2 Facial Injury

Introduction and fine sutures with minimal inflammatory properties

should be used in closing the wounds. Complex lacera-
Soft tissue injuries of the face are common in modern tions involving delicate and essential facial structures
society. The majority of serious injuries occur in the con- such as the eyelid should be referred to a specialist.
text of vehicular trauma or assaults. Use of seatbelts and
airbags has decreased the frequency but not eliminated
facial trauma produced by motor vehicle accidents. In Clinical Examination
addition to direct impact of the face against the wind-
shield, steering wheel, or dashboard, broken glass frag- 1. Examination of the face.
ments frequently produce lacerations and eye injuries. After completion of the primary survey, the face is
The lower face and neck contain structures that examined for areas of swelling and tenderness that can
define and maintain the patency of the airway. Conse- indicate underlying fractures. Palpation of the facial
quently, facial injuries at times assume the highest pri- bones for crepitus or abnormal motion can locate a
ority in trauma management until airway patency and fracture. Grasping the teeth and pulling forward can
adequate ventilation can be established. Because facial demonstrate Le Fort fractures with abnormal motion of
tissues are highly vascularized, massive bleeding into the alveolar ridge, midface, or whole face. Lacerations
the oral cavity can occlude the airway, especially when are noted, and massive bleeding is tamponaded by
patients are obtunded from head injury or intoxication. direct pressure. Blind clamping of bleeding sites is dan-
In the presence of massive bleeding, airway compro- gerous in that it can injure nerves and other structures
mise may be produced by placing the patient supine for that run in proximity to vessels. Lacerations crossing
spinal immobilization. Blood, secretions, fragments of the path of the parotid duct mandate examination of
teeth, and foreign bodies must be removed to avoid Stensen’s duct in the mouth (discussed later). Facial
aspiration and airway occlusion. Although severe facial asymmetry can be due to direct trauma but also to
injuries are dramatic and often distract the inexperi- facial nerve injury, and an assessment of the muscles of
enced clinician from more critical tasks, treatment of facial expression and facial sensation is made. In coma-
most facial injuries can be safely deferred until life- tose patients corneal reflexes should be tested to deter-
threatening problems have been addressed. mine these functions.
The face and scalp also contain many structures that 2. Examination of the eye.
are essential for the function of special senses of sight, Anatomically, the orbit sits relatively protected by
smell, taste, and hearing. Human communication is the orbital ridge, malar prominence, and nose. The cil-
dependent not only on facial structures required for iary and corneal reflexes rapidly close the eyelid,
speech and hearing but also those involved in facial adding further protection to direct contact with the
expression. In addition, many facial landmarks define globe. Injuries to the eye range from minor (e.g.,
human appearance, and their preservation as intact corneal abrasion) to critical (e.g., ruptured globe).
symmetrical structures is important cosmetically and Examination of the eye and its adnexa is an impor-
psychologically. Injury to these structures can result in tant part of the secondary survey. Victims of motor
devastating disability that often can be avoided with vehicle crashes often have fragments of glass that can
early detection and repair. become embedded in the eye causing lacerations or
Special attention is indicated in repairing facial corneal abrasions. Occasionally a patient’s refractory
injuries. Debridement of wound margins should be min- agitation can be cured by treatment of a corneal abra-
imized, cartilaginous structures should be preserved, sion or removal of glass fragments in the eye that were

