Epistaxis

Nasopharyngeal bleeding can usually be controlled by direct pinch pressure on the nose. Thirty minutes of direct pressure without release is often sufficient. If this fails to control the hemorrhage, nasal packing should be performed. Anterior nasal bleeding can be treated by direct external pressure or cautery of the bleeding vessel. If the bleeding cannot be controlled by these measures, packing is indicated. Ribbon gauze impregnated with petroleum jelly works well for this purpose. Bayonet forceps and a nasal speculum are used to approximate the accordion-folded layers of the gauze, which should extend as far back into the nose as possible. Each layer should be pressed down firmly before the next layer is inserted. Posterior epistaxis requires posterior packing, which is accomplished by passing a catheter through one or both nares, through the nasopharynx, and out the mouth. A gauze pack then is secured to the end of the catheter and positioned in the posterior nasopharynx by pulling back on the catheter until the pack is seated in the posterior choana, sealing the posterior nasal passage, and applying pressure to the site of the posterior bleeding. Various balloon systems are effective for managing posterior bleeding and are less complicated than the packing procedure. If nasal packs or balloon systems are not available, a Foley catheter (10 to 14 French) with a 30-ml balloon may be used. The catheter is inserted through the bleeding nostril and visualized in the oropharynx before inflation of the balloon. The balloon then is inflated with approximately 10 ml of saline, and the catheter is withdrawn gently through the nostril, pulling the balloon up and forward. The balloon should seat in the posterior nasal cavity and will tamponade a posterior bleed. With traction maintained on the catheter, the anterior nasal cavity is then packed as previously described. Traction is maintained by placing an umbilical clamp or suture across the catheters outside the nostrils, with padding in between to prevent pressure necrosis of the columella.

Scalp Lacerations

The scalp is richly vascularized and thus lacerations can cause profuse bleeding. A surgical stapler can be used to quickly control this bleeding in an emergent situation. Both edges of the laceration should be stapled, parallel to the wound edge. This will provide hemostasis on a temporary basis until a formal repair can be performed.

Tongue Lacerations

Deep tongue lacerations may cause injury to the lingual artery. Control of this bleeding can be performed by suture ligation of the damaged lingual artery. After a bite block is placed in the mouth, a towel clip or a large suture is used to retract the tongue forward. The bleeding vessel then can be ligated and a formal repair of the tongue can be performed at this time if more serious injuries have already been addressed.

Hemorrhage from LeFort Fractures

In the case of severely displaced LeFort fractures, hemorrhage can be controlled by manually reducing the fracture. This is performed by grasping the maxillary arch of the hard palate and realigning the displaced segments.

General Considerations

The initial evaluation of most facial injuries frequently takes place in a busy emergency department or trauma bay. While this may be an acceptable location for diagnosis, it rarely provides a suitable environment for repair of facial trauma. Before beginning any reconstructive effort, an adequate light source, assistants, and all requisite supplies should be present. Extensive soft tissue injuries are optimally repaired in the operating room.

Local Anesthesia

Local anesthesia is the preferred modality for repair of most soft tissue injuries. While general anesthesia is required for major injuries, it is best avoided if possible since trauma patients may bear significant risks for aspiration, either due to intoxication or gastric contents. Local anesthesia can be combined with intravenous sedation to increase patient comfort and cooperation. Depending upon the choice of anesthetic, the effects of local anesthesia can last up to 7 hours (Table 2). When combined with epinephrine, the duration of anesthesia is extended and more importantly, the resultant vasoconstrictive effect provides increased hemostasis in the operative field. Onset of action is from 2 to 5 minutes for all drugs; however, waiting 7 minutes provides maximal effects.²

Cocaine (5% solution) is the topical anesthetic of choice for nasal mucous membranes. It can be introduced on cotton pledgets or gauze soaked with the solution.

Antibiotics

The use of antibiotics depends on the location and mechanism of the facial injury. Most soft tissue injuries of the face can be prophylaxed with a first-generation cephalosporin or aminoglycoside in the case of penicillin allergic patients. In the case of animal or human bites, gram negative and anaerobic organism coverage should be provided. Wounds with intraoral involvement should also cover these organisms. Duration of treatment should be determined based upon the extent of injury, contamination, and immune status of the patient³ (Table 3).

