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20
Facial Trauma
Chien-Wei Wang
PATIENT EVALUATION
History
Mechanism of injury determines the degree of force
Interpersonal violence (usually low energy)
Motor vehicle accident (usually higher energy)
History of prior facial trauma/surgery
Time of injury
Loss of consciousness
Subjective complaints: diplopia, blindness, hearing loss,
malocclusion, otorrhea and rhinorrhea
Environmental considerations: chemical exposure
Past medical/surgical history, medications, smoking, and
drug abuse
Physical Exam
Trauma patients: ABCs (airway, breathing, circulation)
must be the first priority
Most facial trauma patients need clinical and
radiographic cervical spine (c-spine) evaluation and
management.
*Over 10% of facial trauma patients have
associated c-spine injury.
Control hemorrhage—most hemorrhage can be controlled
with pressure.
*Internal maxillary artery is the most common
source of life-threatening hemorrhage associated
with facial trauma.
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Management: secure airway → posterior nasal
packing.
Stable patient: consider angiography and embolization
via interventional radiology.
Unstable patient: surgical ligation of external carotid
artery.
Adequate lighting, irrigation, and suction are required.
Inspection: lacerations, abrasions, burns, edema,
symmetry, septal hematoma, ruptured tympanic membrane,
otorrhea and dental occlusion.
Palpation.
Skull, orbital rims, zygomatic arches, maxilla, and
mandible
Assess for symmetry, step-offs, crepitus, and pain
Complete cranial nerve exam (prior to administration of
local anesthetic) with emphasis on (Table 20-1).
Sensation: light touch in three divisions of CN V—
ophthalmic, maxillary, and mandibular
Motor: test all CN VII branches (temporal, zygomatic,
buccal, marginal mandibular, and cervical) and look for
asymmetry
Eyes
Test visual acuity with pocket card
Pupillary response to light
Swinging flashlight test to rule out afferent papillary
defect (optic nerve injury)
Diplopia (horizontal versus vertical)
Extraocular movements
*Perform forced duction to rule out muscle
entrapment if intubated/sedated and periorbital
fractures present
Steps for forced duction test
Place 2 drops of tetracaine into the eyes.
Patient may need additional anxiolytics.
Grasp the sclera (away from cornea) with fine
forceps and move the globe into
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upward/downward/lateral gaze positions to
test for entrapment of extraocular muscles.
When in doubt, perform forced duction on the
normal side for comparison.
Hyphema or globe injury
Enophthalmos
Eyelid position
Medial canthal tendon stability (vs telecanthus)
Ears
Inspect external ear on all surfaces for lacerations,
perichondral hematoma.
Observe for Battle sign: bruising of mastoid process
indicative of skull base fracture.
Otoscopy: hemotympanum, cerebrospinal fluid (CSF)
leak, perforation of tympanic membrane.
Hematoma on external ear must be evacuated and
bolstered to prevent reaccumulation.
Nose
Assess contour and stability of nasal bones.
Use nasal speculum for intranasal exam: assess for
lacerations, nasal obstruction, rule out septal
hematoma (can lead to septal necrosis if untreated)
Septal hematoma can be drained via small
incision. After incision and drainage, nasal packing
or nasal stent should be placed to prevent
reaccumulation.
Midface, cheek
*Lacerations should be examined for proximity to
Stenson (parotid) duct (runs in middle third of a
line drawn from oral commissure to tragus).
To assess integrity of the duct:
Cannulating the intraoral papilla at level of
maxillary second molar with a lacrimal probe or
small gauze IV catheter.
Instill propofol or half-strength hydrogen peroxide
solution to see if any white solution or bubbling in
the wound, which indicates ductal injury.
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Any injury must be repaired or stented.
Look for malar flattening and downsloping of palpebral
fissure (ZMC fractures).
Assess for midface mobility while stabilizing the skull
(Le Fort fractures)
Mandible, oral cavity, occlusion
Assess occlusion
Ask patient “Does your bite feel normal?”
Inspect wear facets of teeth—these will
intercuspate if occlusion is normal. This is very
useful in unresponsive patients.
Anterior or posterior open bite, cross bite.
