Facial trauma, though deserving of prompt attention, is rarely life-threatening. Because they are often dramatic in appearance and instinctually interesting, craniofacial injuries have the potential to deter the clinician from appropriate evaluation of other more serious occult injuries. The presence of a facial injury implies that a simultaneous injury to adjacent areas such as the neck, brain, and skull may have occurred. Therefore, brain injury, skull fracture, and cervical spine injury must be excluded, as such injuries often have more serious immediate consequences. In all circumstances, the American College of Surgeons principles of advanced trauma life support (ATLS) remain paramount. Assessment of airway, breathing, and circulation are performed in the primary survey. The level of consciousness according to the Glasgow Coma Scale (Table 1) should be succinctly recorded and serially reassessed.

Evaluation of craniofacial injuries takes place in the secondary survey. The observation of other organ systems must be continued throughout the entire period of facial injury treatment and continuous monitoring provided where appropriate. That said, there are three mechanisms by which craniofacial trauma alone can be inherently life-threatening. These are (a) airway obstruction, (b) aspiration, and (c) hemorrhage.

Cranial base, orbital, and midface fractures may produce hemorrhage from lacerations of arteries and veins within the sinus cavities. Cranial base bleeding can involve major arteries and veins, cannot be controlled by tamponade, and must always be considered in cases of massive facial hemorrhage. It must be quickly recognized when present as it can cause rapid exsanguination. Generally, bleeding from midface fractures can be controlled by four mechanisms: (a) the maxilla can be repositioned and secured in the best “rest” position by applying maxillomandibular fixation (MMF); (b) a posterior pack can be placed as an obturator in the nasopharynx, and anterior packing can be placed against the posterior pack; this provides tamponade pressure for lacerated vessels in sinus walls; (c) selective arterial embolization may be utilized for those cases that do not respond to manual maxillary repositioning and anterior–posterior nasal packing; (d) rarely, and when the above measures fail, bilateral external carotid and superficial temporal artery ligation or coil embolization, performed simultaneously, reduces the pressure in the external carotid system and may assist in control of massive orbital and midface hemorrhage.

Once the initial trauma evaluation is complete, and life-threatening trauma (systemic or isolated craniofacial) has been adequately addressed, management can focus on craniomaxillofacial injury. Details surrounding the traumatic episode including mechanism of injury and elapsed time until presentation are crucial determinants of next steps in diagnostic and therapeutic measures. Historians, including witnesses, family members, and emergency medical staff, can provide valuable information. Many craniofacial trauma patients are under the influence of intoxicating substances, and this potentiality should be investigated through appropriate toxicology screens when indicated. The patient’s current medications and past medical history, including tetanus immunization status, should be documented.

The diagnosis of most facial injuries is accurately suggested by thorough clinical examination. Discoloration, pain, localized tenderness, numbness or paralysis, malocclusion, crepitus step-off or level discrepancies over the margins of facial bones, double vision, decreased visual acuity, facial asymmetry, gross facial deformity, changes in facial contour, and changes in eye position (exophthalmos or enophthalmos, vertical dystopia, etc.) are all symptoms suggestive of deeper structural trauma. Soft-tissue injuries are inevitable and one should suspect an existing fracture of the underlying facial bones beneath any contusion, bruise, or laceration. Ideally, photographs of trauma sites should be taken in the emergency department, or sketches of wounds should be included as part of the craniofacial evaluation.

Two types of physical examination should be performed: sequential and directed. In the sequential examination, an orderly examination of all facial structures is methodically performed. Examination proceeds from cephalad to caudal (or caudal to cephalad), and lateral to medial in each of the following facial regions: forehead, orbits, nose, maxilla, and mandible. Extensive palpation of all bony surfaces should note tenderness and deformity. In particular, the superior and inferior orbital rims, zygomatic arches, and malar prominences should be palpated. The mandible should be thoroughly evaluated with an intraoral examination including direct palpation of the maxillary and mandibular dental arches, mandibular teeth, and the horizontal and vertical portions of the mandible. The occlusal relationship of the maxillary and mandibular dental arches should be noted. If lucid and cooperative, the patient should be asked if his or her teeth feel like they are meeting together normally. The excursion of the mandible while palpating the temporomandibular joint and the relationship of the mandible to the maxilla should also be evaluated. Midface instability suggestive of maxillary fractures can be determined by bimanual palpation (Fig. 1). In this technique, the upper alveolar ridge is manipulated with one hand while the other
hand stabilizes the head while palpating the nasal root.

