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29 Surgical Strategies inTrauma totheHead, Face, andNeck
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agement now largely based on the hemodynamic status of
the patient, rather than the associated anatomical distribution
of external wound(s). Patients who are hemodynamically
unstable or found to have hard signs of vascular injury
(Table29.3) are taken to the operating room for immediate
surgical exploration, delayed only by securing an unstable
airway through endotracheal intubation or surgical airway as
needed. In hemodynamically stable patients, the determination to be made is whether or not the injury has violated the
platysma muscle; supercial wounds need no further workup
and may be closed primarily. Blind exploration of penetrating injuries that violate the platysma is not advised due to
potential for reactivation of bleeding from a stable hematoma, but not all of these injuries will require operative
exploration. Removal of a retained penetrating implement is
best performed after preemptive vascular control is attained,
usually by means of operative exposure but potentially via
angiography if the location of the injury is amenable to this
modality. Given the low incidence of associated cervical
spine injuries, the routine use of cervical collar placement is
not indicated, as this can obscure complete evaluation and
recognition of life-threatening injuries, as well as impede
safe airway securement.
Hemodynamically stable patients with conrmed penetrating neck injury should proceed for computed tomographic angiography (CTA) of the neck for better delineation
of possible internal injury, with the need for surgical intervention pending imaging ndings. Increasingly accurate and
expeditious noninvasive computed tomographic angiography has become commonplace and has largely replaced standard angiography in the initial evaluation of stable penetrating
neck trauma. CT has the added benet of being a single
diagnostic modality that may characterize associated hematoma, laryngeal disruption, as well as both arterial and
venous injuries. However, denitive exclusion of pharyngeal
and esophageal injury requires additional diagnostic
challenges.
Patients with negative CTA ndings should undergo subsequent contrast swallow study, as CT has poor sensitivity
for ruling out pharyngoesophageal injury. The combination
of contrast esophagram and endoscopy in ruling out such
injury has a sensitivity nearing 100%. Positive ndings on
CTA warrant further investigation pending the area of concern, such as directed angiography, bronchoscopy, endoscopy, contrast esophagram, or operative exploration.
Suspected laryngotracheal injuries should be fully evaluated
with endoscopy and bronchoscopy prior to operative exploration. If fracture of the larynx is suspected, a CT of the neck
should be obtained to determine which patients may require
operative repair.
The pharyngoesophagus includes the hypopharynx,
bounded by the tip of the epiglottis superiorly and the cricopharyngeus inferiorly, and the cervical esophagus. This area
is the most protected in the neck, and estimates of rates of
injury in penetrating trauma range from 1 to 8%. While vascular injuries comprise the predominant cause of early mortality (whether due to exsanguination or airway occlusion),
pharyngoesophageal injuries are responsible for the majority
of the late deaths seen in penetrating neck trauma. Delay in
repair of esophageal injury has been described as an independent risk factor for death. Therefore, the screening test
performed should not only have a high sensitivity for detecting injury; it should also be performed and interpreted in a
timely manner to facilitate expeditious repair.
If an injury to the pharynx is discovered and it is <2cm
and does not involve the piriform sinuses below the arytenoid cartilages, the patient may be treated by nonoperative
observation with intravenous prophylactic antibiotics and
without anything by mouth. There has been some debate
over the best modality for esophageal evaluation: esophagography, rigid esophagoscopy, exible esophagoscopy, or a
combination of the above. Weigelt etal. recommended that
patients rst undergo esophagography and, if negative, proceed with rigid esophagoscopy, citing a sensitivity of 100%.
Srinivasan etal. found exible endoscopy to yield a sensitivity of 100% and sensitivity of 92.4%. Most recent guidelines
recommend either esophagography or endoscopy (either
rigid or exible), emphasizing the importance of early
assessment, rather the modality used.
All other hypopharyngeal and all esophageal injuries
should be repaired in two layers after necrotic tissue is
debrided. Muscle aps and closed suction drainage are advocated to encourage sealing of the repair and salivary diversion, particularly in the setting of adjacent vascular repair. It
may be necessary to mobilize the pharynx from the hyoid
bone to achieve greater length and a tension-free repair. If
extensive tissue loss is encountered, more commonly experienced in gunshot wounds to the esophagus, a diverting
esophagostomy and delayed repair should be performed.
For patients in whom vascular injury is discovered, repair
or ligation/embolization of the vessel depends on the nature
of the injury, the vessel injured, and the preoperative examination. The vertebral artery is generally very well protected
within the spinal column, with the exception of the portion in
zone I, where it arises from the subclavian artery. As such,
the incidence of these injuries is relatively low, and most are
asymptomatic, discovered on angiography or CTA.Control
may be achieved via angiographic embolization or with
proximal and distal direct ligation. In situations where access
is particularly difcult, bone wax compression can be used to
obtain temporary control of hemorrhage and obtain time for
either denitive surgical or endovascular management.
