Severe facial injuries are associated with injuries to the brain, orbit, cervical spine, and lungs. Upon stabilization of life-threatening injuries during the primary survey, a thorough secondary survey should identify facial injuries that could affect the patient's normal appearance, vision, smell, mastication, and sensation.
To help localize injuries, a thorough history should begin with questions directed toward whether the patient has vision changes, malocclusion, or facial numbness (Table 162-1). The physical examination begins with inspection, noting facial asymmetry, facial elongation, exophthalmos or enophthalmos, and periorbital or mastoid ecchymoses. Next, palpate the entire face, noting step-offs and tenderness that suggest fractures, and crepitus that suggests a sinus fracture. Finally, perform a focused and thorough examination of the eyes, nose, ears, and mouth, as described in Table 162-1.
Table 162-1 Important Clinical Issues in Facial Trauma |Favorite Table|Download (.pdf)
Table 162-1 Important Clinical Issues in Facial Trauma
- How is your vision?
- Binocular diplopia suggests entrapment of the extraocular muscles; monocular diplopia suggests a lens dislocation.
- Do any parts of your face feel numb?
- Anesthesia suggests damage to the supraorbital, infraorbital, or mental nerves.
- Does your bite feel normal?
- Malocclusion typically occurs with mandibular or maxillary fractures.
- Lateral view for dish face with Le Fort III fractures.
- Frontal view for donkey face with Le Fort II or III fractures.
- Bird's eye view for exophthalmos with retrobulbar hematoma.
- Worm's view for endophthalmos with blow-out fractures or flattening of malar prominence with zygomatic arch fractures.
- Raccoon's eyes (bilateral periorbital ecchymosis) and Battle sign (mastoid ecchymosis) typically develop over several hours, suggesting basilar skull fracture.
- Palpating the entire face will detect the majority of fractures.
- Intraoral palpation of the zygomatic arch, palpating lateral to posterior maxillary molars to distinguish bony from soft tissue injury.
- Assess for Le Fort fractures by gently rocking the hard palate with one hand while stabilizing the forehead with the other.
- Examine early before swelling of lids, or use retractors. Document visual acuity.
- Fat through eyelid wound indicates an orbital septum perforation.
- Widening of the distance between the medial canthi, or telecanthus, suggests serious nasoethmoidal-orbital complex trauma. Widening of the distance between the pupils, or hypertelorism, results from orbital dislocation and often is associated with blindness.
- Examine extraocular muscle movements. Limited upward gaze occurs with entrapment of the inferior rectus or inferior oblique muscles, or damage to the oculomotor nerve.
- Systematically examine the eye. Specifically, the pupil for teardrop sign pointing to globe rupture, the anterior chamber for hyphema, and swinging flashlight test for afferent papillary defect. Perform a fluoroscein test for corneal abrasions or ulcers.
- Check intraocular pressure for evidence of orbital compartment syndrome only in absence of globe injury.
- Crepitus over any facial sinus suggests sinus fracture.
- Septal hematoma appears as blue, boggy swelling on nasal septum. Should be incised and drained to avoid a saddle nose deformity.
- Auricular hematomas should be incised and ...