Maxillary Fractures in Children 

Updated: Apr 06, 2020
Author: Abbas A Younes, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA 

Overview

Background

Trauma is the leading cause of death in children. Pediatric trauma patients admitted to the hospital have a 5% incidence of facial fractures. Pediatric trauma patients differ from their adult counterparts. Patterns of injury, treatment algorithms, and potential consequences of facial trauma and its treatment are affected by the physiology of facial growth and development.

For excellent patient education resources, visit eMedicineHealth's First Aid and Injuries Center and Oral Health Center. Also, see eMedicineHealth's patient education articles Facial Fracture and Broken or Knocked-out Teeth.

See the image below.

Skeleton of the head. Superiofrontal view showing Skeleton of the head. Superiofrontal view showing maxilla and premaxilla

History of the Procedure

Kaban's 1993 review of the history of treatment of pediatric facial fractures during the period from 1943-1993 highlights several changes.[1] Although seat belts were not in use during the early part of this era, overall traffic speed and frequency of car travel were much lower than today. Today, with advances in critical care and trauma medicine, more children survive high-impact accidents. Previously, many children died of associated injuries. Medical management of these patients also improved with the increase in development and availability of antibiotic medications. Surgical management of facial fractures improved and continues to improve with advances in rigid fixation, including the relatively recent advent of resorbable plating systems.

Epidemiology

Frequency

The incidence of facial fractures is lower in the pediatric population than in the adult population.[2] Reported incidence of facial fractures in the pediatric age group approximates 5% of all facial fractures. In Rowe's 1968 series of 1500 facial fractures, less than 1% of fractures occurred in children younger than 5 years.[3]  Incidence in children aged 6-11 years was 4%. These numbers are consistent with McCoy's 1966 series of 1500 facial fractures, in which 6% of patients were aged 14 years or younger.[4] Facial fractures in the pediatric patient are more difficult to diagnose than in the adult patient. Physical examination findings are less accurate, and these patients are less able to communicate their symptoms. In addition, fractures heal quickly; therefore, a significant portion of these fractures may escape diagnosis, particularly if the fractures are nondisplaced. The 2 studies were completed before the widespread use of CT scanning.

Although in Posnick's 1993 series of 137 patients the group most frequently involved was aged 6-12 years, most studies show a general trend toward an increased fracture rate with increasing age.[5] Fractures in children younger than 1 year are rare, and the fracture rate among the youngest group remains low. About 10% of fractures in children occur in those younger than 4 years. A male predominance has been documented in patients with nasal or blowout fractures, but an equal incidence between the sexes seems to exist in patients with mandibular fractures. Males are overrepresented when the etiology is interpersonal violence or most sporting activities. The sex bias diminishes with the increase of motor vehicle collisions as an etiology. The decreased incidence and unique pattern of facial fractures in children are affected by the protected environment and developing facial anatomy of the child.

Etiology

Children younger than 5 years are usually supervised continuously. While developing new skills and exploring, falls occur frequently but are from a low height and do not generate much force. After age 5 years, children become more independent; they leave close supervision and begin to engage in sports and recreational activities such as riding bicycles, playing ball games, and climbing playground equipment.[6] The teenage years involve further risk-taking and a dramatic increase in interpersonal violence.

In many studies, the leading etiologic factor of facial fractures has been motor vehicle collisions. The etiology appears to vary by age. The most common factor in patients younger than 3 years is falls. In those aged 3-5 years, traffic accidents barely exceed falls. By adolescence, recreational activities and interpersonal violence are second to motor vehicle collisions. (Pedestrians struck by vehicles are usually included in the motor vehicle collision group.)[7] In Kaban's 1993 series, motor vehicle collisions were the most frequent cause in children younger than 7 years, but falls were the most common cause in children of all ages.[1]

Although not a commonly reported cause, caregivers should be aware of child abuse as a potential cause of any pediatric injury. In McCoy's 1966 series of 86 pediatric patients with facial fractures, 12% were attributed to battering.[4]

Continued efforts at improving motor vehicle safety, including relatively new seat belt and car seat regulations, and traffic safety awareness for pedestrians, drivers, and cyclists should help prevent these injuries. In addition, schools should emphasize bicycle safety and routine use of protective equipment for sporting activities. Societal changes to decrease violent behaviors are crucial in preventing trauma in teenagers.