33
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 initially unsuspected. Often patients have massive soft mucosa, and misalignment of teeth (indicating a
tissue swelling around the eye that makes examination mandible or maxilla fracture). Blood, loose teeth, and
difficult. In these cases devices to hold the eyelids open foreign bodies are removed manually or by suction.
must be used and can be improvised by bending paper Simultaneously, an evaluation of the airway is made
clips into blunt retractors and gently retracting the lids. examining for stridor, dysphonia, gagging or drooling,
Formal measurement of visual acuity may not be possi- and inability to handle oral secretions. The presence or
ble in the early phases of resuscitation, but an initial absence of a gag reflex in obtunded patients often
estimate of vision can be made by having the patient influences the decision to intubate the patient to pro-
count fingers or report light perception. Complete loss tect against aspiration.
of vision in a previously normal eye requires immediate
consultation with an ophthalmologist. The pupils are
examined for symmetry and equality as well as reaction Investigations
to light. The conjunctivae are assessed for foreign bod-
ies and chemosis that can indicate rupture of the globe. After physical examination has indicated areas of
A peaked pupil is highly suspicious for rupture of the likely injury, specific radiographs or CT scans may be
globe, and the “peak” often points to the site of rupture. indicated to delineate injuries. Plain radiographs are
Visible scleral or corneal lacerations may indicate pene- useful in detecting most facial fractures and in locating
tration of the globe by a foreign object and require radi- radiopaque foreign bodies, but CT scan can more accu-
ographs or CT of the orbits to detect intraocular foreign rately identify these if the patient is sufficiently stable
bodies. The position of the globe in the orbit is noted to undergo this examination. Certain radiographic
for enophthalmos (blow-out fracture) or exophthalmos views are indicated to clarify specific clinical findings
(retro-orbital hematoma). Inability to perform all such as a submentovertex view to detect zygomatic
extraocular movements may indicate a brain lesion, arch fracture or Panorex views for suspected mandible
peripheral nerve injury, or entrapment of extraocular fractures. Leakage of CSF from the nose or ear can be
muscles. Lacerations involving the lacrimal duct and lid assessed by examining the drainage for the presence of
margins should be noted and referred to an ophthalmol- glucose (indicating CSF) or for a double ring sign when
ogist for repair. A brief fundoscopic examination is per- the drainage is applied to filter paper. Suspicion of
formed to assess the position of the lens and presence of injury to the lacrimal duct is best confirmed by an oph-
blood in the anterior chamber (hyphema) or retina. thalmologist using fine probes. Instillation of fluores-
cein into the conjunctival sac and examination with a
3. Examination of the ear.
UV light source can demonstrate corneal abrasion, and
The external ear is inspected for the presence of lac-
Seidel’s test can demonstrate leakage of aqueous humor
erations or hematoma. Cartilaginous lacerations or
from a ruptured globe. A detailed evaluation of the
avulsions require particular attention. The ear canal is
anterior chamber can be performed on stable patients
examined with an otoscope for bleeding or CSF otor-
using a slit-lamp examination. Patients with suspected
rhea indicating a ruptured tympanic membrane and
post-traumatic glaucoma or retro-orbital hematoma
basilar skull fracture. The tympanic membrane is exam-
should undergo tonometry to measure intraocular pres-
ined for perforations or accumulation of blood in the
sure, but this test should never be done if there is a
middle ear that is seen as hemotympanum. Although it
posibility of a ruptured globe. Parotid duct laceration
may take many hours to appear, inspection of the mas-
can be demonstrated by probing the duct or by per-
toid area for Battle’s sign is important in detecting basi-
forming a sialogram.
lar skull fracture.
4. Examination of the nose.
The nose is inspected for lacerations of overlying General Management
skin and of the cartilage. The presence of nasal fracture
is often obvious clinically with deformity, crepitus, Airway management is of prime importance when
epistaxis, and tenderness to palpation. The nares are facial injuries threaten the ability to ventilate the
inspected for the presence of epistaxis or hematoma patient. Suction of secretions and manual removal of
and for CSF drainage. foreign bodies and blood clots may establish airway
5. Examination of the mouth. patency, but often endotracheal intubation is indi-
The mouth is inspected for lacerations, avulsion or cated. Nasotracheal intubation should not be
fracture of teeth, swelling of the tongue and oral attempted with nasal, basilar skull, or Le Fort fractures

