Initial Assessment of the Facial Trauma Patient

Abstract

The initial evaluation of the craniofacial trauma patient must be systematic, thorough, and consistent to ensure that injuries are not missed. Life-threatening conditions are first identified using ATLS principles, and focused head and neck examination conducted by a specialist then follows. Imaging is used to guide operative planning, as many craniofacial injuries ultimately benefit from repair to prevent permanent cosmetic or functional deformity. Peri-operative care is often multi-disciplinary in nature, and specialist consultation should be performed in an efficient fashion. Finally, it should be noted that surgeons operating in the maxillofacial region are at high risk for transmission of COVID-19, and risk of COVID-19 sequelae must be balanced with risks associated with the delay of treatment of craniofacial injury.

Initial Evaluation

The initial evaluation of the craniofacial trauma patient should follow established protocols for all trauma patients as described by Advanced Trauma and Life Support (ATLS) principles. ^{1 2} This typically occurs upon patient presentation to the emergency department, urgent care or primary provider, but should be reviewed by consulting providers to ensure appropriate evaluations and interventions have taken place prior to addressing secondary concerns.

Per ATLS protocols, patients should undergo primary and secondary surveys based on the “ABCs.” These consist of: evaluation of the upper respiratory tract (“Airway”) with urgent management as needed, confirmation or restoration of adequate oxygenation and ventilation (“Breathing”), and assurance or restoration of hemodynamic stability (“Circulation”). ^{2 3} Subsequent to this, determination of neurological status (“D” for deficits) can help identify comorbid intracranial or spine injury, relevant cranial nerve injury, and may guide timing and fitness for surgical intervention.

Airway Evaluation

Examination of the airway is of particular concern in facial trauma patients given the risk of obstruction from a variety of causes. These include: the presence of foreign bodies, injury to upper airway structures, central or peripheral neurological injury causing loss of muscle tone of the tongue, palate and pharynx, hemorrhage in the upper aerodigestive tract, and aspiration of gastric contents. ^{1 2 4} Though these issues are typically identified immediately after injury, some may present later since edema can worsen over 48 to 72 hours after injury and neurological status can fluctuate depending on the nature and degree of injury. When the airway may be at risk, there should be a low threshold to secure the airway with endotracheal intubation and consideration of emergent surgical airway, such as tracheotomy or cricothyrotomy when necessary. ^{2 3 4}

Oxygenation and Ventilation

Evaluation of the adequacy of oxygenation and ventilation should be of highest priority since anoxia can result in death in 4–5 minutes, and neurological deficits can occur with shorter periods of anoxia or hypoventilation. ^{2 3} In the initial period, providing adequate cardiopulmonary support using Basic Life Support (BLS) protocols can be life-saving. Patients with facial trauma are also at risk of concurrent intrathoracic or other aerodigestive tract injury that may also affect pulmonary function. Pulmonary status, like upper airway status, can also change rapidly since aspiration of blood or gastric contents can evolve into pneumonitis or pneumonia and as such, continued awareness and monitoring in the immediate post-injury period may be warranted.

Hemodynamic Function

Significant hemorrhage may result from trauma to the head and neck due to its rich, extensive blood supply. ^{2 3} Facial and scalp lacerations are often clear sources of external blood loss. ^{2 4} In the midface, damage to branches of the internal and external carotid artery systems and ethmoidal arteries can cause high-volume bleeding when nasal or midface fractures are present. ² Hemorrhage in these areas should be identified and controlled with direct pressure, packing or ligation where indicated. ^{2 3 4} Liquid thrombin, epinephrine, surgical, silver nitrate, and electrocautery, when available, make excellent adjuncts. ^{2 3} In the case of critical bleeding in need of immediate stabilization, consultation with interventional radiology for angiography and/or embolization may be warranted. ²

Focused History of the Craniofacial Trauma Patient

History is ideally obtained directly from a patient that is awake, alert and oriented. However, in the case of patients that are intubated and sedated, obtunded or whose mental status is otherwise altered, collateral information from family, friends, ancillary providers or documentation from referring institutions. ⁵ Important details that should be documented include the timing of the event, mechanism of injury and related events, relevant past medical and surgical history, allergies, current medications, and n.p.o. status. ^{3 5} Review of systems and discussion of symptoms related to functional concerns including changes in general appearance, vision, hearing, occlusion and neurosensory changes should be well-characterized and documented, especially if operative intervention is indicated. ^{3 5}

