8. The face
This chapter is devoted to injuries to the face, the eye, and to the limited intersection between minor injury and ear, nose and throat (ENT) problems. Wounds to the face are dealt with in Chapter 6. Assessment of the cranial nerves is dealt with in Chapter 7.
Most injuries to the face are minor. Nevertheless, they require careful consideration. The delicacy and importance of the structures involved, the cosmetic significance of injuries and the dangerous complications which can occur, including trauma to the nearby brain and cervical spine, are all reasons why every injury must be carefully assessed.
The face
The face lies between the eyebrow and the chin in front, and includes the ears at the sides. It is of unique significance for several reasons:
• it has seven openings, which give access to organs of sense (eyes, ears, nose and mouth); of these, the eyes are probably the most delicate, the most exposed and the most vulnerable to injury
• the nose and mouth are the external part of the airway; they are used for speech, and the mouth is the upper access to the digestive tract
• the face has a small range of movement compared with, for instance, the limbs, but it has a large supply of nerves and blood vessels, muscles adapted for fine expressive functions, and organs of sense such as the eyes and mouth
• the face gives access to the brain by several pathways, and violent trauma to the face may also cause brain injury or injury to the cervical spine
• certain infections of the face may enter the brain
• many of the signs of brain injury may also be detected in the face
• the face is the part of the body most associated with vital psychological, social and sexual functions.
Faces are intimately associated with the notion of identity. If we think about an absent person, our mental picture is of the face. The face is a repository and a source for many subtle appearances, expressions and emanations, which seem, to other people, to show something which may be called personality, inner being or, for those who use religious language, soul. We reach all manner of relations and accommodations with other people simply by sharing a look with them: attraction, complicity, intimacy, hostility, warning, reassurance, empathy. We communicate emotion, and we conceal our feelings by the ways that we show our faces. In doing this we must have not only a response to the other person’s signals but also a sense of how our expressions will be received and understood. An injury which changes our faces, alters or impedes the signals we give, reduces our attractiveness or makes us conspicuous can cause suffering, in ways that have nothing to do with the injury but are related to the cosmetic significance of the change. This may also mean that we are less valuable in the world of work or that we become less able to live our normal lives; these are matters which may result in litigation. It is vital, in dealing with injuries to the face, that the importance of this aspect is understood. The word ‘cosmetic’ sounds frivolous but, in this context, it is not.
The fact that the face is a zone where many functions are gathered in a small area is reflected in the number of medical specialities which take responsibility for the management of different problems. In this section we are looking at the musculoskeletal framework of the face.
This facial framework is essentially constructed as a housing for delicate sensory apparatus and for expression and communication. There is a great deal of movement in the face, but these movements are not for the usual purposes of the musculoskeletal system. Many of them simply rearrange the skin surface without causing activity at a joint. This means that muscle injury is limited to wounds and to crush mechanisms. The tears and strains that occur in the rest of the body are unknown. There are only two synovial joints in the face, at the junction between upper and lower jaw on each side, and the potential for ligament problems in the face is limited to these areas. This means that the range of injuries, the mechanisms of injury and the techniques for examining the musculoskeletal face, are unusually limited. Our examinations are usually addressed to the issue of whether or not a fracture has occurred, and very little else.
Many aspects of facial structure are dictated by the somewhat conflicting requirements for the face to display delicate structures and to protect them from injury. The face is very well designed to absorb certain kinds of violence, and is vulnerable to others. This means that injuries have a repetitive nature, with fractures occurring at the weak points in the structure. Some of the well known patterns of facial fracture require a severe mechanism of injury, which usually means that the patient is not delivered to a minor area. The group of injuries which is seen at minor injury clinics tends to be the ones which can occur by lesser force, and they usually do not involve brain or neck (although you must assess those).
Examination is relatively straightforward, with less emphasis on movement testing than is found in other parts of the musculoskeletal frame, and more on palpation. The ‘look’ part of the assessment is always important. However, to compensate for this relative ease of examination, the interpretation of facial X-rays is uncommonly difficult. In addition, very few facial examinations can be restricted to the musculoskeletal elements. The sense organs, brain and neck will also usually require assessment.
