Residency · Residency · Oral Maxillofacial Surgery
Systematic Assessment of the Facial Trauma Patient
Overview
Facial trauma frequently occurs in the setting of polytrauma requiring a systematic, prioritized approach. ATLS (Advanced Trauma Life Support) principles govern the initial management. Maxillofacial injuries are rarely immediately life-threatening but can compromise the airway. The OMFS surgeon must integrate into the trauma team and address facial injuries within the broader context of the multiply injured patient. Definitive facial repair is typically performed after the patient is stabilized.
Primary Survey (ABCDE)
A -- Airway with Cervical Spine Protection
Maxillofacial trauma is the most common cause of a compromised airway in facial injury. Sources of airway obstruction include blood, secretions, vomitus, and foreign bodies (teeth, denture fragments, bone), tongue base prolapse (from bilateral mandible body or parasymphysis fractures causing loss of genioglossus support), soft tissue swelling of the floor of mouth and pharynx, displaced fracture segments (midface down-fracture or bilateral mandible fractures), and laryngeal or tracheal injury (rare but critical).
Immediate interventions include suction, manual removal of debris, jaw thrust (avoiding head tilt-chin lift until the C-spine is cleared), pulling the tongue forward with a towel clip or suture if it is prolapsing, and placement of a nasopharyngeal or oropharyngeal airway. Definitive airway management involves endotracheal intubation (oral or nasal) or a surgical airway. Cervical spine injury should be assumed until cleared, with inline stabilization maintained. The C-spine injury rate in facial fracture patients is 1-10%, with higher association in frontal sinus, Le Fort, and mandibular fractures.
Airway Management Considerations in Facial Trauma
Oral intubation may be difficult with trismus, blood, or displaced fractures. Nasal intubation is contraindicated in suspected skull base fractures (Le Fort II/III, NOE fractures) due to the risk of intracranial passage. Video laryngoscopy provides improved visualization in difficult airways. Fiberoptic intubation, either awake or asleep, is useful when anatomy is distorted. A surgical airway (cricothyrotomy) is indicated if intubation is impossible, and tracheostomy is used for prolonged airway management. Submental intubation is an alternative for cases requiring intraoperative MMF when nasal intubation is contraindicated.
B -- Breathing
Assessment includes bilateral chest expansion, breath sounds, and oxygen saturation. Pneumothorax should be ruled out especially in high-energy trauma, and associated thoracic injuries in polytrauma patients should be identified.
C -- Circulation
Facial hemorrhage can be significant because the midface is highly vascular. Sources include maxillary artery branches, nasal vessels, and ethmoidal arteries. Hemorrhage is controlled through direct pressure, anterior and posterior nasal packing, balloon catheter tamponade (Foley or Rapid Rhino), reduction and stabilization of fractures (which reduces bleeding by reducing dead space), angiographic embolization for refractory hemorrhage (internal maxillary artery, ethmoidal arteries), and external carotid artery ligation as a last resort. Facial bleeding alone rarely causes shock in adults -- if the patient is hypotensive, other sources should be sought.
D -- Disability
Glasgow Coma Scale assessment, pupil examination (size, reactivity, symmetry), and neurologic assessment are performed. TBI is common with facial fractures. The intracranial injury rate with midface and frontal fractures is 10-50%. Altered consciousness mandates head CT before facial fracture repair.
E -- Exposure/Environment
Complete exposure identifies all injuries. Log roll is performed with spinal precautions, and environmental control (warming) is maintained.
<image>Flowchart of the primary survey (ABCDE) adapted for maxillofacial trauma, emphasizing airway obstruction sources unique to facial injuries (tongue prolapse, blood, displaced fractures), contraindications to nasal intubation with skull base fractures, and hemorrhage control methods including nasal packing, Foley catheter tamponade, and angiographic embolization</image>
Secondary Survey -- Facial Examination
History
The AMPLE history includes Allergies, Medications, Past medical history, Last meal, and Events surrounding the injury. The mechanism of injury (assault, MVC, fall, sport, gunshot wound), direction and force of impact, and any loss of consciousness or amnesia are documented. Pre-injury occlusion is established by asking about dental work, orthodontics, and dentures. Visual changes (diplopia, vision loss) and numbness (in the trigeminal nerve distribution) are assessed.
