INTRODUCTION — The face is vital to human appearance and function. Facial injuries can impair a patient's ability to eat, speak, interact with others, and perform other important functions. Studies suggest that disfiguring facial injuries can have severe psychological and social consequences [1-9]. The treatment of facial injuries must first focus on threats to life, but important secondary considerations are function and long-term cosmesis.
The basic anatomy, clinical manifestations, and acute management of facial trauma in adults will be reviewed here. Eye injuries, pediatric facial trauma, and other aspects of facial trauma management are discussed separately. (See "Open globe injuries: Emergency evaluation and initial management" and "Orbital fractures" and "Retinal detachment" and "Oropharyngeal trauma in children" and "Nasal trauma and fractures in children and adolescents" and "Mandibular (jaw) fractures in children".)
EPIDEMIOLOGY — Sports like football, baseball, and hockey account for a high percentage of facial injuries among young adults [10-16]. Severe injuries often occur as a result of motor vehicle collisions, including those involving motorcycles and all-terrain vehicles, as well as interpersonal and domestic violence [17-21]. Other mechanisms include falls, animal bites, and recreational activities. Among combatants, facial injuries occur from gunshot wounds and other explosive or incendiary devices . Facial trauma sustained from gunshot wounds or explosions is associated with greater morbidity and higher mortality rates [23,24]. Associated head and cervical spine injuries are common in patients with significant facial trauma .
ANATOMY, PHYSIOLOGY, AND MECHANISM — The face is anatomically complex. It includes skin, muscles responsible for both gross motor function (eg, mastication) and subtle facial expression, a complex bony structure, and vital sensory organs. Injuries to the face may compromise the patient's ability to breathe, see, speak, hear, and eat, and may involve damage to the central nervous system.
●Bones – The posterior portions of the face form the anterior wall of the calvaria. Thus, the face lies in close proximity to the central nervous system. The anterior facial skeleton is composed of the frontal bone, nasal bones, zygomas, maxillary bones, and mandible (figure 1 and figure 2). The sphenoid, ethmoid, lacrimal, vomer, and temporal bones lie deeper within the facial structure, providing support and sites for muscular attachments, including the muscles used for chewing, speaking, and swallowing.
The temporomandibular joint (TMJ) is the only joint of the face and it engages in complex motions. The condyle of the mandible rotates and translates anteriorly (ie, moves forward) when the mouth opens. A meniscus, which overlies the condyle, maintains the joint and enables motion. The meniscus and the condyle form a hinged joint, allowing rotation, while the meniscus and the temporal bone form a sliding joint, allowing translation.
●Nerves – Cranial nerve V (trigeminal) supplies sensation to the face through three major divisions (figure 3). The ophthalmic division (V1) supplies sensation to the upper third of the face, including the eye and the nose down to the tip. The maxillary division (V2) provides innervation to the midface and includes the infraorbital nerve. The mandibular division (V3) supplies sensation to the lower third of the face. The most anterior muscle layer includes the muscles of facial expression, which are innervated by cranial nerve VII (facial nerve) (figure 4). The facial nerve travels through a narrow canal within the temporal bone and is susceptible to injury when the bone is fractured. The muscles of mastication are innervated by cranial nerves V (jaw movement), IX, and X (palatal movement). (See "The detailed neurologic examination in adults".)
●Vasculature – The face is highly vascular. Soft tissue injuries and fractures that involve vessels can cause large hematomas or heavy bleeding, or even exsanguination in severe cases. Because the face has extensive arterial anastomoses, including some that cross the face's midline, ligation of major branches is unlikely to cause ischemia (figure 5).
●Glands – The parotid glands lie anterior to the auricle and posterior to the ramus of the mandible (figure 6). The parotid (ie, Stensen's) duct travels anteriorly in the horizontal plane and opens in the inner wall of the cheek opposite the second upper molar. The submandibular and sublingual salivary glands are rarely injured because of their better-protected location. (See "Salivary gland stones", section on 'Anatomy'.)
●Muscles – Facial musculature is complex (table 1). Important muscles that may be injured with facial trauma include the extraocular muscles and those surrounding the mouth (figure 7 and figure 8 and figure 9 and figure 10). The inferior rectus, primarily responsible for rotating the eye downward, can become entrapped in fractures of the orbital floor. The orbicularis oris, which encircles the mouth, frequently requires repair with complete perioral lacerations.
●Skin – The skin of the face is among the thinnest of the body. Facial skin develops predictable creases with age, following Langer's lines (figure 11). Lacerations that do not run parallel to Langer's lines develop more prominent scarring than those that do.
PATHOPHYSIOLOGY OF INJURY — Injuries occur when energy (most often kinetic) transferred to the body exceeds the tolerance of the tissue. The likelihood of injury is related to the amount of energy transferred and the condition of the underlying tissue. Traditionally, trauma has been classified as blunt or penetrating, but in many cases the effect is a combination. As an example, the forehead injury sustained when someone falls against the sharp corner of a coffee table involves both a contusion (blunt injury) and a laceration (penetrating injury).
PREHOSPITAL MANAGEMENT — The general indications for airway management remain unchanged in patients with facial trauma. If intubation must be performed in the field, orotracheal intubation is strongly preferred to blind nasotracheal intubation for patients with facial trauma [26-28]. (See "The decision to intubate" and "Approach to the difficult airway in adults for emergency medicine and critical care" and "Airway management in the adult with direct airway trauma for emergency medicine and critical care".)
Facial fractures can affect airway management in several ways. Mandible fractures may make intubation easier by allowing the mouth to be opened wider and more easily. However, facial fractures can increase the difficulty of ventilating with a bag-valve-mask, and possibly impede performance of the jaw thrust maneuver. Thus, a cautious approach including proper assessment of the airway should be performed whenever possible prior to performing rapid sequence intubation.
Bleeding from severe facial wounds can complicate endotracheal intubation. The simultaneous use of two suction devices may be required. Bleeding in many areas of the face can be controlled during transport with external compression. Severe intraoral bleeding or epistaxis can be more difficult to manage. With severe anterior nasal bleeding, tamponade can often still be achieved by pinching the alae tightly against the septum. Epistaxis management is discussed separately. (See "Approach to the adult with epistaxis".)
