Psychosocial Support Following Maxillofacial Trauma and its Impact on Trauma Recurrence

Background

Injuries sustained to the maxillofacial region can result in significant physical trauma and long lasting psychosocial impairment. Maxillofacial trauma has been reported in literature to be a potentially recurrent disease. Patients who suffer maxillofacial trauma can benefit from psychological support.

Aim

This study aims to identify maxillofacial trauma patient characteristics, investigate maxillofacial re-injury rate after provision of psychological support and report incidence of post traumatic stress disorder symptoms after maxillofacial trauma.

Method

A total of 100 patients were identified from the departmental trauma database over two time periods at Royal Darwin Hospital; 50 patients did not have psychosocial intervention and 50 patients received intervention. Data on demographics, trauma pattern and aetiology were collected. A brief counselling session was conducted on second patient group by a trained mental health nurse and a survey using Trauma Screening Questionnaire was completed one month following injury.

Results

The most common cause of injuries was assault in both groups followed by falls and the most common site of injuries was in the mandible in both groups. Almost half of all patients were in the15–24 and 25–34 age groups. 17 % of patients in pre-intervention period and 4 % of patients in intervention period had injury recurrence at 3 year follow up. Patient groups at risk of developing post traumatic symptoms included male, non-indigenous population, employed group with no alcohol involvement.

Conclusion

Maxillofacial trauma can cause considerable psychological morbidity and expose the patient to high risk of post traumatic disorder symptoms. This type of injury was found to affect particular groups of population and is associated with high rate of recurrence. Psychological support should be provided to these patients as a routine part of trauma aftercare.

     

Psychological complications of maxillofacial trauma: preliminary findings from a Nigerian university teaching hospital.

PURPOSE: This study sought to determine 1) the prevalence of psychological distress in a series of subjects who sustained maxillofacial injuries and 2) temporal changes in psychological functioning over 12 weeks compared with baseline values. PATIENTS AND METHODS: This was a prospective, repeated-measures design study of consecutively recruited subjects at a Nigerian university teaching hospital. A total of 51 subjects with facial injuries had repeated follow-up assessments (10 days, 6 to 8 weeks, and 10 to 12 weeks) after the trauma, using standard instruments. RESULTS: The General Health Questionnaire identified a high prevalence of psychological morbidity in the subjects (90%), with 41.2% and 11.8% scoring above threshold values on the hospital anxiety and depression scales, respectively. Five subjects satisfied the criteria on the Trauma Screening Questionnaire for a diagnosis of post-traumatic stress disorder during the follow-up period. Psychological distress (General Health Questionnaire caseness) remained at high levels during the 2 follow-up assessments. CONCLUSIONS: The management of facial injuries should integrate a multidisciplinary approach that addresses the psychological needs of the patients in both the short term and the long term.     

女性患者颌面部损伤后的心理状态、心理需求及护理对策分析

目的: 调查分析女性患者颌面部损伤后的心理状态、心理需求特点,根据调查结果制定相应的护理对策。方法: 通过《症状自评量表（SCL-90）》及《颌面部损伤后女性患者心理需求调查问卷》对我院320例颌面部损伤后的女性患者的心理状态、心理需求进行调查。采用SPSS 16.0软件包对数据进行统计学分析。结果: 颌面部损伤后,女性患者存在不同程度的心理障碍,躯体化、抑郁、焦虑、敌对、恐怖、偏执、人际关系敏感、精神性8个因子与国内常模比较均有统计学意义（P<0.05）,抑郁、焦虑、恐惧3个因子得分较高。在心理需求6个因子的得分比较中,得分最高、最具优势的需求为美需求,其次为生理需求。结论: 颌面部损伤后,女性患者心理状态总体呈现负性精神状态。护理人员应根据颌面部损伤后女性患者的不同心理需求特点,采取相应的护理措施,及时进行干预,帮助患者快速渡过心情低潮期,最终达到躯体和心理的共同康复。     