Pathophysiology

Knowledge of facial growth and development is important in understanding patterns of pediatric facial trauma and the rationale behind its treatment. Changes in facial shape and the development of the sinuses and dentition play crucial roles in the fracture pattern observed in the pediatric patient.[8]

The human head doubles in size from infancy to age 5 years, reaching 80% of adult size by that time. The shape and projection of the face change dramatically during the first years of life. At birth, the face-to-cranium ratio is 1:8. This increases to 1:4 at 5 years and reaches the adult ratio of 1:2.5 during adolescence. The cranium increases 4 times, and the face increases 12 times from birth to adulthood.

The facial skeleton grows by a combination of displacement and remodeling. Displacement is the movement of bone in relation to the rest of the facial skeleton. Remodeling involves change in the shape of an individual bone by deposition at one side and resorption at another. Anatomic growth centers are well described; however, soft tissue covering and muscular pull also appear to be important influences in facial growth.

Growth of the nasomaxillary complex relates to growth of the cranial base. The face grows downward and outward by complex remodeling. The nasal septum is considered a coordinating center of midface growth. Studies in nonhuman primates have demonstrated midface hypoplasia after surgical resection of the septum. Most of midface growth occurs in the lower part of the midface. The lower maxilla grows in a vertical direction. The nasal cavity widens to mid orbit, and the floor of the cavity descends as the permanent dentition erupts.

The mandible in an infant is small and retruded. As it grows, it widens and lengthens the lower face. The condylar growth centers orchestrate mandibular development. Each growth center consists of a fibrous cap with an inner chondrogenic layer, a layer of cartilage, and a layer of ossifying cartilage. The infant mandible grows anteriorly and laterally, thus enlarging the lower face. Addition of bone at the condyle and posterior ramus and bony resorption anteriorly contributes to the forward projection. This process continues after most of the facial skeletal growth is complete; therefore, damage to the condyle has the potential to cause growth disturbances, but the continued growth may also confer a unique healing ability.

Sinus development begins with the maxillary sinus, which is first visible at age 5 months. The sinus enlarges over the first 5 years of life and descends below the floor of the nose with the eruption of permanent dentition at age 12 years. The maxillary sinus is developed fully at age 16 years. The ethmoid sinuses are first visible at age 1 year. The frontal sinus appears at age 6 years and reaches adult size by late puberty. Development of the sinuses directs the force of impact and may exert a cushioning effect.

The development of dentition also plays a crucial role in the treatment of pediatric facial fractures. Deciduous dentition erupts during the first 2 years of life. In children aged 6-12 years, these teeth are gradually replaced by permanent dentition. (This is the period of mixed dentition.) The presence of unerupted teeth confers some protection; however, when fractures do occur, they tend to run along tooth crypts. The status of dentition also affects the treatment of fractures. The youngest patients are edentulous. Deciduous teeth may be loose, and the shape of these teeth is not conducive to circumdental wiring.

In addition to the changing facial projections and growth of underlying sinuses and teeth, the structure of the bone is different in pediatric patients. Pediatric facial skeleton has more cartilage (cartilaginous growth centers) and a higher proportion of cancellous to cortical bone. The medullocortical junction is indistinct, causing an irregular fracture pattern. Bone in the young child is less mineralized and, therefore, more elastic. The overlying soft tissue also is relatively thick. All of these factors increase the incidence of greenstick fractures. The high rate of bone metabolism causes fractures to heal rapidly. Where appropriate, perform early intervention. Active and growing bone may also have the potential for remodeling.

With facial development, different anatomic areas become more vulnerable to injury. The infant's mandible and midface are relatively retruded and so are protected, whereas the frontal area is prominent and prone to injury. In adults and older children, the zygomaticomaxillary complex (ZMC), nasal, and Le Fort fractures become more common.

