Bony and Soft-Tissue Facial Trauma
Alexander Ovchinsky
Jon B. Turk
Trauma is the leading cause of death and disability among Americans younger than 40 years. In the United States more than 150,000 violent deaths occur each year, and more than 500,000 trauma victims are left with permanent disabilities. It is estimated that more than $100 billion are spent annually on trauma situations.
The primary objectives of trauma management are rapid and accurate assessment of the injured patient’s condition and resuscitation and stabilization on a priority basis to increase the likelihood of survival. Death from trauma is known to have a trimodal distribution. The first peak in the incidence of death is within minutes of initial injury. Primary causes of these deaths are related to laceration of the brain, brainstem, high spinal cord, heart, aorta, or other large vessel. The second death peak occurs within minutes to a few hours after injury. This period is referred to as the golden hour during which rapid assessment and resuscitation, if adequately provided, reduce the likelihood of death. The third death peak occurs days or weeks after the initial injury, and usually is caused by sepsis and organ failure.
FACE AND NECK TRAUMA ASSESSMENT
Treatment of a seriously injured patient requires rapid assessment of the injuries and institution of life-preserving therapy. Because time is of the essence, a systematic approach that can be reviewed and practiced is desirable. Initial assessment steps are listed below.
Primary survey
Resuscitation
Secondary survey
Continued postresuscitation monitoring and reevaluation
Definitive care
Patients are evaluated and treatment priorities are based on the injuries, stability of vital signs, and injury mechanism. The airway is always managed first, followed by breathing and circulation. Careful attention is paid to the cervical spine at all times. Cervical spine precautions always should be taken, especially with maxillofacial trauma. This process constitutes the ABCs of trauma care and is used to identify life-threatening conditions.
The secondary survey does not begin until the primary survey (ABCs) is completed, resuscitation is initiated, and the ABCs are reassessed. The secondary survey is a head-to-toe evaluation that includes assessment of vital signs. In this survey, a complete neurologic examination is performed, including Glasgow Coma Scale score if not done during the primary survey. Special procedures (laboratory studies, radiographic studies) are obtained at this time.
The urgency of maxillofacial management is dictated by airway obstruction and severe bleeding. Otherwise, facial trauma is managed after the patient’s condition is stabilized completely and life-threatening injuries have been addressed. Definitive management may be safely delayed without compromising care at the discretion of the otolaryngologist. Potentially threatening situations include pending airway obstruction, changes in airway status, cervical spinal injuries, exsanguinating midface fracture, lacrimal duct lacerations, facial nerve injuries, and skull base fractures with intracranial trauma/hemorrhage.
HISTORY AND PHYSICAL EXAMINATION IN MAXILLOFACIAL TRAUMA
When confronted with a patient who has evidence of a blunt or penetrating injury, the physician should determine the circumstances or mechanism of the injury, because this determines treatment and influences outcome. It is important to record the time of the injury and the presence of associated or concurrent symptoms, such as loss of consciousness. The antecedent medical condition of the patient, including any concurrent diseases such as diabetes or heart disease, or other circumstances that might limit treatment should be recorded in the medical history. The objectives are restoration of form and function to the injured structures.
The physical examination entails a complete head and neck examination that includes the cranial nerves. The approach should be systematic, for example starting with the scalp and examining the ears, eyes, nose, face, oral cavity, oropharynx, and neck. A fiberoptic examination should be performed to evaluate the upper aerodigestive tract if any airway obstruction or internal bleeding is suspected. Diagrams and other visualizations should be used to highlight the injuries.
SOFT-TISSUE TRAUMA
Soft-tissue injuries make up a substantial portion of emergency department cases. A physician who treats patients with facial soft-tissue injuries must remember the psychologic, aesthetic, and functional deficits involved in managing these injuries and also must be mindful that further evaluation of some soft-tissue injuries is necessary (Table 37-1).