5762例非住院颌面部外伤患者回顾分析

目的: 了解颌面部外伤非住院患者的流行病学特点,为预防和治疗颌面部外伤提供参考。方法: 选取2014年1月—2017年12月于中国医科大学附属盛京医院就诊的5762例非住院颌面部外伤患者进行流行病学统计分析。结果: 非住院颌面部外伤患者中,男性多于女性,男女比例为1.736∶1。发病年龄高峰为学龄前儿童（3~6岁,28.55%）,其次为婴幼儿（0~3岁）。未成年患者（0~17岁）占非住院颌面部外伤患者的68.7%。摔伤（72.9%）为最主要的损伤原因,其次分别为交通事故伤（9.2%）和暴力伤（7.5%）。第3季度（30.1%）及9月份（12.9%）为发病高峰。软组织伤中,额部（37.24%）为最常见的损伤部位,其次为颊部（19.04%）及唇部（18.67%）。结论: 非住院颌面部外伤患者以男性多见,3~6岁组为发病高峰。摔伤及额部是最常见的损伤原因及损伤部位。     

面神经损伤182例临床资料回顾性分析

目的 分析颌面部外周性面神经损伤后功能恢复的规律和相关影响因素.方法 回顾分析182例面神经损伤患者的病历资料,分析损伤部位、损伤方式、损伤后治疗时间及治疗方式对于面神经功能恢复结果的影响.结果 口腔颌面部面神经损伤以分支损伤为主.神经损伤方式、部位、患者年龄、修复时间等因素均对面神经功能恢复结果有影响.随访至最终有完整记录的解剖性损伤49例中,45例(92%)在6个月内完全恢复;断裂损伤59例中,53例(90%)于6个月内开始恢复;12个月内,神经吻合35例中33例(94%)面神经功能开始恢复;8例神经移植病例中5例(62%)完全恢复.结论 口腔颌面部手术中应尽量降低对神经的损伤,尽早修复受损神经,这样能够更好地保存面神经功能.     

Endoscopically assisted transconjunctival decompression of traumatic optic neuropathy

Traumatic optic neuropathy (TON) is a severe sequel after maxillofacial trauma. Recent clinical experience has suggested that optic canal decompression is beneficial in the treatment of TON. With the advent of endoscopy in orbital reconstruction, we extended this technique to decompress the optical canal and reported its outcome.This technique was applied to 30 patients with TON who did not improve after corticosteroids treatment. The average age of the patients at the time of injury was 26 years. Nine patients presented preoperative vision of light perception (LP) or better and 21 patients had no light perception (NLP). Surgery was performed within 1 week of injury in 10 patients, between 1 and 2 weeks in another 10 patients, and between 2 and 4 weeks in the last 10 patients. Thirteen patients were found to have optic canal fractures during surgery.The average follow-up time was 9.5 months. Vision improved in 12 patients including 6 patients (28.6%) with NLP and in 6 patients (66.7%) with LP or better. The improvement degree of visual acuity was 50% in average. Only patient age reflected differences in improvement of visual acuity when analyzing the effect of optic canal fracture, timing of surgery and initial visual acuity. Two patients experienced postoperative cerebrospinal fluid leakage due to associated skull base fractures.The endoscope-assisted transconjunctival technique successfully decompresses the optic canal and improves visual acuity with minimal morbidity. Younger patients had a significantly better visual outcome.     

口腔颌面创伤后的早期心理测评及心理干预

目的：探讨性格因素对口腔颌面创伤患者心理干预临床效果的影响。方法：采用暴露疗法、催眠等方式,对72例不同程度口腔颌面创伤住院患者进行心理干预．通过SCL-90症状自评清单对患者干预前后的心理状态进行评估,采用SPSS18．0软件包对数据进行统计学分析。结果：干预前,口腔颌面创伤患者SCL-90因子得分普遍高于常模（P〈O．001）．干预后创伤患者的心理健康水平与常模无显著差异。不同创伤严重等级患者心理干预效果差异显著（P〈0．001）,性格因素对干预效果的影响在强迫、人际关系、抑郁和偏执4个因子上差异显著。结论：心理干预的效果与性格因素有关,早期心理干预对内向性格类型的口腔颌面创伤患者的治疗效果优于外向性格类型的患者：创伤严重程度对心理干预的影响与性格因素有关。     