Presentation

Although facial injuries may be the most obvious, triaging patients who have these injuries as trauma patients is important to avoid missing more threatening injuries.

The airway remains the first priority in treatment of the trauma patient. Modest mucosal edema causes substantially more difficulty in the smaller airway of a child. Carefully suction blood and debris from the oropharynx. Fractures of the anterior mandible may cause the tongue to displace posteriorly. Obstruction caused by the retruded tongue can be managed with positioning or a traction suture; however, take care to ensure appropriate protection of possible cervical spine injuries. Orotracheal intubation may be necessary and is preferred over an emergent surgical airway.

Control of hemorrhage is the next priority. The face and scalp are quite vascular, and blood loss is proportionally greater in a child. Direct pressure on the site of bleeding usually controls bleeding. Expedient closure of scalp lacerations also is helpful.

The secondary examination is more difficult in a child. The patient is fearful after the accident and apprehensive of the hospital environment. Children frequently anticipate additional pain and are less able to articulate concerns. Older children may report abnormalities of occlusion and visual symptoms. A thorough examination begins with inspection of the face. Swelling, ecchymosis, and asymmetry are clues of underlying fractures.

Next, palpation of the face is performed in an orderly fashion, beginning over the cranial vault and then proceeding to the forehead, orbital rims, zygomatic arch, maxillary alveolus, and mandible. Asymmetry, irregularity, step-offs, crepitation, and tenderness may indicate a fracture. Palpation in the external auditory canal may reveal a condylar fracture. Bimanual palpation of the mandible may reveal step-offs and instability. Numbness in the infraorbital, supraorbital, and mental distributions may indicate transection or stretch of a nerve from a nearby bony injury.

Perform careful inspection of the nasal cavity to exclude a septal hematoma, which if found, should be drained promptly. Otoscopy may reveal a hemotympanum, indicative of a temporal bone or basilar skull fracture. Blood in the external auditory canal may be evidence of a condylar fracture. A condylar fracture with impaction through the glenoid fossa may result in an external auditory canal laceration. Inspection of the mouth for missing teeth, intraoral lacerations, and ecchymosis also is necessary. Ophthalmologic examination should include observation of pupillary reflexes, examination of gross visual acuity, testing for diplopia (when possible), and assessment of extraocular muscle movements. Formal ophthalmologic consultation is indicated for fractures involving any of the orbital structures and is crucial for preoperative documentation.

Associated injuries

Children with facial fractures have a high incidence of coexistent injuries. Injuries other than facial wounds occur in 55-60% of these children. In McCoy's 1966 series, 40% of facial fractures were associated with skull fractures.[4] Two of the 86 patients had vertebral injuries. One third of children with facial fractures have injuries to other organ systems. Head injuries are most common, followed by extremity injuries. Interestingly, the rate of associated cervical spine injuries appears to be much lower than the 10-15% commonly reported from adult series. A positive association exists between the complexity of the facial fracture and the likelihood of an associated injury. Fractures of relatively protected and resilient bones generally are due to high impact; therefore, suspect concomitant injuries. Fifty-five percent of patients with orbital fractures have associated injuries (mostly neurocranial), but a third of these patients also have an orthopedic injury.

Indications

If fractures are displaced and a stable reduction cannot be achieved, perform a surgical reduction with rigid fixation (see Surgical therapy).

Relevant Anatomy

Distribution of fractures

The mandible and nasal bones are the 2 most frequent sites of fracture. Nasal fractures are typically managed in an outpatient setting and are excluded from many series. In Posnick's 1993 series, the most common type of fracture was mandibular, at 34%; followed by orbital, at 23%; and dentoalveolar, at 14%.[5] Midface fractures were less common, at 7%. Approximately 90% of midface fractures and zygoma fractures occurred in children older than 6 years. In a 1968 report, Rowe found that only 10% of pediatric fractures involved the midface, and he found these fractures to be very uncommon in those younger than 8 years.[3] Similarly, Dufresne reported mandible fractures to account for 32%, orbital fractures for 23%, and Le Fort fractures for 2.7% of pediatric fractures.[9] Kaban's 1993 series (which included nasal fractures) demonstrated fracture distribution as 45% nasal, 32% mandibular, and 20% ZMC and orbit.[1]

Contraindications

See Surgical therapy.

