi: 10.1503/cmaj.120675
136	Ala A, Shams Vahdati S, Ghaffarzad A, Mousavi H, Mirza-Aghazadeh-Attari M. National emergency X-radiography utilization study guidelines versus Canadian C-spine guidelines on trauma patients, a prospective analytical study. PLoS One. 2018; 13(11): e0206283. doi: 10.1371/journal.pone.0206283
137	Appelbaum RD, Farrell MS, Gelbard RB, Hoth JJ, Jawa RS, Kirsch JM, et al. Antibiotic prophylaxis in injury: an American Association for the Surgery of Trauma Critical Care Committee clinical consensus document. Trauma Surg Acute Care Open. 2024; 9(1): e001304. doi: 10.1136/tsaco-2023-001304
138	Goormans F, Coropciuc R, Vercruysse M, Spriet I, Willaert R, Politis C. Systemic antibiotic prophylaxis in maxillofacial trauma: a scoping review and critical appraisal. Antibiotics (Basel). 2022; 11(4): 483.
139	Metsemakers WJ, Morgenstern M, McNally MA, Moriarty TF, McFadyen I, Scarborough M, et al. Fracture-related infection: a consensus on definition from an international expert group. Injury. 2018; 49(3): 505-10. doi: S0020-1383(17)30563-6 pmid: 28867644
140	Van der Cruyssen F, Forrest M, Holmes S, Bhatti N. A systematic review and meta-analysis of fracture-related infections in maxillofacial trauma: incidence, risk factors, and management strategies. J Clin Med. 2025; 14(4): 1332. doi: 10.3390/jcm14041332
141	Zein Eddine SB, Cooper-Johnson K, Ericksen F, Brookes CC, Peppard WJ, Revolinski SL, et al. Antibiotic duration and outcome complications for surgical site infection prevention in traumatic mandible fracture. J Surg Res. 2020;247: 524-9.
142	Pitak-Arnnop P, Tangmanee C, Muangchan C, Meningaud JP, Neff A. Asymptomatic or mildly symptomatic COVID-19 patients with craniomaxillofacial injuries have an increased risk of surgical site infection. Br J Oral Maxillofac Surg. 2022; 60(8): 1118-24. doi: 10.1016/j.bjoms.2022.05.009 pmid: 35927146
143	Rahman AU, Noor M, Ishaq Y, Saeed T, Manzar S, Farooq A. Evaluation of efficacy of post-operative antibiotic prophylaxis in mandibular fractures. Pak J Med Health Sci. 2022; 16(1): 309-10.
144	Ahmed NJ, Haseeb A, AlQarni A, AlGethamy M, Mahrous AJ, Alshehri AM, et al. Antibiotics for preventing infection at the surgical site: single dose vs. multiple doses. Saudi Pharm J. 2023; 31(12): 101800. doi: 10.1016/j.jsps.2023.101800
145	Southwell-Keely JP, Russo RR, March L, Cumming R, Cameron I, Brnabic AJ. Antibiotic prophylaxis in hip fracture surgery: a meta analysis. Clin Orthop Relat Res. 2004(419): 179-84.
146	Andreasen JO, Jensen SS, Schwartz O, Hillerup Y. A systematic review of prophylactic antibiotics in the surgical treatment of maxillofacial fractures. J Oral Maxillofac Surg. 2006; 64(11): 1664-8. doi: 10.1016/j.joms.2006.02.032
147	Piccioni A, Brigida M, Loria V, Zanza C, Longhitano Y, Zaccaria R, et al. Role of troponin in COVID-19 pandemic: a review of literature. Eur Rev Med Pharmacol Sci. 2020; 24(19): 10293-300.
148	Sudarshan R, Sayo AR, Renner DR, de Saram S, Godbole G, Warrell C, et al. Tetanus: recognition and management. Lancet Infect Dis. 2025:S1473- 3099(25)00292-0.
149	Havers FP, Moro PL, Hunter P, Hariri S, Bernstein H. Use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccines: updated recommendations of the advisory committee on immunization practices - United States, 2019. MMWR Morb Mortal Wkly Rep. 2020; 69(3): 77-83. doi: 10.15585/mmwr.mm6903a5
150	World Health Organization. Tetanus vaccines: WHO position paper, February 2017-Recommendations. Vaccine. 2018; 36(25):3573-5. doi: 10.1016/j.vaccine.2017.02.034
151	Tetanus vaccines: who position paper-February 2017. Wkly Epidemiol Rec. 2017; 92(6): 53-76.
152	Savioli G, Ceresa IF, Piccioni A, Longhitano Y, Planinsic R, Dorfsman M, et al. Pediatric head trauma algorithm for head CT decision-making in the emergency department. J Anesth Analg Crit Care. 2025; 5(1):19. doi: 10.1186/s44158-025-00238-x
153	Morris C, Kushner GM, Tiwana PS. Facial skeletal trauma in the growing patient. Oral Maxillofac Surg Clin North Am. 2012; 24(3): 351-64. doi: 10.1016/j.coms.2012.05.005
154	Grunwaldt L, Smith DM, Zuckerbraun NS, Naran S, Rottgers SA, Bykowski M, et al. Pediatric facial fractures: demographics, injury patterns, and associated injuries in 772 consecutive patients. Plast Reconstr Surg. 2011; 128(6): 1263-71. doi: 10.1097/PRS.0b013e318230c8cf pmid: 21829142
155	Gassner R, Tuli T, Hächl O, Moreira R, Ulmer H. Craniomaxillofacial trauma in children: a review of 3,385 cases with 6, 060 injuries in 10 years. J Oral Maxillofac Surg. 2004; 62(4): 399-407. doi: 10.1016/j.joms.2003.05.013
156	Zerfowski M, Bremerich A. Facial trauma in children and adolescents. Clin Oral Investig. 1998; 2(3): 120-4. doi: 10.1007/s007840050056
157	Brucoli M, Boffano P, Romeo I, Corio C, Benech A, Ruslin M, et al. Management of maxillofacial trauma in the elderly: a European multicenter study. Dent Traumatol. 2020; 36(3): 241-6. doi: 10.1111/edt.12536 pmid: 31863620
158	Kloss FR, Gassner R. Bone and aging: effects on the maxillofacial skeleton. Exp Gerontol. 2006; 41(2): 123-9. pmid: 16412598
159	Imholz B, Combescure C, Scolozzi P. Is age of the patient an independent predictor influencing the management of cranio-maxillo-facial trauma? A retrospective study of 308 patients. Oral Surg Oral Med Oral Pathol Oral Radiol. 2014; 117(6): 690-6. doi: 10.1016/j.oooo.2014.03.010
160	Velayutham L, Sivanandarajasingam A, O’Meara C, Hyam D. Elderly patients with maxillofacial trauma: the effect of an ageing population on a maxillofacial unit’s workload. Br J Oral Maxillofac Surg. 2013; 51(2): 128-32. doi: 10.1016/j.bjoms.2012.05.003
161	Lee KA, Flores RR, Jang IH, Saathoff A, Robbins PD. Immune senescence, immunosenescence and aging. Front Aging. 2022;3: 900028.