In an alert patient with intraoral bleeding, 4 x 4 cm gauze packing may be held firmly, with the fingers pressed against the site of bleeding, or clamped between the jaws if the wound lies along the alveolar ridge. Alert patients may be able to perform these maneuvers themselves. Complete (ie, "through and through") lacerations of the buccal space may be packed and compression applied externally. Another method is to impregnate gauze with lidocaine with epinephrine and press it against the bleeding site using a forceps or similar tool. Gauze may also be impregnated with tranexamic acid and applied with direct pressure to the affected area.
Patients with severe oropharyngeal bleeding who do not require spinal immobilization should be allowed to assume a position of comfort. They can sit leaning forward and may be allowed to suction themselves. If spinal immobilization is required, and provided the patient is alert and bleeding is not severe, the backboard may be tilted with the bleeding side down, to protect the airway and allow suctioning.
If these maneuvers are insufficient to control bleeding and the patient's injuries require spinal immobilization, intubation may be necessary to protect the airway. Following intubation, large amounts of gauze can be placed in the oropharynx and nasopharynx to obtain control via direct pressure.
On rare occasions, vascular injuries in the face cause significant hematomas that extend into the neck or supraclavicular region. There may be little external bleeding. Anatomic distortion of the pharynx and neck from such bleeding can make intubation and cricothyroidotomy difficult. In such circumstances, if transport time is short, definitive airway management is best deferred until the patient reaches the emergency department provided the following conditions are met:
●Patient is conscious and protecting their airway and breathing adequately with SpO2 maintained above 90 percent
●Ventilation can be performed without difficulty using a rescue airway (eg, laryngeal mask airway [LMA]) or bag-mask with SpO2 maintained above 90 percent
Emergency medical services (EMS) personnel should notify the receiving institution of the patient's condition so preparations can be made for a difficult intubation.
If EMS personnel suspect a ruptured globe, protection to prevent compression of the eye (eg, eye cup or noncontact shielding) should be placed in the field. Avulsed tissue, including ears, the tip of the nose, or large skin flaps, should be transported with the patient in saline-soaked gauze. Full-thickness skin flaps are often more readily reattached to the face than other body parts. Therefore, whenever EMS personnel are in doubt about the viability of avulsed tissue, they should transport the tissue with the patient.
Avulsed teeth should be transported with the patient. Patients with normal mental status who are able to protect their airway may be able to carry avulsed teeth in their mouths, held between the gum and buccal mucosa. Patients who are intoxicated or otherwise altered, complain of nausea or vomiting, and those who require cervical spine immobilization or who cannot be transported upright are at risk of aspiration and should NOT be allowed to carry avulsed teeth in their mouth. In such cases, teeth should be transported in a container of sterile saline. Incompletely avulsed teeth should be left in place and not manipulated.
HISTORY AND PHYSICAL EXAMINATION
Initial assessment — Disfiguring facial injuries can be distracting to both the patient and the clinician. Nevertheless, clinicians must focus on the basics of trauma care (ie, the primary survey) and address all life-threatening injuries before performing a complete facial examination. As part of the primary survey, injuries to the oropharynx or lower face that compromise the airway or impair breathing are identified and pupillary size and reaction are assessed. (See "Airway management in the adult with direct airway trauma for emergency medicine and critical care" and "Initial management of trauma in adults".)
After problems identified during the primary survey are adequately addressed, a secondary survey, including careful assessment of facial injuries, must be performed. The secondary survey should include a systematic approach and examination of all major facial structures and functions. A complete evaluation is outlined below.
History — In addition to obtaining a basic history of the injury and past medical problems, the clinician should seek answers to the questions below.
●Can you breathe through both sides of your nose?
Inability to do so is consistent with nasal fracture.
●Are you having any trouble speaking?
Trismus or difficulty speaking suggests a mandibular fracture.
●Do you have double vision or any other trouble with your vision?
Diplopia or visual changes are common in patients with orbital fractures, particularly orbital blowout fractures, but are also seen with more significant facial injuries such as a nasoorbitoethmoid (NOE) fracture.
●Is your hearing normal?
●Are you experiencing any numbness of your face?
Facial paresthesias can occur from a number of facial fractures. As an example, with a zygomatic fracture, a patient could experience numbness related to injury of the infraorbital nerve.
●Have you had any previous facial injuries or surgeries, including ocular procedures to correct vision (eg, LASIK, cataract surgery)?
Prior surgery increases the risk for ocular injuries and possible globe rupture.
●Do your teeth come together the way they did yesterday?
Malocclusion suggests a mandibular fracture.
●Are any of your teeth painful or loose?
A positive response should prompt the examiner to evaluate for a mandibular alveolar injury.
●Were you bleeding from your mouth, nose, or ears?
●Have you experienced any vertigo?
Vertigo is a common symptom in a patient with blunt trauma to the head, face, or neck; but in a patient with significant facial trauma, it raises suspicion for a temporal bone fracture.
General examination — The examination begins by observing the patient's face for any structural asymmetry or gross discrepancies in motor function. It is helpful to observe the face from more than one perspective. Lacerations, abrasions, contusions, and tissue avulsions are usually obvious. Careful assessment of underlying structures is important and all injuries should be carefully documented.
Subtle discrepancies can be important. As an example, differences in the relative positions of the eyeballs may lead to the diagnosis of orbital fractures. Orbital fractures can cause enophthalmos (sunken eye due to fracture of the orbital floor) (picture 1), extraocular muscle entrapment (inability to move the eye properly) (picture 2), hypoesthesia from nerve entrapment, or exophthalmos (from retrobulbar hematoma) (picture 3). (See "Orbital fractures".)