 

Workup

Imaging Studies

See the list below:

  • CT scanning in the axial and/or coronal plane has largely replaced plain radiography as the diagnostic study of choice.[10] The paranasal sinuses are often undeveloped or poorly pneumatized in the pediatric skeleton, the maxilla and mandible are full of tooth buds that often obscure ideal visualization, and patient positioning for different views requires more cooperation than often is practical. All of these factors and the widespread availability of CT scanning have made this the study of choice.

    • Coronal images can be obtained directly, or they may be reconstructed from axial images. Three-dimensional reconstructions also are widely available.

    • For suspected mandibular injuries, the Panorex is the preferred study, which should include separate temporomandibular joint (TMJ) views because plain Panorex views poorly image TMJs due to distortion artifact.

 

Treatment

Surgical Therapy

Pediatric fractures generally heal rapidly. If fractures are displaced and a stable reduction cannot be achieved, perform a surgical reduction with rigid fixation. Plating systems provide the most common method of rigid fixation. The trend in pediatric facial fractures is toward resorbable plating systems.[11] The surgical approach uses the same incisions that are used with adult patients. Nearly the entire face can be exposed with an appropriate combination of coronal, transconjunctival, subciliary, upper and lower gingivobuccal, and Risdon incisions.[12]

Nasal fractures

Isolated nasal fractures are common. These fractures are underrepresented in series because they are often treated in an office or outpatient setting. The nasal cartilage is soft and compliant in the child. This may predispose the child to septal fractures. Children are prone to open-book fractures as well. Initially, the presence of a septal hematoma should be excluded. Bleeding between the internal lining of the perichondrium and septum may occur. Drain septal hematomas to prevent dorsum collapse due to pressure necrosis or superinfection. In the early period, edema often obscures evidence of displacement. Once the edema has subsided (usually 3-4 d after trauma), the child should return to the clinic for examination. If a cosmetic deformity exists, closed reduction under anesthesia usually is successful. If the injury is more than a week old, open reduction is often required.

Orbital fractures

In Posnick's 1993 series, the orbital floor was involved in 32% of orbital fractures, the medial wall was involved in 19%, and the roof was involved in 18%.[5] Most patients (33 of 41) with orbital fractures were aged 6 years and older. In Koltai's 1995 series, incidence of roof fractures was 35%, floor was 25%, mixed was 35%, and medial was 5%.[13] The etiology of orbital fractures in children includes motor vehicle collisions at 42%, sports at 32.5%, and falls at 17.5%. Koltai determined that the age at which the probability of orbital floor fractures exceeds the probability of orbital roof fractures is 7 years. The overall change in facial geometry affects where the orbit is likely to be struck and affects the dissipation of force.[14]

Orbital roof fractures occur in younger children and more frequently have associated neurocranial injuries; however, they are less likely to require operative intervention. The lack of pneumatization of the frontal sinus correlates with the orbital roof fracture in younger children. The postulated reason for this phenomenon is the lack of cushioning effect of the sinus and transmission of force sustained on the frontal prominence directly to the orbital roof.

The need for fracture fixation depends on the presence of gross displacement of fracture segments and on decreased extraocular muscle movement with positive forced duction testing or alteration of orbital volume. A spicule of roof bone may impinge on the extraocular muscles and may decrease orbital volume, leading to exophthalmos. Patients who have sustained orbital roof fractures should be seen by neurosurgery and ophthalmology consultants. A high rate of intracranial injuries is associated with these fractures. Large orbital roof fractures may cause exophthalmos, vertical dystopia, and orbital encephaloceles.

