Facial Soft Tissue Trauma Clinical Presentation
- Author: Daniel D Sutphin, MD; Chief Editor: Arlen D Meyers, MD, MBA more...
Systematically examine the face by means of visual inspection and palpation, starting superiorly with the scalp and the frontal bones and proceeding inferiorly and laterally. Inspect and note any obvious swellings, depressions, or ecchymosis. These indicate possible underlying bone fracture or hematoma. A formal evaluation of the cranial nerves with attention to ocular function, sensation, and facial mimetic motor function should be completed. Any gross soft tissue asymmetry may signify underlying nerve damage.
With palpation, determine the presence and location of any fractured bone fragments and dislodged or dislocated bony prominences; be sure to include the temporomandibular joint. Determining the presence of crepitus, tenderness, or stepoffs is essential. If possible, assess the sensorimotor functions of the face.
The following summarizes examination approaches and findings associated with injuries to specific areas of the face.
Because of the extensive blood supply of the scalp, the amount of bleeding present may not be proportionate to the size of the soft tissue injury. Hemorrhaging of the scalp often appears profuse and always heightens suspicion of intracranial damage. On the other hand, it is not uncommon for minor scalp injures to be missed as a result of an inadequate examination. To avoid missing any scalp injuries, examine patients thoroughly during the secondary survey.
After cleaning the wound, attempt hemostasis with direct pressure. Examine the areas around any lacerations for bony stepoff that would indicate a possible underlying skull fracture. Although shaving of hair is usually unnecessary, some shaving may be needed to avoid missing additional lacerations if obvious foreign body fragments are lodged in the hair or if the patient has long hair. However, adequate visualization of the wound is imperative, as is recognition that scalp wounds can be associated with large-volume blood loss that may even be fatal.
Eyebrow injuries should direct the examiner’s attention toward the possibility of underlying fracture of the supraorbital ridge or frontal sinuses.
Inspect the orbital rim carefully, palpating it around its circumference. Subtle displacement of the rim may be identified by placing an index finger on each infraorbital rim and viewing from above or below with the patient’s head tilted back. If fractures of the underlying bony structures are present, plastic or maxillofacial surgical consultation should be sought and surgical repair of the overlying soft tissues completed depending upon specialist recommendation. Check carefully for any deficit in sensation in the area. Attempt to maintain the alignment of the brow borders during repair. Never shave the eyebrow, because this may result in significant cosmetic deformity; the brow may not grow back or may grow back with an abnormal pattern or color.
Patients presenting with eyelid injuries must be examined thoroughly for any associated ocular and nasolacrimal duct injuries. Exploration for foreign bodies must be performed. Flip the eyelids over and examine the tarsal plate. Damage to either side of the tarsal plate should be referred to an ophthalmologist for repair. If ptosis is present, injury to the levator aponeurosis should be suspected, and this injury should also be referred to a plastic surgeon or ophthalmologist.
Simple lacerations of the eyelid, without involvement of the margins, can be treated without concern for further eye injury. If the protective function of the lid is compromised in any way, eye-threatening keratitis may result. Extensive or complex injuries of the eyelid, particularly those that involve the canthi, lacrimal system, or lid margin, should prompt immediate plastic surgical consultation.
In patients who have sustained injury to the eye, look for any gross injury or asymmetry in the globes.[10, 11] Check the papillary responses to light directly and indirectly. Using an ophthalmoscope, inspect the anterior chamber to look for blood, rupture of the iris, or asymmetry. Examine the cornea, and look for foreign bodies, abrasions, tears, or lacerations. Fluorescein dye and tetracaine (or another topical ocular anesthetic) should be employed to ensure an adequate examination.
Assess extraocular movements. Deficits in movement may indicate entrapment or injury to one of the extraocular muscles. Deficits may also indicate injury to one of the nerves that control globe movement (cranial nerves [CNs] III, IV, and VI). Evaluate for conjugate gaze and smooth pursuit.
Assess visual acuity. Outside the clinical setting (eg, on the sideline or in the locker room at a sporting event), a handheld eye chart may be used for gross investigation. Significant loss of visual acuity may be due to injury of the globe, retina, or optic nerve or due to an injury that is more central. These injuries are an indication for more urgent ophthalmologic care than can be provided in such an environment, and the patient should be sent to the appropriate facility for definitive care.