Embolization is also recommended in vertebral arteriovenous malformation and pseudoaneurysm.
All signicant penetrating carotid artery lesions should be
repaired when technically feasible, either primarily or with
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N. Wall et al.
patch angioplasty. If a signicant segment of artery is lost,
interposition graft or internal to external carotid artery transposition may be performed. Injuries to the distal internal
carotid are especially challenging. Options include ligation,
extracranial-intracranial bypass, or angiographic stenting.
Controversy surrounds the population of injuries with
preoperative coma, as initially it was thought that revascularization was associated with a higher incidence of hemorrhagic conversion of ischemic infarction. More recent series
suggest that because most decits remain unchanged or
improve after repair, carotid repair should be carried out
regardless of preoperative neurologic status, if technically
possible. The majority of jugular venous injuries is likely
unrecognized, due to the low-pressure venous system; however, in those large enough to cause signicant hemorrhage,
ligation of the jugular vein can generally be performed without consequence.
Important Points
• Initial evaluation must begin with airway assessment and,
when injury or compromise is suspected, early denitive
control obtained. Preparation for a difcult airway is key,
and consideration given to use of intubation adjuncts,
ber-optic or rigid bronchoscopy, and surgical cricothyroidotomy depending on the clinical situation.
• Penetrating brain injury should be evaluated with CTA to
delineate injury tract and associated vascular injuries.
Surgical management may include early debridement or
craniectomy for decompression and hematoma
evacuation.
• Facial injury is best imaged with CT or CTA with reconstructed multidimensional views. Timing of repair of soft
tissue injury depends on complexity of wound and degree
of contamination and may range from simple repair to
sequential debridement with delayed secondary, graft or
ap closure.
• Bony trauma is often managed with delayed reconstruction. Perioperative antibiotics should be given and, except
in the most heavily contaminated wounds, should not be
continued beyond 24h postoperatively.
• All patients with penetrating neck injury who display
hemodynamic instability or hard signs of vascular injury
should undergo immediate operative exploration once the
airway is secured.
• Patients with penetrating neck injury in the absence of
hard signs should undergo evaluation with CTA and, if
concern exists for aerodigestive tract injury, evaluation
with esophagography or esophagoscopy.
• Hypopharyngeal and esophageal injuries should be
debrided to viable tissue and repaired in two layers with
closed suction drainage.
• Management of vascular injury in the neck is dependent
on the nature of the injury and specic vessel injured and
may include denitive ligation, endovascular management, or angiographic embolization.
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RizanNashef andThomasB.Dodson
30
The reported frequencies of penetrating maxillofacial injuries in the English literature range from 14% to 52%. The
wide range in reported frequencies is a function of the institution’s location and referral patterns. Level 1 emergency
departments (EDs) located in an urban environment and
military units are more likely to see a large volume of penetrating injuries compared to lower-level EDs or those located
distant from urban environments.
30.1 Types andCharacteristics ofInjuries
Penetrating injuries occur when objects, e.g., a missile or
knife, violate skin or mucosal barriers and enter the body
and are classied as high energy (missile such as a bullet
or shrapnel) or low energy (knife). High-energy penetrating injuries produce avulsion injuries associated with loss
of both soft and hard tissues, producing a composite
defect (Fig.30.1a and b). Composite defect wounds are
complex wounds to manage acutely and commonly
require secondary reconstruction. Internal xation devices
to stabilize bony segments or replace missing bony structures, prudent preservation of the soft tissue, and the use
of advancement aps can produce excellent anatomic restoration of form.
Low-energy penetrating injuries, such as a knife, machete,
or other sharp objects, result in isolated damage to the soft
tissue or a combination of damage to the soft tissue and
facial fractures, generally with preservation of soft and hard
tissue masses (Fig.30.2a and b).
R. Nashef
Oral and Maxillofacial Surgery Unit, Shaare Zedek Medical
Center, Jerusalem, Israel
T. B. Dodson (*)
Department of Oral and Maxillofacial Surgery, University of
Washington School of Dentistry, Seattle, WA, USA
e-mail: tbdodson@uw.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_30
259
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R. Nashef and T. B. Dodson
ab
c d
Fig. 30.1 (a) Clinical picture of a high-energy penetrating injury.
