Traumatic Injuries to the Head and Neck
How common is face and neck trauma in children?
Facial and neck trauma occurs frequently in children, however, because of the small face size, skeletal flexibility and increased fatty tissue in a child’s face, most of these injuries result in soft tissue (cuts and bruising) injuries. Fortunately, serious facial and neck fractures are uncommon. Serious injuries are not normally caused by childhood play, but are usually the result of motor vehicle accidents, kicks by animals, or fights. Serious face and neck injuries are more difficult to recognize in children compared to an adult and are often a challenge to treat.
Serious injuries to the skull (brain) and spine are actually more common in children than injuries to the face and neck. However, these regions are not within the ear, nose and throat specialty.
This topic will focus on the types of problems seen with serious injuries of the face and neck. Lacerations (cuts) that occur on the face, ear, and neck that are disfiguring are usually closed by special suturing (stitching) techniques, so as to minimize scarring. These lacerations will not be addressed in this discussion.
NASAL (nose) TRAUMA
The bones in the nose are the most frequently broken (fractured) in the face. Identification of a nasal bone fracture in children is not easy, as there is usually a lot of swelling, making touching the nose difficult. Additionally, x-rays are difficult to interpret. Immediate evaluation is necessary to make sure a collection of blood (hematoma) is not present in the septum (divider of the nose). If no hematoma is found, the patient is usually re-examined in two to three days, once the swelling has gone down. If the nose looks crooked, then immediate evaluation by an ear, nose and throat surgeon is necessary.
If a fracture is found, correction is usually performed by moving the nose into its normal position (reduction), as soon as possible. This is best performed within 7 to 10 days after the fracture. In more complicated fractures, or when fracture reduction has been delayed, a SEPTORHINOPLASTY may need to be performed at a later date. For girls, this should not be performed before age 16 and with boys, not before 17 or 18 or growth abnormalities may result.
In newborns, the nose at birth may be stuck to one side (subluxed) as a complication of being in the womb or through pressure during delivery. This problem may correct on its own; however, if breathing problems are present, or the nose is markedly deformed, it can be moved back into its normal position by a physician experienced in this procedure.
LOWER JAW (MANDIBULAR) TRAUMA
Because the jaw of a child is more flexible than an adult, few fractures result. However, the jaw joint (in front of the ear) may be pushed out of position causing the jaw to be locked open or not function normally.
The approach to fractures in the lower jaw depends on the age of the patient (how much growth the jaw has left), how the teeth are positioned in the mandible (jaw bone). Fractures are identified an x-ray.
Some general information about these fractures follows:
- The majority of lower jaw fractures involve the part of the lower jaw that is closest to the ears (called the condyle).
- They usually do not go through the entire jawbone and are known as “greenstick” fractures.
- They usually heal rather well with minimal intervention (no surgery and minimal immobilization) and they usually do not go through the area of the lower jaw that is growing.
- It is much more difficult to manage fractures that do damage the jaw area that is growing.
- These types of fractures have the potential to result in deformities of the jaw, problems with teeth development, and damage to the joint that opens and closes the mouth (temporomandibular joint).
- More complicated fractures involve surgical placement of the jawbone into the normal position (open reduction).
- This is best treated by a specialist called a maxillofacial surgeon.
The parotid gland (in front of and below the ear) secretes saliva into the mouth to aid in food digestion. When damage to this gland occurs, there is also a possibility of damage to the nerve that moves the face (please see FACIAL NERVE INJURIES/PARALYSIS). In addition, the duct that drains saliva into the mouth (Stenson’s duct) may also be damaged and require surgical repair.
UPPER JAW (MAXILLARY) INJURIES
Because the middle of the face (including the palate) in children is such a small area, fractures here are uncommon. However, when the middle of the face is involved, it is important to make sure that the eyes (see ORBIT INJURIES below) and nose (see NASAL TRAMA above) are not involved. In addition, children are more likely to have brain injuries (concussions), skull fractures, or upper spine fractures associated with facial fractures than adults.
Special x-rays called CT scans are used to evaluate fractures and brain involvement and to help plan the surgical reconstruction procedure. More severe fractures, especially those involving the lower jaw, may require a TRACHEOTOMY. Depending on the severity of the fractures, reconstruction is usually done in stages. There are different views among surgeons about the sequencing of the surgery, but ultimately the purpose is the same; to achieve as good a functional and cosmetic outcome as possible.