颌面外伤导致颈内动脉钝性损伤继发脑梗死的治疗：8例临床分析

目的 探讨重型颌面外伤导致钝性颈内动脉损伤后脑梗死的治疗策略。方法 回顾性复习2008年1月 —2013年12月本院收治的8例颌面外伤引起颈内动脉损伤后脑梗死患者的临床资料。结果 男6例,女2例;年龄19~54岁,平均36±11.95岁;受伤至我院收治时间5~8 h,平均（6.31±1.00）h;伤后均清醒,入院时6例嗜睡,2例昏睡,其中1例次日进展为昏迷,6例偏瘫;8例颌面部CT显示面部骨折,2例合并颅底骨折,1例合并下颌骨骨折;头颅CT发现颈内动脉供血区低密度缺血病灶,无颅内出血。治疗均给予阿司匹林300 mg/d,口服2周,然后改为100 mg,维持6个月,1例行开颅减压手术。6个月后GOS评价,恢复良好6例,轻残1例,重残1例,死亡0例。结论 颌面骨折合并颈内动脉钝性损伤的患者早期出现缺血导致的中枢神经系统损害表现时,应积极使用抗血小板治疗,以降低卒中引起的病患伤残与死亡率。     

伴全身多系统创伤颌面伤患者的综合救治

目的:研究伴发身体其他部位创伤的颌面伤患者综合救治中专科确定性手术时机和适应证。方法:回顾性统计4所大型综合医院口腔科病房近20年收治的4 869例口腔颌面部创伤患者的临床资料,分析伴发身体其他部位创伤状况和专科手术时机。结果:4 869例患者中,面骨骨折3 364例,软组织伤1 505例。伴发其他部位创伤1 524例(占31.3%),其中颅脑伤570例(37.4%),肢体伤545例(35.8%),胸部伤170例(11.2%),眼创伤151例(9.9%),脊柱伤54例(3.3%),腹部伤34例(2.2%)。74%的颅脑伴发伤患者伤后4周内、76.2%的眼伴发伤患者伤后7d内进行了面骨骨折手术治疗。而肢体、脊柱、胸腹部伴发伤患者,面骨骨折手术均有不同程度延误。结论:伴发多系统创伤的颌面伤患者的救治需要多学科间的合作,在患者呼吸系统、循环系统等全身状况稳定的情况下,大部分颌面多发伤患者可以同期或早期进行专科处理。     

The psychological sequelae of maxillofacial trauma: a scoping review of the literature

Managing the physical sequelae of facial trauma is routine for the maxillofacial surgeon. However, managing the psychological consequences is more challenging. The often violent mechanism of injury, changes in appearance, altered self-perception, and self-confidence can significantly impact daily life. This review summarises the literature regarding post-traumatic stress disorder (PTSD) and facial trauma, highlighting evidence to guide clinical practice. PubMed and MEDLINE were searched for relevant keywords and MeSH headings. Articles between 2000-2022 were independently reviewed by two authors. Articles were excluded if the full text was not available in English, did not relate to facial trauma, or was not related to PTSD/psychological sequelae. A total of 211 articles were retrieved. The most common reasons for exclusion were papers not reporting psychological outcomes (n = 68) or not relating to facial trauma (n = 35). Articles were sub-categorised to enable evaluation of key themes. Categories included children and adolescents, cross sectional, longitudinal studies, and interventional studies. Whilst there were potential confounders such as socioeconomic factors, overall, patients who had experienced facial trauma (regardless of the mechanism of injury) had an increased risk of PTSD and anxiety/depression. PTSD following facial injury is increasingly recognised as an important issue. A robust evidence base is desirable to inform clinical practice and provide holistic care to often vulnerable patients. Identifying those at increased risk of negative psychological sequelae is essential. We have appraised the literature relevant to OMFS trauma clinicians.     

The development of acute post-traumatic stress disorder after orofacial injury: a prospective study in a large urban hospital.

PURPOSE: Psychologic distress is a common outcome among trauma survivors. This report examines both the development and predictors of acute post-traumatic stress disorder (PTSD) symptoms in a sample of US inner-city orofacial trauma survivors seeking treatment in a publicly funded hospital. PATIENTS AND METHODS: Baseline data were collected from 336 patients seeking urgent care for an oral injury (mandibular or midfacial fracture). Participants were predominantly unemployed, unmarried, African American or Hispanic men in their 30s. One-month follow-up assessments of PTSD symptoms were conducted on the available 84% of the sample. RESULTS: Absolute levels of PTSD symptoms were high at 1 month; 25% of the sample appeared to meet diagnostic criteria for acute PTSD, based on a self-report of symptoms. Variables associated with self-reports of higher rates of PTSD symptoms included older age, being female, prior psychologic disturbance as reflected in lifetime and current mental health and social service need and use, exposure to and distress at a prior trauma as well as overall high rates of stressful life events in the past year, injury pain, psychologic distress at hospital discharge, and unmet social support needs during the recovery phase. CONCLUSIONS: A substantial subsample of these traumatized medical patients had negative psychologic outcomes at 1 month. Results underscore the potential use of screening survivors of orofacial injury at urban trauma centers for PTSD and developing systems of care that facilitate referral to appropriate psychologic treatment.     

