Chapter 24. Facial injuries
Most facial injuries will be managed as part of the secondary survey. Severe facial injuries may however compromise the airway through anatomical disruption or by bleeding.
Airway problems
Airway problems arise from:
• Inhalation of foreign bodies
• Posterior impaction of the fractured maxilla
• Loss of tongue control in a fractured mandible
• Intraoral tissue swelling
• Direct trauma to the larynx
• Haemorrhage.
Severe facial injury may necessitate advanced airway procedures such as cricothyroidotomy.
Circulatory problems
Haemorrhage from facial fractures may produce:
• airway obstruction
• hypovolaemic shock.
Two percent of facial injuries have associated cervical injuries and the patient’s cervical spine should be protected using a semi-rigid collar, spine board and head blocks until injury can be excluded.
Soft tissue injuries
Soft tissue injuries may be divided into superficial cuts and grazes, lacerations and penetrating wounds. There may be loss of tissue or degloving injuries, as seen for example in the lower labial sulcus (groove behind the lower lip) when the skin over the chin is forcibly pushed downwards and backwards.
Treatment
• Profuse haemorrhage from cuts and lacerations should be stopped during the primary survey. Pressure applied over the wound with a gauze swab held firmly in place may be all that is required
• Penetrating injuries should not be explored. It is dangerous to explore neck wounds, which should be covered and managed in hospital
• Foreign bodies should be left in place, including those piercing the cheek or penetrating the other intraoral tissues, unless they are causing airway obstruction
• A cheek wound may sever the parotid duct, resulting in an escape of saliva onto the cheek
• During the secondary survey a thorough examination of the scalp and face will be carried out in order to identify all the soft tissue injuries.
Eye injuries
The most common superficial injury is a corneal abrasion in which the superficial layers of the cornea are removed. The resulting injury is exactly analogous to an abrasion of the skin and is very painful.
Blunt injury to the globe of the eye can produce a variety of injuries including haemorrhage into the anterior or posterior chambers and injury to the individual structures of the eye.
As well as a late sign of intracranial haemorrhage a unilateral dilated pupil may be caused by severe concussion to the globe (traumatic mydriasis). Similarly a unilateral constricted pupil may result from blunt trauma to the eyeball (traumatic miosis).
Penetrating injuries may be immediately apparent, especially given knowledge of the mechanism of injury. Foreign bodies on the surface of the eye are remarkably irritant and painful. Chemical injuries to the eye are extremely common, occurring in both domestic and industrial settings and can be eyesight-threatening.
Treatment
• No immediate treatment is usually required for corneal abrasions, although some patients may gain relief from covering the eye with a pad
• Patients with penetrating injuries should be transported to hospital urgently in the supine position. Both eyes should be covered to prevent eye movements but any protruding foreign body must not be forced further into the globe
• Small superficial foreign bodies will require removal in hospital although irrigation with clean water may be helpful in removing general debris if the injury has occurred in a dirty or contaminated environment
• Chemical injuries must be irrigated with copious saline
• Under no circumstances should any attempt be made to ‘neutralise’ an acid with an alkali or vice versa
• Eye injuries from alkalis have a worse prognosis than those from acids
• All such injuries require urgent assessment in the Emergency Department.
Injuries to teeth
Teeth may be loosened, partially extruded or completely avulsed (extracted). They may be fractured at the level of the crown or lower down on the root. Fractures involving segments of tooth-bearing bone may occur and are known as dentoalveolar fractures. Loose and avulsed teeth (and dentures) may be inhaled and are a cause of airway obstruction. Assessment of the patient’s airway and inspection of the mouth are mandatory. Well-fitting dentures may be left in place.
In a patient without a head injury, a completely avulsed tooth (usually a front tooth in a child) can be immediately reinserted. The patient should be asked to hold the tooth in position and the advice of a dentist or maxillofacial surgeon sought. Alternatively, the tooth may be placed in a container of milk and transferred with the patient to hospital. Patients with an associated head injury are at particular risk from inhaling foreign bodies and should not be asked to hold their tooth in the inside of the cheek. If the tooth is fractured, where possible, the pieces should be found and taken with the patient to hospital. A chest radiograph may be necessary if there is any suspicion that a tooth or fragment may have been inhaled.