In addition, evaluate the patient for enophthalmos or exophthalmos. These conditions indicate either an orbital floor fracture or a blow-in fracture, respectively. Such findings also warrant oculoplastic consultation.
A direct blow or application of shearing force to the ear may result in tearing of the blood vessels at the level of the perichondrium. The result is a subperichondrial hematoma. These injuries can result in significant cosmetic deformity if missed or if not treated immediately. Fibrosis develops within 2 weeks of the injury, and the patient may be left with abnormally shaped pinnae (a condition also known as cauliflower ear).
Auricular hematoma and myriad ear lacerations of varying complexity, including ear amputation, should prompt plastic surgical consultation.
Blunt trauma or barotrauma may cause perforation of the tympanic membrane. An otoscope should be used to visualize the defect and to look for any serous or bloody discharge. Most patients are asymptomatic, but vertigo and otalgia may be present.
Visual inspection of the nose usually provides ample information as to the underlying injury. Fracture is usually associated with some degree of deformity. Gross midline deviation of the nose typically indicates underlying fractured nasal bones or cartilages. Soft tissue swelling of the nose indicates hematoma, fractured nasal bones or cartilages, or both. Intranasal inspection with a nasal speculum may reveal a deviated septum.
Nevertheless, epistaxis without obvious nasal deformity may be the only clinical finding in some nasal fractures. The origin of most nosebleeds is the extremely vascular area on the anterior septum (Kiesselbach area). Performing an adequate and thorough nasal examination is difficult when epistaxis is not controlled.
Once the bleeding is controlled, intranasal inspection using a nasal speculum should be performed, and the position and integrity of the nasal septum should be noted. The turbinates and inferior meatus should be visualized bilaterally, and the septum should be inspected for the presence of a septal hematoma. Any mucosal lacerations should be noted because they may be a sign of underlying fracture.
The presence of rhinorrhea associated with significant trauma should suggest a possible cerebrospinal fluid (CSF) leak. The patient may report a very salty taste in the mouth. An easy way of objectively testing for a CSF leak is to look for the halo or ring sign. To perform this test, place a drop of the rhinorrhea in question on a piece of filter paper. A clear ring around a blood-tinged center indicates the presence of CSF. A positive test result may indicate a basilar skull fracture that warrants more urgent tertiary care.
Mouth and lip injuries
Inspect the lips carefully. Any disruption of the vermilion border should be noted; failure to do so can lead to inadequate repair, which can result in significant cosmetic deformity (see the image below). A stepoff of the vermilion border as small as 1 mm may be apparent at conversational distance. The presence of a commissural laceration also adds a level of complexity to the wound that may require plastic surgical consultation.
Inspect the inside of the lips for through-and-through wounds. An intraoral examination is a necessary part of the facial evaluation. The inside of the cheeks should also be examined thoroughly for any through-and-through wounds. Special attention should be given to the area around the parotid duct (see below).
Parotid and lacrimal duct injuries
Because the parotid gland is situated superficially in the cheek, it is vulnerable to any trauma to the face (see the image below). Any injury along an imaginary line drawn from the tragus of the ear to the base of the nose, and lateral to the lateral canthus, should alert practitioners to the possibility of parotid injury. With any injury involving the midcheek, an attempt should be made to milk the parotid gland and observe the flow of saliva from the Stensen duct in order to ensure duct patency.
Consider injury to the gland if there is clear discharge from the cheek wound. Similarly, a sagging upper lip indicates possible injury to the parotid duct, since the buccal branches of the facial nerve often run along with the parotid duct. Any suspected injury should be referred for possible stenting and repair. Also, look for disrupted teeth and hematoma.
Injuries to the medial canthal region must be inspected for lacrimal duct injury. Both upper and lower canaliculi must be examined thoroughly to determine the extent of injury.
When examining the injured tongue, note the depth and length of the injury as well as the absence of any tissue. Many minor lacerations do not require repair. Complex injuries such as through-and-through lacerations may be associated with foreign bodies and can result in a bifid tongue if not properly repaired.