Increased intercanthal distance (telecanthus) suggests the presence of a naso-orbito-ethmoid fracture (as opposed to an isolated nasal fracture), which is typically associated with significant orbital swelling [29-34]. Such injuries may be associated with a basal skull fracture. Normal intercanthal distance (distance between the medial corners of the eye) ranges from approximately 28 to 34 mm in adults, or about the horizontal length of one eye. However, facial edema may obscure measurements such as intercanthal distance. Other findings that may be present with a naso-orbito-ethmoid injury include diplopia, nasal congestion or epistaxis, vision abnormalities, dizziness, and anosmia. (See "Skull fractures in adults", section on 'Basilar skull fracture'.)
Next, the clinician palpates the bony prominences of the face feeling for focal tenderness, step-off, crepitus, and abnormal motion.
Both facial nerve motor function (CN VII) and sensation (CN V1, V2, V3) should be assessed carefully. Acute facial paralysis suggests possible transection of the facial nerve or one of its branches and requires immediate consultation with a maxillofacial surgeon; paralysis that evolves over a few days may be related to nerve swelling and also warrants consultation. Performance of the neurologic examination is discussed separately. (See "The detailed neurologic examination in adults".)
Documentation is a crucial part of the examination in facial trauma, which may result from violent crime, physical abuse, domestic altercation, or an industrial accident. Careful documentation, including photographs or drawings, assists in communicating with other clinicians and provides important forensic evidence that may be helpful in cases that result in litigation or criminal prosecution.
Examination of specific body parts
●Eyes – The eye examination should include evaluation of visual acuity and extraocular movements and close inspection for signs of injury (eg, open globe (picture 4 and picture 5 and picture 6 and picture 7), afferent pupillary defect (picture 8), hyphema (picture 9 and picture 10), corneal abrasion (picture 11 and picture 12 and picture 13), orbital step-off).
Patients who have undergone procedures to correct their vision (eg, LASIK) may sustain disruption of the corneal flap as part of their facial injury. Visual acuity is decreased and the flap may be visible on simple inspection. Such injuries require urgent ophthalmologic evaluation. Prior cataract surgery increases the risk of an occult rupture of the affected eye.
Assessment and management of ocular trauma is discussed separately. (See "Open globe injuries: Emergency evaluation and initial management" and "Orbital fractures" and "Retinal detachment" and "Traumatic hyphema: Clinical features and diagnosis" and "Traumatic hyphema: Management".)
Intraocular injuries take precedence over eyelid lacerations or canalicular injuries and should be evaluated emergently by an ophthalmologist. Lacerations involving the medial canthus or the medial third of the upper or lower eyelid raise suspicion for damage to the canalicular drainage system (figure 12). Such injuries generally require assessment by ophthalmology or plastic surgery and can usually be repaired by a specialist up to 48 hours after the injury.
●Nose – Examination of the nose includes palpation for tenderness, crepitus, and abnormal movement, and inspection using a nasal speculum. The septum is inspected for signs of trauma, including a septal hematoma, which requires urgent drainage, and rhinorrhea, which may represent a cerebrospinal fluid (CSF) leak. A septal hematoma appears as a dark purple or bluish mass against the septum (picture 14). They can be bilateral if blood dissects through a fracture of the nasal cartilage, and thus both nares should be examined closely.
●Midface – Midface fractures involving the zygoma may manifest as a large contusion over the cheekbone, enophthalmos, or malocclusion of the upper teeth (figure 1 and figure 13). Anaesthesia of the area supplied by the infraorbital nerve (ipsilateral lower eyelid, lateral nose, upper lip, anterior maxilla) is a subtle sign of an orbital floor fracture. Such patients may manifest periorbital ecchymosis and lose the ability to look up due to entrapment of the inferior rectus muscle (picture 2). Fractures through the anterior wall of the maxillary sinus may also injure the dentoalveolar nerves, leading to denervation of the maxillary teeth.
More forceful trauma can cause extensive fractures, creating midface instability. Assessment involves inspection, palpation, and manipulation to determine the presence of midface instability. To assess instability, grasp the superior anterior teeth (or alveolar ridge if teeth are absent) between the thumb and index finger and attempt to move the maxilla anteriorly and posteriorly, while stabilizing the patient's forehead with the opposite hand (figure 14). Assessments of facial stability should be performed gently to minimize pain and avoid increased bleeding. Unstable fractures display obvious mobility. Other findings that may be present with naso-orbito-ethmoid injury include facial discrepancies or asymmetry (eg, enophthalmos, increased intercanthal distance), diplopia, nasal congestion or epistaxis, vision abnormalities, dizziness, and anosmia .
●Mouth, maxilla, and mandible – Dysphonia or edema of the oropharynx suggests the presence of a significant hematoma or fracture, and each is associated with an increased risk of airway compromise. Stridor or drooling also suggests airway difficulty. It is best to secure the airway early with endotracheal intubation if it is felt to be at risk of obstruction. (See "Approach to the difficult airway in adults for emergency medicine and critical care" and "The decision to intubate" and "Airway management in the adult with direct airway trauma for emergency medicine and critical care".)
Occlusion is best evaluated by asking the alert and cooperative patient to close their mouth and describe whether the motion and positioning feel normal. There is wide variability in occlusion and the patient's assessment is more sensitive than the clinician's impression of a fracture of the mandible or alveolar ridge. Malocclusion suggests the presence of a mandibular fracture.
Thorough inspection and palpation of the face and mouth may reveal signs of injury. Lacerations or a gap or step-off in the palate suggests a maxillary fracture. A laceration or step-off at the upper alveolar ridge suggests a mid-face fracture, while such injuries at the lower alveolar ridge suggest a mandible fracture. Broken or loose teeth may be identified, as may tongue or lip lacerations (see 'Dental injury' below and "Evaluation and repair of tongue lacerations"). A mandible fracture may be present if the patient complains that mouth-opening is restricted or abnormal (figure 15). Ecchymosis or swelling around the chin or preauricular area is associated with a mandible fracture, as is numbness of the chin or teeth that is present immediately following trauma. Numbness that develops a few days later is more likely to stem from local edema. Palpation of the mandible both externally and within the oropharynx (performed with appropriate caution ‒ some examiners place gauze between the upper and lower teeth) may reveal tenderness, crepitus, or step-off, any of which suggest a mandible fracture.