34 Facial Injury

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 or in apneic patients. Patients with massive facial skin covering for blood supply, an interposed hematoma
injuries present a special problem, and the manage- can result in ischemic necrosis of the cartilage. Conse-
ment of the airway in these cases is controversial. Use quently, the ear must be examined for this condition,
of paralytic agents to facilitate intubation may cause and a hematoma should be aspirated. A pressure dress-
loss of airway patency, as the patient’s voluntary effort ing is applied to prevent reaccumulation of the
to maintain an airway is lost. Consequently, some hematoma or abscess formation.
advocate use of awake orotracheal intubation in these Avulsed cartilage from the ear or nose should be pre-
cases. This is an extremely difficult and often unsuc- served in saline, as it is difficult to re-create the shape
cessful task in an agitated, possibly hypoxic patient of these organs with other tissues.
with massive bleeding in the oropharynx. Others have Most facial fractures can be repaired electively with
demonstrated the safety and efficacy of using rapid- operative fixation and bone grafting if necessary. Intra-
sequence intubation with paralytic drugs in this set- oral lacerations are repaired with absorbable sutures.
ting. Massive facial injuries that distort anatomic Antibiotics are unnecessary for most facial lacerations,
landmarks and produce severe bleeding may make oro- although open fractures require prophylactic coverage.
tracheal intubation impossible. Prolonged attempts at
intubation are detrimental to the patient, and early use
of cricothyrotomy is essential and often life saving. All Common Mistakes and Pitfalls
physicians managing trauma should be familiar with
this technique. 1. Focusing on dramatic but not life-threatening
Facial injuries that do not threaten the airway can facial injuries before assessing the primary survey
safely be deferred to the secondary survey and defini- and overall hemodynamic stability of the patient
tive care phases of trauma management. Active bleed- is a common error.
ing can usually be controlled by direct pressure or
2. Injury to the cranial nerves is difficult to detect
packing of wounds. However, prolonged bleeding from
in severely injured patients, especially if they are
facial or scalp wounds can result in hemorrhagic shock
comatose, intoxicated, or otherwise unable to
and should not be ignored. Treatment of facial frac-
tures can be deferred until the patient is hemodynami- cooperate with physical examination.
cally stable. 3. Leakage of CSF from the ear or nose may be diffi-
Minor eye injuries (e.g., corneal abrasion, rust ring, cult to detect when mixed with blood, and con-
eyelid laceration) can be deferred, but sight-threaten- tinued leakage after bleeding has stopped should
ing injuries should be dealt with immediately and con- suggest a basilar skull fracture.
sultation with an ophthalmologist is essential. Once 4. Evidence of avulsed teeth that are not accounted
the possibility of a ruptured globe has been established, for should prompt a search for possible aspiration of
the eye should be protected by use of a Fox shield or a tooth, which can produce a severe lung abscess.
similar device to prevent further pressure on the globe. 5. Eye injury associated with use of power tools or
Retro-orbital accumulation of blood or air with deteri- “metal-on-metal” hammering should raise suspi-
orating vision or massive elevation of intraocular pres-
cion of a penetrating globe injury. Orbital CT
sure requires decompression by lateral canthotomy or
scan is indicated to locate the foreign body. Sei-
creation of a communication from the retro-orbital
del’s test can indicate perforation of the globe.
space nto the maxillary sinus. Entrapment of extraocu-
lar muscles by fractures should be relieved urgently. 6. Patients with orbital blow-out fracture should
Penetrating trauma of the ear is relatively uncom- have extraocular muscles tested to detect entrap-
mon and is managed by minimal debridement, irriga- ment of the inferior rectus muscle.
tion, and primary closure. Blunt trauma is more 7. Trauma to the mouth and mandible can produce
common and often results in perichondrial hematoma delayed airway occlusion from swelling or bleed-
formation. Because ear cartilage is dependent on its ing, and these patients must be observed carefully.

Facial Injury 35

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 2.1 Corneal Abrasion

Commentary
In spite of brisk protective reflexes, corneal abrasion is anti-inflammatory drugs (NSAIDs) is appropriate,
common. The usual cause is the patient’s own finger and tetanus vaccination should be updated if neces-
as the eye is rubbed to relieve itching or to remove a sary. The use of eye patches is controversial but gener-
foreign body. Other causes are scraping by branches or ally considered unnecessary for small abrasions.
twigs, broken glass, industrial injuries involving power
grinders and saws, or welding without adequate eye
protection. Clinically, the patient presents with a his-
tory of sudden onset of pain in the affected eye and
the sensation of having a foreign body in the eye, with
increased tearing and resultant blurred vision. Physi-
cal examination is often normal unless the eye is
examined using a UV light source with magnification
after fluorescein dye is instilled into the conjunctival
sac. If the patient is capable of sitting, ideally the
examination should be with a slit lamp. Otherwise,
the examination can be made using a portable source
of UV light such as a Wood’s lamp. Areas of abrasion
on the corneal surface show increased dye uptake and
appear intensely fluorescent under UV light. The
patient will experience complete relief of the pain
after instillation of topical anesthetic drops onto the
affected cornea. Treatment is supportive as most 2.1A. Photograph of the eye after instillation of fluorescein
corneal abrasions heal within 48 hours. Antibiotic dye showing bright yellow-green uptake of dye lateral to the
drops are prescribed, oral analgesia with nonsteroidal pupil (arrow).

2.2 Ocular Foreign Bodies

Commentary
There are certain situations that merit special caution bodies, as plain films are less sensitive. A metal foreign
in dealing with apparent corneal abrasions. Patients body that impacts the cornea at lower speed may
who present with symptoms of corneal abrasion after become embedded in the cornea and produce a rust
high-speed grinding or hammering on metal should be ring that can impair vision if it occurs in the visual
suspected of having a perforated globe. Small frag- axis. These should be removed electively after one to
ments of metal can enter the eye at high speed, leaving two days, when they are less adherent to the cornea. A
only minimal evidence of their entry into the globe. retained wood foreign body is also important to detect,
CT scan of the orbit is indicated to locate these foreign as fungal enophthalmitis can result.