Table 3 Tetanus Prophylaxis

Source: Immunization Practices Advisory Committee: Diphtheria, tetanus, and pertussis: guidelines for vaccine prophylaxis and other preventive measures. MMWR Morb Mort Wkly Rep 34:426, 1985.

Abrasions

Abrasions should be cleaned with a mild soap solution. If debris is embedded in the dermis, the skin should be anesthetized and scrubbed using a surgical scrub brush to remove the foreign material and prevent traumatic tattooing. The wound should ideally be cleaned within 12–24 hours. The wound should be kept moist, to facilitate epithelialization, and a sterile dressing placed.

Foreign Bodies

Foreign bodies larger than those that cause traumatic tattooing should be removed from facial wounds to prevent cellulitis and abscess formation. Metal fragments from bullets can be left if removal requires extended dissection since most bullets are relatively aseptic when they penetrate skin.

Treatment of Lacerations—General Concepts

Given the rich vascular supply to the face, wounds usually can be safely closed up to 24 hours following injury. Basic principles that apply to all facial lacerations include debridement of devitalized tissue or jagged wound edges, irrigation, and closure of the wound in layers. Conservative trimming should be performed to create healthy, perpendicular skin edges that are conducive to healing with minimal scarring. Suturing should be done in layers. The deepest layers should be closed with interrupted, buried, absorbable sutures. This will serve to minimize dead space, and help approximate and relieve tension on skin edges. Epidermis should be closed using a fine 5-0 or 6-0 suture. Interrupted sutures allow removal of select stitches for drainage of purulence or hematoma; however, a simple running suture can provide equally good results and save time. The wound should then be kept covered with sterile adhesive strips or antibiotic ointment for 48 hours to allow for epithelialization. Nonabsorbable epidermal sutures should be removed 4–7 days after placement. Areas with thin skin such as the eyelid should have sutures removed by day 4.

Lip Lacerations

Repair of lip lacerations should be done with reference to anatomic landmarks, carefully aligning the edges of the vermilion border and the wet–dry margin. The first suture should be placed at the vermilion border with the remainder of the wound closed in layers. Muscle should be repaired with a braided absorbable suture. The vermilion and mucosa can be repaired with an absorbable chromic gut suture. Finally, skin is closed with a nylon or fine fast-absorbing gut suture.

Nasal Lacerations

Nasal lacerations can be simple, involving skin only, or complex, which involve a combination of the mucosal lining, cartilaginous framework, and skin. Repair should be performed in layers. Cartilage should be repaired with interrupted 4-0 or 5-0 absorbable monofilament or chromic gut sutures. Mucosa is generally repaired in a similar fashion with 4-0 or 5-0 chromic gut suture. Skin can be closed with a fine nylon (5-0 or 6-0) or fast-absorbing gut suture. Nasal septal hematomas can occur after blunt or penetrating trauma and deserve special attention, since failure to drain the hematoma can cause pressure necrosis of the nasal septum. A septal hematoma can be drained within 24 hours of injury with a large-bore needle and syringe or a small scalpel incision followed by intranasal packing with petroleum gauze.

Ear Lacerations

Ear trauma ranges from simple lacerations to complete amputations. Primary repair is paramount since secondary repair is more difficult and often yields significantly less favorable results. The ear has abundant cutaneous blood supply. Lacerations which involve cartilage do not always require repair of the cartilage. If approximation of skin edges or perichondrium brings the severed edges of the cartilage into adequate apposition, then repair of the cartilage is not required. Skin should be repaired with 5-0 or 6-0 nylon or fast-absorbing gut. If the cartilaginous damage is extensive, or the edges are considerably irregular, primary repair of the cartilage should be performed with 4-0 or 5-0 chromic gut or absorbable monofilament sutures in simple interrupted fashion. Following repair, contoured bolsters can be fashioned from petroleum gauze with antibiotic ointment and placed postauricularly and within the conchal bowl of the ear for support. This can be held in place with a gauze head wrap dressing. Avulsion injuries of the ear can be closed primarily if the defect is small enough or may necessitate composite grafting or local flap creation for reconstruction. Total ear avulsion or amputation should be referred for consideration of microsurgical replantation. Care of the amputated part includes placing it in a moist gauze wrap in a sealed container or bag. The container then is placed in an ice water bath. The amputated part should never be placed directly on ice, as this can cause a cold burn.

