Injury to the Face

Overview

Facial injuries represent a significant category of trauma that can have profound physical, functional, and psychological impacts. The face contains critical structures including the eyes, nose, mouth, ears, and underlying bones that support vital functions such as vision, breathing, eating, hearing, and communication. The intricate network of nerves, blood vessels, and muscles in the face means that even seemingly minor injuries can have serious consequences if not properly evaluated and treated.

The complexity of facial anatomy requires careful assessment of injuries to identify all affected structures. Facial trauma can range from simple soft tissue lacerations to complex fractures involving multiple facial bones. The proximity of the face to the brain and cervical spine means that facial injuries often occur in conjunction with other serious injuries, requiring comprehensive evaluation and management. Additionally, the face's prominent role in personal identity and social interaction makes the psychological impact of facial injuries particularly significant.

Modern trauma care has significantly improved outcomes for facial injuries through advances in emergency medicine, imaging technology, and reconstructive surgery. However, the initial management of facial injuries remains crucial for preventing complications and optimizing long-term results. Understanding the signs, symptoms, and appropriate response to facial injuries can help minimize damage and improve recovery outcomes.

Symptoms

Facial injuries can present with a wide variety of symptoms depending on the location, severity, and structures involved. Recognizing these symptoms is crucial for appropriate triage and treatment.

Pain and Sensory Symptoms

• Facial pain - ranging from mild discomfort to severe pain
• Headache - often accompanying facial trauma
• Neck pain - may indicate associated cervical injury
• Ear pain - can suggest temporal bone fracture
• Mouth pain - from dental or oral injuries
• Numbness or tingling in face
• Altered sensation or hypersensitivity

Bleeding and Discharge

• Nosebleed - common with nasal trauma
• Bleeding from ear - may indicate skull base fracture
• Bleeding from lacerations
• Clear fluid from nose or ears (CSF leak)
• Blood in saliva or when coughing

Functional Impairments

• Diminished hearing - from ear injury or blood in canal
• Vision changes or double vision
• Difficulty opening mouth (trismus)
• Difficulty swallowing
• Speech difficulties
• Breathing difficulties

Musculoskeletal Symptoms

• Neck stiffness or tightness - may indicate associated injury
• Jaw deviation or malocclusion
• Facial asymmetry
• Crepitus (grinding sensation) with movement
• Limited range of motion

Visible Signs

• Swelling and edema
• Bruising (ecchymosis)
• Lacerations or abrasions
• Deformity of facial bones
• Black eyes (periorbital ecchymosis)
• Battle's sign (bruising behind ears)
• Raccoon eyes (bilateral periorbital bruising)

Causes

Facial injuries can result from various mechanisms of trauma, each with characteristic patterns of injury. Understanding the cause helps predict the type and severity of injuries and guides appropriate treatment approaches.

Motor Vehicle Accidents

The leading cause of severe facial trauma:

• Dashboard injuries: Impact with steering wheel or dashboard
• Airbag injuries: Burns, abrasions, or blunt trauma from deployment
• Glass injuries: Lacerations from shattered windshield or windows
• Ejection injuries: Multiple trauma from being thrown from vehicle
• Seatbelt injuries: Facial contact with seatbelt during rapid deceleration

Falls

• Ground-level falls: Common in elderly and young children
• Falls from height: Work-related or accidental
• Stairs-related falls: Often result in mid-face injuries
• Slip and fall accidents: Backward falls may cause occipital and facial trauma
• Alcohol-related falls: Impaired protective reflexes increase injury severity

Sports and Recreational Injuries

• Contact sports: Boxing, martial arts, rugby, football
• Ball sports: Baseball, basketball, soccer ball impacts
• Cycling accidents: Falls or collisions without helmet
• Skateboarding/rollerblading: High-speed falls onto pavement
• Winter sports: Skiing, snowboarding, ice hockey injuries

Violence and Assault

• Interpersonal violence: Punches, kicks, or strikes to face
• Domestic violence: Often results in specific injury patterns
• Child abuse: May present with multiple injuries at different healing stages
• Assault with weapons: Blunt objects, knives, or firearms

Occupational Injuries

• Construction accidents: Falling objects, tool injuries
• Industrial accidents: Machinery-related trauma
• Agricultural injuries: Animal kicks, equipment accidents
• Military/law enforcement: Combat or training injuries

Other Causes

• Animal attacks: Dog bites most common, especially in children
• Burns: Thermal, chemical, or electrical
• Penetrating injuries: Sharp objects, projectiles
• Iatrogenic: Complications from medical/dental procedures

Risk Factors

Certain factors increase the likelihood of sustaining facial injuries. Understanding these risk factors can help implement preventive measures and identify high-risk individuals who may benefit from additional safety precautions.