The Head and Neck Exam

The clinical head and neck exam is the foundation of treatment planning. ⁶ As such, it must be systematic, thorough, and consistent to ensure that injuries are not missed. ⁴ However, in some circumstances, it can be helpful to avoid beginning with obvious injuries to prevent pain that may limit the full exam. Instruments and supplies needed include examination gloves, tongue depressors, a Snellen chart, nasal speculum, light source, otoscope and ophthalmoscope. ⁷

Beginning at the top of the head, the scalp should be assessed for soft tissue injuries such as abrasions, contusions, lacerations, and hematomas, with examination of open wounds as indicated for evaluation of foreign body contamination, depth of injury and disruption of neurovascular structures. ^{4 7} Bony cranial deformities should also be noted at this time. Evaluation of the remaining soft tissues of the head and neck can occur in tandem with evaluation of critical anatomical structures, but should include a similar approach, appreciating extent of injury and soft tissue loss, as well as proximity to anatomic structures, risk of neurovascular injury, and communication with sinuses, nasal cavity, mouth and upper aerodigestive tract.

Examination of the periorbital region begins with inspection of the soft tissues, noting patterns of ecchymosis and edema, particularly characteristic of patterns of injury such as bilateral periorbital ecchymosis (racoon eyes) as a sign of skull base injury. ⁷ Lid injury and lid position should be noted, particularly inability for the lids to close since this, if left untreated, can cause, or exacerbate corneal injury. Further evaluation should then include evaluation of globe position, symmetry of the corneal light reflex, pupillary size and symmetry, pupillary light reaction, visual acuity, visual fields, and extraocular mobility. ^{7 8 9} In situations where there is extensive edema preventing lid opening, assistance may be required to retract the lids. If there is risk of or concern for corneal injury or globe injury, ophthalmoscopy and evaluation with fluorescein dye may be of benefit. When available, intraocular pressures should be measured.

Evaluation of the ears begins with inspection of the mastoid process and external ear for obvious injury, including mastoid ecchymosis (Battle's sign for skull base fracture), hematoma or other deformity of the auricular cartilage. ³ The external ear canal should be inspected for signs of bloody otorrhea suggestive of external or middle ear injury or clear otorrhea concerning for cerebrospinal fluid (CSF) leak. If there are concerns for hearing deficit, a tuning fork test can be used to identify conductive or sensorineural hearing loss. Otoscopy should then be performed to determine the integrity of the external auditory canal and the tympanic membranes examined for hemotympanum or rupture. ⁷

The external nose should then be inspected for deformity and signs of injury, and palpated for tenderness, edema, crepitus, and bony displacement. ⁷ The nasal cavities should be examined with a nasal speculum and light source to assess patency of the nasal airway, identify any injury and to rule out a nasal septal hematoma. ³

Examination of the lower face begins with inspection of the lips and soft tissues of the cheeks, chin, and jaw for the presence of soft tissue injuries, especially those involving important aesthetic landmarks such as the melolabial fold, philtrum and vermilion border of the lip. Oral cavity examination should be performed with a light source and tongue depressor to examine all surfaces for signs of injury, with special note of injury to important structures such as salivary gland ducts. ⁷ The presence of edema and hematoma should be noted, including that involving the hard and soft palate, tongue and floor of mouth as these can represent impending airway concerns. The maxilla and mandible should be palpated bimanually for the presence of tenderness, bony displacement and mobility to identify closed and/or open fractures. Evaluation of dentition should include overall dental and gingival health, as well as fracture, avulsion, luxation, other malpositioning, malocclusion or absence of teeth. ⁹ Missing teeth should be accounted for as aspiration or swallowing may have occurred and additional imaging may be indicated to determine the location of any missing fragments.

