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Clinical Summary

Injury patterns of penetrating facial trauma can be predicted based on projectile type, entry location, and path. Midface injuries extend from the supraorbital rim superiorly to the oral commissure inferiorly and to the external auditory meatus posteriorly. Mandibular injuries extend from the oral commissure superiorly and to the lower border of the mandible inferiorly. Shotgun wounds typically involve both facial zones and will involve one or both eyes in 50% of patients. Fifty percent of patients with gunshot wounds (GSWs) to the mandible will require an emergency airway. Stab wounds are less likely to require emergency airway than GSWs. Additional structures that require consideration during the ED evaluation include brain, blood vessels, and esophagus.

Management and Disposition

After the primary survey, strongly consider intubation in patients with any gunshot injury to the mandible, blood or swelling in the oropharynx, or any close range (< 7 m) shotgun injury. If evidence suggests a projectile remains in the face or cranium, obtain plain films in two planes to help guide subsequent evaluation such as CT angiogram or fine cuts of the orbits. CT will provide more detailed information in the injured structures to guide therapy. Removal of any projectile should only be performed after significant structure injury has been excluded and preparation for the consequences of removal is complete.


Facial Zones of Injury. (Reproduced with permission from Chen AY, Stewart MG, Raup G. Penetrating injuries of the face. Otolaryngol Head Neck Surg. 1996;115:464-470. Copyright © 1996, © SAGE Publications.)


  1. Due to the likelihood of multisystem injury (vascular, ocular, cranial, face) with penetrating facial trauma, the patient should be transferred to a facility with comprehensive subspecialty trauma care.

  2. Intubation should be strongly considered in all patients with GSWs to the mandible or with GSWs to the midface if there is any blood or swelling in the oral cavity.

  3. Removal of any projectile is best done in the operating room.


Midface Injury. A jackhammer bit is lodged into the right maxillary sinus. (Photo contributor: R. Jason Thurman, MD.)


Midface Injury Radiograph. Plain film of patient in Fig. 1.70. CT confirmed no other injury. Projectile was removed in the operating room. (Photo contributor: R. Jason Thurman, MD.)


Penetrating Facial Trauma. Facial wound due to a flare gun injury. Surgical closure is delayed until the viable tissue has declared itself, which usually requires approximately 2 weeks. (Photo contributor: Michael Bezzerides, MS4.)


Penetrating Facial Trauma. Intraoral view of the flare gun injury. Note necrotic ...

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