Repair of Facial and Neck Traumatic Injuries
Please refer to TRAUMATIC INJURIES TO THE FACE AND NECK for an overview of the types in injuries that can occur to the face and neck.
This topic will present in more detail the types of procedures most commonly performed by an ear, nose and throat surgeon that aid in the repair of facial and neck injuries.
One of the most common injuries to the nose is a nasal fracture (“broken nose”). This usually is caused by blunt trauma to the nose (e.g. a baseball, elbow, etc.). Swelling, bruising and bleeding may occur. A nasal fracture is usually repaired by a closed reduction. This means that the nose is relocated into a normal position without an incision. IMPORTANT: Often times it is difficult to evaluate a nasal fracture immediately after the injury due to the swelling that is present. Therefore, an ear, nose and throat specialist should do an evaluation about 4 to 5 days after the injury. Repair is best done within seven to ten days of injury.
It is important to have the nose evaluated immediately after the injury to make sure a septal hematoma is not present. A septal hematoma is a collection of blood in the septum (partition in the nose) that needs to be drained (blood removed) or an abscess (infection) and a loss of cartilage in the nose may result.
If your child has an older injury or was born with an abnormally shaped septum, then septoplasty or septorhinoplasty will be necessary. (Please see SEPTOPLASTY for more information on these procedures.
FACIAL NERVE INJURIES (please see this topic for more information)
Trauma to the face and neck including cuts, hits, stabs or jaw fractures may result in trapping or separation of the facial nerve. The ear, nose, and throat specialist is the surgeon of choice for repairing a damaged facial nerve.
The ear drum (tympanic membrane) can “tear” as a result of an explosion or a slap to the ear. In areas popular for water sports, such as Florida, this injury is more commonly seen as a result of water-skiing or wake boarding. The eardrum can also be cut (perforated) because of insertion of an object, such as a Q-tip, stick, or pen. Most of the time (90%), the holes heal without surgical treatment. However, in those cases that do not, TYMPANOPLASTY may be required.
It is important to have an ear, nose, and throat specialist examine the ear and evaluate the hearing as trauma to the ear can cause hemotympanum (blood behind the ear) or a disconnection of the ear bones causing hearing loss. Trauma to the ear may cause a fracture through the ear and hearing organ resulting in hearing loss, disruption of the ear bones, spinal fluid leak or facial nerve injury. These types of injuries would usually be the result of significant head trauma, such as a motor vehicle accident, with loss of consciousness.
ORAL (in the mouth)
Traumatic injuries also occur within the mouth, especially in children. One of the most common is a soft palate (roof of mouth) laceration. These are cuts or punctures on the roof of the mouth caused by pencils, pens, and toothbrushes that get suddenly jammed against something firm and hopefully can be prevented with the “don’t run with that in your mouth” warning. Cuts on the tongue may also occur as a result of a fall or a motor vehicle accident. Most injuries that occur within the mouth heal on their own without stitches. However, blood vessel injuries can occur, so every injury needs to be carefully evaluated. Those that do not heal on their own require surgery.
The neck has many vital structures enclosed in a small space. Therefore, trauma to the neck is one of the more common causes of death in an injured patient. These vital structures include the airway (larynx and trachea), large blood vessels (carotid arteries and jugular veins, among others), the esophagus (tube that goes from the mouth to the stomach), the spinal cord, and many other nerves that are important for breathing, swallowing, arm movement, voice and sensation. The neck also contains glands (thyroid, parathyroid, and salivary) and other structures that are also critical for normal body functioning.
How is trauma to the neck evaluated?
Evaluation starts with the basic ABC’s (airway evaluation, check for breathing, check circulation) of resuscitation. Any patient with trauma to the neck will need to be evaluated to make sure the airway is able to deliver air to the lungs.
If the airway is compromised, a “by-pass” airway must be created either through an endotracheal tube (tube through the mouth), emergency cricothyroidotomy (temporary hole in the neck under the voice box), or a TRACHEOTOMY (a temporary tube through the neck into the breathing tube). Air (oxygen) is then delivered to the patient. Once adequate breathing is assured, any visible bleeding is controlled.
Once the patient is stabilized, the damage to the neck can be assessed.
The mechanism of the neck injury (how the injury occurred) will need to be determined. This is important because different mechanisms can result in different patterns of damage to the neck tissue. Trauma to the neck can be divided into penetrating injury (for example, a gun shot or stab wound) or through blunt injury (a hit or blow to the neck with a fist or foot, for example).
The severity of the neck injury can be assessed by assigning the injury to areas of the neck or zones created by the surgeon. This helps to determine what structures located in the neck are most likely to be damaged. Additionally, with penetrating wounds, a muscle at the front of the neck (platysma) is examined to see if it has been cut. If this muscle has not been cut, serious neck injury is much less likely.
A thorough head to toe evaluation of the patient is necessary to assess for other injuries, and find evidence of nerve, blood vessel, or airway injury associated with the neck injury.
Blood tests, x-rays, blood vessel studies (angiography), swallowing tube imaging (esophogram) or visualization (esophagoscopy), and CT scans are routinely performed to help assess the degree of damage. MRI’s (magnetic resonance imaging) are not routinely used to evaluate trauma patients. MICROLARYNGOSCOPY and BRONCHOSCOPY is commonly used by the ear, nose, and throat specialist to evaluate the airway.
The trauma surgeon usually is involved with the initial surgical management of trauma patients. However, other surgical specialists are consulted depending on the types of injuries found.
In neck trauma, the ear, nose, and throat specialist is consulted to repair laryngotracheal injuries. These injuries can include laryngeal (voice box) fracture, a crush injury to the airway or loss of function (VOCAL CORD PARALYSIS). Rarely, the airway can be completely separated necessitating immediate life-saving repair. Most of these injuries require a TRACHEOTOMY. Also, an ear, nose and throat surgeon will be asked to evaluate penetrating (stab or shot) injuries, due to the high level of expertise in neck anatomy (We know where things are!)
What are complications that can occur after neck trauma?
There are many complications that can occur after neck trauma depending on the extent and type of structures damaged.
Some of the complications primarily managed by the ear nose and throat specialist include short term, long term and post-operative complications.
Short term airway complications that need to be watched for include a slow obstruction of the airway that may occur with air leaking in between skin layers (subcutaneous emphysema), continued bleeding, or swelling of damaged tissues that press on the airway.
Long-term complications of the airway after neck trauma include narrowing (stenosis) of the airway because of scarring related to the injury. This may necessitate AIRWAY RECONSTRUCTION at a later date to reopen the narrowed area.
Fistula formation (abnormal connections between the airway and other structures) may also occur.
Post-operative complications are related to the specific surgical procedures performed by the ear, nose, and throat specialist to help repair the traumatic neck injury. Among these include breakdown of the surgical site, wound infection, bleeding, fistula formation, and airway stenosis (narrowing). Please see the various surgical procedures listed under SURGERIES WE PERFORM for more detail. The doctors at our Pediatric ENT offices are experienced and ready to help your child.
Thomas M. Andrews
Dr. Andrews specializes in the medical and surgical treatment of ear, nose and throat disorders of children and adolescents. His accreditations include Florida State Medical License and Ohio State Medical License. He is also a board member of the National Board of Medical Examiners and American Board of Otolaryngology, Head and Neck Surgery