Document loose/missing/broken teeth
Dentistry consult
Inspect oral lining for lacerations or ecchymosis.
Measure incisal opening distance.
Submucosal hematoma may indicate mandible
fracture.
Palpate temporomandibular joint (TMJ) in external
auditory canal with opening and closing of mouth.
Note oral hygiene and any carious teeth that may serve
as source of infection.
Diagnostic Studies
*Maxillofacial CT is the gold standard to evaluate for
facial fractures (isolated nasal bone fractures do not
require imaging. It is a clinical diagnosis)
Coronal views
Accurate assessment of nasal bones
Orbital walls and potential herniation of contents
into maxillary sinus
Three-dimensional reformats are useful in planning
complex panfacial fracture reconstruction.
Herald findings of fracture
Osseous deformity
Sinus opacification
Pneumocephalus or soft tissue air/edema
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Panorex may be sufficient in cases of mandible fracture
(this requires a patient to sit up in the panoramic radiograph
device and therefore cannot be done in unresponsive
patients).
Consider plain films, three views, to evaluate for missing
mandibular segments (eg, gunshot wounds); also useful
when Panorex not available.
TABLE 20-1 Cranial Nerves and Their Foramina
FACIAL SOFT TISSUE INJURIES
FACIAL FIELD BLOCKS
Facial field blocks are useful for providing anesthesia in awake
patients and usually take about 1-2 cc of local anesthetics for each
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nerve block (Fig. 20-1)
Figure 20-1 Facial blocks.
Supraorbital, supratrochlear, and infratrochlear nerves
Innervates: forehead/anterior scalp/upper eyelid/glabella.
Insert needle in midpupillary line at supraorbital rim (just
lateral to the mid brow), advance medially to capture
supratrochlear nerve.
Infraorbital Nerve
Innervates: lateral nose/upper lip/lower eyelid/medial cheek.
Transoral: insert needle into superior buccal sulcus above
the canine tooth root at midpupillary line 6-10 mm below the
infraorbital rim.
Transcutaneous: insert needle into a few millimeters lateral
to the alar groove at the superior part of the nasolabial
groove and advance to 6-10 mm below the infraorbital rim
at midpupillary line.
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With transcutaneous approach, operator can often feel
the needle entering the foramen.
Zygomaticotemporal/Zygomaticofacial Nerves
Innervates: temporal and lateral orbital regions/lateral
cheek over the zygoma.
ZT block: insert needle from above just 1 cm behind the
lateral orbital rim at the level just below the
zygomaticofrontal suture. Insert along the bony wall to 1 cm
below the lateral canthus and inject on the way out.
ZF block: always done after ZT block. Inject a dime-sized of
injectate just at the junction of lateral and inferior orbit rims.
Dorsal Nasal Nerve
Innervates: cartilaginous dorsum and tip.
Palpate nasal bone with thumb and index finger. Nerve
exits ~6-10 mm from the middle line on both sides. Around
1-2 cc injectate is sufficient for each side.
Mental Nerve
Innervates: lower lip/chin
*Insert needle into inferior buccal sulcus at mandibular
second premolar
Cervical Plexus, Great Auricular, Transverse Cervical
Nerves
Innervates: posterior auricle/mandibular angle/anterior neck
*Both great auricular and transverse cervical nerves
emerge at Erb point
7 cm inferior to tragus
Posterior border of sternocleidomastoid (SCM) muscle
Mark patient’s SCM when flexed, locate midpoint from
clavicle to mastoid for injection
Auriculotemporal, Great Auricular, Lesser Occipital, Arnold
Nerve
Ear “ring block.”
Begin with needle at junction of lobule and cheek and
proceed with four injections circumferentially.
Avoid superficial temporal artery.
*Separate injection in external auditory canal for Arnold
nerve (auricular branch of the vagus nerve, CN X).
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LACERATION REPAIR
General Principles
The face has a robust vascular supply; avoid excessive
debridement.
Repair in layers under minimal tension.
Copious irrigation with normal saline and betadine, remove
foreign bodies.
Deep dermis: 5-0 interrupted buried absorbable sutures
(eg, Vicryl and Monocryl).
