Facial trauma commonly presents in Emergency Departments and primary care. More advanced facial trauma will be redirected to major trauma centres. Due to the proximity to vital structures, it is essential to be able to assess these injuries appropriately and escalate accordingly.

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History

If the patient is stable, it is important to start with a thorough history.

• Main presenting complaint and symptoms
• Date, location and time of incident
• Mechanism of injury?
  • Road traffic accident – driver/passenger, vehicle type, seatbelt, helmet
  • Assault – mechanism, number of blows, location of injuries
  • Sports
  • Fall – walking, running, collapse, from a height?
• Any other bodily injury?
• Any police involvement?
• Any signs of intracranial injury? (LOC, vomiting, nausea, headache)
• Any visual disturbances, numbness/weakness, or malocclusion?

Examination

Use a systematic approach to ensure you do not miss any key areas. Below is one approach you can use; it lists common pathologies and deformities to look out for.

• General Inspection
  • Look for any wounds, bleeding, burns
  • Look for swelling, bruising
  • Assess for facial asymmetry
• Cranium and Ears
  • Palpate for deformity/depression
  • Inspect external auditory canal, consider otoscopy
  • Assess ear for soft tissue injury – lacerations and pinna haematomas
• Frontal
  • Palpate for deformity
  • Assess supraorbital numbness to light touch (CN V1)
• Orbital
  • Ensure to inspect the eyeball even if swollen
  • Look from above for proptosis (retrobulbar haemorrhage)
  • Look for subconjunctival haemorrhage
  • Assess eye movements while checking for diplopia
  • Palpate periorbital tissues and orbital rim for emphysema, tenderness, bony steps
  • Assess pupillary reaction to light
  • Assess visual acuity
• Nasal
  • Look for deviation and flattening
  • Inspect for rhinorrhoea and epistaxis
  • Palpate for bony tenderness
  • Assess patency of each nostril
  • Assess for septal haematoma
• Zygoma
  • Inspect for flattening of the malar prominence
  • Inspect for trismus as fracture cheekbone can impact opening of mandible
  • Palpate for bony tenderness
• Maxilla
  • Look for deformity, facial asymmetryPalpate for bony tendernessAssess for infraorbital numbness (CN V2 deficit)Inspect for malocclusion, missing/fractured teeth and defects/tenderness of the hard palate
  • Assess mobility of maxilla only once to prevent bleeding
• Mandible
  • Assess mouth opening and record in mm
  • Inspect for facial swelling/deformity
  • Palpate for step deformity/bony tenderness
  • Palpate the TMJ
  • Assess for numbness (CN V3 defect)
  • Look for sublingual haematoma
  • Assess for dental trauma/step deformity and occlusion

Investigations

Orbital fractures

Orbital fractures are common given natural areas of weakness in the orbital bones designed to protect the eyeball. Most commonly the walls of the orbit that are broken are the floor (roof of the maxillary sinus) and the medial wall.

Patients with orbital fractures will present with swelling and periorbital bruising. It is essential that a comprehensive examination is done to detect damage to the eyeball, optic nerve or muscles. Even if severely swollen, the eyelids must be pried open to assess the eyeball.

Examination of possible orbital floor fracture:

• Presence of proptosis/exophthalmos, enophthalmos or hypoglobus
• Visual acuity in both eyes
• Check eye movements
• Presence of diplopia and in which gaze?
• Subconjunctival haematoma
• Pupils and reaction to light

Sometimes the fat or inferior rectus muscle can get trapped in a fracture and cause restriction in upward gaze. This normally resolves once the swelling improves.

If there are no concerning features such as damage to the eyeball, reduction in visual acuity, proptosis, most patients can be discharged with safety netting advice and brough back to OMFS outpatient clinic in 5-7 days. However, all these patients should ideally be examined by an OMFS specialist prior to discharge. Patients normally have surgery if there is a cosmetic or functional issue such as ongoing diplopia or restricted gaze. They must avoid blowing their nose for 6 weeks.

Rarely if children have an orbital floor fracture, the elastic bone can spring back into place trapping the soft tissue. This can lead to the oculo-cardiac reflex causing vomiting and bradycardia. This is a life-altering injury and requires immediate surgery.

Orbital Compartment Syndrome

In all facial trauma, but particularly with orbital fractures, it is crucial to check for orbital compartment syndrome. The orbit is a bony cavity with no ability to expand. Any swelling in this area posterior to the eyeball will increase the pressure and cause permanent damage to the optic nerve and retinal artery resulting in blindness. Swelling is most commonly caused by blood (retrobulbar haemorrhage) but can be caused by air, infection or tumours.

Signs of orbital compartment syndrome:

• Severe eye behind pain
• Reduced and painful eye movements
• Proptosis
• Reduced visual acuity
• Tense globe
• Pupil defect

Treatment is urgent surgical decompression in the form of a lateral canthotomy to allow the pressure to be released.

Nasal fractures

The nose is prone to injuries. Normally if it is an isolated nasal fracture with no concerning features the patient is reviewed by ENT in outpatient clinic once the swelling has reduced (7-10 days). Patients with complex nasal fractures involving other facial fractures are often seen by OMFS. If surgery is indicated, the nasal bones are manipulated under anaesthesia and splinted until healed in a more favourable position.