Orbital Soft Tissue Injuries

Blunt or penetrating trauma to the globe can cause bleeding into the anterior chamber of the eye, which is called hyphema. Any injury involving the periorbital area warrants a basic eye exam for visual acuity and extraocular muscle patency. Frequently, an ophthalmology consultation is indicated. However, in mild cases of hyphema, no treatment is required and the blood is absorbed within a few days. Bed rest, eye patching, and sedation to minimize activity and reduce the likelihood of recurrent bleeding, may be prescribed for hyphema. In severe cases, surgical intervention to evacuate the hematoma is necessary.

Eyelid lacerations warrant special consideration due to their complex anatomy and relationship with the eye. Before repair is attempted, underlying injury to the globe must be ruled out. Removal of all foreign bodies should be performed by avoiding further injury in the removal process. Irrigation can be performed with a syringe and an 18-gauge intravenous catheter. Debridement should be kept to a minimum. Blood clot around the globe must be evacuated with caution, as it may be adherent to the richly vascular iris, which also can resemble clot. While attempting eyelid repair, remember to keep the globe lubricated. Lidocaine jelly and a corneal protector can provide adequate anesthesia for an awake patient. Eyelid lacerations can be divided into two categories: superficial, involving skin only, and deep. Superficial lacerations are then subdivided into those that are parallel to the lid margin and those that are perpendicular to it. Lacerations that run parallel require only a few simple interrupted sutures of 6-0 nylon. Smaller lacerations may not require any suturing or may heal well with a topical dermal adhesive such as cyanoacrylate glue. Conjunctival repair can be performed with 6-0 plain gut suture; small lacerations may not require any suturing. Lacerations which run perpendicular tend to spread and require suturing to close.

Deep lacerations which involve subcutaneous musculature or transect the lid margin generally require special attention. Realignment of the lid margin must be precise. A 6-0 silk suture on a nontraumatic ophthalmic needle is passed into the tarsus through a meibomian gland on one side of the wound, across the wound margin, and exited through a meibomian gland orifice on the opposing side. Tension can be held on this suture while two more sutures are placed, one at the anterior margin and the other at the posterior margin of the meibomian gland. These sutures are then retracted superiorly to align the edges of the laceration inferior to the lid margin. The pretarsal and muscle layers are repaired first with a fine absorbable suture and then the skin is closed with a fine nonabsorbable monofilament suture.

Lacrimal System Injuries

Any injury near the medial canthus should raise suspicion for a lacrimal duct injury. Disruption of the lacrimal duct can lead to epiphora, or tear overflow as a result of outflow obstruction. This is often seen as a late complication of naso-orbito-ethmoid (NOE) fractures. In cases of incomplete division of the duct, the surrounding tissues can be repaired which in most cases is enough to restore patency of the ductal system. More severe injuries require a dacryocystorhinostomy (DCR), which is a procedure in which the duct is cannulated and sutured around a silastic tube. DCR is most often a secondary reconstructive procedure, performed months after the injury if symptoms dictate its use.

Parotid Duct Injuries

The parotid, or Stensen’s, duct arises from deep within the parotid gland and emerges from the superior third of the gland at its anterior border. From there it courses below the zygomatic arch, into the buccal space, through the buccinator muscle, and enters the oral cavity in the buccal mucosa, opposite the upper second molar. Its course can be visualized by the middle third of a line drawn from the tragus of the ear to the midportion of the upper lip. Since the parotid duct is more superficial than the facial nerve, it is more susceptible to injury trauma. Disruption of Stensen’s duct can result in a parotid fistula or sialocele if left unrepaired. If injury is suspected, the ostium of the duct can be cannulated with a small-gauge silastic tube. A 22-gauge intravenous catheter can be used for this purpose. Once catheterized, the disrupted ends of the duct can be sutured around the tube with fine absorbable suture material on an atraumatic needle. The end of the tube should be anchored in place in the mouth with nonabsorbable sutures and left in place for approximately 1–2 weeks. Persistent fluid accumulation can be treated with percutaneous drainage or re-insertion of the tube.

