Initial evaluation and management of facial trauma in adults
- Ryanne J Mayersak, MD, MS
Ryanne J Mayersak, MD, MS
- Assistant Professor of Emergency Medicine
- Assistant Residency Director
- Oregon Health & Science University
The face is vital to human appearance and function. Facial injuries can impair a patient's ability to eat, speak, interact with others, and perform other important functions. Studies suggest that disfiguring facial injuries can have severe psychological and social consequences [1-9]. The treatment of facial injuries must first focus on threats to life, but important secondary considerations are function and long-term cosmesis.
The basic anatomy, clinical manifestations, and acute management of facial trauma in adults will be reviewed here. Eye injuries, pediatric facial trauma, and other aspects of facial trauma management are discussed separately. (See "Open globe injuries: Emergent evaluation and initial management" and "Orbital fractures" and "Retinal detachment" and "Oropharyngeal trauma in children" and "Nasal trauma and fractures in children" and "Jaw fractures in children".)
Sports like football, baseball, and hockey account for a high percentage of facial injuries among young adults [10-16]. Severe injuries often occur as a result of motor vehicle collisions, including those involving motorcycles and all-terrain vehicles, as well as interpersonal and domestic violence [17-20]. Other mechanisms include falls, animal bites, and recreational activities. Among combatants, facial injuries occur from gunshot wounds and other explosive or incendiary devices . Facial trauma sustained from gunshot wounds or explosions is associated with greater morbidity and higher mortality rates [22,23]. Associated head and cervical spine injuries are common in patients with significant facial trauma .
ANATOMY, PHYSIOLOGY, AND MECHANISM
The face is anatomically complex. It includes skin, muscles responsible for both gross motor function (eg, mastication) and subtle facial expression, a complex bony structure, and vital sensory organs. Injuries to the face may compromise the patient's ability to breathe, see, speak, hear, and eat, and may involve damage to the central nervous system.
●Bones – The posterior portions of the face form the anterior wall of the calvaria. Thus, the face lies in close proximity to the central nervous system. The anterior facial skeleton is composed of the frontal bone, nasal bones, zygomas, maxillary bones, and mandible (figure 1 and figure 2). The sphenoid, ethmoid, lacrimal, vomer, and temporal bones lie deeper within the facial structure, providing support and sites for muscular attachments, including the muscles used for chewing, speaking, and swallowing.
The temporomandibular joint (TMJ) is the only joint of the face and it engages in complex motions. The condyle of the mandible rotates and translates anteriorly (ie, moves forward) when the mouth opens. A meniscus, which overlies the condyle, maintains the joint and enables motion. The meniscus and the condyle form a hinged joint, allowing rotation, while the meniscus and the temporal bone form a sliding joint, allowing translation.
- Rankin M, Borah GL. Perceived functional impact of abnormal facial appearance. Plast Reconstr Surg 2003; 111:2140.
- Langlois JH, Kalakanis L, Rubenstein AJ, et al. Maxims or myths of beauty? A meta-analytic and theoretical review. Psychol Bull 2000; 126:390.
- Pashos A, Niemitz C. Results of an explorative empirical study on human mating in Germany: handsome men, not high-status men, succeed in courtship. Anthropol Anz 2003; 61:331.
- Thornton B, Ryckman RM. Relationship between physical attractiveness, physical effectiveness, and self-esteem: a cross-sectional analysis among adolescents. J Adolesc 1991; 14:85.
- Glynn SM, Shetty V, Elliot-Brown K, et al. Chronic posttraumatic stress disorder after facial injury: a 1-year prospective cohort study. J Trauma 2007; 62:410.
- Shetty V, Dent DM, Glynn S, Brown KE. Psychosocial sequelae and correlates of orofacial injury. Dent Clin North Am 2003; 47:141.
- Wong EC, Marshall GN, Shetty V, et al. Survivors of violence-related facial injury: psychiatric needs and barriers to mental health care. Gen Hosp Psychiatry 2007; 29:117.
- Glynn SM, Asarnow JR, Asarnow R, et al. The development of acute post-traumatic stress disorder after orofacial injury: a prospective study in a large urban hospital. J Oral Maxillofac Surg 2003; 61:785.
- Borah GL, Rankin MK. Appearance is a function of the face. Plast Reconstr Surg 2010; 125:873.
- Kraus JF, Rice TM, Peek-Asa C, McArthur DL. Facial trauma and the risk of intracranial injury in motorcycle riders. Ann Emerg Med 2003; 41:18.
- Shapiro AJ, Johnson RM, Miller SF, McCarthy MC. Facial fractures in a level I trauma centre: the importance of protective devices and alcohol abuse. Injury 2001; 32:353.
- Perkins SW, Dayan SH, Sklarew EC, et al. The incidence of sports-related facial trauma in children. Ear Nose Throat J 2000; 79:632.
- Marshall SW, Mueller FO, Kirby DP, Yang J. Evaluation of safety balls and faceguards for prevention of injuries in youth baseball. JAMA 2003; 289:568.