Incidence of oral and maxillofacial skiing injuries due to different injury mechanisms.

PURPOSE: This study emphasizes the significance of maxillofacial injuries in skiing accidents, correlating injury mechanisms and patterns, by evaluating a large population of maxillofacial injuries over a 6-year period. PATIENTS AND METHODS: Between 1991 and 1996, of 5,623 patients showing oral and maxillofacial injuries, 1,859 were sports-related. Records of 579 patients with 882 incidents of oral and maxillofacial injury due to skiing were reviewed and analyzed according to age, sex, type of injury, cause of accident, location, and frequency of fractures. Additionally, the five main injury mechanisms were analyzed. RESULTS: The oral and maxillofacial injuries in 10.3% of all trauma patients, or 33% of all sports-related trauma patients, were due to skiing. A total of 310 patients (53.5%) had facial bone fractures, 236 patients (40.8%) suffered from dentoalveolar trauma, and 336 patients (58%) showed soft tissue injuries. Five major causes and mechanisms of injury existed, namely, 263 falls (45%); 135 collisions with other skiers (23%); 70 individuals struck by their own ski equipment (12%); 46 collisions against stationary objects (8%); and 34 lift-track accidents (6%). Sex distribution showed an overall male-to-female ratio of 1.9:1.0, but varied depending on the injury mechanism. The age distribution ranged from 2 to 81 years. CONCLUSION: The results of this study show the high incidence of oral and maxillofacial injuries due to skiing accidents. Depending on the mechanism of injury, different patterns occur. Facial bone fractures are more likely in collisions with other persons, falls, and collisions with stationary objects, whereas dentoalveolar trauma is more common when persons are struck by their own ski equipment, or when accidents on lift-tracks occur.     

Elevated blood lead resulting from maxillofacial gunshot injuries with lead ingestion.

PURPOSE: The purpose of this study was to identify the contribution of ingested lead particles to elevated blood lead concentrations in victims of gunshot injury to the maxillofacial region. PATIENTS AND METHODS: As part of a larger study of the effects of retained lead bullets on blood lead, a retrospective review of study findings was completed on 5 of 8 patients who sustained injuries to the maxillofacial region. These 5 patients were recruited into the larger study within 11 days of injury and showed a penetration path for the projectile that engaged the upper aerodigestive tract. All subjects were recruited from patients presenting for care of their gunshot injuries to a large inner-city trauma center with a retained bullet resulting from a gunshot injury. An initial blood lead level was measured for all recruited patients and repeated 1 to 17 weeks later. Medical history was taken along with a screening and risk factor questionnaire to determine other potential or actual sources (occupational/recreational) of lead exposure. (109)Cd K-shell x-ray fluorescence determinations of bone lead were completed to determine past lead exposure not revealed by medical history and risk factor questionnaire. Radiographs taken of the abdomen and chest, required as a part of the patient's hospital care, were retrospectively reviewed for signs of metallic fragments along the aerodigestive tract. RESULTS: All 5 patients retained multiple lead pellets or fragments at the site of injury, sustained fractures of the facial bones, and showed increases in blood lead. Three of the 5 study subjects who sustained maxillofacial gunshot injuries involving the mouth, nose, or throat region showed metallic densities along the gastrointestinal tract indicative of ingested bullet fragments. Each patient with ingested bullet fragments showed rapid elevation of blood lead exceeding 25 microg/dL and sustained increases well beyond the time when all ingested fragments were eliminated. A 3-year follow-up on these 3 patients showed significantly sustained elevation of blood lead but less than that observed during the initial 6 months after injury. None of the 5 study subjects showed any evidence of metallic foreign bodies within the tracheobronchial regions indicative of aspiration. CONCLUSION: Ingestion of lead fragments can result from gunshot injuries to the maxillofacial region and may substantially contribute to a rapid increase in blood lead level. Prompt diagnosis and elimination of ingested lead fragments are essential steps necessary to prevent lead being absorbed from the gastrointestinal tract. Increased blood lead in victims after gunshot injuries must be fully evaluated for all potential sources, including recent environmental exposure, absorption of lead from any remaining bullets in body tissues, and the possibility of mobilization of lead from long-term body stores such as bone.     

