Trauma

Assessing and Managing Facial Trauma

Issue 6 and Volume 40.

For many providers (including this author), facial trauma is at least cringeworthy, if not absolutely despised. Much of this particular disdain for facial injuries is probably deeply rooted within our psyche as humans, because the face is associated with a great deal of psychological and sociological meaning. From the recognition of a friend or an enemy, to the expressions of joy and pain, one’s mind has a huge appreciation for the human face. Thus, it only makes sense that anytime a person’s face is injured or disfigured, it tends to elicit a very strong emotional response.

However, aside from this very strong psychosomatic reaction, there’s also a very real and present danger associated with facial trauma. The brain, along with the origin of the airway, is housed within the bounds of the face. Additionally, any strong force to the face can also disrupt the cervical spine, leading to devastating disability. Injuries to any of these structures can prove fatal for the patient and always warrant immediate recognition. With this in mind, it’s imperative providers quickly suppress the initial emotional response associated with facial trauma and immediately be on the lookout for serious injuries. Both visible and hidden injuries associated with facial trauma can pose grave detriments to a patient’s morbidity and mortality.

Anatomy

The musculoskeletal structures of the face are extremely intricate. It’s this complex system of bone and connective tissue that gives way to the face’s ultimate shape. As mentioned, the central nervous system sits in very close proximity to the visible face. In all actuality, the posterior/internal surface of the face makes up the anterior portions of the cranial vault, where the brain is actually housed. Always keep this in mind when assessing facial injuries.

The face has a relatively large blood supply with an extensive arterial and venous system. Most of the arterial supply to the face comes from the facial and external temporal arteries. An exception to this is the ophthalmic artery, which originates intracranially from the internal carotid artery and then dives through the optic canal to supply parts of the face. This makes the vasculature of the face highly complex–in fact, fairly unique to the face, many of the vessels of the face cross the midline to form anastomoses with vessels originating on the contralateral side. Due to these phenomena, injuries that compromise the integrity of the facial vasculature (especially arterial) can cause profound hemorrhage and can rarely lead to exsanguination. Controlling these hemorrhages can be a bit problematic because there’s no single pressure point. For instance, applying direct pressure to a large forehead laceration may stop the bleeding on one side of the laceration, but due to the anastomoses, this may only increase the bleeding from the other side of the wound.

Facial innervation is also complex. Essentially, all of the innervation of the face happens via the cranial nerves. The facial nerve (cranial nerve VII) supplies the vast majority of the face’s motor function. This nerve originates in the brainstem and exits through the temporal bone of the skull before branching out to the face, so injury to this nerve can cause devastating facial paralysis.

The sensation of the face is innervated almost entirely via the three branches of the trigeminal nerve (cranial nerve V). This nerve also originates from the brainstem, but immediately branches into three segments before traveling through the skull to supply sensation. Depending on where an injury occurs and which branch of the trigeminal nerve is affected will determine where the associated paresthesia is located.

Assessment & Management

As always, your trauma assessment will follow the exact same process as it would for any other injury. However, remember not to let the gruesomeness or severity distract you. Stay focused! You’ll first assess for mental status–if the patient is altered, unconscious and/or unresponsive in the presence of facial trauma, you’ll certainly want to have a very high index of suspicion for traumatic brain injury.

Inability to maintain a patent airway is always a medical emergency. Rapid deployment of an oral airway or oral endotracheal tube is a must. Providers should avoid any form of therapy that involves passing an object into the nasopharynx. There’s anecdotal evidence that when a basilar skull fracture is present, an object passed through the nares could inadvertently end up terminating inside the cranial vault.1

Direct airway trauma can be one of the greatest challenges for any provider–from first responder to physician. Depending on the severity, airway trauma can necessitate immediate and invasive intervention. Excessive hemorrhage, disruption of tissue, or structural deformity involving the airway should always be handled with the utmost care. If airway compromise is suspected or impending, quick measures must be taken to secure and protect the airway. However, if the nature of the injury is so severe that oral airway, intubation and emergency adjunct airways aren’t possible, the decision to perform a surgical airway must be definitive and immediate. The greatest complication in performing a surgical airway is simply deciding that it needs to be done.