Neurosensory examination of the face must be performed on every initial evaluation. ⁴ If a patient is too sedated to cooperate with the exam, the exam should be repeated once the patient is responsive. Ideally, this examination should be included as part of a complete cranial nerve examination, that documents: pupillary reactivity, extraocular muscle movement, sensation in all trigeminal nerve distributions, facial movement in upper, middle, and lower divisions, hearing (via tuning fork test) when indicated, palate symmetry and presence of gag reflex, tongue mobility, and shoulder strength. If a patient cannot cooperate fully, symmetry of grimace in response to any noxious stimuli can be noted, as well as presence of corneal reflex, and gag reflex. Forced duction tests can also be performed to ensure there is no extraocular muscle entrapment.

Following neurosensory examination, palpation of the bones of the face should be performed. ^{3 7} This is often left to the end of the examination to minimize patient discomfort. A systematic approach should be used, although deferral of the obvious areas of injury until the end can be considered to minimize pain. Key bony landmarks including the following should be palpated for tenderness and step-off deformities: the supraorbital and lateral orbital rims, malar eminences, zygomatic arches, temporomandibular joints, nasal bones, alveolar arch, and mandible. ^{3 7} This examination can transition to a screening examination of the neck, with the posterior neck evaluated for cervical spine injury, and the anterior neck for hematomata, soft tissue injury (particularly that extends deep to the platysma warranting further evaluation), and to ensure airway landmarks are palpable in case urgent airway intervention is needed.

Investigations

Imaging of the facial trauma patient is valuable for evaluating injury in the acute setting, as well as for operative planning. Plain radiographs historically were standard imaging but typically do not provide enough information regarding injury severity and displacement, which are essential for surgical planning. ¹⁰ They are still used in locations were where computer tomography (CT) scanning is not available. Maxillofacial CT scans are currently the gold standard for imaging of facial trauma. ^{1 3 4 10} Institutional protocols vary with regard to the thickness of the slices obtained, but in general, axial and coronal views are obtained, with sagittal views often available after reformatting. ^{3 10} Hard and soft tissue windows are available, and 3-D reconstructions of CT scans are often used for visualization of fracture displacement and rotation during operative planning. Vascular imaging is indicated when penetrating injury to the head and neck (zones I – III) has occurred, and for fractures involving the carotid canal. ^{3 10} Panoramic radiographs, when available are useful for evaluation of dental structures and can be used in conjunction with CT to determine the relationship of fractures to the surrounding teeth, which is particularly useful in the case of mandibular angle fractures. ¹⁰

Magnetic resonance imaging (MRI) can be used to evaluate soft tissue injury and is particularly useful in assessment of cranial nerve deficits but is limited in its assessment of cortical bone. ¹⁰ It is not practical in the acute setting due to limited availability, the need to rule out life threatening injuries promptly, and the need for patients to remain still for the length of the examination. ¹⁰ In addition, metallic fragments must be excluded before its use. When indicated, it may be a helpful adjunct in conjunction with CT scans. With the patient's permission, obtaining digital photographs at the time of assessment is useful for evaluation of the repair over time and for patient education. ⁵ In the case of mid- and panfacial fractures, pre-injury photographs may be helpful during operative planning and repair.

Timing of Intervention

In general, most isolated maxillofacial injuries do not require emergent intervention. ^{6 9} Indications for urgent or emergent intervention include airway compromise, uncontrolled hemorrhage, extraocular muscle entrapment, the presence of an oculocardiac reflex in pediatric patients, nasal septal hematoma, or auricular hematoma. Common comorbid injuries that may require urgent or emergent management include open head injury, CSF leak, globe injury, and spine injury.

Many craniofacial injuries ultimately benefit from repair to prevent permanent cosmetic or functional deformity and/or infection. Soft tissue craniofacial injury should ideally be repaired within hours of injury to improve cosmetic results. All wounds should be irrigated copiously with saline and assessed for signs of neurovascular injury or injury to deep structures. In settings where a wound is highly contaminated, a drain may be left in place after aggressive irrigation and debridement of obvious foreign material. Drains should be removed within 3–4 days to prevent secondary infection. When there is soft tissue loss, wounds should still be closed as well as feasible to prevent secondary soft tissue retraction. In these settings, repair is often a multi-stage procedure requiring consideration of local, regional, or free flap techniques.