36 Facial Injury

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 2.2A. Photograph of the eye showing a metallic foreign
body on the cornea that is deforming the iris and pupil
(arrow).

2.2C. CT scan of the orbit showing one small intraocular

foreign body of the left eye (arrow) and another lateral to
the right orbit.

2.2B. Plain radiograph showing an intraocular bullet

(arrow).

2.2D. Photograph of the eye

showing a central rust ring in
the cornea (arrow). This rust
ring is in the visual axis and
will seriously impair vision if
not removed.

2.2 Ocular Foreign Bodies 37

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 2.3 Hyphema

Commentary
Hyphema is the accumulation of blood in the anterior
chamber of the eye. With the patient laying supine,
the blood is less visible than in an upright position,
when it forms a clearly visible layer of blood in the
dependent portion of the anterior chamber. The ini-
tial bleeding usually resorbs without complication, but
in up to a third of cases rebleeding will occur two to
five days after the initial injury. Complications from
hyphema include hemosiderin staining of the inner
surface of the cornea with resulting loss of vision, as
well as post-traumatic glaucoma due to fibrotic occlu-
sion of the canals of Schlemm. Treatment is conserva-
tive and consists of bed rest with the head elevated,
sedation, and monitoring of intraocular pressure. Sur- 2.3A. Photograph of the eye showing a collection of blood
pooled (hyphema) in the inferior aspect of the anterior
gery is required occasionally for evacuation of blood or
chamber (arrow).
to decompress the anterior chamber.

2.4 Ruptured Globe

Commentary
Rupture of the globe usually occurs after penetrating and a positive Seidel’s test. The latter is performed by
injury but can be caused by blunt trauma as well. Pen- instilling fluorescein dye into the conjunctiva and
etration of the sclera results in herniation of orbital observing the dye clearing from the cornea or sclera in
contents through the wound and exposure of the the area of rupture because of the flow of aqueous
choroid membrane, visible as a dark layer of tissue in humor from the anterior chamber. Although intraoc-
the wound. Penetration of the cornea allows leakage ular pressure is reduced in the presence of a ruptured
of vitreous humor through the wound. In either case, globe, tonometry and any other maneuver that
distortion of the globe results in loss of functional increases pressure on the globe are contraindicated.
vision at the time of injury, although light perception The conjunctiva is very distensible and often becomes
may be preserved. Patients report pain and often resist edematous after trauma, resulting in bulging chemosis
eye examination. that frequently limits complete examination. Because
Signs of globe penetration include enophthalmos, of its common association with rupture of the globe,
loss of eyeball turgor, a peaked pupil that points bulging chemosis itself should be considered a sign of
toward the site of injury, loss of pupillary reactivity, possible ruptured globe.

38 Facial Injury

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 2.4C. Photograph of an irregular, peaked pupil (arrow A),
bulging chemosis (arrow B), and laceration of the iris due to
a ruptured globe.

2.4A. Photograph of the eye showing a scleral laceration

with exposure of the choroid (arrow). This is highly
suggestive of rupture of the globe.

2.4D. Photograph of a ruptured globe with a peaked pupil

(arrow A), laceration of the inferior/lateral sclera (arrow B),
and bulging chemosis (arrow C). The peak in the pupil
points toward the laceration.

2.4B. Photograph of a patient with enucleation and

destruction of the eye.

2.4E. CT scan showing destruction of the right eye with

intraocular bone fragments and periorbital fractures.

2.4 Ruptured Globe 39

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 2.5 Retrobulbar Hematoma

Commentary
Trauma to the globe can result in bleeding from retro-
orbital vessels including the ophthalmic artery and
vein. In addition, fractures of the orbit that communi-
cate with paranasal sinuses can result in the accumu-
lation of air in the retro-orbital space. If air or blood
accumulates under sufficient pressure, ischemic necro-
sis of the optic nerve can occur. Clinical evidence of
this condition includes proptosis, impaired extraocu-
lar movements, and progressive loss of vision. Tonom-
etry will demonstrate elevated intraocular pressure.
Treatment of a symptomatic retrobulbar hematoma
is by lateral canthotomy or by surgically perforating
the floor of the orbit to allow decompression of the
retrobulbar space. In a lateral canthotomy, the lat-
eral canthal ligaments are grasped with a forceps and
crushed. Iris scissors are then used to divide the liga- 2.5B. Photograph showing increased proptosis of the eye
after lateral canthotomy. Allowing the eye to protrude
ment, allowing the globe to protrude forward. If done
further decreases the retrobulbar pressure on the optic
in a timely manner, normal vision can be restored nerve.
once the globe is repositioned and the canthal liga-
ment is repaired. Alternatively, a forceps can be
introduced beneath the globe and the floor of the
orbit fractured to allow drainage of the retro-orbital
space.