Skin: 5-0 or 6-0 interrupted or running permanent suture
(eg, nylon and Prolene).
In young children, skin closure may be performed with 6-0
fast absorbing gut or 7-0 chromic gut to eliminate the need
for suture removal.
Nonabsorbable sutures are removed in 5-7 days; delayed
removal will result in suture track marks.
Avoid undermining and/or local tissue rearrangement.
Partial avulsions: tissue present on small pedicles will
usually survive.
Scalp
Close with surgical staples or running locking absorbable
suture (eg, chromic gut).
Avulsions are indication for microvascular replantation.
Scalp can tolerate 12-18 hours cold ischemia time.
Superficial temporal or occipital vessels can serve as
recipient vessels during scalp replantation.
Eyebrows
Direction of hair growth helpful in realigning wound edges
Inspect within the wound for occult fracture
Avoid cautery: cicatricial alopecia
*Temporal branch of facial nerve: Pitanguy line
0.5 cm inferior to tragus to 1.5 cm superior to
lateral margin of eyebrow
Deep surface of superficial temporal fascia (ie,
temporal parietal fascia) with superficial temporal artery
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Advance lateral brow if necessary to close, medial brow
position more aesthetically important
Eyelids
Conjunctiva meets the skin at gray line on lid margin.
Ptosis on exam may indicate levator injury.
Rounding and mobility of medial canthus may indicate
nasoorbitoethmoid (NOE) fracture (telecanthus) (normal
intercanthal distance 32 mm).
Epiphora (excessive tearing) indicates possible lacrimal
canalicular injury.
Repair techniques
Repair conjunctiva only if large defect present (eg, 5-0
fast absorbing chromic)
Repair tarsal plate (eg, 5-0 Vicryl)
Repair lid margin with vertical mattress at gray line
using polyfilament (eg, 6-0 Vicryl)
Eversion of closure prevents notching of lid margin
Avoids corneal abrasion from monofilament suture
May be removed in 5-7 days
Keep all suture tails long, tied into an inferior suture
knot away from globe
Lacrimal System Injury
Canaliculus courses 2 mm perpendicular to lid margin then
heads medially to lacrimal sac and nasolacrimal apparatus
*Drains into nose at inferior meatus
Laceration to medial third of eyelid ⇒ suspect canaliculus
injury
Exploration: after dilating the punctum, place lacrimal
probe in punctum and pass it into canaliculus, look for
probe within the wound.
Place silastic lacrimal stent; “Crawford tubes” (±suture
repair of duct)
Stents should exit from inferior nasal meatus. They
should be tie and cut short.
Stent remains in place for 2-3 months.
Dacryocystorhinostomy may be necessary if
cannulation is impossible with resulting epiphora.
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*Jones I and II tests may be used clinically.
Jones I test: performed by instilling fluorescein into
the conjunctival fornices and passing a cotton-tip
into the inferior meatus to recover the dye. This is
done at 2 and 5 minutes after instilling fluorescein.
Jones II test: performed after an unsuccessful
Jones I test. Remaining of the fluorescein is
injected into the punctum (after dilating) with a 23-
gauge catheter. Failure to see dye at inferior
meatus indicates negative test and possible
lacrimal injury or obstruction.
Cheek
Stenson duct penetrates buccinator to enter oral cavity
opposite second molar; travels with buccal branches of
facial nerve.
Probe intraoral papilla with 22G angiocath peripheral
venous catheter and inject hydrogen peroxide: if duct is
injured, visualize gas bubbles in wound.
Repair duct to prevent sialocele, or leave drain.
*If sialocele develops, aspirate and apply pressure
dressing.
Nerve injury—can use nerve stimulator up to 48-72 hours
later
Considerable crossover between zygomatic and buccal
CN VII branches
Does not require repair if medial to lateral canthus
Nose
Redundant arterial supply: lateral nasal, external nasal,
septal, and columellar arteries
Septum composed of septal cartilage, vomer bone,
perpendicular plate of ethmoid, maxillary crest, and
premaxilla
Septal hematoma
Evacuate with needle aspiration or blade to prevent
necrosis and septal perforation.
Place running quilted 4-0 gut suture or nasal packing.
Laceration repair
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