In alert patients, the tongue blade test is helpful for determining the presence of a mandible fracture [35-37]. It is performed by having the patient bite down firmly on a tongue depressor placed between the upper and lower molars and then having the clinician twist the blade. A fracture is highly unlikely if the patient is able to maintain a strong bite such that the blade cracks when twisted. The test is performed on both sides of the mouth. In two prospective studies of emergency department patients, including over 100 with mandible fractures, the reported sensitivity of the test was 95 and 96 percent, and the specificity 64 and 68 percent [35,37]. One study reported a negative predictive value for mandible fracture of greater than 92 percent for patients able to crack the tongue blade on both sides of their mouth .
External lacerations in the parotid area raise suspicion for disruption of Stensen's duct (figure 6). The opening of the duct, which lies in the inner wall of the cheek opposite the second upper molar, should be examined for bleeding while the gland is compressed. If blood is expressed from the duct or the severed ends of the duct are identified within a facial wound, specialized repair over a stent will be required to prevent formation of a cutaneous fistula. Cranial nerve V should also be tested as injuries may occur from soft tissue lacerations.
●Ears – The external ear is examined for lacerations and hematomas. Postauricular ecchymosis (Battle sign) (picture 15), while highly suggestive of the presence of a basilar skull fracture, does not develop until two or more days following trauma. (See "Skull fractures in adults", section on 'Basilar skull fracture'.)
After examining the external ear, the clinician performs otoscopy to evaluate the integrity of the external canal and to look for hemotympanum (picture 16) and otorrhea. Clear fluid draining from the ear following trauma may be cerebrospinal fluid (CSF).To assess this, the clinician can place a drop of the fluid onto filter paper. A rapidly advancing "halo" or ring of clear fluid around red blood defines a positive test. This quick bedside test has reasonable sensitivity in a laboratory setting provided the mix is approximately equal parts blood and CSF . Of note, the halo test does not differentiate among CSF, saline, saliva, and other clear fluids and has not been formally studied in a clinical setting.
Urine dipsticks have also been used to determine the presence of CSF by checking for the presence of glucose. However, this approach is not reliable because both blood and CSF contain glucose. When in doubt about the presence of a CSF leak, it is best to obtain urgent neurosurgical consultation.
CSF leaks can be detected by beta2-transferrin electrophoretic examination, high-resolution computer tomography (HRCT), magnetic resonance cisternography with contrast, and surgical exploration; however, these methods can be timely, costly, or invasive [39,40].
●Upper face – Fractures of the forehead often involve the frontal sinuses. Lacerations or bony depression in this region following significant trauma suggest such an injury.
Cerebrovascular injury — (See 'Facial injuries associated with cerebrovascular trauma or intracranial hemorrhage' below.)
Facial injury — The choice of imaging for facial fractures depends upon the patient's hemodynamic stability, ability to cooperate, and available resources. Visualization of fractures among the complex curves of facial bones is best achieved using computed tomography (CT) . CT scans of the face should include fine cuts and both coronal and sagittal reconstructions. The preferred study is high-resolution CT using 1 mm cuts, with the capability to format in three dimensions to aid operative planning .
The combination of standard two-dimensional facial CT and three-dimensional CT reconstructions appears to improve diagnosis and aids in preoperative planning for patients with complex fractures of the midface (image 1) [43-49]. CT angiography may be useful if the patient has a significant or expanding facial hematoma or if injury to or dissection of the carotid artery is a concern.
Plain radiographs may be used to screen for fracture if CT is unavailable or the patient is less likely to have sustained a midface or maxillary fracture. In such cases, evaluation may begin with a single occipitomental view (sometimes called a Water's view) (image 2). CT is obtained if the plain film reveals a fracture or an air-fluid level in any sinus [50-52].
Plain radiographs have many drawbacks and are only useful for screening for minor facial trauma, such as an isolated injury of the nose, jaw, or teeth. Not only do radiographs lack sensitivity for many bony and soft tissue injuries, but additional diagnostic imaging is often needed to assess the extent of any injury identified, exposing patients to increased cost and unnecessary radiation.
Ocular and orbital injury — Patients with suspected ocular injuries may benefit from assessment with bedside ultrasound, a noninvasive and economical diagnostic tool, particularly if urgent operative management of nonfacial injuries is planned and no time is available for a dedicated facial CT [53,54]. In skilled hands, ultrasound of the eye can readily detect vitreous hemorrhage, retinal detachment, and globe rupture (image 3 and image 4 and image 5). According to small observational studies, the accuracy of high-resolution ultrasound for detecting orbital fractures and emphysema correlates closely with axial and coronal CT imaging .
For suspected open globe injuries requiring ophthalmologic evaluation, ultrasound may not be the diagnostic modality of choice, and the examiner should avoid applying direct pressure to the affected eye and proceed to CT imaging whenever possible and obtain emergency ophthalmologic consultation.
CT remains the preferred method of evaluating ocular injuries, when time permits. Assessment and management of ocular trauma is discussed separately. (See "Open globe injuries: Emergency evaluation and initial management" and "Orbital fractures" and "Retinal detachment" and "Traumatic hyphema: Clinical features and diagnosis" and "Traumatic hyphema: Management".)
Nasal injury — Nasal bone x-rays need not be obtained in the ED provided the following criteria are met:
●Tenderness and swelling are isolated to the bony bridge of the nose
●The patient can breathe through each naris
●The nose is straight (ie, no deviation of the septum)
●No septal hematoma (picture 17) is present (draining the hematoma can convert a closed into an open fracture, which would require antibiotic prophylaxis)
Imaging results will not alter initial treatment if these criteria are met. Consultants providing follow-up care within a few days of the injury may obtain radiographs as needed.
Plain films may be obtained if any of these criteria are not met and an isolated nasal injury is suspected. If there is concern for a foreign body in a superficial wound, two standard x-ray views (Water's and Caldwell's views) are used to triangulate the position of the foreign body. Plain x-rays may also be performed if the clinician has concerns about legal ramifications from the case (eg, alleged assault).