Facial Nerve Injuries

The 7th cranial nerve exits the skull from the stylomastoid foramen and enters the parotid gland at its deep surface. Adjacent to the parotid duct, the nerve divides into two major branches, the temporofacial branch and the cervicofacial branch. The nerve courses more superficially as it passes across the surface of the masseter muscle to its terminal branches, which have intercommunications. The major branches of the facial nerve lie deep to the muscles of facial expression and are thus well protected from trauma. Nerve injury anterior to a line perpendicular to the lateral canthus does not necessitate repair. Injury distal to this arborization allows maintenance of cross-innervation to the musculature. Injury to the larger, more proximal branches warrants repair of the nerve with loupe or microscopic magnification.

Intraoral Injuries

Intraoral injuries should be treated with copious irrigation and debridement of devitalized tissues. Then the mucosa should be loosely approximated using absorbable sutures such as 4-0 chromic gut. The patient should be encouraged to rinse the mouth with half-strength peroxide, or oral chlorhexidine solution to reduce bacterial load.

General Principles

A CT scan is the preferred modality for diagnosing facial fractures. Three-millimeter cuts in the coronal, sagittal, and axial planes with three-dimensional reconstruction are usually adequate for diagnosis. Facial fractures are classified as either open or closed, and by anatomic location. Anatomically, fractures are divided into upper, middle, and lower third fractures. The upper third of the face consists of the frontal bones and the orbits. Orbital fractures are subdivided into orbital rim fractures and internal orbital fractures. The middle third of the face contains the zygoma, maxilla, and nasal bones. The lower third is represented by the mandible.

Facial fractures tend to occur in reproducible patterns due to weaker areas that fracture first despite the location of impact. Some common patterns are the zygomaticomaxillary complex (ZMC) fractures, Le Fort fractures, NOE fractures, orbital blowout fractures, and frontobasilar fractures. Knowledge of these patterns can help in the identification of their component fractures and extent of injury which helps in preoperative planning. Primary treatment consisting of open reduction and internal fixation of facial fractures yield the best cosmetic and functional results. This may be delayed, however, for up to a week to allow coordination of a multidisciplinary approach. Open reduction and internal fixation is the treatment of choice allowing anatomical reduction of fractures, stable internal fixation, and early jaw mobilization. Reestablishment of the effective occlusion is of prime importance when addressing fractures that involve the occlusal plane. Most often this involves placing the patient in intermaxillary fixation.

Frontal Sinus/Frontobasilar Fractures

Frontal sinus fractures often result from forceful blunt trauma to the forehead, commonly from a steering wheel when involved in a motor vehicle collision. The frontal bone is comprised of a thicker outer (anterior) table and relatively thinner inner (posterior) table. Just deep to the posterior table are the meninges; any displaced fracture of the posterior table should raise suspicion of dural injury and warrants neurosurgical consultation. Clinical signs of anterior table fracture include forehead depression and malleability upon palpation. Signs of dural involvement include cerebrospinal fluid rhinorrhea and pneumocephaly. Extensive fractures of the frontal sinus can cause disruption of the nasofrontal drainage system. Obstruction of the nasofrontal ducts can cause late post-traumatic complications such as recurrent suppurative sinusitis or mucopyelocele formation. Acute obstruction of the nasofrontal ducts is generally treated by obliteration of the frontal sinus. This process consists of removing the mucosal lining of the sinus, obliteration of the nasofrontal duct and sinus with graft material, and reconstruction of the anterior table. Cranialization of the sinus, where the posterior table is completely removed and the brain is allowed to expand into the sinus, is reserved for severely comminuted or displaced posterior table fractures.^10,11

Naso-Orbital-Ethmoid Fractures

Naso-orbital-ethmoid fractures consist of injury to the frontal processes of the maxilla and nasal bones; these can be some of the most difficult facial fractures to manage. The frontal process of the maxilla contains the attachment of the medial canthal tendon (MCT), which shapes the medial palpebral fissure and supports the globe. Disruption of the medial canthal tendon in NOE fractures results in traumatic telecanthus. These injuries are of significant clinical importance because of all facial fractures they have the great potential for subsequent deformity. Signs of NOE fractures include telecanthus (intercanthal distance greater than 30–35 mm), rounded medial palpebral fissures, a flattened nasal dorsum, and a mobile medial canthus on physical examination. Mobility of the frontal process of the maxilla on direct finger pressure over the medial canthal tendon is a reliable sign of NOE fracture. The Manson test consists of palpating the frontal process with one hand while applying lateral pressure with an instrument inserted into the nostril and advanced to a position medial to the frontal process.⁵ NOE fractures are classified by the extent of the fracture and the involvement of the MCT attachment. Type 1 NOE fractures contain a single, central segment fracture. Type 2 NOE fractures contain a comminuted central fragment not involving the attachment of the medial canthal tendon. Type 3 NOE fractures involve a comminuted fracture disrupting the attachment of the medial canthal tendon.⁶ Treatment is generally open reduction and fixation of fragments with miniplates, screws, and/or interfragmentary wiring.^10,11