Systematic Facial Examination
Inspection
Lacerations are assessed for location, depth, and involvement of specialized structures (parotid duct, facial nerve, lacrimal system, lip vermillion). Edema and ecchymosis are noted, with periorbital "raccoon eyes" suggesting anterior skull base fracture and mastoid Battle sign suggesting posterior skull base fracture. Facial symmetry is evaluated, as asymmetry suggests displaced fractures. Facial width, height, and projection are assessed -- increased intercanthal distance suggests NOE fracture, flattened malar eminence suggests ZMC fracture, and an elongated face suggests midface impaction. The dental examination checks for missing teeth, fractured teeth, malocclusion, gingival tears, step deformities at the occlusal level, and sublingual hematoma (indicating mandible fracture). Nasal examination evaluates deviation, septal hematoma (which must be drained urgently to prevent septal necrosis), and CSF rhinorrhea.
Palpation
Systematic palpation of the entire facial skeleton includes the frontal bar and supraorbital rims, nasal bridge and dorsum, infraorbital rims, zygomaticofrontal sutures bilaterally, zygomatic arches bilaterally, maxillary buttresses (piriform rim and zygomaticomaxillary buttress), maxillary mobility (grasping the anterior maxilla and rocking to perform the Le Fort test), mandibular borders, symphysis, body, angle, ramus, condyles, and the TMJ (palpation for tenderness, crepitus, and condylar translation). The examiner looks for step deformities, tenderness, crepitus, mobility, and depression.
Cranial Nerve Examination
CN I (Olfactory) assesses smell, which is often impaired with frontal or ethmoidal fractures. CN II (Optic) assessment includes visual acuity, visual fields, pupillary light reflex, and fundoscopy, with critical screening for traumatic optic neuropathy requiring emergent ophthalmology consultation if suspected. CN III, IV, and VI (Extraocular muscles) assessment evaluates eye movements and diplopia, where restriction suggests muscle entrapment from an orbital floor fracture. A forced duction test differentiates entrapment from edema or hemorrhage. CN V (Trigeminal) assessment tests sensation in V1 (supraorbital), V2 (infraorbital), and V3 (mental nerve) distributions -- infraorbital numbness suggests ZMC or orbital floor fracture, mental nerve numbness suggests mandibular body or parasymphysis fracture, and IAN numbness suggests mandible fracture involving the canal. CN VII (Facial) motor function of all five branches is tested before local anesthesia or significant swelling obscures findings, with documentation of pre-existing versus traumatic weakness. The temporal branch controls forehead elevation, zygomatic branch controls eye closure, buccal branch controls smile and cheek puff, marginal mandibular controls lip depressor function, and cervical controls the platysma.
Ocular Examination
Visual acuity is tested with a Snellen chart or finger counting. Pupillary reflex is assessed, with an afferent pupillary defect (Marcus Gunn pupil) indicating optic nerve injury. Extraocular movements are tested in all gazes. Enophthalmos or proptosis is compared using the worm's-eye view. Circumferential subconjunctival hemorrhage suggests orbital wall fracture. Hyphema (blood in the anterior chamber) requires ophthalmology consultation. Globe rupture signs include a teardrop pupil and extrusion of intraocular contents -- this is an emergency requiring eye protection without applying pressure.
Occlusion Assessment
The patient is asked to bite together and report any change from pre-injury occlusion. Premature contacts, open bite, and crossbite are checked. Intercuspal position and centric relation are assessed. Dental fractures are classified by the Ellis system, and luxation and avulsion are documented. Sublingual hematoma is pathognomonic for mandibular fracture.