CT scan remains the preferred means of imaging facial trauma and should be obtained if concern exists about more extensive injury in the vicinity of the nose. As an example, CT would be preferable following severe facial trauma associated with more diffuse tenderness (ie, NOT isolated to the nasal bridge).
Mandibular injury — The U-shape of the mandible and the presence of adjacent bony structures make it impossible to isolate the mandible on a flat x-ray film. Therefore, simple radiographs of the mandible are less sensitive for detecting fractures than panoramic radiographs (ie, Panorex) and can miss fractures of the condyle. If available, Panorex imaging can be used for isolated mandibular fractures, dental fractures, or fractures of the alveolar ridge. CT accurately detects mandible fractures. A decision rule to reduce the need for imaging of suspected mandible fractures has been developed, but further study, including prospective validation, is needed .
Although traditional teaching states that mandible fractures occur in pairs because of the bone's structure, a case series of 102 mandible fractures assessed by CT found that 42 percent involved a single fracture .
GENERAL MANAGEMENT OF ACUTE INJURIES — Patients with multiple injuries are resuscitated according to standard trauma protocols. The general management of trauma patients is reviewed separately. (See "Initial management of trauma in adults".)
Airway — Supine trauma patients with heavy bleeding or oral debris from facial injuries are at risk of aspiration and airway compromise. Blood and debris must be removed and the airway secured as necessary. Manual removal of debris and aggressive suctioning with two suction devices may be necessary.
Patients with severe oropharyngeal bleeding who do not require spinal immobilization should be allowed to assume a position of comfort. They can sit leaning forward and may be allowed to suction themselves. Should spinal protection be required, the backboard may be tilted in a manner that reduces the risk of aspiration.
When endotracheal intubation is indicated, clinicians should anticipate difficulty in patients with heavy bleeding or evidence of a hematoma extending into the neck or supraclavicular region. Simultaneous preparation for oral intubation and cricothyrotomy (ie, double set-up) is prudent in such cases. (See "Approach to the difficult airway in adults for emergency medicine and critical care" and "Airway management in the adult with direct airway trauma for emergency medicine and critical care" and "Rapid sequence intubation in adults for emergency medicine and critical care" and "Emergency cricothyrotomy (cricothyroidotomy) in adults".)
Bleeding — Bleeding from facial injuries is usually managed initially with compression. If that fails, hemostasis can be achieved by urgent suturing of the laceration or ligation of the relevant vessel. Tissue ischemia is highly unlikely due to the extensive anastomoses among facial arteries. Great care should be taken not to clamp or tie structures blindly because injury to nerves or ducts can result.
Massive, uncontrollable bleeding from facial fractures occurs rarely and is best treated with arterial embolization via interventional radiology [57,58]. Tranexamic acid may be useful in controlling acute hemorrhage from severe facial trauma . (See "Overview of topical hemostatic agents and tissue adhesives" and "Initial management of moderate to severe hemorrhage in the adult trauma patient", section on 'Antifibrinolytic agents'.)
In the rare case of a patient acutely exsanguinating from a facial wound, the external carotid artery can be emergently ligated by a surgeon. This is performed via a lateral neck incision (if necessary), dissection and identification of the external carotid artery at approximately the level of the hyoid bone, and simple ligation. Once severe bleeding is controlled, a more careful surgical repair can be performed.
Facial injuries associated with cerebrovascular trauma or intracranial hemorrhage — Blunt facial trauma rarely causes injuries of the carotid or vertebral arteries. When such injuries do occur, symptoms and signs may be subtle or absent and the diagnosis delayed, possibly resulting in permanent disability. Signs of injury may include a bruit or thrill, expanding hematoma, pulse deficit, or focal or lateralizing neurologic deficits. Diagnostic imaging should be obtained in patients with any of these signs following facial trauma, and in any patient with severe epistaxis or other hemorrhage suspected to stem from an arterial source.
In addition, several groups suggest that patients who have sustained severe, blunt facial or head trauma and meet specific criteria are at increased risk of cerebrovascular injury and recommend that imaging studies be obtained. Among the injuries associated with an increased risk for cerebrovascular injury are LeFort Type II and Type III midface fractures. The criteria for obtaining diagnostic imaging and the decision about which study to obtain are discussed in detail separately. (See "Blunt cerebrovascular injury: Mechanisms, screening, and diagnostic evaluation", section on 'Indications for imaging' and "Blunt cerebrovascular injury: Mechanisms, screening, and diagnostic evaluation", section on 'Imaging evaluation'.)
Patients who have sustained significant head trauma along with their facial injuries, particularly patients with a depressed mental status or other neurologic abnormalities and those taking anticoagulant medications, are at risk for intracranial hemorrhage. The evaluation and management of such patients is reviewed separately. (See "Management of acute moderate and severe traumatic brain injury" and "Acute mild traumatic brain injury (concussion) in adults" and "Skull fractures in adults".)
Wounds — To optimize cosmesis, bite wounds and wounds with gross contamination or embedded foreign bodies should be cleaned, debrided, and definitively repaired as soon as possible. Debridement of the wound edges of facial lacerations should be as limited as possible. Careful attention should be paid to removing all embedded material. After irrigation and emergent wound approximation is performed, formal repair of soft tissue injuries can be performed within 24 hours if needed. Delays in wound care may be unavoidable in patients that require management of life- or limb-threatening injuries. (See "Assessment and management of facial lacerations" and "Assessment and management of lip lacerations".)
The most appropriate clinician to close an open facial wound may be the emergency clinician or a consultant (eg, plastic surgeon). Such decisions are generally made by the emergency clinician. Factors to consider include resource availability; the size, shape, depth, and location of the wound; and the time required for careful, cosmetic wound closure. The patient's priority with facial lacerations is cosmesis, and a patient may request specialty services for minor wounds out of this concern . Decisions and techniques related to wound closure are discussed separately. (See "Skin laceration repair with sutures" and "Minor wound repair with tissue adhesives (cyanoacrylates)".)
