The following CBME core competencies are covered in this chapter. EN4.31: Describe the clinical features, investigations and principles of management of trauma to the face and neck. AN3.6: Observe and describe the indications for and steps involved in the skills of emergency procedures in ear, nose and throat.

Facial Trauma (Maxillofacial Injuries)

Introduction and Clinical Relevance

Facial trauma refers to any injury involving the soft tissues, bones, or vital structures of the face, including the nose, maxilla, mandible, orbit, and frontal sinus. It is one of the most common emergencies encountered in ENT and trauma care. However, facial trauma is not only a cosmetic problem. It can rapidly become life-threatening because it may cause airway obstruction, massive bleeding, aspiration, cervical spine injury, or intracranial trauma. Road traffic accidents are the leading cause, followed by Physical assault, Falls (elderly and children), Sports injuries, Industrial injuries and Firearm injuries (gunshot, blast trauma).

Therefore, every MBBS and ENT PG student must follow the Advanced Trauma Life Support (ATLS) protocol for every patient.

ATLS in Facial Trauma (ABCDE Approach)

This systematic flow prevents complications and aligns with CBME competencies for emergency ENT management.

• A (Airway):  Secure the airway immediately and always assume cervical spine injury, so stabilise the neck. Suction blood and secretions to clear the airway. Use jaw thrust (avoid head tilt) to open the airway safely. If the patient is unconscious, insert an oropharyngeal airway, and try endotracheal intubation if possible. If intubation fails or facial trauma blocks the airway, do an emergency tracheostomy (or temporary cricothyrotomy).
• B (Breathing): Assess respiratory rate, oxygen saturation and maintain adequate ventilation.
• C (Circulation): Stop bleeding and correct hypovolemic shock. Control nasal bleeding by pinching the nose or by nasal packing. Perform arterial ligation in the neck for severe bleeding.
• D (Disability): Assess neurological status using GCS, pupillary reflexes, and look for signs of intracranial injury. Urgently refer to neurosurgery if there is altered sensorium, CSF leak, seizures, or suspected skull base fracture.
• E (Exposure): Expose the entire body to identify associated injuries to the head, chest, abdomen, neck, larynx, cervical spine, or limbs.

Secondary Survey in Facial Trauma

1. After stabilisation, take the history of the mechanism and time of injury, and ask about epistaxis, obstruction, diplopia, malocclusion, numbness, CSF leak, and trismus.
2. Inspect the face for asymmetry, deformity, swelling, bruising, lacerations, and periorbital ecchymosis.
3. Palpate for tenderness, crepitus, step deformity, abnormal mobility, and surgical emphysema.
4. Examine the nose for deviation, septal hematoma, perforation, or mucosal tears.
5. Check the oral cavity and teeth for broken/loose teeth, blood-stained saliva, malocclusion, and gum injury.
6. Perform eye and cranial nerve exam: vision, pupils, eye movements, diplopia, proptosis/enophthalmos, facial nerve, infraorbital and mental nerve sensation.

Classification of Facial Trauma

1. Soft Tissue Injuries – Lacerations, Abrasions, Burns, Bruises, Parotid Gland and Duct Injuries and Facial Nerve Injury.
2. Bony Fractures – Nasal, Mandibular, Maxillary, Zygomatic, Orbit, Frontal Sinus.
3. Orbital Injuries – Blowout Fractures, Hematoma

Soft Tissue Injuries

1. Facial Lacerations. For any laceration, thoroughly clean the wound to remove dirt, grease, or any foreign matter. Subsequently, close the laceration by accurately approximating each layer (skin, muscle, and mucosa) to achieve the best cosmetic result.
2. Parotid Gland and Duct Injuries. If parotid tissue is exposed, repair it by suturing the tissue carefully. However, injuries of the parotid duct are more serious and require prompt identification of both ends of the duct. After identifying the ends, suture them over a polyethylene tube using a fine suture, and leave the tube in place for 3 days to 2 weeks.
3. Facial Nerve Injury. If the facial nerve is severed, expose the nerve via a superficial parotidectomy. Then, approximate the cut ends with 8–0 or 10–0 silk sutures under magnification (microsurgery). Early repair is essential for good functional recovery.