Incidence of orbital floor fractures parallels development of the maxillary sinus. Symptoms of floor fractures include periorbital ecchymosis, lid edema, subconjunctival hemorrhage, diplopia, pain, and step-offs. Infraorbital anesthesia almost always exists. Upward gaze restriction may be secondary to entrapment or soft tissue edema. Initial edema can be misleading. Enophthalmos may become apparent with resolution of edema. Floor fractures are best evaluated with coronal CT scanning, but they can be visualized adequately with well-performed coronal reformations of high-quality axial CT scans.

If fractures are severe or clinical or CT scan evidence of entrapment exists, early surgical exploration and repair are indicated. Otherwise, patients may be observed for a week for development of enophthalmos or step-offs, both of which may become more apparent with resolution of edema.

Frontal sinus/frontobasilar fractures

Frontal sinus and frontobasilar fractures are managed as are similar fractures in adults. The frontal sinus is not well developed until ages 5-8 years, and without the sinus to provide a cushion, fractures tend to extend superiorly up the skull or across the orbital roof. If displaced, perform operative reduction through a coronal incision and fixate the anterior wall to maintain the forehead and brow contour. In children, however, the posterior sinus wall is more frequently involved and cerebrospinal fluid (CSF) leaks are more common. If the floor of the sinus is also involved, injury to the frontonasal duct is likely; remove the sinus mucosa, plug the frontonasal duct, and obliterate the sinus. If the posterior wall is involved, consult a neurosurgeon. If displacement of the posterior table by more than the thickness of the table exists, obliterate the frontal sinus with debridement of the mucous membranes and occlusion of the nasofrontal duct.

Midface fractures

Midface fractures are relatively rare in children and are rarer still in the younger age groups. These fractures account for less than 1% of Rowe's 1968 series of 1500 cases.[3] In a series of 54 midface fractures in patients younger than 16 years, only 11% were in patients younger than 6 years. Lack of development of paranasal sinuses and the presence of unerupted maxillary dentition decrease incidence of these fracture types in children younger than 6 years. Additionally, the younger child's maxilla is soft, spongy, and elastic and is sheltered by a thick adipose layer. These fractures are most commonly caused by high-velocity injuries; therefore, associated injuries are frequent. Half of patients have associated injuries, mostly to the head and face. A quarter of pediatric patients with midface fractures have injuries outside the head and face region.

Motor vehicle collisions are the most frequent etiology overall, and falls are the leading cause in children younger than 6 years. The pattern of maxillary injuries includes dentoalveolar (34.3%), zygoma (30%), and Le Fort fractures (20%). Children may have a sagittal split of the palate. In Rowe's 1968 series, only 4% of pediatric fractures were Le Fort-type fractures.[3] In Iizuka's 1995 series, Le Fort fractures only occurred in children older than 5 years.[15] In children younger than 5 years, dentoalveolar fractures are more common. In fact, in patients younger than 6 years, only dentoalveolar fractures occurred. In addition to their anatomic variance, these younger patients frequently sustain falls that generally are low-velocity injuries.

Le Fort fractures in children are classified as in adults. Le Fort I describes a fracture separating the palate and alveolus from the rest of the maxilla. The fracture line extends through the floor of the nose, maxillary sinus, and pterygoid plates. These fractures are associated with older patients, in whom the maxillary sinus is more developed and the permanent teeth are erupted. A Le Fort II or pyramidal fracture separates the midface from the skull. The fracture extends across the maxilla, the medial and lateral orbital walls, and the nasofrontal sutures, thus creating a free-floating pyramidal segment.

A Le Fort III fracture or craniofacial dysjunction involves a complete separation of the face from the cranium. The fracture line includes the zygomatic arch, frontozygomatic suture, lateral and medial orbital walls, nasofrontal suture, septum, and pterygoid plates. Massive edema and periorbital ecchymosis are common in patients with these fractures. Undertake treatment to establish occlusion, normal facial proportions, and symmetry.

If these fractures are displaced, rigidly fixate the bony segments. As with the mandible, take care to avoid damaging teeth developing in the maxilla. Operative strategy involves establishing occlusion, fixating the mandible, and reestablishing the horizontal and vertical buttresses of the face. Fractures may be approached through the same incisions used in adult patients: gingivolabial sulcus, bicoronal, transconjunctival, or subciliary incisions. As with other pediatric facial fractures, perform treatment within a week of injury.