Patients with behavioral problems may require sedation to allow sufficient control for a cosmetic repair. Repair of facial wounds in uncooperative patients who are acutely intoxicated may be delayed until they have received appropriate sedation or become sufficiently sober to cooperate with the procedure. (See "Procedural sedation in adults in the emergency department: General considerations, preparation, monitoring, and mitigating complications".)
Clinicians should warn patients with significant trauma to the brow, forehead, or bridge of the nose to expect periorbital swelling or ecchymosis, or both, to occur within 12 to 36 hours.
Prophylaxis against infection — Antibiotics are not required for simple facial wounds, which rarely become infected. Exceptions include the following:
●Some bite wounds (particularly cat or human bites) (see "Animal bites (dogs, cats, and other mammals): Evaluation and management" and "Human bites: Evaluation and management")
●Wounds with any evidence of devascularization
●Wounds that penetrate the buccal mucosa, and through-and-through injuries of the lip
●Wounds involving exposed cartilage of the ear or nose
●Grossly contaminated wounds that require closure
●Wounds associated with open fractures
If prophylactic antibiotic therapy is needed, the antibiotic should be selected based on the normal bacterial flora associated with the affected site . The general issue of antibiotic prophylaxis for wounds is discussed separately. (See "Skin laceration repair with sutures", section on 'Prophylactic antibiotics'.)
Tetanus prophylaxis is often necessary with open wounds and should be provided as indicated. This issue is discussed separately. (See "Tetanus-diphtheria toxoid vaccination in adults", section on 'Immunization for patients with injuries'.)
If the injury stems from an animal bite, rabies prophylaxis may be needed. Indications for rabies prophylaxis are discussed separately. (See "Indications for post-exposure rabies prophylaxis".)
Antibiotic prophylaxis in the setting of nasal packing for the management of bleeding is discussed separately. (See "Approach to the adult with epistaxis", section on 'Antibiotics and toxic shock syndrome'.)
Fractures — Accurate diagnosis and appropriate referral represent the keys to the initial management of facial fractures. CT is the means of diagnosis in most cases. (See 'Diagnostic imaging' above.)
Definitive repair is NOT required for nondisplaced fractures and, in most instances, for minimally displaced fractures. Fractures in adults develop firm fibrous union within about 10 days; definitive repair is performed most easily before day seven.
Facial fractures that warrant urgent evaluation and admission include:
●Nasoethmoid fractures, to monitor for cerebrospinal fluid (CSF) leaks and possible complications (eg, meningitis)
●Zygomatic arch fractures associated with trismus, to monitor for airway complications (figure 13)
●LeFort-type fractures of the midface, for surgical repair (figure 16)
●Facial fractures in patients with multiple significant injuries
Tripod fractures associated with any ocular findings (eg, abnormal extraocular motion) need urgent ophthalmologic evaluation.
SPECIFIC INJURIES — When examining and treating facial injuries the emergency clinician should pay special attention to the following areas.
Orbit — Injury to the orbit, particularly fractures, can cause a hematoma to form within the orbit, behind the globe. A sizable retroorbital hematoma can cause acute exophthalmos, which can lead to neurapraxia of the retinal nerve and compression of the retinal artery, diminishing flow to the retina. Emergency lateral canthotomy may be required to prevent blindness. (See "Approach to diagnosis and initial treatment of eye injuries in the emergency department", section on 'Orbital compartment syndrome'.)
Evaluation and management of orbital hematoma and other ocular injuries are discussed separately. (See "Orbital fractures" and "Open globe injuries: Emergency evaluation and initial management" and "Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis" and "Traumatic hyphema: Clinical features and diagnosis" and "Traumatic hyphema: Management".)
Nose — The nose often sustains soft tissue injuries and fractures with facial trauma. Nasal fractures may be associated with other injuries, including orbital or midface fractures, and thus a careful examination of the orbits and midface is necessary. (See 'Examination of specific body parts' above.)
Septal hematomas are associated with necrosis of the septum if left untreated and should be drained as soon as possible (picture 14). Infections can develop as soon as three days following injury. Simple incision and expression of the clot followed by anterior packing is sufficient. Packing is kept in place for two to three days. The patient should follow-up with an otolaryngologist for packing removal and reassessment. Nasal packing and the management of epistaxis are discussed separately. (See "Approach to the adult with epistaxis".)
Fractures of the thin bones of the nasal bridge are common. Patients with a contusion or tenderness over the bridge of the nose may be assumed to have a fracture of the nasal bones. Imaging is often unnecessary; indications for radiographs are described above. (See 'Nasal injury' above.)
Initial treatment of nasal fractures consists of ice and head elevation. Ideally, displaced but otherwise uncomplicated nasal fractures evaluated within six hours of injury are reduced immediately . However, some otolaryngologists prefer to wait for three to seven days to allow swelling to resolve. Isolated nasal fractures older than 10 days are referred to an otolaryngologist for outpatient management.
The patient may be unable to determine at the time of injury whether his or her appearance will be acceptable due to the degree of swelling over the nasal bridge. Such patients can be provided with a referral for outpatient specialty follow-up three to five days following the injury.
Perforated septal injuries may be identified during patient evaluation. They should be referred to an otolaryngologist for outpatient management within three to five days.
Midface — The zygoma is often fractured during severe facial trauma because of its prominence and superficial location. Displacement can be significant (figure 13). Fractures to the adjacent portion of the maxilla, orbit, and sphenoid bones frequently accompany zygoma fractures due to their close structural relationship. Many of these midface fractures require operative repair, and surgical referral should be obtained.
The so-called "tripod" fracture of the midface involves the zygoma, lateral orbit, and the maxilla (image 1). These tripod fractures, which are typically caused by a direct blow, are often displaced and require operative repair. If left untreated, the area may sink posteriorly and inferiorly, giving an unacceptable appearance of facial asymmetry emphasized by the inferior position of the orbit and malar flattening.
On the initial physical examination, complex midface fractures involving the zygoma and adjacent structures (particularly the anterior wall of the maxilla) may manifest as a large contusion over the cheekbone, enophthalmos, or malocclusion, due to displacement of the upper teeth.