Fractures of the facial skeleton
Fractures of the mandible
A patient with a fractured mandible will give a history of recent trauma to the jaw. A blow to the right side of the jaw may lead to a fracture through the right angle and/or a fracture of the left condylar neck. An injury to the chin may produce a midline fracture together with bilateral condylar neck fractures.
The patient will complain of pain and swelling over the site of the injury and be unable to open the mouth fully. A number of teeth may have been lost or displaced and the patient may notice that their teeth no longer fit together properly (malocclusion).
Examination may reveal a step deformity along the line of the lower jaw. Intraoral inspection may show lacerated and bleeding gums and loose teeth. Bruising underneath the tongue (sublingual haematoma) usually occurs adjacent to the fracture line.
Loss of tongue control in a fractured mandible
The fractured mandible may become an immediate airway management problem when there are bilateral symphysial fractures or there is extensive bone loss resulting in loss of tongue support.
The musculature of the tongue is attached to the genial tubercles in the midline and if this fragment becomes detached, the tongue may fall backwards to obstruct the oropharynx. Patients at particular risk from this complication are those with a depressed conscious level who are unable to control their tongue.
Immediate management involves pulling the tongue forward and holding it in an unobstructed position. This may be achieved manually or a doctor may use a large suture (0 gauge black silk) placed transversely through the dorsum of the tongue (a large safety pin may even be used) and the suture taped to the side of the face. A transverse stitch is less likely to cut through the tongue when traction is applied.
Fractures of the maxilla
A patient with a fractured upper jaw is likely to have sustained high-impact trauma to the face. Gentle manipulation of the maxilla will reveal mobility of the upper jaw and the patient may have a ‘dish-face’ deformity.
Marked swelling is a feature of the Le Fort II and Le Fort III fractures and may be accompanied by bruising around the eyes. The patient may complain that the teeth do not meet properly.
Posterior impaction of a fractured maxilla
A fractured maxilla may cause obstruction of the nasopharynx by backward and downward displacement along the slope of the base of the skull.
Disimpaction of the maxilla can relieve the obstruction and is performed by placing the gloved middle and index fingers behind the soft palate and pulling forwards.
Management of haemorrhage
Profuse haemorrhage can result from a fractured maxilla after damage to the terminal branches of the maxillary and ethmoidal arteries. Nasal Epistats® should be inserted – the distal balloon is inflated first, traction applied and then the proximal balloon inflated.
This may further displace a fractured maxilla downwards in which case bite-blocks (such as rolled up gauze) should be placed between the teeth to splint the upper jaw.
Orbital and zygomaticomaxillary complex fractures
Fractures in this region potentially involve the eye. Trauma to the cheek can produce marked periorbital swelling and bruising. A step deformity may be felt along the zygoma and there may be flattening of the cheek.
Swelling of the eyelids may make examination of the eye more difficult but it is important that any globe injuries are not missed. Examination of the pupils should be undertaken to assess size and reactivity.
The patient may also complain of double vision (diplopia).
A blow to the eye may cause a fracture to the weak orbital floor, tethering the globe and restricting eye movement when looking up (orbital blow-out fracture).
Nasal complex fractures
Nasal fractures can be accompanied by profuse haemorrhage. The patient should bend forward (c-spine injuries permitting) to prevent blood filling the posterior oropharynx.
If simple compression of the anterior part of the nose (Little’s area) does not stop the bleeding then it can be controlled by inserting expanding foam packs (Merocel® packs). The packs should be lubricated, inserted into the nostril and activated by injecting some normal saline with a syringe. The strings should be taped to the patient’s face to prevent the pack displacing into the airway.
For further information, see Ch. 24 in Emergency Care: A Textbook for Paramedics.
