Facial trauma - Clinical Tree

Essentials

1
Facial trauma occurs as isolated injury with assault, sporting mishaps, falls and as part of complex multisystem injury.
2
Immediate threat to life may relate to airway obstruction or local haemorrhage; however, threat to life is mostly due to associated injuries. Therefore assessment of facial trauma usually takes place in the secondary survey.
3
It is vitally important to understand the relationship between structure and function in managing facial trauma. Functions of the face include vital activities, sensation, and important social functions. Cosmetic outcome cannot be separated from functional outcome in facial trauma.
4
Plain radiographs are rarely used and have been replaced by computed tomography (CT) scanning; however, the orthopantomogram is still valued by some dental surgeons, who may provide definitive care for some facial trauma.
5
Although difficult, some assessment of vision must be made after facial trauma, as simple procedures may be sight-saving.

Introduction

This chapter covers the assessment and emergency department (ED) management of facial injuries. Eye injuries, dental trauma and radiology of dental trauma are covered in detail elsewhere in this book.

Facial trauma is most common in young males; drug and/or alcohol intoxication is frequently involved. Aetiology varies around the world. The main causes in adults are road trauma, interpersonal violence, falls and sporting injuries. Most of the developing world is seeing an increasing frequency of road trauma as a cause, whereas parts of the developed world have witnessed reductions in such injuries due to legislative and technological changes. Falls in elderly people are becoming a more common cause in developed countries as populations age. Intimate partner violence is often associated with facial injury, especially affecting female patients .

Anatomically, the face is supported on a bony scaffold that is suspended beneath the base of the anterior and middle cranial fossae. Muscles are grouped into the superficial layer of muscles of facial expression, the deep muscles of mastication and the tongue and the musculature of the oropharynx. Viscera include the eyes, the salivary and lacrimal glands and ducts and the upper parts of the hollow viscera or the gastrointestinal and respiratory tracts.

Vital functions include eating and drinking (mastication, salivation and swallowing) and breathing (the upper airway). Sensory function is performed by the organs for sight, hearing, smell and taste as well as a finely mapped area of touch and proprioceptive sensation. Activities critical to human social functions include facial expression and speech, gestures of affection and sexuality and identification.

The intimate relationship between form and function is demonstrated extremely clearly in the face. After immediate threats to life are excluded or managed, the goal of management of facial trauma is to return the face to as close to its normal form as possible, although association between facial trauma and psychological difficulties may be less clear than previously assumed.

Association with other injury

Estimates of the rate of associated life-threatening injury depend on the population surveyed; however, it is reported as high as 20% in some series.

Risk of associated injuries is proportional to the force transmitted, and the severity of facial injury correlates with the likelihood of associated injury. High-energy facial injuries include fractures of the frontal bone and symphysis mandible, whereas isolated fractures of the zygoma, nasal bones and angle of the mandible occur with relatively low levels of energy transfer. As well as occurring as part of complex multi-system trauma, facial injuries may be directly associated with injury to the brain, cervical spine and cerebrovascular system.

Mandibular and displaced mid-face fractures occurring in high-energy mechanisms (e.g. motor vehicle crashes) are associated with blunt cerebrovascular injury; however, this is not the case with low-energy mechanisms (e.g. a punch to the face).

Simple assaults resulting in facial fracture are unlikely to cause cervical spine injury unless there is an associated fall.

Increased age, a lower score on the Glasgow Coma Scale (GCS), another injury below the face and high-energy mechanisms are all associated with injury to the cervical spine and blunt cerebrovascular and/or brain injury.

Patient frailty, medical co-morbidities and the effects of polypharmacy are important to consider in the case of elderly patients with low falls; such individuals are at risk of complex multisystem trauma from relatively minor mechanisms.

History

As with all trauma, it is essential to determine the mechanism of injury for risk stratification and to guide further assessment. Sensitive enquiry about intimate partner violence should also be made. The use of anticoagulants and anti-platelet agents should be documented.

Primary survey

The primary survey should be completed as usual regardless of the apparent severity of the facial injury, ensuring that associated life-threatening injury is excluded or managed before non–life threatening facial injury.

When facial trauma itself is life-threatening, it will be due to either airway obstruction or uncontrolled haemorrhage.

Airway

Airway management in facial trauma presents a challenge of competing priorities. Simple, isolated facial trauma that can be assessed and managed in a position of comfort for the patient is unlikely to involve airway challenges. More severe facial trauma—in which the airway may be threatened by blood, deformity, oedema or loose bodies like teeth, bone fragments and projectiles—is more commonly associated with other injury, including spinal injury. This mandates initial assessment and management in the supine position, which impedes the patient’s ability to manage his or her own airway.

When a sophisticated trauma team response is possible, these competing demands are dealt with by expert and prompt management of the airway by a dedicated provider supported by assistants as required. Thus prompt exclusion or stabilization of other injuries will allow for better patient positioning as soon as practicable. In austere settings it may be necessary to accept a position other than supine, allowing the patient to manage his or her own airway until more resources can be deployed.

Signs of partial airway obstruction include restlessness, agitation, inability to lie flat, gurgling, snoring and stridor as well as signs of increased respiratory effort. It is important to remember that airway obstruction can be a dynamic process, developing as oedema or bleeding increase or as conscious state decreases.

Usual airway management skills should be employed. Jaw thrust and suction may significantly improve the airway function of an injured face. An assistant can provide continuous suction. Unstable fractures of the mandible or mid-face may need to have anterior traction applied to open the airway and reduce haemorrhage.

In a badly injured face the main barriers to laryngoscopy are blood, loose bodies and altered anatomy rather than geometry and patient resistance. Rapid sequence induction may be modified to allow for attempted laryngoscopy after the induction of anaesthesia but before muscle relaxation has been administered, allowing the airway reflexes to keep the airway open until it can be secured or until the cords are visualized. Easy recourse to a surgical airway must be available and should be explicitly planned for. In occasional cases a primary surgical airway will be the safest option.

Breathing

The assessment and management of breathing generally focuses on other injuries or lung injury due to aspirated blood or teeth. A two-person bag-valve-mask technique may be required owing to the effects of facial deformity.

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