Bony anatomy of the face
In terms of bone structure, the frontal bone, the parietal, sphenoid and temporal bones at the sides, and the occipital bone at the back enclose the cranial part of the skull, which houses the brain (see Figure 7.1). Structures such as the orbits, the nasal structures, the zygomas, the maxilla and the mandible are facial.
Many of the joints of the skull are of an immoveable, or only slightly moveable type, and are called sutures.
The orbits are the bony sockets for the eyes. They also contain muscles to move the eyes, blood vessels and nerves and the lacrimal structures for the production of tears. They are formed by the meeting of several bones of the skull and face, the frontal above, the zygoma on the lateral aspect and the maxilla medially. In the floor of the hollow, the sphenoid, ethmoid, palatine and lacrimal bones contribute to the jigsaw of interlocking bones. There are three major openings in the bony basin: the superior and inferior orbital fissures and the optic canal. These convey nerves and vessels, including cranial nerves, from the brain to the eye and other parts of the face. On the medial side of the socket is the nasolacrimal duct, which allows tears to drain from eye into nose.
Between the orbits, the two nasal bones meet in the midline of the upper face, forming the bony upper part of the nose called the bridge. Below them, the remaining nasal structures are made of cartilage. The part of the nose which divides the two nostrils is called the septum. Paranasal sinuses are air-filled hollows inside adjoining bones of the face; they are lined with mucosal tissue and surround and are linked to the nasal cavity.
The maxillae (singular, maxilla) are two bones which meet in the midline of the face above the mouth and form the boundaries of the lower parts of the orbits, the sides of the nose and top half of the mouth. They hold the upper teeth. The maxilla is the main structure in the part of the facial skeleton known as the middle third (lying between the frontal bone and the mandible). The maxillary and ethmoid air sinuses lie in this area, and fractures which involve them are treated as compound. Backward displacement of the maxilla can compromise the airway.
The temporal bones are on the sides of the skull, below the parietal bones and in front of the occipital bones. They correspond, in their frontal parts, to the area called the temple. The temporal bone is subdivided into four regions. The upper part, the squamous region, gives rise to the zygoma (see below). The tympanic region is the area where the bony structure of the outer canal of the ear is found, the external auditory meatus. The mastoid region is the site of the mastoid process, an attachment point for muscles of the neck. This can be felt as a smooth firm bump behind the ear. The mastoid lies between the middle ear and the brain. It is an area of sinuses which can harbour infection. There is, therefore, a risk, in some cases, that ear infections can pass to the brain through the mastoid. The petrous region of the temporal bone forms part of the inside of the cranium and encloses the structures of the middle and inner parts of the ear.
The zygoma is the cheekbone. It is one of the bony structures of the middle third of the face. It arises from the zygomatic processes of the maxilla and the frontal bone, on the lateral and inferior aspects of the orbit, and passes back along the side of the face towards the ear, as the zygomatic arch. It is the distinctive bony ledge which divides the temple from the cheek. It joins the zygomatic process of the temporal bone. Here, it forms a roof for the temporomandibular joint, the joint between the upper and lower jaws, just in front of the outer canal of the ear. There is a small hollow on the underside of the temporal zygomatic process, called the mandibular fossa, which receives the articulating part of the mandible, called the condyle. The external auditory meatus (see above) lies just below the zygomatic process as it merges with the temporal bone. The zygoma rises from the face and then rejoins it, in an arc something like a single-span bridge. If it suffers a crushing injury, usually from a blow to the side of the face, the span of the bone can be depressed towards the face, a fracture which creates a characteristic asymmetry, a flattening of the outline of the injured cheekbone.
