Introduction

Facial trauma is a common presentation in the Emergency Department. As the face is vital to both physical appearance and the ability to eat, speak, and perform other important functions, proper management of patients presenting with facial trauma is critical. Initial treatment must focus on life-threatening injuries, but careful attention to long-term function and cosmesis must also be considered. Any patient presenting with facial trauma must also be evaluated for other traumatic injuries, as more than 50% of these patients will have injuries in multiple systems.¹ As with any trauma patient, ATLS guidelines should be followed, and the initial evaluation of injuries should begin with management of the airway, breathing, and circulation.

Facial injuries commonly occur secondary to sport injuries, assault, and motor vehicle collisions. Interestingly, in developing countries severe facial trauma most commonly results from motor vehicle collisions, while in the developed world assault is the most common cause (Figure 8.1).² As with all patients presenting with traumatic injuries, careful documentation for forensic purposes plays an important part of patient care, especially when injuries occur secondary to assault.³

(A) Photographs of a patient with a complex facial laceration involving loss of tissue from the upper lip with avulsion of almost half the upper lip (left). After careful alignment of the vermilion border and restoration of the “cupid’s bow,” an acceptable cosmetic result is obtained (right).

(B) Photographs before (left) and after (right) repair of a complex laceration of the lower lip caused by a human bite. An acceptable cosmetic result is obtained.

(C) Amputation of the distal tongue caused by a human bite from the patient’s girlfriend.

(D) Patient with gunshot wound to the mouth and missing teeth. This patient should undergo radiological evaluation of the neck, chest, and abdomen to locate the missing teeth.

(E) Photograph of a laceration through the nasal cartilage

(reproduced with permission from Color Atlas of Emergency Trauma, Second Edition)

Figure 8.1 Image of patient with facial trauma.

The ABCs

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  Facial trauma can complicate the early management of a trauma patient due to its close proximity to the brain, cervical spine, and airway.⁴

  
  
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  Even minor maxillofacial injuries can pose a significant threat to the airway, as broken teeth, avulsed tissues, mandibular fractures, glottis edema, and foreign bodies all have the potential to compromise the airway.⁴

  
  
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  Facial fractures can make bag-mask-valve techniques more challenging by impeding jaw-thrust maneuvers.⁴

  
  
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  The fundamental strategy of look, listen, and feel can help to determine causes of airway obstruction and anticipate potential complications.⁴

  
  
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  All maxillofacial trauma patients should receive adequate oxygenation and uninterrupted saturation monitoring.⁴

  
  
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  Spinal collars should be applied with caution to prevent any posterior displacement of the mandible which could further compromise the airway.⁴

  
  
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  If intubation is necessary, nasotracheal intubation may be contraindicated in patients with comminuted mid-face fractures due to fear of iatrogenic penetration of the skull base.⁵ A study by Crewdson and Jerry⁵ demonstrated a 12% unsuccessful intubation rate in trauma patients with noisy or clogged airways.^5–7

  
  
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  A “difficult intubation” tray should always be present so that a surgical airway can quickly be obtained if oral intubation is unsuccessful.⁴

After stabilization of the airway and addressing breathing problems, attention must switch to circulation. Maxillofacial trauma predisposes a patient to significant hemorrhage. Studies have shown life threatening hemorrhage rates in these patients range anywhere from 1.4% to 11% (Box 8.1).^8–11

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  Hemostasis is necessary to reduce blood loss and, in supine patients, to protect the airway.⁴

  
  
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  Patients with oral bleeding who require c-spine precautions may require head elevation in order to reduce the risk of aspiration.⁴

  
  
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  Control of bleeding can be achieved by urgent suturing of lacerations, pressure packing, manual reduction of fractures, administration of tranexamic acid, balloon tamponade, or angiography with trans-arterial embolization or ligation.^12–14 Ligation of these commonly implicated vessels carries a relatively low risk of tissue ischemia due to extensive facial artery collateral flow.^12–14

  
  
• 
  

  Balloon tamponade must be performed with caution in patients with comminuted mid-face fractures that are at risk for displacement of fractured fragments into the orbit or brain.⁴

  
  
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  Facial injuries can be associated with traumatic occlusion or dissection of the internal carotid artery or vertebral arteries.⁴ Clinical suspicion should be increased if examination demonstrates a bruit/thrill, expanding hematoma, pulse deficit, or any focal or lateralizing neurological deficits.⁴

Anatomy

The posterior portion of the face forms the anterior wall of the calvaria. The face is divided anatomically into three parts (Table 8.1).