Orbital Fractures

The bony framework of the orbit can be divided into the rim and internal orbit. The anterior orbit is comprised of thick bone, the middle third is relatively thin bone and posteriorly the bone becomes thick again. The weakest areas of the orbit are the floor and medial wall. Orbital fractures are described as pure or impure. A pure orbital fracture involves only the inner orbit while an impure fracture also involves the rim. An orbital blowout fracture refers to a pure fracture of the orbital floor and medial wall where orbital contents herniate into the maxillary and ethmoid sinuses. This can cause entrapment of adjacent medial and inferior rectus muscles. These are generally the result of a low energy impact. Impure fractures involving the rim are often the result of high energy impact. Signs of orbital fractures include subconjunctival and palpebral hematoma, paresthesias in the infraorbital nerve distribution, and diplopia. Diplopia and abnormal extraocular movements may indicate entrapment. If entrapment is suspected, a forced duction test should be performed. This is done by instilling topical anesthetic into the conjunctival sac. Forceps are used to grasp the inferior rectus muscle approximately 7 mm from the limbus. The globe is then rotated in all directions to assess resistance to motion which would indicate entrapment. Enophthalmos is another complication of orbital fractures and can become clinically apparent with an increase in orbital volume of 5%.⁷ Correction of these defects requires reconstruction of the orbital floor and medial wall with titanium mesh, synthetic orbital plate constructs, or bone grafting.

Superior orbital fissure syndrome consists of abnormal extraocular movements, forehead and brow paresthesias, and pupillary dilation. This results from injury or compression of cranial nerves III, IV, ophthalmic division of V, and VI as they pass between the greater and lesser wings of the sphenoid bone, which comprises the superior orbital fissure.^10,11

Orbital fractures have a significant incidence of associated ocular injures including vitreous hemorrhage, hyphema, damage to optic nerve, and globe laceration. A thorough eye exam is indicated in the presence of such fractures. If the optic nerve is involved, it is termed orbital apex syndrome.

Zygoma Fractures

Due to the prominent and superficial position of the zygoma, it is frequently fractured. With the exception of an isolated zygomatic arch fracture, all fractures of the zygoma include fractures of the adjacent orbital bones. This pattern is called a zygomaticomaxillary complex (ZMC) fracture. The zygoma has four bony attachments to the skull at the frontal, maxillary, temporal, and sphenoid bones. Thus, ZMC fractures should be referred to as “tetrapod” fractures, and not “tripod” fractures, by which they are commonly known. Most ZMC fractures are posteroinferiorly displaced due to the pull of attached muscles including the masseter, zygomaticus, and temporalis.

Clinical signs and symptoms of a ZMC fracture include periorbital ecchymosis/edema, painful and limited jaw motion, inferior displacement of lateral palpebral fissure, anesthesia in the distribution of the infraorbital nerve, palpable step-off deformity of inferior orbital rim and zygomatico-frontal region, and enophthalmos with laterally displaced ZMC fractures. Nondisplaced zygomatic fractures can be treated nonoperatively with observation. Displaced fractures, or fractures causing functional impairment, require reduction and fixation. Late complications of untreated ZMC fractures include malunion, enophthalmos, ectropion, diplopia, and permanent dysesthesia of the infraorbital nerve.^10,11

