Facial structures participate in essential functions of human life, including respiration, mastication, deglutition, vision, and the expression of both verbal and nonverbal communication. The face is the focal point of human social interaction.1 Thus, to restore facial form and function is to restore much of a patient’s opportunity to live a normal life.
In order to effectively manage facial trauma, the surgeon must understand care in the emergency room; the anatomy, evaluation, and management of injuries to the soft tissue, visceral, and bony components of the face; and the management of secondary deformities and complications. In this manner, not only is a broad discussion of facial trauma achieved, but the reader is also made aware of the place occupied by facial trauma within advanced trauma life support (ATLS) (see Chapter 10) and subsequent management.
Primary Survey of the Face
Care of facial trauma in the emergent setting, as in the management of any trauma, is initially focused on the “ABCs.” The adequacy of airway, breathing, and circulation are determined, and the appropriate ATLS algorithms are instituted. In addition to airway and circulation or bleeding issues, the cervical spine must be appropriately managed, and it adds potential difficulty to management of the airway.
Injuries to the upper aerodigestive tract and craniofacial skeleton may result in airway obstruction from tissue trauma and edema, foreign debris, or bleeding. The natural mechanisms of airway protection rely on functioning oropharyngeal structures supported by an intact facial skeleton. Injuries may lead to retrodisplacement of these structures, which may cause compromise of the airway. Trauma to the airway itself or neurologic injury can cause direct airway obstruction or loss of vocal cord function.
Airway compromise may be rapidly lethal and is assessed first. The reader is cautioned that significant obstruction of the airway, even impending loss of the airway, may be accompanied by normal or near-normal oximetry. The Glasgow Coma Scale (GCS) is used to rapidly assess for neurologic impairment that may lead to centrally based loss of airway protection. Subcutaneous emphysema may suggest pharyngeal, laryngeal, or tracheal disruption. Stridor (the sound of breathing through a partially obstructed airway) suggests airway narrowing and possible impending obstruction. If time permits, flexible fiberoptic nasopharyngolaryngoscopy allows rapid and definitive evaluation of the potentially compromised hypopharyngeal and laryngeal airway.
Foreign material in the airway may be manually evacuated, and blood and secretions are suctioned from the oral cavity and pharynx. A “jaw thrust,” even in the setting of mandibular trauma, and bag-valve mask (BVM) assistance may allow oxygenation, especially in the setting of injury to the brain or spinal cord. The compromised airway can then be secured via rapid sequence orotracheal or nasotracheal intubation. Orotracheal intubation is preferred in the setting of possible midface fractures, though nasal intubation can be accomplished with care and a thorough knowledge of the anatomy of the ...