- Ogundare BO, Bonnick A, Bayley N. Pattern of mandibular fractures in an urban major trauma center. J Oral Maxillofac Surg 2003; 61:713.
- Reehal P. Facial injury in sport. Curr Sports Med Rep 2010; 9:27.
- Erdmann D, Follmar KE, Debruijn M, et al. A retrospective analysis of facial fracture etiologies. Ann Plast Surg 2008; 60:398.
- Holmes PJ, Koehler J, McGwin G Jr, Rue LW 3rd. Frequency of maxillofacial injuries in all-terrain vehicle collisions. J Oral Maxillofac Surg 2004; 62:697.
- Shults RA, Wiles SD, Vajani M, Helmkamp JC. All-terrain vehicle-related nonfatal injuries among young riders: United States, 2001-2003. Pediatrics 2005; 116:e608.
- Arosarena OA, Fritsch TA, Hsueh Y, et al. Maxillofacial injuries and violence against women. Arch Facial Plast Surg 2009; 11:48.
- Motamedi MH, Dadgar E, Ebrahimi A, et al. Pattern of maxillofacial fractures: a 5-year analysis of 8,818 patients. J Trauma Acute Care Surg 2014; 77:630.
- Owens BD, Kragh JF Jr, Wenke JC, et al. Combat wounds in operation Iraqi Freedom and operation Enduring Freedom. J Trauma 2008; 64:295.
- Pereira C, Boyd JB, Dickenson B, Putnam B. Gunshot wounds to the face: level I urban trauma center: a 10-year level I urban trauma center experience. Ann Plast Surg 2012; 68:378.
- Shackford SR, Kahl JE, Calvo RY, et al. Gunshot wounds and blast injuries to the face are associated with significant morbidity and mortality: results of an 11-year multi-institutional study of 720 patients. J Trauma Acute Care Surg 2014; 76:347.
- Mulligan RP, Friedman JA, Mahabir RC. A nationwide review of the associations among cervical spine injuries, head injuries, and facial fractures. J Trauma 2010; 68:587.
- Rosen CL, Wolfe RE, Chew SE, et al. Blind nasotracheal intubation in the presence of facial trauma. J Emerg Med 1997; 15:141.
- Walls RM. Blind nasotracheal intubation in the presence of facial trauma--is it safe? J Emerg Med 1997; 15:243.
- Roppolo LP, Vilke GM, Chan TC, et al. Nasotracheal intubation in the emergency department, revisited. J Emerg Med 1999; 17:791.
- Kalavrezos ND, Graetz KW, Eyrich GK, Sailer HF. Late sequelae after high midface trauma. J R Coll Surg Edinb 2000; 45:359.
- Freihofer HP. Inner intercanthal and interorbital distances. J Maxillofac Surg 1980; 8:324.
- Gulses A, Varol A, Gayretli O, et al. Anthropometry of the medial canthal ligament related to naso-orbitoethmoidal fractures. J Craniofac Surg 2012; 23:1151.
- Murphy WK, Laskin DM. Intercanthal and interpupillary distance in the black population. Oral Surg Oral Med Oral Pathol 1990; 69:676.
- Sargent LA, Rogers GF. Nasoethmoid orbital fractures: diagnosis and management. J Craniomaxillofac Trauma 1999; 5:19.
- Committee on Trauma. Upper Facial Trauma. In: Resident Manual of Trauma to the Face, Head, and Neck, 1st ed, American Academy of Otolyaryngology Head and Neck Surgery, 2012.
- Alonso LL, Purcell TB. Accuracy of the tongue blade test in patients with suspected mandibular fracture. J Emerg Med 1995; 13:297.
- Schwab RA, Genners K, Robinson WA. Clinical predictors of mandibular fractures. Am J Emerg Med 1998; 16:304.
- Caputo ND, Raja A, Shields C, Menke N. Re-evaluating the diagnostic accuracy of the tongue blade test: still useful as a screening tool for mandibular fractures? J Emerg Med 2013; 45:8.
- Dula DJ, Fales W. The 'ring sign': is it a reliable indicator for cerebral spinal fluid? Ann Emerg Med 1993; 22:718.
- McCudden CR, Senior BA, Hainsworth S, et al. Evaluation of high resolution gel β(2)-transferrin for detection of cerebrospinal fluid leak. Clin Chem Lab Med 2013; 51:311.
- Prosser JD, Vender JR, Solares CA. Traumatic cerebrospinal fluid leaks. Otolaryngol Clin North Am 2011; 44:857.
- Sun JK, LeMay DR. Imaging of facial trauma. Neuroimaging Clin N Am 2002; 12:295.
- Pogrel MA, Podlesh SW, Goldman KE. Efficacy of a single occipitomental radiograph to screen for midfacial fractures. J Oral Maxillofac Surg 2000; 58:24.
- McGhee A, Guse J. Radiography for midfacial trauma: is a single OM 15 degrees radiograph as sensitive as OM 15 degrees and OM 30 degrees combined? Br J Radiol 2000; 73:883.