Notice the avulsion injury producing a composite defect characterized
by loss of both soft and hard tissues. (b) CT demonstrating the hard
tissue damage caused by high-velocity penetrating injury. (c) Clinical
picture of the same patient after treatment which includes restoring
facial form. (d) CT scan demonstrating reduction and xation of facial
fractures with restoration of facial form
ab
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Fig. 30.2 (a) Low-energy penetrating injury results in isolated damage to the soft tissue. (b) Notice the preservation of soft tissue mass after repair
30.2 Structures at Risk forInjury
Maxillofacial injuries, while not generally life threatening,
present challenging problems to trauma surgeons because of
the concentration of complex, vital anatomic structures with
their associated functions. These structures include the brain
with its 12 cranial nerves, 4 of the 5 senses, the airway, an
intricate bone conguration, the cervical spine, the major
blood vessels, the salivary glands, and the centers for speech
and deglutition. In addition, the face has an important esthetic
component that affects patients’ self-worth and psychological well-being.
30.3 Goals ofManagement
Penetrating maxillofacial injuries do not usually create major
resuscitation challenges. As such, immediate attention needs
to be directed toward evaluating and managing the airway
and bleeding. After the patient is stabilized, the long-term
treatment objectives are to restore facial form and function
(Fig.30.1c and d), while preventing or minimizing complications, e.g., infection, inadvertent damage to the facial
nerve, or discarding valuable soft or hard tissue structures.
The purpose of this chapter is to highlight the principles
of evaluation and management of patients with penetrating
maxillofacial injuries focusing on the acute management
skills required by the trauma surgeon and the latter management issues addressed by the specialty service.
30.4 Acute Management
30.4.1 Patient Evaluation
Most maxillofacial injuries are not life-threatening and are
usually evaluated as a component of the secondary trauma
survey. Airway and bleeding, however, require immediate
evaluation and control. Simultaneously, the clinician must
avoid unnecessary manipulation of the neck pending cervical
spine clearance. Ten percent of facial penetrating injuries
associated with a motor vehicle collision (MVC) or fall from
height have associated cervical spine injuries.
Other potential complications initiated during the initial
evaluation and management are due to inappropriate management of the maxillofacial soft and hard tissues. For example, careless vessel clamping and ligation while trying to
obtain homeostasis may result in facial nerve damage. Direct
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R. Nashef and T. B. Dodson
a
b
Fig. 30.3 Frontal repose view of frontal bone deformity as a result of
discarded hard tissue at the time of neurosurgical treatment
pressure often provides adequate homeostasis. Discarding
nearly avulsed tissues, especially those involving the eyelid,
may result in soft tissue defects that are challenging to correct. Discarding fracture segments could impair subsequent
early or late treatment (Fig.30.3).
30.5 Airway Management
Airway control is a priority. Obstruction may be due to foreign bodies, e.g., dentures, teeth, uids (blood or vomit), soft
tissue (tongue or loss of tongue support due to a mandible
fracture), or direct laryngeal injury. While assessing the airway, bleeding from maxillofacial injuries can be managed
acutely with pressure and local hemostatic measures.
Primary airway management is a core competency of the
trauma surgeon and addressed in detail elsewhere in text.
There are a few considerations worth noting when managing
the airway of patients with maxillofacial injuries. Usually,
the initial airway control is by endotracheal intubation or
performance of a surgical airway. With few exceptions, at a
later stage and depending on oral endotracheal tube that
needs to be converted to the maxillofacial operative proce-
Fig. 30.4 (a) Extraoral and (b) intraoral views of submental intuba-
tion. Arrow points to endotracheal tube as it enters the oor of the
mouth
dure, the orotracheal intubation is changed to nasotracheal or
converted to tracheostomy. Occasionally, maxillofacial surgeons can work around an oral airway or may elect to perform submental intubation (Fig.30.4a and b).
30.6 Evaluation andManagement
ofMaxillofacial Bleeding
Penetrating injuries of the face may bleed profusely due to
the highly vascular nature of this region. The corollary of this
is that injuries to hard or soft tissues are more likely to survive and be resistant to infection. Many times, because of the
copious blood supply and relatively small wounds, maxillofacial injuries appear serious. As such, it is critical to clean
the wounds, to establish the nature and severity of the injuries, and to identify and control bleeding sources.
Magnication (loupes) and illumination (headlights) are
invaluable to assist in identifying and controlling bleeding.