The presence of “step-off” or “level” deformities in the dentition, bleeding, loose teeth, and intraoral lacerations all suggest areas of deeper bony involvement. Irregularities in the dental arch and abnormal areas of occlusion are all suggestive of localized fractures. Avulsed or missing teeth and intraoral or gingival lacerations indicate the possibility of an underlying fracture of the alveolus, or more extensive fracture of the mandible or maxilla. Lacerations of the lips, chin, palate, and floor of the mouth often accompany fractures of the jaws. The search for occult lacerations must include the eyelids, ear canal, mouth, floor of the mouth under the tongue, pharynx, and nasal cavity. Nasal examination is greatly facilitated by using a nasal speculum. Pain and pressure sensation, including complete anesthesia or hypoesthesia, should be documented in the supraorbital, corneal, infraorbital, and mental nerve distributions. Crucially, the neurologic facial examination, including evaluation of all cranial nerves, must be completed and documented before the administration of any local infiltrative anesthesia or nerve blocks. Any history of posttraumatic neck pain or alteration in peripheral motor or sensory function precludes operative treatment of facial injuries, as this raises suspicion for concomitant cervical spine injury.

The eye and function of vision must be specifically evaluated in the sequential examination with ophthalmologic consultations called when appropriate. The symmetry of the pupil, speed of pupillary reaction, presence of hyphema, and range of extraocular motion should be evaluated. The presence of periorbital or subconjunctival ecchymosis implies the possibility of an orbital fracture or globe injury. Visual acuity, field deficits, diplopia, afferent pupillary defect, or decreased light perception must be promptly evaluated.

Following the sequential physical examination, a directed physical examination should then thoroughly reevaluate specific areas where fractures or injury to specific structures are suspected as suggested by the sequential examination. The following key injuries are common, and warrant extensive directed examination.

Any lacerations of the eyelid suggest the possibility of globe rupture, and the globe must be examined for integrity if an eyelid laceration is discovered. Lacerations occurring in the medial third of the lower or upper eyelids suggest the possibility of lacrimal system injury, and the punctae and lacrimal duct should be thoroughly examined. The repair of injuries to the lacrimal system is discussed later in the chapter.

Fractures that involve the frontal or basilar skull may lacerate the dura, leading to pneumocephalus (passage of air inside the skull) or cerebrospinal fluid (CSF) leak. CSF may exit from the nose (CSF rhinorrhea) or ear (CSF otorrhea). This implies a communication between the subdural space and the external environment, raising the possibility of meningitis. CSF rhinorrhea or otorrhea is often obscured by the presence of blood mixed with draining CSF, making the detection and confirmation of a CSF leak difficult. A “double ring” or “halo” sign may be visible when draining blood and CSF is absorbed to a paper towel. This may be subsequently confirmed via serum electrophoresis. In the presence of displaced fractures, intracranial repair of the dura is indicated. Definitive operative treatment is accompanied by the administration of prophylactic antibiotics for several days. Therefore, rhinorrhea and/or otorrhea in the setting of craniofacial trauma should be evaluated thoroughly for the presence of CSF, warranting detailed computed tomography (CT) evaluation of the cranial base. Conversely, the presence of pneumocephalus on CT imaging raises high clinical suspicion for a CSF leak that should be thoroughly investigated and ruled out.

Computed tomographic scans of the face, cervical spine, and head are warranted in nearly all cases of facial trauma. A thin-cut (<3 mm/slice) axial face CT with coronal and sagittal reconstructions is the current “gold standard” for radiographic evaluation of the craniofacial trauma patient. Historically, plain radiographs were ordered to evaluate facial and cervical fractures. This modality has been outdated due to the superior image quality and three-dimensional anatomic relationships afforded by CT. CT scans provide reliable, accurate information that aids in surgical planning, and have been shown to be more cost-effective than radiographic series.

CT images should include the frontal bone, frontal sinus, orbital and nasal regions, midface, and mandible, including the temporomandibular joints. If there is tooth involvement in any identified fracture on CT, a Panorex image should be obtained to assess tooth and tooth root injury. This is the only situation in craniofacial trauma where thin-cut, multiplanar CT imaging is not the gold standard for bony injury. Patients with multiple injuries cannot be sent unmonitored for radiographic evaluation. Three-dimensional CT scans can greatly aid in operative planning of complex craniofacial trauma, and will likely play an increasing role in the imaging of craniofacial trauma as this technology becomes more widely available.

In most cases, CT evaluation of the craniofacial trauma patient supplements and confirms, but never replaces, the findings of a thorough clinical examination. A review of both bone and soft-tissue CT windows should be promptly completed, and the specific areas with radiographically identified fractures reexamined. This is particularly useful in cases of suspected intraocular muscle entrapment as discussed later.