The mandible is the lower jaw bone, the skeletal structure for the lower half of the mouth, the lower teeth and the chin. It comprises two symmetrical L-shaped parts which meet in the midline below the mouth (at the central dip in the chin, called the mandibular symphysis). The vertical legs of the bone, called the rami (singular, ramus, meaning branch), meet the horizontal parts at the mandibular angle, the posterior angle of the chin. The superior part of each ramus is made up of two processes divided by a groove called the mandibular notch. The anterior process is called the coronoid, and it is the insertion point for the temporalis muscle, which arises from the temporal bone and passes under the zygomatic arch to the lower jaw. It closes the mouth. The posterior process of the ramus is the mandibular condyle, which articulates with the mandibular fossa on the inferior surface of the temporal zygomatic process to form the synovial temporomandibular joint. This joint allows movement at the mouth, opening and closing, lateral deviation and protrusion of the mandible (thrusting the lower jaw forward). The mandibular condyles can be felt protruding if the fingertips are placed below the zygoma, just anterior to the entrance to the canals of the ears, and the patient is asked to open his mouth. The condyles become prominent as the mouth opens, and move under the zygoma as it closes.
Fractures of the face
Any patient who presents with fracture of the face should be referred. Fractures of the face are commonly accompanied by other injuries and often occur in serious incidents such as road traffic accidents or falls from great height. The patients presenting to minor injury clinics are of a different type. There are three common causes of injury:
1. Assault. The face has been punched, kicked or struck with an implement like a baseball bat, a brick, a bottle, a hammer or a metal bar. Issues such as crime (and the injury itself represents a crime), alcohol and drug misuse and domestic violence are often related to the event, and it may be difficult to obtain a clear history.
2. Sports injuries. These include blows to the face with hockey sticks and golf clubs, eye injuries from squash balls and orbit lacerations from clashes of heads at rugby. Patients who fall from bicycles, perhaps because they reflexively squeeze the brakes as they fall, often meet the ground or a wall face first.
3. Elderly people. When elderly people fall, they often fail to put out their hands to break the fall and will take the brunt on their faces. These injuries are often eyebrow and nose lacerations with no fractures. The question of why the fall happened may take more time than the facial injuries.
Facial fractures can obstruct the airway, and any patient is at risk who has suffered an injury which reduces the ability to open and close the mouth or to speak properly, or which produces the sounds of obstructed breathing, stridor or snoring. A fracture of the maxilla which is displaced backwards may endanger the airway and may need prompt reduction. Blood and vomit and broken teeth may be inhaled.
If the airway is threatened, summon emergency help. An anaesthetist will be required, possibly to intubate the patient or perform an emergency cricothyroidotomy.
Make a neurological assessment of a patient with a face injury (see Chapter 7), checking both head and neck. Exclude other injuries, especially if the patient is elderly or very young. These are particularly common when the patient has fallen in the street or from a bicycle. Focus, in the patient’s history, on why the injury occurred, whether or not the patient was knocked out, whether or not the patient remembers the incident. Has the patient walked since it happened? Find out about past medical history and medications. Anticoagulants are of particular importance if there is a risk of cranial bleeding or bleeding within or behind the eye. Discover if there is a history of falls with an elderly person, or medical conditions which predispose to a fall, of which there are many (the list includes Parkinson’s disease, cardiac arrhythmias, arthritis, cataract, transient ischaemic attacks and diabetes). The patient’s home circumstances, and whether or not there is someone to provide care, will be important.
A clinical examination of the face should show whether or not a fracture is present. Facial fractures often involve more than one bone, and any separate discussion of the bones should be read with that in mind.
Look for asymmetry or deformity of the face. Look from the front, the sides and from above and behind the patient, looking down. Try to distinguish a genuine bony asymmetry from soft tissue swelling and any imbalance between the sides of the face which is normal for the patient.
Other features which will alert to the presence of a fracture are tenderness, crepitus or gaps in the bone, facial paraesthesia and subcutaneous emphysema (if there is a fracture through an air sinus). There may be a loss of movement of the eye or jaw, a change in the position of the eyes in the orbits or a characteristic pattern of bruising and swelling. Fractures can occur to a number of bones.
The floor of the orbit
A blow on the eye may cause the orbit to give way at its weakest point, the floor. There may be no external bony tenderness. A blowout fracture of the floor of the orbit is indicated if the eye is retracted in its socket (enophthalmos), if there is loss of upward eye movement or double vision (diplopia) on upward movement, a difference in the level of the two pupils, if there is loss of sensation over the area of the infraorbital nerve (on the cheek just below the eye, side of nose, top of lip), a subcutaneous emphysema or a nosebleed on the injured side. There may be herniation of the eye, the fat of the orbit and perhaps the muscles of the eye into the maxillary sinus (the source of any subcutaneous emphysema).