Direct pressure is effective for controlling bleeding from
facial injuries. The wounds can be cleaned efciently with
sponges soaked in saline or dilute hydrogen peroxide.
ab
30 Penetrating Injuries oftheFace
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Fig. 30.5 (a) Typical blunt midface injury demonstrating stabilization
of the neck with a cervical collar, oral intubation, facial edema, periorbital ecchymoses, and posterior nasal pack (Foley catheter) and anterior
nasal pack to control nasal bleeding. Marked facial edema develops
Nasal injuries associated with bleeding are common and
can be challenging to manage. Injury of Kiesselbach’s plexus
accounts for nasal bleeding in 90% of the cases. Nasal bleed-
within a few hours of injury, making the physical examination more
difcult. (b) Same patient few days later. Notice the decreased swelling
allows better delineation of the deformity and facilitates operative
repair of the injuries
Management of the maxillofacial bleeding can be
achieved by any one or a combination of the following
options:
ing can be caused by laceration of the nasal mucosa, and any
of the nasal vessels can be the source of the bleeding. Since
the branches of the internal maxillary artery and the anterior
and posterior ethmoidal arteries are located in the posterior
aspect of the nose, it is most likely that these vessels will
cause posterior bleeding toward the pharynx and anterior
packing of the nose or packing of the oral cavity is ineffective. As such, posterior nasal packing is indicated. Posterior
packing consists of placing a Foley catheter into the far posterior portion of the nasal cavity and then inserting an anterior nasal pack in front of the balloon. The posterior pack is
maintained for 1–3days (Fig.30.5a).
Nasal septal hematomas are associated with septal fractures. Septal hematomas need to be diagnosed and managed
efciently. Left untreated, a septal hematoma may produce
necrosis of the underlying cartilage, producing a nasal deformity characterized by collapse of the nasal dorsum and may
be very difcult to correct.
1. Direct pressure:
• Bleeding from maxillofacial injuries responds well to
direct pressure. Use dry sponges and abdominal swabs,
and press on the bleeding site to produce pressure
hemostasis (Fig.30.6).
2. Ligation:
• Ligating vessels is done in the usual manner; however,
avoid blind clamping of tissues to prevent iatrogenic
injury to vital structures such as the facial nerve.
3. Hemostatic agents:
• Incremental measures to obtain homeostasis include
packing with hemostatic agents, e.g., oxidized cellulose, microbrillar collagen, and chitosan-based
hemostatic dressing.
4. Interventional radiology:
• Occasionally, bleeding from the nose and infratemporal fossa or indeterminate, profuse maxillofacial
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Fig. 30.6 Hemostasis obtained by packing the wound with sponges
bleeding cannot be controlled with usual methods.
Under these circumstances, consider consultation with
interventional radiology for diagnostic angiography
and embolization.
R. Nashef and T. B. Dodson
underlying injuries, making physical identication of injuries more difcult (Fig.30.5a).
Inspect the scalp and face for obvious lacerations or
deformities. Probe the laceration to determine if it communicates with the underling bony structures. Assess facial nerve
function by asking patients to raise their eyebrows, squeeze
their eyes shut, smile, pucker their lips, and grimace.
Lacerations posterior to a line dropped perpendicular to the
horizontal at the lateral canthus of the eye increase the risk
for a facial nerve or salivary duct injury (Fig.30.7).
Gently stroke the forehead, infraorbital region, and lower
lip to assess trigeminal nerve sensory function. Abnormal
sensation suggests a facial bone fracture due to injury to a
trigeminal nerve branch.
Palpate the supraorbital, lateral, and infraorbital rims to
identify periorbital or zygomatic fractures as evidenced by
bony steps or pain. Examine the nasal bridge and look for
deviation of the nose or deformity. Place your nondominant
hand on the patient’s forehead to stabilize the head, and
using your dominant hand, place your index and the thumb
ngers over the nasal bridge, and assess stability by trying to
move it side to side (Fig.30.8). Using a headlight and a nasal
speculum, perform an intranasal examination. Inspect the
nasal septum for evidence of deformity or deviation of the
30.7 History andPhysical Examination
ofMaxillofacial Injuries
In most cases, evaluating maxillofacial injuries is a component of the secondary trauma survey. Historical information
regarding the mechanism of injury, timing, and location of
injury can be valuable. Unless the patient is awake and oriented, these data are best collected from witnesses of the
incident. Medical history may be important, and family
members are helpful with an unconscious or intubated
patient. The simplest way to ascertain quickly if there is a
fracture of the maxilla or mandible is to ask patients if their
bite is altered. If the answer is yes, there is a high likelihood
of a fracture. If the answer is no, there is a low likelihood of
fracture. The following paragraphs outline a method for
completing the initial examination for maxillofacial
injuries.
30.8 External Examination
The goal of the examination is to determine quickly and efciently the presence or absence of maxillofacial injuries.
Edema develops within a few hours after injury, masking
Fig. 30.7 Lacerations located posterior to the line dropped perpendicular to the horizontal at the lateral canthus of the eye are associated
with an increased risk for a facial nerve or salivary duct injury
septum and a septal hematoma.
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