Population group	Gender distribution
Adults (Europe)
Assaults (39.0%)	Male:Female 2:1
Falls (31.0%)
Motor vehicle accidents (11.0%)
Sport accidents (11.0%)
Work-related accidents (3.0%)
Adults (developing countries)
Motor vehicle accidents (73.8%)	Male:Female 2:1
Falls (18.0%)
Assaults (6.7%)
Pediatric (0-16 years old) (global)
Motor vehicle accidents (33.8%)	Male prevalence
Falls (20.7%)
Violence (9.9%)
Sport accidents (8.1%)
Geriatric (>75 years old)
Household falls (83.5%)	Female prevalence
Low-energy trauma

Assessment phase	Key components	Specific evaluations	Critical warning signs
Primary survey
Airway	•Risk assessment •Anatomical distortion •C-spine status	•Chin lift/jaw thrust •Foreign body removal •Intubation readiness •Surgical airway preparation	•Stridor •Gurgling •Posterior tongue displacement •Progressive facial edema
Breathing	•Respiratory pattern •Chest examination •Stridor assessment	•Two-person bagmask ventilation •Early intubation if needed	•Respiratory distress/failure •Inadequate ventilation
Circulation	•Heart rate/rhythm •Blood pressure •Hemorrhage assessment	•Pressure packing •Manual fracture reduction •Balloon tamponade •Angiography if needed	•Hemodynamic instability •Uncontrolled bleeding •Bradycardia (oculocardiac reflex)
Secondary survey
Eyes	•Visual acuity •Pupillary response •Orbital integrity	•Vision testing •Extraocular movements •Pupillary reflexes •Intraocular pressure	•Orbital compartment syndrome •Double vision •Vision loss •Relative afferent pupillary defect
Oral cavity	•Intraoral lacerations •Tooth stability •Occlusion assessment	•Superior/inferior ridge stability •Malocclusion testing	•Broken/missing teeth •Alveolar ridge injuries •Airwaythreatening swelling
Face	•Symmetry •Stability •Nerve function	•Midface stability testing •Sensory/motor nerve function •Parotid duct patency	•Facial nerve deficits •Midface instability •Expanding hematomas • CSF leak
Nose	•Symmetry •Stability •Internal examination	•Rhinoscopy •Septal hematoma check	•Septal hematoma •Anosmia •CSF rhinorrhea
Ears	•External examination •Otoscopy	•Foreign body assessment •Tympanic membrane evaluation	•Hemotympanum •CSF otorrhea •Battle sign

Clinical scenario	Duration	First-line options	Alternative (penicillin allergy)
Open/contaminated fractures	≤24 h	•Cefazolin (Gram+) •Ceftriaxone (Gram^-& CNS) •Ampicillin/sulbactam (Gram^- & anaerobes)	Clindamycin
Salt water contamination	3-5 d	Doxycycline + ceftazidime	Doxycycline + Ceftazidime
Fresh water contamination	3-5 d	Ciprofloxacin or 3rd/4th generation cephalosporin	Levofloxacin
Soil contamination	3-5 d	High-dose penicillin	Clindamycin
Mammalian bites	3-5 d	Amoxicillin-clavulanate	Clindamycin + TMP-SMX
Complex lacerations*	≤24 h	Amoxicillin-clavulanate	Clindamycin
Closed operative fractures**	Preoperation only	Standard preoperative prophylaxis	Clindamycin
Closed nonoperative fractures	Not indicated	-	-
Nasal packing	Not indicated	-	-