After ensuring that airway and breathing are appropriately addressed, the focus moves to circulation. As always, adequate perfusion in trauma patients is paramount. In isolated facial injury, shock is rarely an initial presentation. That being said, with facial trauma, most of your management will still center on hemorrhage control. Facial hemorrhages can appear severe and quite difficult to manage, but generally the best treatment is direct pressure and bulky dressings. Following these, frequent reassessment is a must. Streams of blood from heavily dressed facial wounds always seem to find their way underneath the patient, only to surprise the provider and trauma team when the large puddle is discovered once the patient is moved off of the EMS stretcher. I make it a regular part of my practice to do frequent blood sweeps when I’ve dressed a head wound. Any new blood found during a blood sweep should have you hunting for the source; examine all dressings and be on the lookout for very subtle streams of blood.

After the primary survey and aside from other potential life-threatening injuries, a detailed and focused secondary survey of the face and head is next. The best approach to facial trauma is to always be on surveillance of other underlying injuries and issues. Your brain considers your face to be prime real estate. After all, the face houses four of the five senses. In essence, your brain will always do what it can to protect the face/head from injury. When a facial injury occurs, the mechanisms that protect the face have failed for one reason or another: the mechanism was too fast or unexpected (gunshot wound), intoxication, incoordination (disease or age), or the mechanism simply exceeds the protective ability of the patient (motor vehicle collision or industrial accident). Regardless of the cause, a provider will always want to have a high index of suspicion for the cause of facial injuries, especially when the cause is related to an unexplained fall or syncopal event. You don’t want to be that provider who missed a syncopal patient in v tach because you were too worried about a scalp laceration.

While not covered in detail here, as with any trauma patient, providers must also always be cognizant of the need for pain management in patients with these types of injuries.

Forehead & Orbits

The most superior portion of the face forms the forehead, which directly corresponds to the frontal bone of the skull. This bone is fairly sturdy in its construction and comprises a large portion of the face’s area. Within this bone, the frontal sinuses are found. These sinuses tend to be a bit more susceptible to fracture than the rest of the structure because the walls are thinner. Forehead wounds are generally superficial depending on the force involved. Unless there’s evidence of skull fracture, frequently the only concern is hemorrhage control. However, the most superior portions of the weaker orbital structures reside within the bounds of the forehead.

This 26-year-old male patient received a single, unexpected blow to the right face by the assailant's fist. He was immobilized and taken to a local hospital for treatment. The patient suffered significant structural injuries to his face that included: several fractures to the right maxillary sinuses, right orbital floor fracture, displaced right lateral orbital wall fracture, right zygomatic arch fracture, right intraorbital emphysema, right facial subcutaneous emphysema, right maxillary sinus hemorrhage, and right periorbital hematoma. The patient was later discharged to the care of a tertiary Level 1 trauma center for a multidisciplinary surgical repair of his injuries. Photo courtesy A. Dickinson

The orbits are a spherical composite of several bones that in consort house the globes (eyes). Some of these structures are very thin and susceptible to injury. The majority of orbital structures are housed posterior to the anterior, visible face. The three main bones that make up the orbit are the frontal bone (the superior margin), zygomatic bone (the inferior-lateral margin), and maxilla (the inferior-medial margin).

Orbital fractures can occur on the outer ring of the orbit or deep within the socket. Any severe pain, disfigurement, periorbital hematomas or crepitus to the orbit should be suspicious for orbital fracture. Fractures of the orbital floor can often disrupt the infraorbital nerve that emerges from the skull just inferior to the inferior portion of orbit. Patients with this type of injury will generally present with ipsilateral paresthesias of the lower eyelid, lateral nose, upper lip and anterior cheek. Additionally, any asymmetry of the globes or the patient’s gaze should be suspicious for orbital and/or ocular injury.