2.5C. CT scan of the orbits showing proptosis (arrow A),

retro-orbital blood and air (arrow B), and a fracture of the
2.5A. Photograph of a lateral canthotomy in progress. posterior orbital wall.

40 Facial Injury

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 2.6 Periorbital Lacerations

Commentary
In addition to the globe itself, there are numerous each layer of tissue is done independently in a layered
structures in the adnexa of the eye that merit special closure to preserve the mobility of the brow.
consideration. The lacrimal system ensures that a con-
stant flow of tears streams across the surface of the eye,
maintaining lubrication to facilitate ocular motion,
preventing desiccation, and clearing debris, including
potential infectious agents. Lacerations involving the
lacrimal apparatus, lid margins, and lacrimal duct
must all be sought out and referred to an ophthalmol-
ogist for repair. Lacerations of the lid margins must be
reapproximated exactly under microscopic vision to
avoid a step-off that can result in constant dripping of
tears onto the face. Injury to the lacrimal duct at the
medial canthus of the eye is important to detect and
repair, as scarring and stenosis of the duct can result in
a similar problem. Delayed repair of a stenotic
lacrimal duct is very difficult and yields suboptimal
results in most cases.
Laceration of the eyebrow is common and can be
repaired in the ED. Exact alignment is essential to
preserve facial expression. Consequently, the eye-
brows should never be shaved in preparation for sutur- 2.6A. Photograph of a complex laceration of the eyelid that
ing as the alignment landmarks will be lost. Repair of involves the lid margins.

2.7 Orbital Blowout Fracture

Commentary
Blunt impact to the orbital area is common. The globe fracture. This injury typically occurs in certain sports
itself is usually spared when large objects strike the face activities such as racquetball, lacrosse, boxing, and
because of the protection afforded by the malar promi- baseball but may also be seen in blunt eye trauma of
nence, nose, and superior orbital ridge. However, any type. The patient presents with enophthalmos and
smaller objects can strike the globe directly, resulting pain in the orbital area. A common complication of
in a massive rise in intraocular pressure. This pressure this injury is that the inferior rectus muscle becomes
is transmitted to the bony orbit, often resulting in frac- entrapped in the fracture fragments, resulting in
ture at its weakest points, the orbital floor and the restricted upward gaze and diplopia when the patient
medial wall of the orbit (lamina papyracea). Fracture attempts to look upward. Consequently, it is essential
of the orbital floor by this means is called a blow-out that physical examination should verify that extraocu-

2.7 Orbital Blowout Fracture 41

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 lar movements are intact. Finding an entrapped infe- is opacification of the maxillary sinus caused by herni-
rior rectus muscle mandates surgical repair. ation of periorbital fat and blood into the sinus. CT
Plain radiographs of the face seldom reveal the scan reveals the herniation as well, and special recon-
actual orbital floor fracture. The characteristic finding structions of the orbit may reveal the fracture in detail.

2.7A. Illustration showing typical

mechanism of injury that produces
an orbital blowout fracture.

2.7C. CT scan of the orbits showing fracture of the

posterior/inferior orbital wall (arrow A) with herniation of
orbital contents into the maxillary sinus on the left (arrow B).

2.7B. Photograph of patient with blunt trauma to the

orbital area from an airbag deployment, who proved to have
an orbital blow-out fracture.

42 Facial Injury

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 2.7D. CT scan showing fracture of the inferior
orbital wall with opacification of the right
maxillary sinus (arrow).

2.7E. Photograph of a patient

with blow-out fracture showing
enophthalmos of the left eye.

2.7F. Photographs of a patient with a blow-out fracture of

the right eye and subconjunctival hemorrhage. There is no
evidence of divergent gaze with the eyes in neutral position.
Downward gaze reveals entrapment of the extraocular
muscles of the right eye, resulting in a subtle divergent gaze.

2.7 Orbital Blowout Fracture 43

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 2.8 Mandible Fracture

Commentary
Fractures of the mandible are common after blunt swelling and tenderness over the fracture site.
facial trauma. The most common etiologies are vehic- Dysarthria and drooling are common because any
ular-related trauma and assaults. Fractures are distrib- movement of the jaw is painful. Maximal incisor
uted almost equally between the condyles, angle, and opening (normally 5 cm) is reduced, and the patient
body of the mandible. Clinically, patients present with will note malocclusion of the teeth if the fracture frag-
ments are displaced. At times bony crepitus can be
elicited by examination or with voluntary movement
of the mandible. Inspection of the mouth often reveals
that the fracture is open, with gingival laceration
overlying the fracture site. Airway obstruction can
occur in unconscious patients with bilateral mandibu-
lar rami fractures, as the tongue is unsupported and
falls back into the posterior pharynx. Trauma to the
temporomandibular joint is common and may result in
dislocation of the joint or chronic pain with chewing.
Plain films are usually adequate to reveal a mandibu-
lar fracture, particularly if it is displaced. However a
Panorex view of the jaw is more accurate and should be
used if available. Treatment is operative, with wiring or
plating of the fracture fragments into anatomic posi-
tion. Open fractures of the mandible should be treated
with antibiotics that are active against mouth flora
(e.g., penicillin or clindamycin) because osteomyelitis
and abscess formation can occur.