Bony Fractures

Nasal Bone Fractures (Most Common)

Nasal fractures are the most common facial fractures because the nose projects prominently from the face. Therefore, you will frequently encounter these injuries.

Types of Nasal Fractures

Traumatic forces can act from the front or from the side. The magnitude of the force determines the depth of injury.

1. Depressed Fracture (Frontal Blow): The lower part of the nasal bones collapses. A severe frontal blow causes an “open-book fracture,” where the nasal septum collapses, and the nasal bones splay outward. Greater forces cause comminution of the nasal bones and the frontal processes of the maxillae, leading to flattening and widening of the nasal dorsum.
2. Angulated Fracture (Lateral Blow): A lateral blow causes unilateral depression of the nasal bone on the same side or fractures both nasal bones and the septum, resulting in deviation of the nasal bridge.

Classification Based on Pattern

Class	Name	Fracture Pattern	Key Features
Class 1	Chevallet Fracture	Vertical fracture across the septum	Low-impact injury, minimal cosmetic deformity.
Class 2	Jarjavay Fracture	Horizontal fracture across the septum	Greater force, involves nasal bones, frontal process of maxilla, and septum. Significant cosmetic deformity.
Class 3	Naso-orbito-ethmoid (NOE) Fracture	Complex fracture involving nose, orbits, and ethmoids.	High-impact frontal trauma. Causes “pig snout deformity,” telecanthus, CSF leak, and skull base fracture , requiring open fixation with plates.

Clinical Features of Nasal Trauma

1. Nasal obstruction and external deformity suggest nasal bone trauma. Bilateral complete nasal obstruction indicates a septal hematoma (a surgical emergency).
2. Telecanthus (increased distance between the medial canthi) occurs due to lateral displacement of the medial orbital wall in NOE fractures.
3. Pug nose or saddle nose deformity results from a depressed nasal bridge with the tip turned up.
4. Periorbital ecchymosis (raccoon eyes) and CSF rhinorrhoea suggest a fracture of the cribriform plate.
5. Diplopia, decreased vision, or epiphora suggests associated orbital trauma.

Diagnosis.

Nasal X-rays (Waters’ view, lateral views) are often not required for diagnosis but may be used for medicolegal purposes. A CT scan with 3D reconstruction is the gold standard for severe facial trauma, especially when NOE or skull base fractures are suspected.

Management of Nasal Fractures.

Timing is critical. Reduce the fracture before oedema appears or after it subsides (usually in 5–7 days). Do not attempt reduction after 2 weeks because the bone heals by then.

1. No intervention is needed if there is no cosmetic deformity.
2. Drain a septal hematoma immediately to prevent septal cartilage necrosis and subsequent saddle nose deformity or perforation.
3. Closed Reduction: Use digital pressure for simple depressed/deviated fractures. Use Asch’s or Walsham’s forceps for more severe deviations. This method works for Class 1 and most Class 2 fractures. An external splint is applied for around 2–3 weeks.
4. Open Reduction: This is required for severe Class 2 fractures, Class 3 (NOE) fractures, or when closed reduction fails. Use an H-type incision to expose the fractured area, reduce the bones under vision, and restore the medial canthal ligaments with transnasal wiring.

Complications of Nasal Fractures

• Residual deviation, drooping tip, or saddle nose (later requires septorhinoplasty).
• Nasal obstruction from valve collapse, septal deviation, or residual hematoma.
• Septal perforation from an untreated hematoma or abscess.

Mandibular Fractures (Second Most Common)

The mandible is the strongest bone of the face, yet it fractures frequently because it forms a prominent and exposed structure. Moreover, it participates directly in chewing, speech, and occlusion. Therefore, even a small fracture can cause major functional disability. Mandibular fractures commonly occur at the condyle (most common), followed by the angle, body, and symphysis (mnemonic: CABS).