●LeFort I injuries involve a transverse fracture through the maxilla above the roots of the teeth. The injury may be unilateral or bilateral. Patients may complain of malocclusion. The clinician may detect motion in the maxilla when the upper teeth are grasped and rocked, while the forehead is held stationary with the other hand.
●LeFort II injuries are typically bilateral and involve fractures that extend superiorly in the midface to include the nasal bridge, maxilla, lacrimal bones, orbital floor, and rim. The fracture lines are shaped like a pyramid. When examined, the nasal complex moves as a unit with the maxilla when the teeth are grasped and rocked, while the forehead is held stationary.
●LeFort III injuries (ie, craniofacial dissociation) involve fractures that result in discontinuity between the skull and the face. The fractures begin at the bridge of the nose and extend posteriorly along the medial wall of the orbit and the floor of the orbit, and then through the lateral orbital wall and the zygomatic arch. Intranasally, they extend through all the lesser bones to the base of the sphenoid and are frequently associated with a cerebrospinal fluid (CSF) leak. According to the results of computed tomography (CT) imaging studies that show the full extent of fracture comminution, true LeFort III injuries are rare.
Significant trauma to the central midface caused by a motor vehicle crash or forceful direct blow may fracture the deep nasoethmoid complex, orbital walls, and maxilla without creating a formal LeFort pattern. While patients with isolated nasal bridge injuries from less severe trauma do not need radiographs, imaging should be obtained when midface fractures are a concern. CT is the initial test of choice in this setting.
Fractures to the central portion of the ethmoid bone (cribriform plate) are likely to be associated with a CSF leak and commonly result in anosmia (loss of smell), due to injury to the first cranial nerve. If possible, patients with a CSF leak should have the head of their bed elevated 40 to 60 degrees. Head elevation minimizes intracranial pressure purportedly by decreasing arterial inflow and increasing venous outflow, thereby allowing the leak to seal.
Often, patients with significant midface trauma are treated with antibiotics. However, such treatment is frequently not indicated, and most studies supporting such treatment involve small case series. Prophylactic antibiotics are appropriate for patients with significant midface trauma associated with one or more open contaminated wounds. Neurosurgeons should be consulted for patients with CSF leaks, although many such leaks will resolve spontaneously . For more complex patients with underlying comorbidities that may place them at greater risk of infection, we suggest consultation with an infectious disease specialist to determine the need for antibiotic prophylaxis. (See "Overview of inpatient management of the adult trauma patient", section on 'Antibiotics' and "Treatment of bacterial meningitis caused by specific pathogens in adults", section on 'Basilar skull fracture and cerebrospinal fluid leak'.)
Oral lacerations — Through-and-through lacerations of the mouth should be closed in layers, beginning with the intraoral mucosa and working outward toward the skin. Following closure of the mucosal layer, copious irrigation of the external wound is performed to remove debris and bacteria that otherwise would be incorporated into the wound. Most authorities use new equipment and a new pair of sterile gloves for repair of the skin. Prophylactic antibiotics are necessary in some cases. (See "Assessment and management of intra-oral lacerations".)
The integrity of the parotid (Stensen's) or submandibular (Wharton's) ducts should be assessed before any laceration is repaired whenever the laceration occurs close to these structures. Ductal lacerations should be evaluated by a facial surgeon. (See 'Examination of specific body parts' above.)
Tongue lacerations are discussed separately. (See "Evaluation and repair of tongue lacerations".)
Approach to dental trauma and classification — In a critically ill trauma patient, avulsed teeth are among the lowest priorities and should be replanted only if the care of other injuries allows and there is no risk of aspiration if the tooth loosens. Dental trauma may occur with or without other facial injury (figure 17).
Trauma to the mouth of sufficient force can avulse teeth from their sockets. Major trauma patients, particularly those who are intoxicated, neurologically impaired, or require cervical spine immobilization should have fully or partially avulsed teeth removed from the mouth to prevent aspiration. However, teeth should be removed only if this can be done easily with gloved fingers. Teeth that would require instruments for removal are left in place.
Fractures through the alveolar ridge may result in a group of teeth being dislodged and out of position, often bent inward. These teeth require stabilization with wire, arch bars, or acrylic splinting after fracture reduction. Such stabilization is often complex and generally requires the urgent involvement of an oral surgeon. Patients with a displaced alveolar ridge fracture should not eat or drink until the fracture is reduced. Prophylactic antibiotics (eg, penicillin) are given for open fractures. Depending upon the severity of injury, follow-up with a dentist or oral-maxillofacial surgeon is necessary for patients with dental trauma.
Tooth fractures are classified by the Ellis system:
●Class I fractures involve only the enamel of the tooth, are not painful, and can be evaluated on an outpatient basis.
●Class II fractures expose the yellow dentin and may be painful. These injuries are suitable for outpatient care. They may be dressed. This is done by covering the exposed area with calcium hydroxide (taking care that the tooth is dry to ensure adherence) and then wrapping dental foil around the tooth to create a protective barrier. Advise patients to drink liquids and avoid solids until they are seen by a dentist in follow-up to avoid losing the dressing.
●Class III fractures expose the dental pulp, seen as a red line or dot, and are exquisitely painful. They require evaluation by a dentist or endodontist within 48 hours.
Reimplantation of avulsed teeth — The studies available to determine the best approach to the management of dental trauma are limited, and the approach described here is based upon observational data and expert opinion . When they cannot be immediately reimplanted, teeth are stored in a culture media or milk. These storage solutions are discussed separately. (See "Evaluation and management of dental injuries in children", section on 'Permanent tooth injury'.)
In patients with minor trauma and no risk of aspiration, avulsed teeth should be reimplanted as soon as possible. Ideally, a dentist, oral-maxillofacial surgeon, or comparable specialist should perform the reimplantation, but often this is not possible. Reimplantation is performed as follows:
●Disturb the socket as little as possible
●Handle the tooth by the crown (the root should not be wiped or handled)
●Gently rinse the tooth and socket with tap water or saline
●Replace the tooth in the socket, where it generally "clicks" into place
If the tooth is only partially avulsed, extruded, or laterally luxated, it should not be removed. Rather, it should be reimplanted or relocated. Intruded teeth should not be manipulated.