How do oral and maxillofacial surgeons manage concussion?

Craniofacial trauma results in distracting injuries that are easy to see, and as oral and maxillofacial surgeons (OMFS) we gravitate towards injuries that can be seen and are treatable surgically. However, we do tend not to involve ourselves (and may potentially overlook) injuries that are not obvious either visually or radiographically, and concussion is one such. We reviewed the records of 500 consecutive patients who presented with facial fractures at the Queen Elizabeth Hospital, Birmingham, to identify whether patients had been screened for concussion, and how they had been managed. Of the 500 cases 186 (37%) had concussion, and 174 (35%) had a more severe traumatic brain injury. The maxillofacial team documented loss of consciousness in 314 (63%) and pupillary reactions in 215 (43%). Ninety-three (19%) were referred for a neurosurgical opinion, although most of these were patients who presented with a Glasgow coma scale (GCS) of ≤13. Only 37 patients (7%) were referred to the traumatic brain injury clinic. Recent reports have indicated that 15% of all patients diagnosed with concussion have symptoms that persist for longer than two weeks. These can have far-reaching effects on recovery, and have an appreciable effect on the psychosocial aspects of the patients’ lives. As we have found, over one third of patients with craniofacial trauma are concussed. We think, therefore, that all patients who have been referred to OMFS with craniofacial trauma should be screened for concussion on admission, and at the OMFS follow up clinic. In addition, there should be an agreement between consultants that such patients should be referred to the traumatic brain injury clinic for follow up.     

Cranioplasty of large cranial defect at an early stage after decompressive craniectomy performed for severe head trauma

Large cranial defects resulting from decompressive craniectomy performed for refractory intracranial hypertension after head trauma is one of the indications for cranioplasty, and this procedure is commonly performed 3 months after craniectomy. However, the large cranial defect would lead to the kinds of complications early during the phase of these patients' recovery, which would go against rehabilitation. This study retrospectively reviewed 23 patients undergoing early cranioplasty (5-8 weeks after craniectomy) in the last 4 years with a detailed choice of patients, outcome of complications after head trauma and large craniectomy, as well as assessment of prognosis. The early outcome (1 month later) revealed most of the patients who had conscious disturbance before the cranioplasty recovered their consciousness and presented an improved neurologic function. The long-dated prognosis (18 months later) revealed that 17 patients were good (independent patients) in this series (74%), whereas four patients survived with a severe disability (17%) and two remained in a vegetative state (9%). No dead patients or intracranial infection after the procedure were found in this study. Most patients' complications were relieved after the cranioplasty with improvements of symptoms or image of computed tomography scan. In conclusion, we consider that with the appropriate choice of patients and materials, early cranioplasty for large cranial defects after decompressive craniectomy would be safe and helpful for the improvement of patients' neurologic function and prognosis. To our knowledge, this series may be the first detailed report in English about early cranioplasty after decompressive craniectomy. We are going to perform prospective and retrospective contrastive studies to further confirm the effects of this procedure on the patients with large cranial defects after decompressive craniectomy.     

60例老年颌面外伤患者的心理特点及疏导

目的:了解颌面外伤老年患者的心理特点,提出相应的心理疏导对策。方法:选择60例老年颌面外伤住院患者,通过临床观察和语言交流,了解他们不同的心理状态,采取相应的心理疏导措施,观察对老年患者医疗活动所起的意义。结果:通过对老年颌面外伤患者心理状态的了解,使用相应的心理疏导对策,对患者的医疗过程和治疗效果可以起到积极的作用。结论:对老年颌面外伤患者除了积极的医疗救助外,还应进行适当的心理疏导。     

Provider perceptions of patient psychosocial needs after orofacial injury.