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  Nasal fractures are the most common facial injuries.

  
  
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  Nasoethmoidal fractures rarely occur as isolated injuries. Associated injuries often include central nervous system injury, cribriform plate fractures, cerebrospinal fluid rhinorrhea, lacrimal system injury, and fractures of the frontal bone, orbital floor, and mid-face.¹⁵

  
  
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  Up to one third of patients with frontal sinus fractures may have concomitant intracranial injures.¹

  
  
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  Alveolar fractures can occur in isolation from a direct blow or as an extension of a fracture through the alveolar portion of the maxilla or mandible.¹

  
  
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  The supraorbital rim, maxilla, mandible, and frontal bones require high-impact forces in order to be damaged, but bones such as the zygoma and nasal bone are susceptible to injury with even low-impact forces.¹

  
  
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  Facial fractures may be associated with cranial nerve injuries (Table 8.2).

Approach

Clues from the history and physical exam can help to elucidate concern for facial injuries, even when there are minimal external signs of trauma.

History

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  As with all trauma patients, it is critical to ask the patient information about the mechanism of injury, and whether or not there is any substance use that could be altering the patient’s memory or perception of what has happened to them.

  
  
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  Additional history should be obtained from EMS, associates, or bystanders whenever possible.

  
  
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  It is important to note if there was a loss of consciousness associated with the event, if there is difficulty with swallowing or shortness of breath, and to assess for as complete a review of systems as possible.

Examination

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  Initial examination must include palpation of the bony prominences for focal tenderness, step-off, crepitus, or abnormal motion.

  
  
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  It can be helpful to ask the patient to breathe out of each nare separately, and to assess for double vision, hearing changes, difficulty speaking, facial numbness, alignment of the teeth, and to determine if there are any painful or loose teeth.

  
  
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  Basilar skull fractures are at high risk for epidural hematomas. These fractures often cause a dural tear, and, therefore, up to 45% of these fractures can cause a CSF leak. Otorrhea or rhinorrhea after facial trauma is considered pathognomonic for a basilar skull fracture. Other clinical signs may include retroauricular ecchymosis (Battle sign), periorbital ecchymosis (raccoon eyes), and/or hemotympanum.^17–19

  
  
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  An increased intercanthal distance suggests a naso-orbital-ethmoid fracture which may also indicate the presence of an additional basal skull fracture. Typically, the normal intercanthal distance (telecanthus) in adults ranges from 28 to 34 mm, which is about the horizontal length of one eye.^{15, 20}

  
  
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  Assessment for immediate facial paralysis raises concern for transection of the facial nerve, whereas delayed facial paralysis is more often related to nerve edema or facial swelling.²¹

Imaging

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  Plain x-rays may be used for screening purposes, but the ideal imaging for facial fractures is computed tomography (CT). Typically, a CT max-face will visualize most of the territory required to screen for facial fractures (Figure 8.2), but occasionally a CT orbit and/or CT head will be needed as well.

  
  
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  Studies have shown that there is no indication for nasal bone x-ray if both nares are patent, there is no septal deviation or hematoma on inspection, and if the tenderness and swelling is isolated to only the bony bridge.²²

  
  
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  A panorex may help to identify any isolated mandibular fractures, dental fractures, or alveolar ridge fractures (Figure 8.3).²²

  
  
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  CT angiography should be considered if there is a hematoma or any clinical concern for injury or dissection of the carotid/vertebral artery (Figure 8.4).²²

(A) CT scan of the orbits showing fracture of the posterior/inferior orbital wall (arrow A) with herniation of orbital contents into the maxillary sinus on the left (arrow B).

(B) CT scan showing fracture of the inferior orbital wall with opacification of the right maxillary sinus (arrow)

(reproduced with permission from Color Atlas of Emergency Trauma, Second Edition)

Figure 8.2 CT max/face with fractures.

(A) Anteroposterior radiograph of the mandible showing bilateral displaced fractures of the angles of the mandible (arrows).

(B) Panorex view of the mandible showing an undisplaced fracture of the left mandibular ramus (arrow)

(reproduced with permission from Color Atlas of Emergency Trauma, Second Edition)

Figure 8.3 Image of panorex with alveolar ridge fracture.