Classification of Mandibular Fractures (Based on Location)

Mandibular fractures are classified anatomically into:

1. Symphysis
2. Parasymphysis
3. Body
4. Angle
5. Ramus
6. Condylar process (neck/head)
7. Coronoid process
8. Alveolar process (less common but clinically relevant)

Mechanism of Injury (Direct vs Indirect Trauma)

• Direct Trauma: A direct blow causes a fracture at the site of impact, such as Road traffic accidents, assaults, falls, and sports injuries.
• Indirect Trauma: A blow to the chin transmits force posteriorly and fractures the condyle. Therefore, condylar fractures commonly occur even when the chin takes the main impact.

Clinical Features of Mandibular Fracture

Symptoms: A patient with a mandibular fracture usually complains of:

• Pain in the jaw, especially while speaking or chewing,
• Difficulty in mouth opening,
• Change in bite (malocclusion),
• Bleeding from the mouth,
• Numbness of the lower lip.

Signs: Mandibular fracture typically shows:

• Step deformity (palpable intraorally or externally)
• Malocclusion (most reliable sign)
• Crepitus at the fracture site
• Tenderness and swelling
• Blood-stained saliva
• Ecchymosis of the oral mucosa
• Asymmetry of the lower dental arch
• Paradoxical mobility of the fracture segment
• Anaesthesia/paraesthesia of lower lip (inferior alveolar nerve injury)

Clinical Features of Condylar Fracture.

Condylar fractures are the most common mandibular fractures, and they often occur due to indirect trauma.

Symptoms and Signs

• Pain and tenderness over the TMJ
• Trismus (restricted mouth opening)
• Deviation of the jaw towards the injured side on opening
• Inability to move the jaw to the opposite side
• Malocclusion
• Anterior open bite (especially in bilateral condylar fractures)

Diagnosis

The panoramic radiograph (OPG) is the single best initial investigation because it shows the entire mandible in one image. Additionally, a PA view (Townes view) helps visualise the condylar heads, and oblique views assess the angle and ramus. A CT scan with 3D reconstruction is now preferred because it detects occult fractures, shows displacement clearly and helps surgical planning. It is best for complex or condylar neck fractures.

Management of Mandibular Fractures

• Conservative and Closed Management. Intermaxillary fixation (IMF) with arch bars or wires now has a limited role, reserved for undisplaced fractures, unilateral condylar fractures in children, or edentulous patients. For children with condylar fractures, limit IMF to 1-2 weeks followed by active jaw exercises, because prolonged immobilisation beyond 3 weeks can cause TMJ ankylosis. Remove IMF wires after 2-3 weeks in adults and start jaw exercises.
• Open Reduction and Internal Fixation (ORIF). The gold standard is open reduction and internal fixation (ORIF) using titanium miniplates, preferably via an intraoral approach. Use an intraoral (gingivobuccal) incision for fractures of the symphysis, body, and angle. Use a retromandibular or preauricular incision for condylar neck fractures, and a submandibular incision for angle or lower border fractures.
• Special Considerations for Condylar Fractures. In children: Treat with IMF for only 1-2 weeks, followed by active jaw exercises. Prolonged immobilisation (beyond 3 weeks) can cause TMJ ankylosis, a devastating complication. In adults: Perform ORIF for dislocated condylar fractures, especially those with a shortened ramus. Use a retromandibular approach and fix with miniplates.

 

—-End—-

Reference Textbooks.

• Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
• Cummings, Otolaryngology-Head and Neck Surgery.
• Stell and Maran’s Textbook of Head and Neck Surgery and Oncology.
• Ballenger’s, Otorhinolaryngology Head And Neck Surgery
• Susan Standring, Gray’s Anatomy.
• Frank H. Netter, Atlas of Human Anatomy.
• B.D. Chaurasiya, Human Anatomy.
• P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
• Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
• Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck Surgery.
• Hans Behrbohm, Textbook of Ear, Nose, and Throat Diseases With Head and Neck Surgery.
• Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
• Arnold, U. Ganzer, Textbook of  Otorhinolaryngology, Head and Neck Surgery.
• Ganong’s Review of Medical Physiology.
• Guyton & Hall Textbook of Medical Physiology.

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