Naso-orbito-ethmoid fractures

Naso-orbito-ethmoid (NOE) fractures are uncommon in children. The region is not prominent or well developed in the young child. These fractures range from simple fractures to severely comminuted fractures involving the orbits, maxilla, and frontal bone. Symptoms include a depressed and flattened nasal root, telecanthus, subconjunctival hemorrhage, and mobility of the medial canthal tendon on bimanual palpation. Additional clinical features include rounding of the medial canthus, horizontal shortening of the palpebral fissure, and an intercanthic distance greater than the palpebral fissure width.

Note that children have a relatively wide intercanthic distance, especially children younger than 10 years. Also, more soft tissue is draped across the nasal bridge, making the area difficult to assess.

The operative approach is through a coronal incision. The surgical goal is to reposition the canthal-bearing segment to stable bone in the frontonasal and medial maxillary buttresses and to establish a normal intercanthic distance, normal nasal form, and bony and soft tissue support for the eye. Do not set the intercanthic distance too wide.

Zygomaticomaxillary complex fractures

ZMC fractures become more common with increasing age, as the zygoma becomes more prominent. The frontozygomatic ligament is weak in children, and force applied to this area may cause unilateral craniofacial detachment. Therefore, these fractures more commonly involve the lateral wall and orbital floor. Symptoms of these fractures include depressed contour, bony step-off, subconjunctival hemorrhage, periorbital hematoma, depressed lateral canthus, abnormal mandibular movement due to restriction of the underlying coronoid process, and epistaxis from bleeding into the maxillary sinus.

Because these fractures often are greenstick, open reduction and internal fixation (ORIF) frequently is unnecessary. Nondisplaced fractures can be managed conservatively. A Gillies approach can be used for simple reduction. Rigid fixation is indicated for fractures that are more displaced or unstable.[16] These fractures must be reduced at 3 sites: frontozygomatic, infraorbital rim, and zygomaticomaxillary buttress. If orbital symptoms (eg, enophthalmos, diplopia) are present or if evidence of a floor defect is found on imaging studies, the question of floor involvement and prolapse of orbital contents should be raised and the orbital floor explored. In children, calvarial bone grafts are generally used to re-create the floor.

Eppley (2005) showed that the use of resorbable plates and screws for fixation of pediatric facial fractures enables realignment and stable positioning of rapidly healing fracture segments without any future metal retention. He treated 15 patients (age range: 4-11 y) with isolated frontal, supraorbital, intraorbital, or orbitozygomatic fractures by ORIF with 1.5-mm resorbable plates, mesh, and screws. No long-term implant-related complications were seen.

Complications

The major concern in treating pediatric facial fractures is the effect on long-term growth and development. Concerns over growth disturbance secondary to soft tissue disruption with dissection must be balanced with poor result and growth disturbance from leaving a grossly displaced fracture untreated. In general, if a fracture is stable or out of alignment, it should be fixated using as little dissection as possible.

The clinical effects of treatment on facial growth are unknown. Animal studies on the effect of fracture and fracture fixation on craniofacial growth have yielded conflicting results. In 1991, Lin demonstrated a regional growth restriction in animal craniofacial skeletal growth with plate and screw fixation and with wire fixation over an osteotomy.[17] Plating across a suture alone did not affect growth, nor did wide undermining and periosteal elevation.

Outcome and Prognosis

In general, the outcome from timely surgical intervention is excellent in the pediatric population.[2, 18] In McCoy's 1966 series of 64 children, only a single documented case of growth disturbance was found.[4] This case involved a patient with a delayed treatment of a nasoethmoidal fracture.

Both leaving untreated fractures in a nonanatomic position (eg, displaced) and overtreating fractures with excess periosteal elevation, soft tissue disturbance, and plating may result in growth disturbance. The consensus appears to indicate fixation of malpositioned fragments using the smallest amount of surgery possible. Minimize dissection. Use the fewest number and smallest-size plates. Additionally, consider possible interval removal of hardware (if not using resorbable systems).