For bony injury, assessment for consideration of repair is often performed in an outpatient setting at least 48 to 72 hours, and preferably around 5–7 days after the initial injury to allow time for the initial edema and inflammatory response to settle in order that degree of persistent deformity can be properly assessed. ¹ The indications for surgery typical include cosmetic or functional concerns such as vision, nasal breathing and mastication (occlusion). ^{1 6 11} Mandibular and maxillary alveolar trauma may benefit from early intervention, within 7 days, prior to the onset of granulation, scarring, fibrosis and bony resorption which can interfere with reduction. ^{9 12} Orbital injury may benefit from delayed repair after 10–14 days to enable intraorbital edema to settle and reduce the impact of surgical retraction during repair on orbital structures. ^{1 11} When combinations of injury occur, timing of treatment planning can be nuanced, and compromise of timing or staging of procedures may be required. In most cases definitive repair of bony injury is ideally performed within 7–14 days of injury, but often 48 to 72 hours after injury when swelling has improved. Temporizing measures are often performed for fracture stabilization and to improve patient comfort prior to discharge from the emergency department.

Multidisciplinary Management

Outcomes of management of craniofacial injury have been shown to be improved from high-volume centers and are likely related to the benefit of multidisciplinary care. ⁵ As noted earlier, neurosurgery should be consulted when there is concern for intracranial injury, depressed skull fracture, open frontal sinus fracture, skull base fractures and concern for CSF leak. Ophthalmology should be consulted for ocular injuries, the presence of a foreign body in the globe, acute changes in visual acuity, retrobulbar hematoma, ocular muscle entrapment, complex periocular lacerations involving the eyelid margin and canaliculi and for pre-operative visual assessments on a non-emergent basis when indicated. ^{8 13} Otolaryngology should be consulted regarding temporal bone fractures, frontal sinus injury, facial nerve injury, and laryngeal or airway trauma. ⁵ Dental services may be consulted (or outpatient follow-up with a general dentist indicated) when dental trauma, dentoalveolar fractures or malocclusion is present.

Peri-operative care is often thus best when multidisciplinary in nature. ⁴ The potential for sub-optimal esthetic and functional outcomes is high if communication between care teams is lacking. ⁵ Specialist consultation should be performed in an efficient fashion to optimize peri-operative treatment planning, to enable timely pre-operative clearance and coordination of joint procedures. ⁵

Patient Education

As many facial trauma patients may be managed in the outpatient setting, patient education is paramount for optimal results. After initial assessment, if discharge is planned, patients should be given clear return precautions including for signs of infection, worsening swelling of the face and neck, difficulty breathing or swallowing, uncontrolled bleeding, and changes in vision or hearing. ⁵ This is also an opportunity to set realistic expectations for patients around timing of re-evaluation and possible repair, trajectory of soft-tissue healing, timing of nerve healing, and the potential need for staged procedures as appropriate.When procedures are performed, detailed verbal and written aftercare instructions should be provided around wound care, activity limitations, oral care, and diet limitations. ⁵ Likewise, expectations around prognosis, particularly for restoration of cosmesis should be shared so that patients can have realistic expectations.

COVID-19 Pandemic Considerations

Surgeons operating in the maxillofacial region are at high risk for transmission of COVID-19 when the disease is present due to the high viral burden in the nasopharynx and risk of stimulating a deep cough, sneeze or other aerosolizing procedure. ¹⁴ Significant advances in COVID-19 detection and prophylactic measures have been made since the advent of the pandemic, though variants continue to be identified. Every attempt should be made to determine the COVID status of a patient, including the presence or absence of symptoms and if they have been vaccinated within a reasonable time frame of presentation. For urgent or emergent cases, or when clinical history cannot be obtained, a rapid test should be performed, and airborne precautions utilized until the results of the test or sufficient collateral data are available. For elective cases, pre-operative COVID testing should be performed according to institutional guidelines, and operative intervention postponed if the patient is symptomatic. ¹⁴ Risk of COVID-19 sequelae must be balanced with risks associated with the delay of treatment of craniofacial injury.