TABLE 37-1. Soft tissue injuries necessitating further evaluation | |||||||
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Blunt Trauma
Blunt trauma to the neck may be associated with airway compromise and requires prompt otolaryngologic examination. Injuries to the cervical spine always must be ruled out. Local pain, dysphagia, odynophagia, and voice change are common. They may result from damage to strap muscles and other subcutaneous muscles and tissues and do not necessarily indicate fracture of the laryngeal cartilages. However, fiberoptic laryngoscopy is indicated. Among the signs highly suggestive of laryngeal fracture or other severe injury are loss of the palpable prominence of the thyroid cartilage, subcutaneous emphysema, loss of voice, odynophonia, hemoptysis, and stridor. These findings mandate upper airway assessment by means of examination, radiographic assessment by means of computed tomographic (CT) scans, and neck exploration in selected instances. In severe laryngeal injuries, the airway is established by means of tracheostomy; endotracheal intubation should be avoided since it may inflict additional injury to the laryngeal framework.
Abrasions
Abrasions should be cleaned thoroughly with normal saline solution, and all foreign material should be removed. Sterile antibiotic ointment is applied for protection and to enhance reepithelialization. A loose dressing (such as Telfa, Xeroform, or Furacin gauze) is applied to the wound and followed by a supportive dressing. The wound should be checked frequently until healing is complete.
Contusions
Contusions often need no treatment if the skin has not been broken and if there is no subcutaneous accumulation of blood or purulent material. The only two exceptions are contusions of the auricle and neck. Auricular contusions have a tendency toward subperichondral or subcutaneous hematoma and must be drained. Neck contusions also have a tendency toward hematoma formation. Neck contusions must be observed carefully for expansion. Hematoma necessitates aspiration or drainage if it becomes infected or does not resolve spontaneously.
Lacerations
Lacerations may be closed primarily within the first 24 hours after appropriate cleaning and administration of local anesthesia. Lacerations in the upper or lower eyelids, upper or lower lip, nasal cartilage and nasal rim, buccal region over the parotid duct, and external auditory canal and injuries associated with loss of nerve function are particularly dangerous in that they can be accompanied by immediate or eventual loss of function. They require immediate attention by an otolaryngologist-facial plastic surgeon.
Superficial lacerations of the skin are closed with everting sutures of nonabsorbable, nonreactive material (such as 5-0 or finer nylon). For infants, fine absorbable sutures can be used so there is no need for suture removal. Deeper lacerations necessitate subcutaneous closure with absorbable sutures, such as chromic catgut or polyglactin 910 (Vicryl). Facial sutures should
stay in no longer than 5 days to minimize scarring. An exception to this rule is treatment of patients with poor healing capacity such as those with diabetes or renal disease. Sterile adhesive strips, which afford relaxation of tension on the wound edges, are applied after sutures are removed. This is particularly important in the management of lacerations over mobile areas.
stay in no longer than 5 days to minimize scarring. An exception to this rule is treatment of patients with poor healing capacity such as those with diabetes or renal disease. Sterile adhesive strips, which afford relaxation of tension on the wound edges, are applied after sutures are removed. This is particularly important in the management of lacerations over mobile areas.
Penetrating Wounds
Penetrating wounds of the head and neck are particularly dangerous when the penetrating instrument and the depth of injury are not known. Among the structures that may be injured in penetrating wounds of the neck are the carotid sheath and its contents (carotid artery, internal jugular vein, vagus nerve), sympathetic trunk, pharynx, esophagus, larynx, trachea, and nerves of this region (lingual, hypoglossal, facial, spinal accessory, and brachial plexus). Although superficial penetrating injuries without evidence of damage to any of these structures or without evidence of contamination or expanding hematoma can be conservatively managed and observed, most penetrating injuries to the head and neck necessitate surgical exploration to avoid lethal complications. Penetrating neck wounds are classified according to their location. Zone I injuries are below the level of the clavicles, zone II are between the clavicles and the angle of the mandible, and zone III injuries are above the angle of the mandible. The diagnostic evaluation for a patient in stable condition may include barium swallow examination, angiography, CT scanning, and upper gastrointestinal tract endoscopy. Unstable patients with active hemorrhage mandate surgical exploration. Blind probing of the wound to estimate the depth of the injury is very dangerous and must be avoided.
FACIAL BONE TRAUMA
Because of its location, fragile structure, and occasionally insulting manner, the face frequently is the subject of mechanical trauma that results in underlying bony trauma. The nasal bones are the bones most often fractured in facial injuries, followed by the mandible and midfacial bones. Depending on the nature of the injury, immediate attention should be directed at potentially coexisting injuries such as those involving the cervical spine, intracranium, thorax, or abdomen (Table 37-2).
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