Chp13Face&NeckInjuries.pdf

Face and Neck Injuries

Chapter 13

Face and Neck Injuries

Introduction

Immediate recognition and appropriate management of

airway compromise is critical to survival.

Face and neck injuries can be the most difficult-to-manage

wounds encountered by health care providers in the combat

zone. Focusing on ABC priorities is vital.

During airway control, maintain cervical spine

immobilization in bluntly injured patients. (Unstable C-spine

injury is very rare in neurologically intact penetrating face

and neck wounds.)

Bleeding should be initially controlled with direct pressure.

If bleeding cannot be controlled, immediate operative

intervention is necessary.

Complete assessment of remaining injuries (fractures,

lacerations, esophageal injury, ocular injuries).

Immediate Management of Facial Injuries

Airway.

ο Airway distress due to upper airway obstruction above

the vocal cords is generally marked by inspiratory stridor:

♦ Blood or edema resulting from the injury.

♦ Tongue may obstruct the airway in a patient with a

mandible fracture.

♦ A fractured, free-floating maxilla can fall back,

obstructing the airway.

♦ Displaced tooth fragments may also become foreign

bodies.

ο Maneuvers to relieve upper airway obstruction:

13.1

Emergency War Surgery

♦ Remove foreign bodies (strong suction, Magill forceps,

among others).

♦ Anterior jaw-thrust maneuver.

♦ Place adjunctive airway device (nasal trumpet or

oropharyngeal airway).

♦ Endotracheal intubation and assisted ventilation.

♦ Cricothyroidotomy or emergent tracheotomy may

become necessary.

Cervical spine.

ο Up to 10% of patients with significant blunt facial injuries

will also have a C-spine injury.

♦ In awake patients, the C-spine can be cleared clinically

by palpating for point tenderness.

♦ Obtunded patients with blunt facial trauma should be

treated with C-spine immobilization.

Vascular Injury.

ο Injuries to the face are often accompanied by significant

bleeding .

ο Control of facial vascular injuries should progress from

simple wound compression for mild bleeding to vessel

ligation for significant bleeding.

Vessel ligation should only be performed under direct

visualization after careful identification of the bleeding

vessel. Blind clamping of bleeding areas should be

avoided, because critical structures such as the facial nerve

and parotid duct are susceptible to injury.

♦ Foley catheter inserted blindly into a wound may

rapidly staunch bleeding.

ο Intraoral bleeding must be controlled to ensure a patent

and safe airway.

♦ Do not pack the oropharynx in an awake patient due to

risk of airway compromise: first secure the airway with

an endotracheal tube.

♦ Copious irrigation and antibiotics with gram-positive

coverage should be used liberally for penetrating

injuries of the face.

13.2

Face and Neck Injuries

Evaluation.

ο Once the casualty is stabilized, cleanse dried blood and

foreign bodies gently from wound sites in order to evaluate

the depth and extent of injury.

ο The bony orbits, maxilla, forehead, and mandible should

be palpated for stepoffs or mobile segments suggestive of

a fracture.

ο A complete intraoral examination includes inspection and

palpation of all mucosal surfaces for lacerations, ecchymosis,

stepoffs, and malocclusion as well as dental integrity.

ο In the awake patient, abnormal dental occlusion

indicates probable fracture.

ο Perform a cranial nerve examination to assess vision, gross

hearing, facial sensation, facial muscle movement, tongue

mobility, extraocular movements, and to rule out

entrapment of the globe.

ο Consult an ophthalmologist for decreased vision on gross

visual field testing, diplopia, or decreased ocular mobility.

ο If the intercanthal distance measures > 40 mm

(approximately the width of the patient’s eye), the patient

should be evaluated and treated for a possible naso-orbito-

ethmoid (NOE) fracture.

If a NOE fracture is present, do not instrument the nose if

possible. There may be a tear in the dura, and instrumentation

may contaminate the CSF via the cribiform.

Facial Bone Fracture Management

The goals of fracture repair are realignment and fixation of

fragments in correct anatomic position with dental wire (inferior,

but easier) or plates and screws.

With the exception of fractures that significantly alter

normal dental occlusion or compromise the airway (eg,

mandible fractures), repair of facial fractures may be

delayed for two weeks.

Fractures of the mandible.

ο Second most commonly fractured bone of the face.

ο Most often fractured in the subcondylar region.

13.3

Emergency War Surgery

ο Multiple mandible fracture sites present in 50% of cases.

ο Patients present with limited jaw mobility or malocclusion.

ο Dental Panorex is the single best plain film (but is

unavailable in the field environment); mandible serves as

a less reliable but satisfactory study (might overlook

subcondylar fractures).

ο Fine cut (1–3 mm) CT scan will delineate mandibular

fractures.

ο Treatment is determined by the location and severity of

the fracture and condition of existing dentition.

♦ Remove only teeth that are severely loose or fractured

with exposed pulp.

♦ Even teeth in the line of a fracture, if stable, and not

impeding the occlusion, should be maintained.

ο Nondisplaced subcondylar fractures in patients with

normal occlusion may be treated simply with a soft diet

and limited wear of Kevlar helmet and protective mask.

ο Immediate reduction of the mandibular fracture and

improvement of occlusion can be accomplished with a

bridle wire (24 or 25 gauge) placed around at least 2 teeth

on either side of the fracture.

ο More severe fractures with malocclusion will require

immobilization with maxillary-mandibular fixation

(MMF) for 6–7 weeks.

ο Place commercially made arch bars onto the facial aspect

of the maxillary and mandibular teeth.

♦ The arch-bars are then fixed to the teeth with simple

circumdental (24 or 25 gauge) wires (Fig. 13-1).

♦ After proper occlusion is established, the maxillary arch

bar is fixed to the mandibular arch bar with either wire

or elastics.

♦ If the patient’s jaws are wired together, it is imperative

that wire cutters be with the patient at all times.

♦ If portions of the mandible have been avulsed or the mandib-

ular fragments are extremely contaminated, an external

biphase splint should be placed to maintain alignment.

13.4

Face and Neck Injuries

Fig. 13-1. Arch bar applications.

ο Open reduction and internal fixation with a mandibular

plate across fracture sites may obviate the need for MMF.

Nasal fractures.

ο Most common fracture.

♦ Control of epistaxis: anterior pack-gauze/balloon/

tamponade.

ο Diagnosed clinically by the appearance and mobility of

the nasal bones.

The patient’s septum should be evaluated for the presence

of a septal hematoma, which if present, must be

immediately drained by incision, followed by packing.

ο Treat by closed reduction of the fractured bones and/or

septum into their correct anatomic positions up to 7 days

after fracture.

13.5

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