The facial nerve (CN VII), because of its extracranial course and relatively superficial distribution, is susceptible to facial injuries (see the image below). Injury to the nerve may cause significant cosmetic and functional defects.
If a neurapraxic or axonometric injury has occurred, obvious signs of motor deficit will be present. Injuries to the temporal and eyebrow regions affect the temporal and zygomatic branches, causing inability to raise the eyebrows or close the eyelids. Buccal branch injuries may contribute to an inability to smile and loss of the nasolabial crease. Injuries to the mandibular area may affect the marginal mandibular branch, causing an asymmetric smile with elevation of the lower lip on the affected side.
Any wound with a corresponding facial nerve deficit warrants operative exploration.
In addition, examine sensation for each of the 3 branches of the trigeminal nerve. Deficits in any distribution may correspond to underlying bony injuries.
Gordon CR, Siemionow M, Papay F, et al. The world's experience with facial transplantation: what have we learned thus far?. Ann Plast Surg. 2009 Nov. 63(5):572-8. [Medline].
Alam DS, Chi JJ. Facial transplantation for massive traumatic injuries. Otolaryngol Clin North Am. 2013 Oct. 46(5):883-901. [Medline].
Massimiliano B, Nicola S, Sante B, Carmela F, Palmieri V, Paolo Z. Female boxing in Italy: 2002-2007 report. Br J Sports Med. 2011 Jun. 45(7):563-70. [Medline].
Lawson BR, Comstock RD, Smith GA. Baseball-related injuries to children treated in hospital emergency departments in the United States, 1994-2006. Pediatrics. 2009 Jun. 123(6):e1028-34. [Medline].
Day C, Stolz U, Mehan TJ, Smith GA, McKenzie LB. Diving-related injuries in children 11111111111Pediatrics</i>. 2008 Aug. 122(2):e388-94. [Medline].
Rajput D, Bariar LM. Study of maxillofacial trauma, its aetiology, distribution, specturm, and management. J Indian Med Assoc. 2013 Jan. 111(1):18-20. [Medline].
Romeo SJ, Hawley CJ, Romeo MW, Romeo JP. Facial Injuries in Sports: A Team Physician's Guide to Diagnosis and Treatment. Phys Sportsmed. 2005 Apr. 33(4):45-53. [Medline].
Hamilton J, Sunter J, Cooper P. Fatal hemorrhage from simple lacerations of the scalp. Forensic Science, Medicine, and Pathology. Humana Press; December, 2005. Vol 1, No 4: 267-71.
Bodor RM, Breithaupt AD, Buncke GM, Bailey JR, Buncke HJ. Swimmer's nose deformity. Ann Plast Surg. 2008 Jun. 60(6):658-60. [Medline].
Sitzman TJ, Hanson SE, Alsheik NH, Gentry LR, Doyle JF, Gutowski KA. Clinical criteria for obtaining maxillofacial computed tomographic scans in trauma patients. Plast Reconstr Surg. 2011 Mar. 127(3):1270-8. [Medline].
Goodstein WA, Stryker A, Weiner LJ. Primary treatment of shotgun injuries to the face. J Trauma. 1979 Dec. 19(12):961-4. [Medline].
Kersten TE, McQuarrie DG. Surgical management of shotgun injuries of the face. Surg Gynecol Obstet. 1975 Apr. 140(4):517-22. [Medline].
Toure G, Angoulangouli G, Meningaud JP. Epidemiology and classification of dog bite injuries to the face: a prospective study of 108 patients. J Plast Reconstr Aesthet Surg. 2015 May. 68 (5):654-8. [Medline].
Tan E, Mortimer N, Salmon P. Full-thickness skin grafts for surgical defects of the nasal ala - a comprehensive review, approach and outcomes of 186 cases over 9 years. Br J Dermatol. 2014 May. 170 (5):1106-13. [Medline].
Ardeshirpour F, Shaye DA, Hilger PA. Improving posttraumatic facial scars. Otolaryngol Clin North Am. 2013 Oct. 46(5):867-81. [Medline].