2.8A. AP radiograph of the mandible showing bilateral

displaced fractures of the angles of the mandible (arrows).

2.8B. Panorex view of the

mandible showing an
undisplaced fracture of the
left mandibular ramus
(arrow).

44 Facial Injury

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 2.9 Zygoma Fractures

Commentary
The zygoma provides the bony support to the cheek tures is surgical elevation of the fragments to restore a
and thus is commonly implicated in blunt trauma to normal facial contour.
the face. Because of its arched structure, comminuted A more complex zygoma fracture is the tripod frac-
fractures are typically seen. Associated injury to the ture that involves fractures at the origins of the
infraorbital nerve should be sought out. The patient zygoma, resulting in a large triangular fragment. The
typically presents with loss of the malar prominence fractures occur at the zygomaticofacial and zygomati-
on the affected side. In the acute phase, however, cofrontal sutures and through the inferior orbital fora-
swelling may mask this finding, so careful palpation of men. The result is a free-floating fragment of bone
the facial bones to detect pain, a bony step-off, and that often requires surgical repair.
crepitus of the zygoma should be routine. Injury to the
infraorbital nerve may occur and results in anesthesia
of the upper lip. Impingement of the zygoma onto the
coronoid process of the mandible may result in limited
excursion of the mandible. Diagnosis is made by plain
radiographs. The submentovertex view (or “bucket
handle” view) clearly demonstrates fractures of the
zygoma and should be ordered if this fracture is sus-
pected clinically. Treatment of displaced zygoma frac-

2.9A. Submentovertex plain radiograph showing a 2.9B. Illustration outlining a tripod fracture of the zygoma
depressed right zygomatic arch fracture (arrow). (see 2.10E as well).

2.9 Zygoma Fractures 45

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 2.10 Le Fort Fractures

Commentary
Le Fort fractures result from high-energy facial trauma Pulling on the upper teeth demonstrates mobility of
and are classified according to their location. Le Fort the entire midface. Radiographs reveal fracture lines
II and III fractures are potentially life-threatening through both maxillae extending upward to include
injuries in that they are commonly associated with air- the nasal bones. Associated basilar skull fracture is
way compromise, massive bleeding, basilar skull frac- common, and CSF rhinorrhea can occur. Massive
ture, and intracranial injury. Nasal intubation and epistaxis may require nasal packing or surgery to con-
nasogastric tubes must be avoided in these patients, as trol the bleeding.
fatal intracranial insertion may result. Patients often Le Fort III The most severe form of Le Fort fracture
have combinations of injuries, such as a Le Fort II on results in complete craniofacial dissociation due to
one side with a Le Fort I on the other. fractures of both maxillae, zygomas, nasal bones, eth-
Le Fort I This fracture separates the upper alveolar moids, and vomer, as well as bones at the base of the
ridge from the face and extends into the nasal fossa. skull. Examination reveals mobility of the entire face,
Clinically, the patient will have mobility of the upper as it can be pulled forward from the skull. Complica-
teeth when they are grasped and pulled forward. Air- tions such as intracranial injury, airway compromise,
way compromise is rarely associated with this fracture. basilar skull fracture, CSF rhinorrhea, and massive
Le Fort II The Le Fort II fracture separates the mid- epistaxis are common. Nasal intubation and nasogas-
face from the skull, resulting in a pyramid-shaped large tric tubes should be avoided.
fragment of the central maxilla and nasal bones.

2.10B. Photograph of a car accident patient with Le Fort III

fracture demonstrating the method of examining for
craniofacial dissociation.

2.10A. Schematic showing three types of Le Fort fracture.

46 Facial Injury

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 2.10C. Photograph of a
patient who had a garage
door crush his face. The
abnormal concavity of the
face (“dish face”) is
characteristic of a Le Fort III
fracture.

2.10D. CT scan of the face

showing Le Fort III fracture:
(a) anterior ethmoid fracture
(arrow); (b) midethmoid and
lateral orbit fractures
(arrows); (c) frontal sinus
fracture (arrow); (d)
Pterygoid fractures (arrow).