- Goh SH, Low BY. Radiologic screening for midfacial fractures: a single 30-degree occipitomental view is enough. J Trauma 2002; 52:688.
- Escott EJ, Branstetter BF. Incidence and characterization of unifocal mandible fractures on CT. AJNR Am J Neuroradiol 2008; 29:890.
- Dolynchuk KN, Tadjalli HE, Manson PN. Orbital volumetric analysis: clinical application in orbitozygomatic complex injuries. J Craniomaxillofac Trauma 1996; 2:56.
- Remmler D, Denny A, Gosain A, Subichin S. Role of three-dimensional computed tomography in the assessment of nasoorbitoethmoidal fractures. Ann Plast Surg 2000; 44:553.
- Saigal K, Winokur RS, Finden S, et al. Use of three-dimensional computerized tomography reconstruction in complex facial trauma. Facial Plast Surg 2005; 21:214.
- Kelley P, Hopper R, Gruss J. Evaluation and treatment of zygomatic fractures. Plast Reconstr Surg 2007; 120:5S.
- Sargent LA. Nasoethmoid orbital fractures: diagnosis and treatment. Plast Reconstr Surg 2007; 120:16S.
- Avery LL, Susarla SM, Novelline RA. Multidetector and three-dimensional CT evaluation of the patient with maxillofacial injury. Radiol Clin North Am 2011; 49:183.
- McIlrath ST, Blaivas M, Lyon M. Diagnosis of periorbital gas on ocular ultrasound after facial trauma. Am J Emerg Med 2005; 23:517.
- Nunn KP, Thompson PK. Towards evidence based emergency medicine: PRIVATE Best BETs from the Manchester Royal Infirmary. BET 1: Can the nature and extent of orbital trauma be optimally assessed with ultrasound imaging in the emergency department? Emerg Med J 2011; 28:809.
- Forrest CR, Lata AC, Marcuzzi DW, Bailey MH. The role of orbital ultrasound in the diagnosis of orbital fractures. Plast Reconstr Surg 1993; 92:28.
- Charalambous C, Dunning J, Omorphos S, et al. A maximally sensitive clinical decision rule to reduce the need for radiography in mandibular trauma. Ann R Coll Surg Engl 2005; 87:259.
- Shimoyama T, Kaneko T, Horie N. Initial management of massive oral bleeding after midfacial fracture. J Trauma 2003; 54:332.
- Bynoe RP, Kerwin AJ, Parker HH 3rd, et al. Maxillofacial injuries and life-threatening hemorrhage: treatment with transcatheter arterial embolization. J Trauma 2003; 55:74.
- Dakir A, Ramalingam B, Ebenezer V, Dhanavelu P. Efficacy of Tranexamic Acid in Reducing Blood Loss during Maxillofacial Trauma Surgery-A Pilot Study. J Clin Diagn Res 2014; 8:ZC06.
- Singer AJ, Mach C, Thode HC Jr, et al. Patient priorities with traumatic lacerations. Am J Emerg Med 2000; 18:683.
- Moran GJ, Talan DA, Abrahamian FM. Antimicrobial prophylaxis for wounds and procedures in the emergency department. Infect Dis Clin North Am 2008; 22:117.
- Mondin V, Rinaldo A, Ferlito A. Management of nasal bone fractures. Am J Otolaryngol 2005; 26:181.
- Fraioli RE, Branstetter BF 4th, Deleyiannis FW. Facial fractures: beyond Le Fort. Otolaryngol Clin North Am 2008; 41:51.
- Bell RB, Dierks EJ, Homer L, Potter BE. Management of cerebrospinal fluid leak associated with craniomaxillofacial trauma. J Oral Maxillofac Surg 2004; 62:676.
- Belmonte FM, Macedo CR, Day PF, et al. Interventions for treating traumatised permanent front teeth: luxated (dislodged) teeth. Cochrane Database Syst Rev 2013; :CD006203.
- Schatz JP, Hausherr C, Joho JP. A retrospective clinical and radiologic study of teeth re-implanted following traumatic avulsion. Endod Dent Traumatol 1995; 11:235.
- Petrovic B, Marković D, Peric T, Blagojevic D. Factors related to treatment and outcomes of avulsed teeth. Dent Traumatol 2010; 26:52.
- ANATOMY, PHYSIOLOGY, AND MECHANISM
- PATHOPHYSIOLOGY OF INJURY
- PREHOSPITAL MANAGEMENT
- HISTORY AND PHYSICAL EXAMINATION
- Initial assessment
- General examination
- Examination of specific body parts
- DIAGNOSTIC IMAGING
- Cerebrovascular injury
- Facial injury
- Ocular and orbital injury
- Nasal injury
- Mandibular injury
- GENERAL MANAGEMENT OF ACUTE INJURIES
- Facial injuries associated with cerebrovascular trauma or intracranial hemorrhage
- Prophylaxis against infection
- SPECIFIC INJURIES
- Oral lacerations
- Dental injury
- Temporomandibular joint
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS