Abstract
Facial injuries are common and can involve both soft tissue injury and bony injury. These often occur because of motor vehicle collisions, secondary to direct impact against the windshield, steering wheel, or dashboard, as well as from broken glass fragments, causing lacerations and eye injuries. Many facial injuries also occur because of physical assault or because of falls to the head and face, especially in the elderly, who are less able to protect their face while falling.
Introduction
Facial injuries are common and can involve both soft tissue injury and bony injury. These often occur because of motor vehicle collisions, secondary to direct impact against the windshield, steering wheel, or dashboard, as well as from broken glass fragments, causing lacerations and eye injuries. Many facial injuries also occur because of physical assault or because of falls to the head and face, especially in the elderly, who are less able to protect their face while falling.
Clinical Examination
The face contains many sensitive structures intimately involved in the human senses of sight, smell, hearing, and taste, all of which are vital for human communication. After completion of the primary survey, it is important to examine each systematically to detect and manage localized injuries.
Overall Face – The face should be palpated for areas of localized tenderness, swelling, malformation, crepitus, and abnormal motion, all of which can indicate the presence of underlying fractures. All lacerations should be identified and direct pressure applied while the exam continues. The teeth, maxilla, and mandible should be palpated and pulled forward slightly to reveal a possible LeFort fracture. The face should be examined for asymmetry, which can be due to direct trauma and also secondary to facial nerve injury.
Eyes – The orbit and periorbit should be examined as part of the secondary survey. The exam should include assessment of the following important elements: (1) external examination, (2) extraocular motility, (3) confrontation of visual fields, (4) visual acuity, (5) pupil examination, (6) intraocular pressure, (7) slit lamp exam, and (8) fundoscopic exam.
Various elements of a full ocular exam may be challenging to obtain in the acute trauma setting and may be deferred to specialist consultation. Visual acuity, for example, may be difficult to obtain formally; however, a rough estimate can be made by having the patient count fingers or report light perception. External visual exam should assess for evidence of soft tissue swelling, foreign body, or laceration. The pupils should be checked for symmetry and equality of pupillary reflex. Findings such as a peaked pupil can raise suspicion for globe rupture. The position of the globe should be noted with concern for enophthalmos (indicates blowout fracture) or exophthalmos (indicates increased retroorbital pressure from hematoma). If the patient is stable, a slit lamp exam can be performed to look for evidence of corneal foreign bodies, lacerations, or abrasions, as well as to visualize the anterior chamber for a hyphema.
Ears – Both the external ear and external auditory canal should be inspected during the secondary survey. Lacerations, avulsions, or hematomas in the cartilaginous portions or soft tissues of the external ear must be noted. The auditory canal should be examined with an otoscope for bleeding or CSF otorrhea (concerning for ruptured tympanic membrane and/or basilar skull fractures). The tympanic membranes must be examined for hemotympanum, which represents accumulation of blood in the middle ear and is associated with an increased risk of intracranial injury or fracture.
Nose – The nose is inspected for skin or cartilage lacerations, as well as for nasal bone fractures, often causing deformity and localized tenderness at the nasal bridge. The nares should be inspected with an otoscope for the presence of epistaxis or CSF leak, as well as nasal septal hematoma.
Mouth – The mouth should be examined for lacerations, teeth avulsions or fractures, swelling of the tongue, and oral mucosa. Occlusion should also be noted, which would suggest an isolated mandible or more complex facial fracture. This is accompanied by an evaluation of the patient’s airway, which will have a direct impact on the clinician’s decision to intubate the patient.
Investigations
The provider must use clinical judgment in assessing the need for diagnostic imaging for facial injuries. Not all patients require imaging; however, if there is any concern for a facial fracture due to localized tenderness, asymmetry, or other concerning signs, the imaging modality of choice is the maxillofacial CT. Given the ubiquity and superiority of CT scans, plain radiographs are now rarely indicated for facial trauma. However, if available, panorex X-ray views remain useful for identifying suspected mandible fractures.
There are several non-radiographic tests that are useful for facial injuries, depending on the specific injury and the practice location. Specialists, such as ophthalmologists, may be called upon to carry out many of these tests, but they can also often be performed in an emergency department. Retinal detachment and other intraocular injuries (anterior chamber hyphema, corneal abrasions) should be examined with careful fundoscopy and slit lamp exam. Tonometry can be used to assess for posttraumatic glaucoma or retroorbital hematoma; however, this test should never be done if there is concern for ruptured globe. Lacrimal duct laceration can be assessed with fine probes by an ophthalmologist, whereas parotid duct laceration is often demonstrated with a sialogram performed by a surgeon.
General Management
The lower face and neck contain structures that define and maintain the integrity of the airway. Consequently, facial injuries at times assume the highest priority in trauma management until airway patency and adequate ventilation can be established. Because facial tissues are highly vascularized, severe bleeding into the oral cavity can occlude the airway, especially when patients are obtunded from head injury or intoxication. In the presence of massive bleeding, airway compromise may be produced by placing the patient supine for spinal immobilization. Blood, secretions, fragments of teeth, and foreign bodies must be directly removed or suctioned to avoid aspiration and airway occlusion. Intubation is often indicated for facial injuries in order to protect the patient’s ability to ventilate. With severe trauma, normal oropharyngeal landmarks may be severely distorted and alternative approaches, including awake, fiberoptic oral- or naso-tracheal intubation, should be considered. Nasotracheal intubation should not be attempted in patients with concern for nasal, basilar skull, or Le Fort fractures. The decision regarding the method of intubation should be based on the urgency of protecting the patient’s airway, experience of the physician, and the facilities and resources of the emergency room. Finally, in all cases, the physician should be immediately available to perform a cricothyroidotomy if conventional intubation fails. Prolonged and repeated attempts at intubation are detrimental to the patient, and early use of cricothyroidotomy is essential and often life-saving.
As facial injuries are often dramatic, they can easily distract the inexperienced clinician from more critical tasks. If the airway is not threatened, most facial injuries can be safely deferred until additional systemic life-threatening problems have been addressed. Active bleeding (such as scalp wounds) should be timely addressed, as these injuries can typically be controlled with local measures, and ongoing blood loss can lead to hemorrhagic shock. Treatment of facial fractures can be deferred until the patient is hemodynamically stable.
Minor eye injuries (e.g., corneal abrasion, rust ring, eyelid laceration) can be deferred, but sight-threatening injuries should be dealt with immediately and consultation with an ophthalmologist is essential. Once the possibility of a ruptured globe has been established, the eye should be protected by use of a Fox shield or similar device to prevent further pressure on the globe. Retroorbital accumulation of blood or air, often due to direct facial and eye trauma, associated with deteriorating vision, massive elevation of intraocular pressure, or exophthalmos, requires emergent decompression by lateral canthotomy with cantholysis. Entrapment of extraocular muscles by fractures, indicated by loss of extraocular movements, or seen on facial/orbit CT, should be relieved urgently. All of the aforementioned factors should prompt emergent consultation to an ophthalmologist.
Penetrating trauma of the ear is relatively uncommon and is managed by minimal debridement, irrigation, and primary closure. Blunt trauma is more common and often results in perichondrial hematoma formation in the ear pinna or cartilage. As ear cartilage is dependent on its perichondrium covering for blood supply, an interposed hematoma can result in ischemic necrosis of the cartilage, resulting in a “cauliflower ear” deformity. Consequently, the ear must be examined for this condition, and a hematoma should be drained or aspirated. A pressure dressing is applied to prevent reaccumulation of the hematoma or abscess formation.
Superficial facial lacerations can typically be managed at the bedside and should be repaired carefully to maximize cosmetic outcome. Debridement of wound margins should be minimized, cartilaginous structures should be preserved, and fine sutures with minimal inflammatory properties should be used in closing the wounds. Complex lacerations involving delicate and essential facial structures such as the eyelid should be referred to a specialist. Intraoral lacerations are repaired with absorbable sutures. Antibiotics are unnecessary for most facial lacerations, although open fractures require prophylactic coverage.
Tips and Pitfalls
Severe oromaxillofacial trauma can produce delayed airway occlusion from swelling or bleeding. These patients should be intubated early or observed carefully in a monitored environment.
Any attempts to perform endotracheal intubation in the presence of extensive facial trauma should be accompanied by preparation for cricothyroidotomy in the event that oral intubation fails.
Always account for missing teeth. The missing teeth might be in the tracheobronchial tree, resulting in airway obstruction and even a lung abscess.
Blind clamping of bleeding sites is rarely successful, and it can injure nerves and other structures that run in proximity to vessels.
Injury to the cranial nerves is difficult to detect in severely injured patients, especially if they are comatose, intoxicated, or otherwise unable to cooperate with physical examination. Reassess again during the tertiary survey.
Eye Injuries
Corneal Abrasion
In spite of brisk protective reflexes, corneal abrasion is common. Although this is typically caused by rubbing or itching the eyes, it is also caused by scraping with twigs, broken glass, or sand, or by industrial accidents involving power grinders, saws, or welders. The patient will typically have a sudden onset of pain in the affected eye and a foreign body sensation in the eye, with increased tearing and blurry vision. Physical exam may reveal conjunctival injection and tearing; however, external inspection can also be normal. The eye should be examined with magnification, and an ultraviolet (UV) light source after fluorescein dye is instilled onto the conjunctiva. This should ideally be performed with a slit lamp, but a Wood’s lamp can also be used if the patient is not capable of sitting up. Corneal abrasions appear as areas of increased dye uptake on the corneal surface (Figure 2.1). Anesthetic drops will also completely relieve the patient’s pain. Most corneal abrasions will heal within 2–3 days, and although commonly prescribed, ocular antibiotic drops are not necessary for most cases.
Ocular Foreign Body
Corneal abrasions may also be associated with a retained foreign body. If this is small and well visualized (e.g., small piece of metal, glass, or wood in the lid margin or on the cornea), it can be gently removed with the point of a needle under magnification in the emergency room. Irrigation should be performed to wash out the foreign body. A rust ring around a small piece of metal can form and interfere with the patient’s vision. Importantly, any patient presenting with symptoms of corneal abrasion after use of industrial equipment, such as high-speed grinding or hammering on metal, should be suspected of having a perforated globe. Small metal fragments can enter the globe at very high speed leaving minimal evidence of entry on the surface. These are best diagnosed with orbital CT scan and, if found, should prompt ophthalmology consultation (Figure 2.2 AD).
Figure 2.2 A–D Photograph of the eye showing a metallic foreign body on the cornea deforming the iris and the pupil (arrow; A). Plain radiograph showing an intraocular bullet (arrow; B). CT scan of the orbit showing one small intraocular foreign body of the left eye (arrow), and another lateral to the right orbit (C). Photograph of the eye showing a central rust ring in the cornea (arrow; D). This rust ring is in the visual axis and will seriously impair vision if not removed.
Hyphema
Hyphema is the accumulation of blood in the anterior chamber of the eye, most often due to direct trauma. The blood is most easily visible with the patient in a supine position when it forms a clearly visible layer in the dependent portion of the anterior chamber (Figure 2.3). Initial bleeding usually reabsorbs without complications; however, approximately one-third of cases exhibit rebleeding after several days. Complications from hyphema include hemosiderin staining of the inner surface of the cornea with resulting loss of vision, as well as posttraumatic glaucoma due to fibrotic occlusion of the canals of Schlemm. Treatment of posttraumatic glaucoma is conservative, including bed rest with head elevated, sedation, and monitoring of intraocular pressure. Surgery is required occasionally for evacuation of blood or to decompress the anterior chamber.
Figure 2.3 Photograph of the eye showing a collection of blood pooled (hyphema) in the inferior aspect of the anterior chamber (arrow).
Ruptured Globe
Globe rupture usually occurs after penetrating injury but can be caused by blunt trauma as well. Penetration of the sclera results in herniation of orbital contents through the wound and exposure of the choroid membrane, visible as a dark layer of tissue in the wound. Penetration of the cornea allows leakage of vitreous humor through the wound. In either case, distortion of the globe results in loss of functional vision at the time of injury, although light perception may be preserved. Patients report pain and often resist eye examination. Additional signs of globe rupture may include enophthalmos, loss of eyeball turgor, a peaked pupil that often points toward the site of injury, loss of pupillary reactivity, and a positive Seidel’s test. Seidel’s test is performed by instilling fluorescein dye into the conjunctiva and observing the dye as it clears from the cornea or sclera in the area of presumed rupture. This clearance is due to the flow of aqueous humor from the anterior chamber.
Although intraocular pressure is reduced in the presence of a ruptured globe, tonometry or any other maneuver that increases pressure on the globe is contraindicated. The conjunctiva is very distensible and often becomes edematous after trauma, resulting in bulging chemosis, which frequently limits a complete exam. Because of its common association with rupture of the globe, bulging chemosis itself should be considered a sign of possible ruptured globe. The ruptured globe is commonly enucleated if sight cannot be restored to avoid the development of a sympathetic ophthalmoplegia in the normal eye (Figure 2.4 A–E).
