A 25-year-old male who came by ambulance to the Emergency Department of a private institution in the city of Querétaro, Mexico, in February 2013, with a history of having suffered a previous motor vehicle accident and 3 hours since its onset.
The patient's companions report that, during the automobile shock, the patient had been released from the rear seat of the vehicle outside, through the parabris, suffering an impact against a metal.
Upon admission to the emergency department, the patient was conscious and alternated with episodes of drowsiness; the rest of the neurological examination showed no pathological data.
The patient responded to the initial interview and did not have records of drug or alcohol consumption.
She had pain in the right costal region and right pelvic limb.
His vital signs at admission were: blood pressure 100/60; heart rate 110x; respiratory rate 25x.
We also found active bleeding of blunt wound healing in the malar, oral, palatal and frontal regions.
Initial hemostasis was performed in situ on request for admission to the operating room.
Preoperatively, blood values were: 7.8g hemoglobin, hematocrit 28, leukocytes 5.4 thousand, segmented 40, platelet 139,000.
Prothrombin time and partial thromboplastin time were within normal limits.
Anteroposterior and lateral skull x rays without evidence of fractures.
The chest X-ray showed fractures of the 5th and 6th costal arches, and the right-sided radiography showed a total fracture with displacement G I.
The patient required transfusion of 2 units of packed red blood cells and received antibiotic regimen, analgesic-opioid scheme and non-steroidal triple drug infusion intravenously.
Under inhalational general anesthesia, performed with difficulty given the orofacial injuries and active bleeding, we initially performed hemostasis of the vessels of the facial region, and after asepsis and antisepsis of the wounds, we started.
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Material and method
The surgical plan was initially to control active bleeding of the median vessels in order to identify the lost and seated structures.
The frontalis fascia was located in the scalp, the frontalis mucosa was located in the greater nasal blade and the multiple wounds in both oral commissures were located in all planes, affecting some of the facial branches
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There was loss of teeth 17, 36 teeth, 46 teeth and 47 according to the international classification, FDI System (5), and trauma of the temporomandibular joint (TMJ).
We repaired the oral mucosa, fat tissue and skin.
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Because the patient had hemodynamic instability, prolonged transoperative (6 hours), and according to the Anesthesiology Service, we chose facial nerve neurorrhaphy.
The patient was referred to the Intensive Care Unit where a subclavian catheter was placed and a hemopneumothorax was found in a new chest X-ray that was drained, finally resolving water through a seal.
Eight days after admission, open reduction and osteosysis of the fracture site were performed.
Functional orthopedic treatment was also performed using a persistent neurorehabilitation device (simple planar indirect cues) in order to restore dynamic muscle balance and thus improve TMJ by means of the resting position,
The patient was hospitalized for 30 days in the Intensive Care Unit and was discharged 45 days after admission.
The process did not present signs or symptoms of aggregated infection and the patient was referred to Physical Medicine and Rehabilitation, where he was admitted with a diagnosis of dismantled muscle tone, incompetence of the oral sphincter type.
The treatment plan consisted of isolated muscle exercises specific to the frontal muscles, with zygomatic picture, mastication management, orbicular oral exercises, selected sensory modulations, videocomparisons, localized ophthalmic psychotherapy, medication.
This program included neurostimulation with alternating current and therapeutic laser in three facial areas: upper, middle and lower, for 10 minutes, and therapeutic ultrasound with attention to the orbicularis muscle of the eyelids bilaterally for 10 minutes.
All this was carried out in 3 sessions per week for 3 months.
Language therapy was attended by a speech therapist after reducing the inflammatory process, approximately at 12 weeks, with evidence of moderate dysarthria.
The oral rehabilitation consisted in replacing teeth and in functional orthodontia for the maxilla in order to improve inter-relations and functional maladjustment of masticatory muscles.
Mandibular movements and masticatory functions were also identified.
One year later, the patient had 85% competence of the eyelid orbicularis, as well as suction function without fluid leakage through the oral commissures.
Interrogate refused a new intervention to explore the facial nerve and to carry out revision of the jawbones.
She was discharged to return to work.