Demographic Risk Factors

• Age:
  • Young adults (20-30 years) - highest overall risk
  • Children - playground and sports injuries
  • Elderly - falls due to balance and vision issues
  • Infants - non-accidental trauma risk
• Gender: Males 3-4 times more likely to sustain facial trauma
• Socioeconomic factors: Lower income associated with higher injury rates
• Geographic location: Urban areas have higher assault rates

Behavioral Risk Factors

• Alcohol and substance use:
  • Impaired judgment and coordination
  • Increased aggression and risk-taking
  • Delayed reaction times
  • Associated with 40-50% of facial injuries
• Non-use of protective equipment:
  • Not wearing seatbelts
  • Absence of helmets in sports/cycling
  • Lack of face guards in contact sports
  • No safety glasses in hazardous work
• Risk-taking behaviors: Speeding, aggressive driving, extreme sports

Environmental Risk Factors

• Occupational hazards: Construction, manufacturing, agriculture
• Poor lighting conditions: Increases fall risk
• Hazardous weather: Ice, rain, poor visibility
• Unsafe living conditions: Cluttered walkways, loose carpets
• High-crime areas: Increased assault risk

Medical Risk Factors

• Medical conditions affecting balance:
  • Parkinson's disease
  • Epilepsy
  • Vestibular disorders
  • Orthostatic hypotension
• Visual impairments: Cataracts, glaucoma, macular degeneration
• Cognitive impairments: Dementia, developmental disabilities
• Medications: Sedatives, antihypertensives, psychotropics
• Osteoporosis: Increased fracture risk from minor trauma

Diagnosis

Proper diagnosis of facial injuries requires a systematic approach combining clinical examination, imaging studies, and specialized assessments. The complexity of facial anatomy necessitates thorough evaluation to identify all injuries and plan appropriate treatment.

Initial Assessment

The primary survey follows ATLS (Advanced Trauma Life Support) protocols:

• Airway assessment: Check for obstruction from blood, teeth, or swelling
• Breathing evaluation: Ensure adequate ventilation
• Circulation: Control active bleeding, assess for shock
• Disability: Neurological assessment, cervical spine protection
• Exposure: Full examination for associated injuries

Clinical Examination

Systematic Facial Examination

• Inspection:
  • Asymmetry, swelling, deformity
  • Lacerations, abrasions, burns
  • Ecchymosis patterns (raccoon eyes, Battle's sign)
  • Active bleeding sites
• Palpation:
  • Bony step-offs or crepitus
  • Tenderness over specific areas
  • Subcutaneous emphysema
  • TMJ function and stability

Specialized Examinations

• Ocular examination:
  • Visual acuity testing
  • Pupillary responses
  • Extraocular movements
  • Fundoscopy for retinal damage
• Dental examination: Tooth mobility, fractures, malocclusion
• Neurological assessment: Cranial nerves, especially facial nerve
• Nasal examination: Septal hematoma, CSF rhinorrhea

Imaging Studies

Plain Radiographs

• Facial series (Waters, Caldwell, lateral views)
• Panoramic radiograph for mandibular fractures
• Limited use due to overlapping structures
• May miss up to 50% of facial fractures

Computed Tomography (CT)

• Gold standard for facial trauma:
  • High-resolution bone windows
  • 3D reconstructions for surgical planning
  • Soft tissue evaluation
  • Can detect associated brain injury
• CT angiography: For suspected vascular injury

Magnetic Resonance Imaging (MRI)

• Soft tissue injuries
• Optic nerve evaluation
• Ligamentous injuries
• Not for acute trauma (time-consuming)

Specialized Tests

• Forced duction test: For orbital floor fractures
• Facial nerve testing: If paralysis present
• Lacrimal system assessment: Dye testing for duct injury
• Endoscopy: For sinus evaluation

Treatment Options

Treatment of facial injuries ranges from simple first aid measures to complex surgical reconstruction. The approach depends on the type, location, and severity of injuries, as well as the patient's overall condition and associated injuries.

Immediate First Aid

Initial management at the scene or emergency department:

• Control bleeding:
  • Direct pressure with clean cloth
  • Avoid pressure on suspected fractures
  • Head elevation if no spinal injury
  • Avoid nasal packing if CSF leak suspected
• Ice application:
  • 20 minutes on, 20 minutes off
  • Wrap ice in cloth to prevent frostbite
  • Reduces swelling and pain
• Pain management: Appropriate analgesics based on severity
• Wound care: Gentle cleaning, avoid tissue removal

Soft Tissue Management

• Wound cleaning and debridement:
  • Copious irrigation with saline
  • Removal of foreign bodies
  • Minimal debridement (facial tissue valuable)
  • Antibiotic prophylaxis for contaminated wounds
• Laceration repair:
  • Layer-by-layer closure
  • Fine sutures for cosmetic areas
  • Special attention to anatomical landmarks
  • Consider plastic surgery referral for complex wounds

Fracture Management

Nasal Fractures

• Closed reduction within 7-10 days
• Splinting for 1-2 weeks
• Open reduction for severe displacement
• Septoplasty for septal fractures

Mandibular Fractures

• Intermaxillary fixation (wiring)
• Open reduction internal fixation (ORIF)
• Miniplate fixation
• Soft diet for 4-6 weeks