Maxillary LeFort Fractures

Fractures of the maxilla generally involve multiple midface structures. In 1901, Rene LeFort described reproducible patterns of fracture propagation in midface trauma. He concluded that predictable patterns of fractures follow certain injuries. Three predominant types were described.⁸ A LeFort I fracture (horizontal fracture) is a fracture separating the maxillary alveolus from the upper midface. A LeFort II fracture (pyramidal fracture) separates a pyramid shaped fragment containing the maxillary alveolus, nasal bones, and inferior medial orbit from the remainder of the face. A LeFort III fracture (transverse fracture or craniofacial disjunction) separates the midface at the level of the upper zygoma, orbital floor, and naso-ethmoid region from the remaining upper facial skeleton. Most LeFort III fractures are combinations of LeFort I, II, and III fractures with a high degree of comminution. Physical findings include midfacial edema, profuse epistaxis, malocclusion, and palpable bony defects, depending on the fracture type. The most significant physical findings on exam are the mobility of the maxilla in relation to the remainder of the facial skeleton. The level at which the mobility occurs dictates the type of LeFort fracture. Isolated maxilla movement with intact upper facial structures point toward a LeFort I fracture. Mobility at the nasofrontal region upon manipulation of the palate indicates a LeFort II. Movement at the zygomaticofrontal sutures with manipulation of the palate is consistent with LeFort III fractures. A small percentage of LeFort fractures are not mobile and are classified as incomplete. One must rely on CT findings in this scenario. Ten percent of LeFort fractures include palatal fracture.⁹ Displacement of LeFort fractures is in the posteroinferior vector as a consequence of pull from the pterygoid musculature. Often the patient will appear to have a sunken and elongated midface with an open bite deformity.

Emergency management of LeFort fractures is required only with airway compromise and massive hemorrhage. Manual anterior distraction of the maxilla can be attempted in the event of oropharyngeal obstruction which precludes endotracheal intubation. If this maneuver fails, emergency cricothyroidotomy should be performed. Reducing a badly displaced LeFort fracture can help to tamponade hemorrhage in conjunction with packing. Definitive surgical treatment can be delayed up to 7 days to allow time for stabilization of the patient. The goal of surgery is to restore proper anatomic relationships. In particular, attempt to normalize the integrity of the support bolsters of the facial skeleton, the midfacial height and projection, and dental occlusion.^10,11

Nasal Fractures

Nasal fractures are the most common facial fractures encountered in facial trauma, and often go undiagnosed. Isolated nasal bone fractures are uncommon, and more often are seen in combination with septal disruption. Nasal fractures can be displaced posteriorly or laterally. Nasal bone fractures are easily seen on CT scans, but can be diagnosed by visual inspection and palpation. Pain, crepitus, and mobility of the nasal pyramid upon palpation are common physical findings. Epistaxis is often present. Visual inspection of the septum is paramount to rule out a septal hematoma.

Closed reduction of displaced nasal pyramid and septal fractures can be performed in the acute care setting. Adequate closed reduction usually leads to minimally noticeable subsequent deformity which can be addressed by rhinoplasty if needed 6 months to a year after injury. The procedure for acute closed reduction involves local anesthesia and IV sedation if available. The upper lateral cartilages, the base, the columella, and the infraorbital foramen are infiltrated with local anesthetic. If available, 4% cocaine soaked pledgets are placed intranasally. Using the thumb and index finger, the laterally displaced nasal bone fractures are reduced medially. Medially displaced nasal bone fractures can be reduced with a scalpel handle placed within the nares and pressed laterally against the displaced structures. Septal deviation is best reduced with an Asch or Walsham forceps. Steri-strips should be placed across the dorsum of the nose and a moldable thermoplast nasal splint is applied for 1 week.^10,11

Mandibular Fractures

Mandibular fractures are the second most common facial fractures seen in trauma. Signs and symptoms include malocclusion, anesthesia in the distribution of the inferior alveolar nerve, preauricular pain, and limited or painful jaw excursion. A Panorex film is the study of choice; however, a CT scan can provide useful information as well. Physical exam should include palpation for pain and step-off as well as an intraoral exam to inspect for lacerations and possible open fractures. Mandibular fractures are classified by anatomic location, symphysis, alveolar, body, angle, ramus, coronoid, or condyle. Due to the ring shaped configuration of the mandible, a fracture will also have a contralateral (indirect) fracture. Fractures can be classified as open or closed, displaced or nondisplaced. Restoration of occlusion is the primary goal of treatment. Treatment options range from intermaxillary fixation with wires and arch bars for closed, minimally displaced fractures to open reduction and internal plating for more severe fractures.^10,11