(A) Patient with gunshot wound in zone III of the neck. CT angiogram with 3-D reconstruction shows a pseudoaneurysm of the distal vertebral artery (circle).

(B) Patient with a gunshot wound to the neck. The CT scan shows a fracture of the vertebral foramen (left, circle). In such cases there is concern of injury to the vertebral artery that travels through the foramen. Angiography confirms injury and thrombosis of the vertebral artery (right, arrow).

(C) Patient with a transcervical gunshot wound to the neck and fracture of the cervical spine. Angiography showing thrombosis of both vertebral arteries (arrows). The patient had no neurological deficits from this injury

(reproduced with permission from Color Atlas of Emergency Trauma, Second Edition)

Figure 8.4 CTA neck with dissection of carotid artery. Penetrating injuries to the vertebral artery.

Management

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  Any patient with trauma to the brow, forehead, or nasal bridge should expect additional periorbital swelling and ecchymosis to occur within 12–36 hours.²³

  
  
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  Definitive repair of non-displaced facial fractures is typically not required emergently, as adults will typically not develop firm fibrous union until 10 days after the injury. Therefore, most injuries requiring surgical internal fixation are usually performed at 4–10 days post-injury once the swelling has dissipated.^{4, 9}

  
  
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  All external wounds should be debrided and repaired for both cosmesis and hemostasis.²⁴

  
  
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  Typically, antibiotics are provided if injuries were secondary to a human or animal bite, and when there is evidence of devascularization, penetration of the buccal mucosa, through-and-through injuries of the lip, exposed cartilage of the nose or ear, gross contamination, or open fractures.^{24, 25}

  
  
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  Although controversial, antibiotics do not need to be routinely prescribed for nasal packing that is placed for management of epistaxis.²⁵

  
  
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  Tetanus vaccination should be administered if the patient is not up-to-date, and rabies vaccination is implicated with certain animal bites.²⁵

Specific Injuries

Ear

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  Hematoma formation from blunt trauma to the ear can accumulate in the subperichondrial potential space which can lead to formation of a cauliflower ear (wrestler’s ear) (Figure 8.5), and therefore any hematoma in this area should be drained (Box 8.2).²⁷

  
  
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  Tympanic membrane perforation can occur with trauma. Although this can lead to conductive hearing loss and an increased risk of infection, most heal spontaneously on their own within 4 weeks.²⁹

  
  
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  Typically, TM perforations are managed by ENT as an outpatient and ultimately require myringoplasty if they do not resolve on their own.²⁹

  
  
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  Patients with TM perforation and severe hearing loss, vertigo, nystagmus, or ataxia should be evaluated urgently by ENT.

  
  
• 
  

  Additionally, post-auricular ecchymosis (battle sign) can indicate a basilar skull fracture (although bruising in this area does not usually develop until 1–2 days after trauma).³⁰

  
  
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  Otoscopic evaluation should be performed to evaluate for hemotympanum and otorrhea (Figure 8.6).³⁰

  
  
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  If otorrhea is found, a drop of the fluid can be placed onto filter paper. A rapidly advancing halo, or ring of clear fluid surrounding a circle of dark red fluid, is considered a positive test and may indicate a CSF leak (Figure 8.7).^31–33

  
  
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  It is important to note that a false positive can occur if the fluid obtained is actually saline or saliva.^31–33

  
  
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  Although not commonly done, a more specific test to evaluate for a CSF leak is to test the fluid obtained for beta2-transferrin, as this protein is only found in CSF, aqueous humor, and perilymph.^31–33

Figure 8.5 Image of cauliflower ear

(photograph courtesy of MartialArtsNomad.com, reproduced under CC BY 2.0; https://creativecommons.org/licenses/by/2.0/)

Box 8.2 Steps of Draining a Subperichondrial Hematoma²⁸

1. 
   

   1. Cleanse the area with an antiseptic solution

   
   
2. 
   

   2. Provide local anesthesia (epinephrine should be avoided due to the limited blood supply to the external ear) either around the hematoma itself or via a greater auricular nerve block

   
   
3. 
   

   3. Aspirate from the most fluctuant area of the hematoma with an 18 gauge needle or make a small incision with an #11 blade scalpel

   
   
4. 
   