Midface Fractures

• Orbital fractures:
  • Observation for small defects
  • Surgical repair for entrapment or large defects
  • Orbital floor reconstruction
• Zygoma fractures: ORIF for displacement
• Le Fort fractures: Complex surgical reconstruction

Dental Injuries

• Tooth avulsion:
  • Immediate reimplantation if possible
  • Store in milk or saline
  • Splinting for 2-4 weeks
  • Root canal often needed
• Tooth fractures: Bonding, crowns, or extraction
• Alveolar fractures: Reduction and splinting

Specialized Treatments

• Nerve repair: Microsurgical techniques for facial nerve
• Lacrimal system repair: Stenting and reconstruction
• Vascular repair: For major vessel injuries
• Reconstructive surgery: Delayed for complex defects

Post-Treatment Care

• Antibiotics: For open fractures or contaminated wounds
• Tetanus prophylaxis: Update as needed
• Follow-up imaging: To assess healing
• Physical therapy: For TMJ or facial nerve injuries
• Scar management: Silicone sheets, massage, laser therapy

Prevention

Many facial injuries are preventable through proper safety measures, protective equipment use, and risk awareness. Prevention strategies vary based on the activity and environment but share common principles of protection and caution.

Vehicle Safety

• Seatbelt use:
  • Always wear properly adjusted seatbelts
  • Ensure shoulder strap crosses chest, not neck
  • Use booster seats for children as appropriate
  • Never place rear-facing car seats in front of airbags
• Airbag safety:
  • Sit at least 10 inches from steering wheel
  • Adjust seat position properly
  • Keep hands at 9 and 3 o'clock positions
• Motorcycle/bicycle safety: Always wear DOT-approved helmets
• Avoid impaired driving: No alcohol or drug use

Sports Safety

• Protective equipment:
  • Sport-specific helmets and face guards
  • Mouthguards for contact sports
  • Protective eyewear for racquet sports
  • Proper fitting and maintenance of equipment
• Training and technique:
  • Learn proper techniques from qualified instructors
  • Progressive skill development
  • Adequate warm-up and conditioning
  • Know and follow sport rules

Fall Prevention

• Home safety:
  • Remove tripping hazards (rugs, cords)
  • Install handrails on stairs
  • Adequate lighting in all areas
  • Non-slip mats in bathrooms
• For elderly individuals:
  • Regular vision and hearing checks
  • Medication review for side effects
  • Balance and strength exercises
  • Appropriate footwear

Workplace Safety

• Personal protective equipment:
  • Safety glasses or face shields
  • Hard hats in construction zones
  • Proper training on equipment use
  • Regular safety inspections
• Safety protocols:
  • Follow lockout/tagout procedures
  • Machine guards in place
  • Report hazards immediately
  • Participate in safety training

Violence Prevention

• Personal safety:
  • Avoid high-risk situations and locations
  • De-escalation techniques
  • Self-defense training
  • Trust instincts about dangerous situations
• Domestic violence resources:
  • Know local helpline numbers
  • Safety planning
  • Support group participation
  • Legal protection options

When to See a Doctor

Call 911 or seek emergency care immediately for:

• Severe facial pain or deformity
• Difficulty breathing or swallowing
• Uncontrolled bleeding
• Clear fluid draining from nose or ears
• Loss of consciousness or confusion
• Vision changes or loss
• Inability to open or close mouth
• Severe headache with vomiting
• Bleeding from ear

Seek urgent medical attention for:

• Deep facial lacerations or gaping wounds
• Suspected facial bone fractures
• Tooth loss or severe dental injury
• Persistent nosebleed lasting over 20 minutes
• Neck pain or neck stiffness after trauma
• Significant swelling affecting vision
• Diminished hearing after injury

Schedule a medical appointment for:

• Minor cuts that may need stitches
• Persistent ear pain after facial trauma
• Ongoing mouth pain or dental sensitivity
• Facial numbness or tingling lasting over 24 hours
• Concerns about scarring or cosmetic outcome
• Follow-up care for previous facial injuries

Related Conditions

• Concussion
• Traumatic Brain Injury
• Whiplash
• Orbital Fracture
• TMJ Disorder
• Dental Trauma

References

1. Ellis E 3rd, Scott K. Assessment of patients with facial fractures. Emerg Med Clin North Am. 2000;18(3):411-448.
2. Kellman RM. Maxillofacial trauma. In: Flint PW, et al., eds. Cummings Otolaryngology: Head and Neck Surgery. 6th ed. Philadelphia, PA: Elsevier Saunders; 2015.
3. Perry M, Holmes S. Atlas of Operative Maxillofacial Trauma Surgery. London: Springer; 2014.
4. Erdmann D, Follmar KE, Debruijn M, et al. A retrospective analysis of facial fracture etiologies. Ann Plast Surg. 2008;60(4):398-403.
5. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual. 10th ed. Chicago, IL: American College of Surgeons; 2018.