PURPOSE: Vulnerable populations are at particular risk for developing psychosocial sequelae after they experience orofacial injury. To enhance understanding of awareness, perspectives, and beliefs regarding attendant psychosocial issues, surgeons who provide orofacial injury care to indigent patients were surveyed. MATERIALS AND METHODS: We surveyed 26 oral and maxillofacial surgeons and 15 otolaryngology surgeons at a large, urban, Level 1 trauma center. The survey, which measured providers' perceptions of pertinent contextual elements and patients' psychosocial needs after assaultive orofacial injury, was based on semistructured interviews with 15 oral and maxillofacial surgeons. The overall survey response rate was 85.4% (35 of 41). RESULTS: Respondents ranked interpersonal violence as the dominant cause of orofacial injury among patients. Anxiety (eg, post-traumatic stress), depression, and legal issues were the most significant psychosocial sequelae identified by respondents. Alcohol abuse, drug abuse, and homelessness were identified as the most important contributors to orofacial reinjury and patient noncompliance with postsurgical instructions. Less than half of respondents (44.7%) believed that patients' problems with depression, anxiety, or substance abuse were currently addressed in an adequate way in the hospital. The vast majority (94.7%) believed that a psychosocial aftercare program was needed, and most agreed that such a program would decrease the risk of reinjury and would promote patient compliance with aftercare instructions and return for scheduled follow-up care. Respondents identified the specialty mental health service in their hospital or a community-based setting as the preferred locations for such a program, and they indicated that lack of financial resources and trained personnel were the most significant barriers to implementation of such a program within the setting of trauma services. CONCLUSIONS: Surgeons who provide care to indigent patients with orofacial injury perceive a great need for psychosocial aftercare programs for patients, and they believe that such programs could reduce the risk of reinjury and promote patient compliance.     

Maxillofacial trauma in severely injured patients

A study was made of maxillofacial trauma in seriously injured patients to determine the likely role of oral and maxillofacial surgeons working in the regional trauma centres proposed by the Royal College of Surgeons of England. There were 153 patients, aged 70 years or less, who sustained major trauma (injury severity score 16 or more) and were admitted directly to the accident departments of the Bristol Royal Infirmary or Derriford Hospital, Plymouth during 1989. Maxillofacial injuries occurred in 50 (33%) of these patients with lacerations present in 39, burns in 1 and facial bone fractures in 28 (18%); soft tissue abrasions and contusions were excluded. The aetiology, patterns of injury, surgical treatment and outcome were reviewed. The implications for the provision of maxillofacial surgical services in regional trauma centres is discussed.     

农村儿童口腔颌面创伤926例临床分析

目的：探讨农村儿童口腔颌面创伤的发病特点。方法：对926名农村儿童口腔颌面创伤患者的性别、年龄、致伤原因以及创伤的类型、部位、时间进行临床分析。结果：男性患者与女性患者的比例为1．48：1；4岁以下年龄组患者人数所占比例明显高于4岁以上年龄组；摔伤在所有致伤原因中的比例达67．82％；软组织创伤和和牙外伤在所有创伤类型中的比例分别达到61．45％和30．65％；816个软组织创伤部位中唇颏部和颊面部分别达到30．39％和22．79％；夏季创伤的发病比例高于其他季节。结论：农村儿童口腔颌面创伤的发生与性别、年龄、季节有一定关系，摔伤是主要的致伤原因；软组织创伤和牙外伤较为常见；创伤多见于唇、颏和颊部。     

Post-traumatic eye observations

Retrobulbar haemorrhage after facial trauma or surgery is an uncommon but well-documented complication. The assessment and management of this condition is variable. We asked 288 maxillofacial surgeons in the UK about the signs and symptoms, incidence, and management of retrobulbar haemorrhage. We also enquired about the regimen that they used for eye observations, the patients who, in their opinion, required observation, and the method of communication of instructions to the nursing staff. A total of 185 responded (64%). Each surgeon had seen a mean of 1.3 cases of retrobulbar haemorrhage, of which most, n=190 (91%) were treated by surgery. There were 96 different eye observations regimens documented. There was a general consensus about the signs and symptoms, and 82 (44%) of respondents used a proforma for recording eye observations. On the basis of this study we recommend a standard regimen for eye observations, and have a designed a facial injury advice sheet to be given to patients who attend the accident and emergency department and are to be discharged home and followed up at a later date.