2.10 Le Fort Fractures 47

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 2.10E. 3-D reconstruction CT
scan of a Le Fort III fracture
showing multiple fractures,
including a tripod fracture of the
zygoma (arrows).

2.10F. Photograph at
autopsy of nasogastric tube
coiled intracranially.

2.11 Nasal Injuries

Commentary
Superficial lacerations of the nose are common and sutures for the cartilage repair. Avulsed cartilage
easily repaired, but several serious injuries merit dis- should be preserved in saline if repair can be done
cussion. Laceration extending through nasal cartilage urgently or in a subcutaneous pocket if repair is
must be repaired in separate layers using absorbable delayed. Reconstruction of the nose can be done in

48 Facial Injury

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 delayed fashion, but finding appropriate cartilage for
reconstruction is difficult.
Nasal fractures may be treated conservatively if
undisplaced. Deviation of the septum or impairment
of nasal breathing is an indication for repair within
the first week after injury. Open fractures should be
treated with antibiotics. The nasal septum should be
inspected for the presence of a septal hematoma,
which appears as a swollen, ecchymotic area separat-
ing the nasal mucosa from underlying cartilage. The
septal hematoma must be drained and the nose packed
to avoid reaccumulation of the hematoma. Because
the blood supply to the cartilage depends on the nasal
mucosa, increasing the distance for diffusion causes 2.11A. Photograph of a laceration through the nasal
cartilage.
ischemic necrosis of the cartilage, and eventually a
saddle-nose deformity results.

2.12 Complex Facial Lacerations

Commentary
Massive facial injury can result from blunt force extremely difficult and usually unsuccessful. Conse-
trauma or penetrating injury from gunshot or shotgun quently, use of a cricothyrotomy is often the only
wounds. The primary initial challenge in these cases is viable choice to establish a patent airway and should
to secure an airway. Massive facial injury can result in be employed early in the management.
airway obstruction either by loss of the supporting Once the airway is secured, the spine is immobi-
bony framework of the face or by accumulation of lized and the remainder of the primary survey and
blood, debris such as fractured teeth, edema, or tissue resuscitative interventions are completed. Massive
flaps that occlude the larynx. Immediate restoration of facial injuries are dramatic and often distract clini-
a patent airway is the highest priority in trauma man- cians from a systematic primary survey. Unless there is
agement. Initially, simple airway maneuvers such as massive bleeding present, repair of the vast majority of
chin lift, suctioning blood and secretions, and place- facial injuries can be deferred until the patient is sta-
ment of an oral airway should be attempted. If these ble. Repair of facial lacerations can produce surpris-
are unsuccessful in restoring air flow, a definitive air- ingly good results, providing that tissue has not been
way must be obtained rapidly. Orotracheal intubation avulsed and the arterial supply is intact. Debridement
is difficult because of massive bleeding and edema, dis- of tissue should be kept to a minimum, and tissues
torted anatomic landmarks, and debris, including should be closed in layers, with individual muscle lay-
avulsed teeth, fragments of bone, and bullet frag- ers, subcutaneous tissues, and skin closed separately.
ments. Use of paralytic agents for orotracheal intuba- Fine sutures with minimal inflammatory properties are
tion may cause loss of voluntary muscle maintenance used to close the skin. Revision of wounds should
of a patent airway, but on the other hand will facili- attempt to orient wounds parallel to the natural wrin-
tate intubation in a struggling, hypoxic patient. kle lines of the face, as these scars will be less notice-
Attempted awake orotracheal intubation, although able. Scars that are perpendicular to the natural
often recommended in these cases, is similarly wrinkle lines are much more apparent.

2.12 Complex Facial Lacerations 49

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 2.12A. Photograph of a large laceration of the temporal and
malar area and the same laceration after placement of
subcutaneous sutures as part of a multilayered closure. The
ultimate cosmetic result was very acceptable.

2.12B. Photograph of a patient with avulsion of the scalp.

2.12C. Photograph of a patient with a shotgun wound of

the face. Airway management is extremely difficult in these
cases, as anatomic landmarks are severely distorted.

50 Facial Injury

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 2.12D. Schematic showing
the cricothyroid membrane
(arrow) and its relationship to
the thyroid cartilage (above)
and the cricoid cartilage.

2.12E. Photograph of a
cricothyrotomy in progress.