<image>Annotated clinical photograph of a facial trauma patient demonstrating the key examination findings: periorbital ecchymosis, subconjunctival hemorrhage, nasal deviation, facial asymmetry from a displaced ZMC fracture, step deformity along the infraorbital rim, and an intraoral view showing malocclusion with a sublingual hematoma indicating a mandibular fracture</image>
Imaging
CT Face (Gold Standard)
Axial and coronal fine-cut (0.5-1 mm) CT of the facial bones with 3D reconstruction is invaluable for fracture pattern recognition and surgical planning. The frontal sinus, orbits, nose, zygoma, maxilla, mandible, and TMJ are all evaluated. CT head is mandatory if the GCS is less than 15, there was loss of consciousness, or intracranial injury is suspected. CT C-spine is obtained if cervical spine injury is suspected.
Panoramic Radiograph
The panoramic radiograph is excellent for mandibular fractures when the patient can cooperate. It supplements CT but does not replace it in complex trauma and may miss condylar fractures or non-displaced fractures.
Plain Films
Plain films have been largely replaced by CT in most trauma centers. Waters view, Caldwell view, and submentovertex projections remain useful in resource-limited settings. A mandible series (PA, lateral oblique, Towne view) provides supplemental information.
Timing of Repair
| Timing | Timeframe | Indications |
|---|---|---|
| Emergent | Within hours | Uncontrolled hemorrhage, airway compromise, open/contaminated fractures, globe injury requiring decompression, septal hematoma |
| Urgent | 24-72 hours | Orbital floor fracture with muscle entrapment (white-eyed blowout), frontal sinus with CSF leak, severely displaced fractures |
| Delayed | 5-14 days | Most facial fractures (swelling subsides, patient optimized); beyond 2-3 weeks healing complicates reduction |
Emergent (Within Hours)
Emergent indications include uncontrolled hemorrhage, airway compromise, open or contaminated fractures at high risk of infection, globe injury requiring orbital decompression, and septal hematoma drainage.
Urgent (24-72 Hours)
Urgent indications include orbital floor fracture with muscle entrapment and restricted gaze (white-eyed blowout fracture, especially in children), frontal sinus fractures with CSF leak, and severely displaced fractures that will become more difficult to reduce with delay.
Delayed (5-14 Days)
Most facial fractures are repaired within 1-2 weeks, allowing initial swelling to subside for improved surgical access and fracture visualization. The patient must be medically optimized. Beyond 2-3 weeks, fracture healing begins to complicate reduction.
Clinical Pearls
The airway is the priority -- a beautiful fracture repair is worthless if the patient dies from airway compromise. Nasal intubation should never be performed on a patient with suspected skull base fracture because the tube can enter the cranium. There should always be an assumption that a more severe injury exists until proven otherwise, as facial fractures are markers of significant force. Bilateral mandibular fractures involving the body or parasymphysis can cause acute airway obstruction from loss of tongue support, demanding vigilance. A thorough eye examination should be performed before the patient becomes too swollen, documenting visual acuity, pupillary responses, and extraocular movements. Sublingual hematoma is pathognomonic for mandibular fracture and must not be missed on intraoral examination. CSF rhinorrhea or otorrhea indicates a skull base fracture -- the halo test (clear fluid spreading on filter paper with a central blood spot) can help confirm, but the beta-2 transferrin assay is definitive. All injuries should be photographed at presentation, as documentation is medicolegally essential and aids in surgical planning.
<image>CT face with 3D reconstruction of a panfacial trauma patient showing multiple fracture lines involving the frontal sinus, bilateral ZMC, bilateral orbital floors, bilateral Le Fort I and II fracture patterns, and bilateral mandibular fractures (parasymphysis and subcondylar), with key fracture lines annotated</image>
References
- Perry M, et al. Advanced Trauma Life Support (ATLS) and facial trauma: can one size fit all? Br J Oral Maxillofac Surg. 2008.
- Kellman RM, Losquadro WD. Comprehensive approach to the management of facial trauma. Facial Plast Surg Clin North Am. 2017.
- Nasser M, et al. Imaging in facial trauma. Oral Maxillofac Surg Clin North Am. 2019.
- Jose A, et al. Management of maxillofacial trauma in emergency: an update of challenges and controversies. J Emerg Trauma Shock. 2016.
- American College of Surgeons. ATLS Student Course Manual, 10th Edition. 2018.
- Allareddy V, et al. Epidemiology of facial fracture injuries. J Oral Maxillofac Surg. 2011.