The zygoma
A fracture of the cheekbone, often caused by assault, will cause a depression of the cheek which is plainly visible as an asymmetry.
There may be damage to vital structures within the eye; bleeding behind the eyeball (retrobulbar haemorrhage), optic nerve injury and damage to the orbit are common. Assess visual acuity. If the eye is protruding (exophthalmos), retrobulbar haemorrhage is possible.
Palpate the two sutures at the joints with the frontal bone, on the outer side of the orbit, and with the maxilla below the orbit. Palpate the lower margin of the orbit. Palpate the nasomaxillary and nasofrontal sutures. Assess the temporomandibular joints for disruption. All of these may be involved in the fracture. There may be paraesthesia, as for blowout fracture. A tripod fracture of the zygoma and maxilla is usually caused by a punch to the side of the face and is characterised by three fractures. These are found at the zygoma/frontal suture on the rim of the lateral orbit, the zygoma/maxilla suture below the orbit and the arch of the zygoma itself. This fracture disrupts the floor of the orbit.
The maxilla
The maxilla can be fractured by blunt injury, during assault or in sport (although road traffic accidents are the most common cause of fractures). These are much less common in minor areas than tripod and blowout fractures. Assess the airway. The maxilla may be driven back, obstructing the airway, a very violent injury. Fracture through the maxillary sinus may cause subcutaneous emphysema. Patients should not blow their noses to avoid worsening the emphysema or pushing air into the orbit. A fractured maxilla may drop down, giving the face a lengthened appearance. Maxilla fractures are accompanied by injuries to other parts of the middle third of the face, and this complex of injuries is classified in ascending order of severity as Le Fort fractures I, II and III.
I. The bone containing the top teeth is separated from the face above it.
II. The middle section of the face, including nose and the areas immediately lateral to the nose and the upper teeth, are separated from the face. The face may look elongated, and the front of the face may be mobile.
III. The face is separated in its entirety from the cranium. This is a major injury.
The nose
The nose is often punched, and a sideways impact can easily cause a displacement to the other side, a deformity which most patients will regard as cosmetically serious.
In the initial stage, the priority of management has to do with function. Is there a severe displacement? Are the airways patent? Is there a septal haematoma which should be drained? Is there a severe nosebleed? Are there associated fractures on the face?
Be alert for the presence of cerebrospinal fluid draining from the nose, indicating a fracture of the ethmoid bone. This exposes the cranium to infection. Look also for black eyes and orbital swelling, a flattening of the nose, a very mobile fracture and facial paraesthesia.
If the nose is undisplaced, there is no wound, and its functions are undisturbed, there may be no need, from the point of view of treatment which would follow, to refer the patient for X-ray. Follow local policy on that issue.
If there is a cosmetically significant injury which requires manipulation of the bone or cartilage of the septum, the patient should be referred to the ENT team. There will be a local arrangement for referral. This is usually postponed until the initial swelling is settled, but should be done before manipulation becomes difficult. This should be done in between a week and 10 days from the time of injury.
Mandible
Assess the airway. The lower jaw may be broken or dislocated at the temporomandibular joints by trauma. There is often more than one fracture, and the point of the impact will not necessarily be the site of the fracture. Check the teeth for injury and the tissues of the mouth for injury and haematoma. There may be paraesthesia of the lower lip. Look for bleeding from the ear. If the jaw is dislocated, there will be deformity and an inability to close the mouth. Is the patient’s bite normal? Is the patient swallowing properly? Does speech seem difficult? There may be visible deformity, swelling and bruising, and any fracture may be clearly palpable as a step in the bone.
The eye
Patients will present to a minor injury clinic with eye problems of every degree of severity and urgency, traumatic and non-traumatic. In many units, patients who present themselves with eye problems are referred to another site. The referral may be to a GP, an A&E department or an eye hospital. This section will give some basic information on first aid to the eye, and on discrimination between problems of different degrees of severity so that an accurate referral can be made. The eye will also be examined as part of an assessment of the patient after other injuries, such as trauma to the head.
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