The introduction of resorbable plates may alleviate some concern over long-term effects of fixation. Resorbable plates undergo a 2-step degradation. The first step is hydrolysis, which breaks the long chains into shorter ones. This step markedly reduces the strength of the substance. The second step is phagocytosis of the shorter chains by macrophages. This step decreases the mass of the substance. Most current resorbable plates are made of a combination of polyglycolic acid, which is subject to rapid hydrolysis and poly L-lactic acid, which is more slowly resorbed. Lactosorb is a trade name for a combination plate that resorbs in 9-15 months.

Future and Controversies

As discussed, the introduction of resorbable plates may alleviate some concern over long-term effects of fixation. Also, these plates may decrease the foreign body risk as well as the possible need for future removal. The use of a combination type plate in pediatric craniofacial surgery (including both developmental abnormalities and trauma) has been reported. In limited series, no instability or relapse of fracture site has been reported. Unfortunately, little long-term follow-up information currently is available. Some technical aspects remain to be improved; however, these plates appear adequate for stabilization of bone segments during the healing process; long-term follow-up of effects on growth remains to be seen.

 

Guidelines

Guidelines Summary

Coronavirus disease 2019 (COVID-19)

Bann et al compiled a set of recommendations for best pediatric otolaryngology practices with regard to the coronavirus disease 2019 (COVID-19) pandemic. These included the following for procedures involving the oral cavity, oropharynx, nasal cavity, or nasopharynx[19] :

  • Whenever possible, defer procedures involving the nasal cavity, nasopharynx, oral cavity, or oropharynx, as these pose a high risk for COVID-19 owing to the high viral burden in these locations
  • Whenever possible, preoperative COVID-19 testing should be administered to patients and caregivers prior to surgical intervention
  • Employment of enhanced personal protective equipment (PPE), with a strong recommendation for the use of a powered air-purifying respirator (PAPR), should be undertaken with any patient with unknown, suspected, or positive COVID-19 status
  • Limit the use of powered instrumentation, including microdebriders, to reduce aerosol generation

With regard to audiologic evaluation and otologic surgery, the recommendations include the following[19] :

  • Perform routine newborn hearing screening and early intervention as indicated in the Joint Committee on Infant Hearing (JCIH) recommendations
  • Defer tympanostomy tube placement for unilateral otitis media with effusion
  • Although it should be prioritized, intervention for bilateral otitis media with effusion and hearing loss may be deferred based on the availability of COVID-19 testing
  • Surgery involving the middle ear and mastoid, owing to their continuity with the upper aerodigestive tract, should be considered high risk for COVID-19 transmission
  • Whenever possible, defer mastoidectomy, but if the surgery is required, employ enhanced PPE and avoid the use of high-speed drills
  • Employment of a PAPR is strongly recommended when, in patients with unknown, suspected, or positive COVID-19 status, high-speed drills are required for otologic procedures

With regard to head and neck surgery and deep neck space infections, the recommendations include the following[19] :

  • Defer surgical excision of benign neck masses
  • A multidisciplinary tumor board should decide the most appropriate treatment modality for pediatric patients with solid tumors of the head and neck, including thyroid cancer, with the availability of local resources taken into account
  • Prior to surgical intervention, medical management of infectious conditions should, whenever possible, be attempted; on admission, patients and caregivers should be tested for COVID-19 and strictly quarantined pending test results

With regard to craniomaxillofacial trauma, the guidelines include the following[19] :

  • When urgent or emergent bedside procedures, including closure of facial lacerations, are required, patients should be presumed positive for COVID-19, even if they are asymptomatic; carry out procedures in a negative-pressure room using enhanced PPE
  • Employ closed-reduction techniques, when possible, until preoperative COVID-19 testing is available
  • Avoid the use of high-speed drills, to reduce aerosol formation
  • When urgent or emergent surgical intervention is required, patients should be presumed positive for COVID-19, even if they are asymptomatic