2.12 Complex Facial Lacerations 51

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 2.13 Oral Lacerations

Commentary
Lacerations of the lips occur commonly as the lip is tions involving the skin and mucosal surfaces of the
crushed between a striking object and the underlying mouth, the mucosal laceration is repaired first, fol-
teeth. Because the blood supply to the lips is excel- lowed by skin closure. Lacerations of the tongue
lent, uncomplicated healing is the rule. However, care should be repaired using absorbable sutures after
must be taken to properly align lacerations that trans- removal of clots and irrigation of the wound. Because
verse the vermilion border because even minor mis- of its rich vascularity, the tongue is capable of massive
alignment in this area is noticeable and disfiguring. swelling, and delayed airway compromise is possible.
Intraoral lacerations should be repaired using soft,
absorbable sutures. With through-and-through lacera-

2.13A. Photographs of a patient with

a complex facial laceration involving
loss of tissue from the upper lip with
avulsion of almost half the upper lip.
After careful alignment of the
vermilion border and restoration of
the “cupid’s bow,” an acceptable
cosmetic result is obtained.

2.13B. Photograph before and after

repair of a complex laceration of the
lower lip caused by a human bite. An
acceptable cosmetic result is
obtained.

52 Facial Injury

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 2.13C. Photograph of a patient with a close-range gunshot
wound of the mouth and massive destruction of perioral
tissue.

2.13E. Lateral radiograph of the soft tissues of the neck

showing an aspirated tooth anterior to C4.

2.13D. Autoamputation of the distal tongue caused by a

human bite from the patient’s girlfriend.

2.13F. Chest radiograph showing an aspirated tooth in the

left main bronchus.

2.13 Oral Lacerations 53

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 2.14 Facial Nerve Injury

Commentary
Facial nerve injury is most commonly idiopathic in ful examination of the muscles of facial expression
etiology (Bell’s palsy). However, penetrating facial because facial nerve injury is frequently missed during
trauma can occasionally result in transection of the the initial examination of patients with multiple
facial nerve as it courses through the face. The facial trauma. Injury of the smaller branches of the facial
nerve exits the base of the skull, enters the face just nerve may also merit exploration and surgical repair,
anterior to the tragus of the ear, and continues as a depending on the severity of the deficit. Care should
large trunk for approximately one centimeter before it be taken to moisten the conjunctiva with artificial
subdivides extensively into smaller branches. Lacera- tears to avoid desiccation and ulceration of the cornea
tions in the vicinity of the tragus should prompt care- due to incomplete closure of the eyelid.

2.14A. Photograph of a patient with facial nerve injury on

the left side showing loss of the left nasolabial fold,
incomplete eyelid closure, and facial droop.

2.14B. Intraoperative photograph showing a transected

facial nerve.

54 Facial Injury

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 2.15 Facial Artery Injury

Commentary
The facial artery branches from the external carotid parotid gland along a line drawn from the tragus to the
artery and courses deep to the angle of the mandible upper lip and enters the mouth as Stensen’s duct at the
until it crosses under the middle of the mandibular level of the second upper molar. Lacerations that cross
ramus to run subcutaneously into the face. The trans- this line proximal to the entry of the parotid duct into
verse facial artery courses with the facial nerve before the mouth should be suspected of transecting the duct.
branching extensively in the face, and the maxillary Examination of the duct is performed by milking the
artery branches from the external carotid deep to the parotid gland while examining Stensen’s duct intra-
coronoid process of the mandible. orally. Expression of saliva suggests that the duct is
Injury to any of the major arterial trunks supplying intact. Expression of blood or failure to express saliva
the face can result in massive bleeding and exsan- suggests transection of the duct. If injury is suspected,
guination. Accumulation of large hematomas may Stensen’s duct is probed retrograde, and the wound is
threaten the airway. Because they are located deep to examined for the probe. Alternately, a sialogram can
bony structures of the face, they are often inaccessible be performed to determine the integrity of the duct.
for direct external compression and may require emer- Careful surgical repair of the duct will prevent forma-
gent surgical intervention to obtain vascular control. tion of a salivary-cutaneous fistula.
Lacerations of smaller arterial branches often heal
without noticeable consequence because of the excel-
lent collateral blood supply in the face. However, all of
the recognized vascular complications including
pseudoaneurysm, arteriovenous fistula, and delayed
thrombosis can occur, and these often present weeks
to months after the original injury.
Lacerations over the malar area can involve several
other important structures. The parotid gland lies
anterior to the tragus of the ear and extends to the
midpupillary line external to the maxilla. Lacerations
of the parotid gland may result in creation of a salivary
fistula but generally heal uneventfully. Laceration of
the parotid duct, however, commonly results in com- 2.15A. Angiogram showing two large pseudoaneurysms of
plications. The parotid duct courses through the the facial artery (arrows A and B).

2.15 Facial Artery Injury 55

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