While ocular injuries aren’t the topic of this article, a quick note is certainly warranted here. All providers should be highly suspicious for ocular injuries when there’s a disruption to the integrity of orbit. In lieu of severe hemorrhage or other life threats, ocular injuries take precedence. Protecting the eye from further injury must be achieved. Typically a cup fastened over the injured eye with the uninjured eye being taped shut or blindfolded is sufficient. With obvious or suspected ocular trauma, pressure should never be applied to the eye or surrounding tissue so as not to increase intraocular pressure. Increasing the pressure inside the eye in the presence of trauma can cause increased damage and the likelihood of blindness. If possible, patients with obvious or suspected ocular injury should be kept at least 30% upright to also minimize intraocular pressure.

Maxilla & Nose

The maxilla is a large, strong bone that comprises the superior gumline, nose and areas inferior to the orbits. This area is collectively termed the “midface.” The upper teeth are rooted in this bone. Numerous blood vessels, nerves and sinuses communicate with this bone. Any disruption to this area can result in serious complications. Injuries to this area can run the gamut of severity. Simple nasal fractures can be treated with time and oral analgesics. However, severe injuries require emergent otolaryngological and maxillofacial surgical repair.

In between the orbits are the bones that compose the nose and some of the sinuses. The boney bridge of the nose is composed of the nasal bones. As one of the more exposed and weaker structures of the face, the nose is very susceptible to injury. The internal septum houses what’s called the “perpendicular pilate of the ethmoid bone.” This bone is also fairly weak. Any significant trauma to these structures can possibly lead to a disfigured nose.

Of special note to this area is the Le Fort group of fractures, which involve either complete or partial detachment of the maxilla from the skull. (See Figure 1, p. 59.) Le Fort I fractures involve a horizontal fracture line that runs just superior to the superior gumline. In essence, the upper gums and soft pallet are detached from the skull. A Le Fort II fracture forms a fracture line in the shape of a pyramid. The apex of the pyramid is at the bridge of the nose with each side of the pyramid extending to each corner of the mouth, terminating at the posterior portion of each upper gumline. With this fracture, most of the maxilla is free-floating from the skull.

The Le Fort III fracture is characterized by a complete dislocation of the midface from the skull. This fracture line travels horizontally through the midface at the level of the bridge of the nose. The fracture line transverses each orbit and then extends down into each zygomatic arch. The entire midface and nose is detached from the skull and the anterior face is mobile. Surveillance for Le Fort II/III fractures is extremely important when assessing patients with blunt facial trauma, as there’s an increased risk for cerebrovascular injury in this population.2

Cheekbone

The cheek bones are created from a tunnel that runs through the zygomatic bone. The most outer portion of this tunnel is the zygomatic arch, which is what gives the cheek its external shape and definition. This structure is fairly strong but can be susceptible to injury and fracture. The tunnel formed via the zygomatic arch has some very important structures running through it that control a great deal of facial movement and expression; any disruption to the canal can result in possible disability of the movements of the mandible.

Figure 1: LeFort fractures  CanStockPhoto/Blambs

Lacerations to this area can often appear quite deep because of the thickness of the tissue here. Hemorrhage from these wounds can be fairly substantial and require hemorrhage control.

Oral Cavity & Mandible

The most inferior portion of the face is comprised of the mandible, or the jaw bone. The inferior gumline and teeth are housed on the mandible. Of the facial bones, the mandible is unique in that it’s the only mobile one. The mandible and its associated muscles are solely responsible for the actions of mastication and the opening/closing of the mouth.

Oral and mandibular trauma can pose a host of complications for patients who’ve sustained facial trauma. Trauma to the fleshy cheeks can often be extremely gruesome. There’s very little supportive tissue within the body of the cheeks, thus they’re highly susceptible to perforating injuries. These injuries can bleed extensively, so packing them with bulky dressings is often necessary to slow down the hemorrhage. It’s also quite important to provide the patient with plenty of suctioning. This holds true for any injury that could result in patients ingesting blood. Free blood within the gastrointestinal track is very irritating and may lead to profuse vomiting.