Reimplantation can be painful and may require local anesthesia with a regional dental block. Alternatively, the area of a single socket may be anesthetized by placing approximately 0.5 mL of 1 percent lidocaine without epinephrine into the buccal sulcus and gum on the outer side of the alveolar ridge. After reimplantation, the tooth requires stabilization with an acrylic splint or wiring to adjacent teeth.
Replanted teeth may not "take" acutely, and weeks may be needed to determine whether reimplantation was successful. The length of time out of the socket appears to play an important role. In one small retrospective study, 66 percent of teeth reimplanted within one hour were radiographically healed and functionally normal after five years, while 80 percent of teeth reimplanted after three hours demonstrated signs of inflammation and bone resorption after the same period [66,67].
Patients involved in major trauma, particularly those who are intoxicated or have sustained a neurologic injury, may not recall aspirating a tooth. Clinicians should look carefully for missing avulsed teeth and a chest x-ray should be obtained if they are not found. If the tooth is below the diaphragm on the radiograph, retrieval is unnecessary. Teeth lodged in a bronchus or the esophagus require bronchoscopic or endoscopic retrieval. Aspirated teeth result in pulmonary abscess formation unless removed. (See "Airway foreign bodies in adults".)
Ear — Blunt trauma to the ear may cause hematoma formation in the subperichondrial potential space. Such hematomas are the prelude to the development of "cauliflower" (or wrestler's) ear and should be drained. Ear lacerations often involve the cartilage and require precise repair. Antibiotic prophylaxis may be needed. The management of ear trauma is reviewed in detail separately. (See "Assessment and management of auricular hematoma and cauliflower ear" and "Assessment and management of auricle (ear) lacerations".)
Temporomandibular joint — Trauma to the temporomandibular joint (TMJ) may result in soft tissue injury, fracture, or dislocation. Injuries to the meniscus or collateral ligaments can cause malposition of the jaw. Meniscal injury can impair TMJ translation, resulting in clicking or popping or the inability to open the mouth fully. Patients without a fracture or dislocation but with pain and difficulty opening their mouth should be instructed to limit their diet to soft foods and avoid yawning or straining to open their mouths wide. Follow-up with an oral surgeon with expertise in TMJ pathology is recommended within two weeks.
Anterior dislocation of the TMJ can occur after any action that involves opening the mouth wide, including yawning, laughing, kissing, or singing. Once the condyle is dislocated, the muscles of mastication spasm, preventing spontaneous reduction. TMJ dislocations more often involve both condyles but may be unilateral. The patient typically complains of being unable to close his or her mouth. In unilateral dislocation, the jaw is rotated laterally, away from the affected side. Garbled speech and drooling are often present. If the dislocation occurred as a result of trauma, a plain x-ray should be obtained before reduction is attempted to determine the presence of a fracture. The reduction of TMJ dislocations is discussed separately. (See "Temporomandibular joint (TMJ) dislocation".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Human bites" and "Society guideline links: General issues of trauma management in adults" and "Society guideline links: Fractures of the skull, face, and upper extremity in adults".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)
SUMMARY AND RECOMMENDATIONS
●Trauma management priorities; orbital injury – Disfiguring facial injuries can be distracting. Nevertheless, clinicians must focus on the basics of trauma care (ie, the primary survey) before performing a complete facial examination (as part of secondary survey). Orbital trauma is discussed separately. (See "Open globe injuries: Emergency evaluation and initial management" and "Orbital fractures" and "Retinal detachment" and "Traumatic hyphema: Clinical features and diagnosis" and "Traumatic hyphema: Management".)
●Airway assessment and management – Potential airway compromise is suggested by dysphonia, edema of the oropharynx, or stridor. Supine trauma patients with heavy bleeding or oral debris from facial injuries are at risk of aspiration and airway compromise. Blood and debris must be removed with aggressive suctioning (two suction devices may be needed) and by hand if necessary. It is best to secure the airway early with tracheal intubation if it is felt to be at risk of obstruction.
Facial fractures may impede the performance of bag-valve-mask ventilation; back-up airway techniques and adjuncts should be prepared and available. Patients with severe oropharyngeal bleeding who do not require spinal immobilization should be allowed to assume a position of comfort. (See 'Airway' above and "Airway management in the adult with direct airway trauma for emergency medicine and critical care".)
●Bleeding – Bleeding is usually managed with direct pressure. If that fails, hemostasis can be achieved by urgent suturing of the laceration or ligation of the relevant vessel. Tissue ischemia is highly unlikely due to the extensive anastomoses among facial arteries. Care should be taken not to clamp or tie structures blindly because injury to nerves or ducts can result. (See 'Bleeding' above.)
●History – In addition to obtaining a basic history of the injury and past medical problems, the clinician should seek answers to specific questions related to facial function and injury, such as:
•Can you breathe through both sides of your nose?
•Are you having any trouble speaking?
•Do you have double vision or any trouble with your vision?
•Is your hearing normal?
•Have you had any previous facial injuries or surgeries, including procedures to correct vision (eg, LASIK, cataract surgery)? (See 'History and physical examination' above.)
●Wound care and antibiotic prophylaxis – To optimize cosmesis, bite wounds and wounds with gross contamination or embedded foreign bodies should be cleaned, debrided, and definitively repaired as soon as possible. Antibiotics are not required for simple facial wounds; wounds likely to warrant antibiotics are described in the text. (See 'Wounds' above and 'Prophylaxis against infection' above.)
●Diagnostic imaging – Accurate diagnosis and appropriate referral represent the keys to the initial management of facial fractures. Computed tomography (CT) scan is the means of diagnosis in most cases. CT scans of the face should include fine cuts and both coronal and sagittal reconstructions. Isolated nasal trauma generally does not require radiographic imaging; exceptions are described in the text. (See 'Diagnostic imaging' above.)
●Specific injuries – The initial management of important and common facial injuries, such as nasal fractures, midface fractures (eg, zygoma, LeFort), oral lacerations, and dental injuries, is discussed in the text. (See 'Specific injuries' above.)
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