Mandibular fractures

Mandible fractures are commonly seen following trauma given its structure and position.

Signs and symptoms of mandible fractures:

• Obvious jaw deformity
• Pain and swelling in the jaw
• Altered occlusion (teeth not meeting as they should)
• Numbness or paraesthesia of the inferior dental nerve
• Gingival tear or bleeding around the teeth in the lower jaw or floor of mouth

For isolated mandible injuries, it is essential to get 2 radiographic views – an orthopantogram (OPG) and a PA mandible (XR mandible). Due to the U-shape of the mandible, it is common for it to be fractured in 2 places. For more complex fractures a CT scan may be needed for surgical planning. Nearly all mandible fractures require urgent OMFS review, admission and surgery within a few days of injury, with IV antibiotics due to the risk of infection and airway compromise. Most will have open reduction and internal fixation done by the OMFS team.

Midface fractures

Midface fractures are commonly the result of blunt trauma. They are often complex and don’t fit into specific categories. All must be reviewed by an OMFS doctor.

Le Fort fracture classification

Le Fort fractures are midface fractures which involve separation of a portion of the midface from the skull base. Therefore, by definition, they must involve fracture on the pterygoid plates on the sphenoid bone. It is important to remember that these rarely occur fully in isolation.

1. Le Fort I – horizontal fracture line separating palate from maxillary complex
2. Le Fort II – Horizontal fracture line crossing bridge of nose superiorly (pyramid)
3. Le Fort III – High horizontal fracture through nasofrontal buttress, orbital floors and zygomaticofrontal sutures (craniofacial dysfunction)

The majority of these patients can be discharged and brought back to OMFS outpatient clinic once the swelling (5-7 days) has settled for surgical planning. If the fractures are very unstable, there is uncontrolled bleeding, or any risk of airway compromise the patient must be admitted.

Zygoma fractures

Zygomatic arch and zygomatic complex fractures are very common, especially in sports. They commonly present with a ‘flattened cheekbone’ and can involve orbital rim as well. Again, these can normally be brought back to OMFS clinic in 5-7 days to decide if surgery is needed. Sometimes the fracture can impinge on the mandible preventing opening and closing of the jaw which may need more urgent surgery.

Zygomatic complex fractures involve the following structures:

• Zygomatic arch
• Inferior orbital rim, and anterior and posterior maxillary sinus walls
• Lateral orbital rim

Alternatively, patients can present with isolated zygomatic arch (‘cheekbone’) fractures.

Facial lacerations

Facial lacerations presenting to ED are common. It is important to remember to assess the vital structures of the face in all these patients to ensure there is no underlying injury. Many of these injuries will bleed profusely given the vasculature of the face but normally stop quickly.

When examining these lacerations, it is important to assess for the following:

• Where is the wound and are there any functional/aesthetic implications?
• When did the injury occur?
• Is the wound clean or contaminated?
• Is there any damage to underlying structures? E.g. Vasculature, nerves (facial nerve), other structures (parotid duct)
• Is there any tissue loss?
• Can the wound be closed under local anaesthetic or is formal exploration and debridement needed under general anaesthetic?
• Are there any underlying fractures?

Most simple lacerations can be closed by ED doctors or nurses. However, if severely contaminated, large, with underlying damage to structures, uncontrolled bleeding or requiring a general anaesthetic then specialist input is needed (OMFS, ENT or plastics).

Specific areas listed below may also need specialist involvement:

• Eyelids
• Nasal lacerations exposing the cartilage
• Lacerations crossing the vermillion border of the lip
• Neck

Closing facial lacerations:

• Assess for any damage to underlying structures (facial nerve, parotid duct)
• Give local anaesthetic around the laceration if using sutures
• Wash thoroughly with saline +/- iodine if contaminated
• Close with sutures (non-resorbable unless on children or patients where they will be difficult to remove), steri-strips or glue

Antibiotic prophylaxis should be given if contaminated or if there are any bites. Tetanus prophylaxis should be offered to all eligible patients.

Wound care:

• Keep dry for 3-5 days
• Sutures to be removed by GP/outpatient department in 7-10 days
• Return if any signs of infection (redness, swelling, warmth, pus/discharge)

Conclusion

Facial injuries are common and present frequently. It is important that all medical professionals can assess these and escalate appropriately to prevent long-lasting or life-changing consequences.

References

• On-call in Oral and Maxillofacial Surgery. F Payne, K.F., Goodson, A.M., Tahim, A.S., Ahmed, N. and Fan, K.F., 2015.
• Oral and Maxillofacial Surgery: An Illustrated Guide for Medical Students and Allied Healthcare Professionals. Isaac, R., Goodson, A.M., Payne, K.F., Tahim, A.S. and Brennan, P.A., 2022. (available for free online through BAOMS)
• Radiopaedia.org

Written by Dr Janhvi Shah BDS (Hons) MBBS MFDS (RCSEd) PgCert MedEd