Because of the mandible’s unique shape and location on the face, fractures of the mandible are fairly common among all maxillofacial fractures. Fractures to the mandible account for nearly 60% of all facial fractures.3 Fracture is highly suspected if a patient can’t freely open their mouth greater than 5 cm (about 2 inches), or if there’s significant ecchymosis to the chin or preauricular area. Patients with suspected or obvious mandibular or maxillary fracture are at an increased risk for airway compromise. Providers should be extremely cautious of airway deterioration any time a patient with maxillofacial injury is also presenting with dysphonia and oropharyngeal edema. In fact, anytime a patient presents with upper chest, neck, or facial trauma, and also has trouble speaking, hoarseness, and/or drooling, providers must be extremely suspicious for airway deterioration and the need for rapid intubation and possibly surgical airway maneuvers. As with all of these injuries, mandibular fractures should be treated for hemorrhage control as applicable.

Destination Criteria

Patients with significant facial trauma must be transported to the correct facility by the correct means. Air medical services should be considered in patients with serious risk for uncontrolled airway deterioration and long transport times to the appropriate receiving facilities. Additionally, patients with significant facial trauma need to be transported to a center with a trauma service at the minimum, but preferably a trauma center with maxillofacial surgery and plastic surgery services.

Conclusion

While the anatomy and degree of injury associated with facial trauma is complex, the prehospital management is straightforward. Providers should be hypervigilant about maintaining a high degree of suspicion for airway deterioration, intracranial pathology and the possibility for C-spine injury. Adding to that, facial trauma is all about planning. If the provider has done a thorough and focused assessment of the injury and is able to appropriately plan for the plausible and possible complications, there should be no surprises, and the patient will receive the quality care they deserve.  

Robert P. Girardeau, BS, NRP, FP-C, is a critical care and flight paramedic with Thomas Jefferson University Hospital’s Critical Care Transport & Flight Program, JeffSTAT. He’s also an educator and field provider in the greater Philadelphia area. He can be reached at [email protected]

References

  1. Pandey AK, Sharma AK, Diyora BD, et al. Inadvertent insertion of nasogastric tube into the brain. J Assoc Physicians India. 2004;52:322–323.
  2. Biffl W, Moore E, Offner P, et al. Optimizing screening for blunt cerebrovascular injuries. Am J Surg. 1999;178(6):517–522.
  3. Sojat A, Meisami T, Sandor G, et al. The epidemiology of mandibular fractures treated at the Toronto General Hospital: A review of 246 cases. J Can Dent Assoc. 2001;67(11):640–644.

Resource

  • Mayersak R. (March 2014.) Facial trauma in adults. Up to Date. Retrieved March 28, 2015, from www.uptodate.com/contents/facial-trauma-in-adults.

LEARNING Objectives

  • Relate the complex anatomy of the face with the more common facial injuries experienced by prehospital providers.
  • Understand the complications of blood loss and airway compromise associated with facial trauma.
  • Learn how to plan for all complications and possible life threats associated with certain facial injuries.

KEY Terms

Anastomoses: Joining two parts, such as blood vessels, to allow flow from one to the other.
Cranial nerves:
The 12 pairs of nerves emerging from the cranial cavity through openings in the skull.
Le Fort group of fractures: Facial fractures classified into three types: Le Fort 1 (Guerin’s fracture) is a fracture involving the maxilla. Le Fort II (pyramidal fracture) involves the maxilla, nasal bones and medial eye orbits. Le Fort III (craniofacial disjunction) encompasses fractures of the maxilla, nasal bones, ethmoids, zygoma, vomer and all the smaller bones of the base of the cranium.
Orbits: Pair of bony, cup-shaped openings in the skull that contain the eyes and various eye muscles, nerves and blood vessels.