Evaluation of injuries in the eye should involve the consultation of an ophthalmologist (eye specialist). The initial evaluation of an eye injury does not involve touching the eye area until the eye is evaluated thoroughly by inspection and with x-rays and/or CTscans. Examination includes making sure that the eye can move in all directions, has normal vision (see normally), and that the eyeball itself looks normal, among other things. Special testing may be necessary to evaluate the retina (area in the eye responsible for seeing).
There are different types of fractures that can occur around the eye depending on where the facial injury occurred. Fractures can be located on the cheekbone (zygoma), above the eye, below the eye, or in the bones surrounding the eye socket. Early diagnosis of these fractures is important to avoid some later complications; these include the appearance of the eye sinking back into or pushing out of the eye socket, abnormal positioning of the eye, excessive tear production, double vision, or muscle spasms and nerve abnormalities around the eye area.
CUTS (LACERATIONS) IN THE EYE AREA
In addition to eye swelling, and fractures, cuts can occur around the eye. Occasionally a cut will damage the tear (lacrimal) duct, a tube that drains tears from the corner of the eye into the nose. Ophthalmologists are usually involved in the treatment of these lacerations to help prevent later complications with tear production or drainage.
TEMPORAL (SIDE OF FOREHEAD) INJURIES
Trauma to the temporal area of the head more commonly results in fractures than any other area of the skull (head). Complications from these types of fractures can include hearing loss or vertigo (feels like the room is spinning around). Although the vertigo can resolve over time, the hearing loss unfortunately is usually permanent. Fractures In this area may also involve the facial nerve (the nerve that moves the face).
IN THE MOUTH (INTRAORAL) INJURIES
Injuries involving the palate (roof of the mouth) are common in children. These usually occur when a child is running or playing with something in the mouth like a pencil, toothbrush or stick. Other injuries that may occur in the mouth include cuts or tears on the tongue, tonsils, and/or inside the cheek.
Cuts on the tongue if small usually heal on their own. Larger cuts may require stitches. However, it is common for stitches in the tongue to pull out because the tongue is a large muscle.
Tears on the soft palate usually heal on their own. However, if the cut extends to the side of the roof of the mouth, the patient may be admitted to the hospital for observation to make sure a large blood vessel (carotid artery) has not been injured. A special test called an angiogram may also be necessary.
Lacerations (cuts) can occur inside the ear in the outer ear canal (external auditory canal). A short-term complication with these lacerations includes infection; therefore, packing of the ear with antibiotic medicine is usually advised. A longer-term complication can include narrowing of the outer ear canal once the laceration heals, which, if problematic may require correction. The eardrum (tympanic membrane) can also tear causing a perforation. This will cause hearing loss at least temporarily. Drops should not be used in this situation because it may delay healing of the perforation. If the tear doesn’t heal on its own, TYMPANOPLASTY may be required. Your ear, nose and throat specialist will perform hearing tests after healing to ensure the hearing has returned to normal.
NECK (LAYRNGEAL) TRAUMA
Trauma to the larynx (voice box) can occur by an injury to the front of the neck, as well as a significant hit to the back of the neck (upper spine). The biggest immediate concern with this type of injury is to evaluate for signs of AIRWAY OBSTRUCTION. Complications of injury that can result in airway obstruction include cuts in the airway with swelling, VOCAL CORD PARALYSIS, and collection of blood (hematoma) of the vocal cords. Immediate treatment for this type of airway obstruction is a TRACHEOTOMY; an endotracheal tube (a tube put into the airway through the mouth) is not usually placed, as it can cause further damage to the airway.
A long-term consequence of airway trauma may be narrowing (stenosis) of the airway; this may require surgical reconstruction in the future.
Who can repair facial and neck trauma in children?
Because trauma to the face and neck can result in so many different types of injuries, more than one specialty may be involved in the evaluation and repair(s). An otolaryngologist is very experienced with injuries that involve the nose, face, neck, or ear. Other specialists that may be involved include oral surgeons and other dental specialists, neurosurgeons (brain surgeons), plastic and reconstructive surgeons, and ophthalmologists (eye specialists), among others. Please see “REPAIR OF FACIAL AND NECK TRAUMATIC INJURIES in “surgeries we perform” section for information on what types of repair procedures we perform at our office.
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