   4. Milk the hematoma to ensure complete drainage

   
   
5. 
   

   5. Apply direct pressure for 5–10 minutes and then place a pressure dressing over the area to prevent reaccumulation

Larger hematomas may require an incision with an 11 blade (best preformed parallel to the helical curve for cosmesis) followed by mattress suturing

(A) Battle’s sign – ecchymosis over the mastoid process, indicating basilar fracture and tracking of blood through the mastoid air cells.

(B) Bloody otorrhea following basilar skull fracture of the middle cranial fossa with rupture of tympanic membrane

(reproduced with permission from Color Atlas of Emergency Trauma, Second Edition)

Figure 8.6 Image of battle sign or hemotympanum. Physical exam findings indicative of basilar skull fracture of the middle cranial fossa.

Figure 8.7 Image of halo sign. Bloody otorrhea, arrow reveals the “halo effect” or “double ring sign” of CSF separating from blood when applied to the sheet. This sign can also be seen when the bloody drainage is applied to a paper towel or filter paper

(reproduced with permission from Color Atlas of Emergency Trauma, Second Edition)

Tripod Fracture

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  Tripod fractures are a specific type of injury that involves the zygoma, lateral orbit, and maxilla (Figure 8.8).³⁸ This fracture pattern poses a significant threat of airway compromise.

  
  
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  Isolated tripod fractures typically occur secondary to a direct blow injury and, since these fractures are frequently displaced, they often require surgical correction.³⁸

  
  
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  This constellation of injuries is often associated with ocular findings, such as abnormal extra-ocular movements. Therefore, ophthalmic consultation is typically obtained for patients with these injuries.³⁸

Figure 8.8 Image of a tripod fracture. Illustration outlining a tripod fracture of the zygoma

(reproduced with permission from Color Atlas of Emergency Trauma, Second Edition)

Maxillary Fractures

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  Maxilla fractures may be present in patients with dysphonia or edema of oropharynx, suggesting a hematoma or fracture.^{4, 9, 39}

  
  
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  A fracture of the anterior wall of the maxillary sinus may present with denervation of the maxillary teeth.^{4, 40}

Maxillary fractures are classified as a LeFort I, II, or III injuries (Table 8.3) (Figure 8.9).

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  LeFort II and III fractures are considered to be unstable fractures and have a high risk for concurrent cerebrovascular injury.^{4, 40}

  
  
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  Inspection, palpation, and manipulation (by gasping the superior anterior teeth/alveolar ridge while moving the maxilla anteriorly and posteriorly) may be used to evaluate for unstable LeFort fractures.^{4, 40}

Table 8.3 LeFort fractures^{4, 9, 40}

Type	Caused By	Fracture Extends Through	Indicates
LeFort I	Horizontal maxillary fracture across the inferior aspect of the maxilla separating the alveolar process from the rest of the maxilla	The lower third of the septum and includes the medial and lateral maxillary sinus walls, extending into the palatine bones and pterygoid plates	Palate-facial separation
LeFort II	Pyramidal fracture originating at the nasal bone	The ethmoid and lacrimal bones into the zygomaticomaxillary suture, through the maxilla, and into the pterygoid plates	Pyramidal disjunction
LeFort III	Full separation of the facial bones from the cranial base	The zygoma, maxilla, and nasal bones	Craniofacial disjunction

(A) Schematic showing three types of Le Fort fracture.

(B) Photograph of a patient who had a garage door crush his face. The abnormal concavity of the face (“dish face”) is characteristic of a Le Fort III fracture.

(C) CT scan of the face showing Le Fort III fracture: (a) anterior ethmoid fracture (arrow); (b) mid ethmoid and lateral orbit fractures (arrows); (c) frontal sinus fracture (arrow); (d) pterygoid fractures (arrows).

(D) CT scan 3-D reconstruction of a Le Fort III fracture showing multiple fractures, including a tripod fracture of the zygoma (arrows)

(reproduced with permission from Color Atlas of Emergency Trauma, Second Edition)

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Chapter 5 – Pediatric Trauma Chapter 6 – Geriatric Trauma Chapter 11 – Thoracolumbar Trauma Chapter 10 – Cervical Spine Trauma Chapter 13 – Pulmonary Trauma Chapter 20 – Lower Extremity Trauma