Author: Quentin Reuter, MD (EM Resident Physician, PGY-2, NUEM) // Edited by: Michael Macias, (EM Resident Physician, PGY-3, NUEM) // Expert Commentary: Matt Levine, MD
Citation: [Peer-Reviewed, Web Publication] Reuter Q, Macias M (2016, June 28). Quick Guide To Minor Facial Trauma: Part 2. [NUEM Blog. Expert Commentary by Levine M]. Retrieved from http://www.nuemblog.com/blog/minor-facial-trauma-2/
In the emergency department, we commonly encounter minor injuries to the face and mouth. In a two part series, we provide a short overview of some helpful strategies for dealing with these cosmetically sensitive injuries in an effective manner. You can read Part I of this series here.
Core facial laceration management principles
Cosmesis is very important to consider when deciding on closure of facial lacerations thus primary closure should be considered in all facial lacerations unless significant tissue loss or swelling is present.
Injury to important underlying structures of the face should always be ruled out and proper physical exam & consultation should be considered when appropriate.
The facial skin has an abundant blood supply and as a result lacerations can be repaired up to a day after the injury occurred without a high risk of subsequent infection.
Facial nerve blocks should be considered to obtain anesthesia for lacerations that cross important facial creases or borders to avoid distortion of anatomy.
Proper alignment of the vermillion border or facial crease affected by a laceration is critical to avoid obvious cosmetic defects.
Sutures on the face should be placed approximately 1-2 mm from the skin edge and 3 mm apart to achieve optimal tissue approximation.
Hair does not increase in the risk of wound infection and shaving (such as the scalp or eyebrow) should be avoided.
Ear Lacerations
Goals: Cover the cartilage.
Importance: Can develop chronic chondritis and cosmetic deformities if you fail to cover the cartilage. Perichondral hematoma formation causes direct pressure on underlying cartilage and can lead to resultant ear deformity known as “cauliflower ear.”
Tips:
- Inspect internal & external ear completely to assess for associated injuries from ear lacerations from trauma including tympanic membrane perforation & basilar skull fracture (hemotympanum or Battle’s sign).
- Debridement should be minimized given minimal flexibility of skin overlying ear cartilage.
- Simple lacerations not involving the cartilage can be repaired with interrupted 6-0 monofilament, taking small bites (1-2 mm) to prevent eversion of skin edge.
- Lacerations that are simple but involve the cartilage can be managed similarly by approximating the overlying skin which is sufficiently adherent to the underlying cartilage to bring together its edges.
- Lacerations that are through-and-through the helix can be managed by suturing the anterior and posterior portions of the laceration, again the cartilage comes together with suture of the skin only.
- Complex cartilage injuries usually require consultation however some irregular wounds can be repaired by ED physicians with the goals that: (1) Debridement is minimal(< 5 mm cartilage can be sacrificed without deforming ear structure) & (2) No cartilage is left exposed.
Perichondral Hematoma
Image obtained from Wounds and Lacerations: Emergency Care and Closure
Goals: Drainage of hematoma and prevention of re-accumulation.
Importance: Perichondral hematoma formation causes direct pressure on underlying cartilage and can lead to resultant ear deformity known as cauliflower ear. There is a 72-hour window for which beyond this, the risk of cauliflower ear significantly increases.
Tips:
- Make a small incision in the hematoma, evacuate the clot between the perichondrium and the cartilage.
- A mastoid dressing should be placed immediately after drainage and checked in 24 hours for re-accumulation of blood.
Buccal Mucosal and Gingival Laceration
Goals: Identify and repair only injuries that mandate repair. Identify foreign bodies (tooth fragments).
Importance: As a general rule, most intraoral lacerations heal without repair. Damage to salivary structures, bone and tooth should be ruled out. Tooth fragments can lodge deep in lacerations and lead to infection so thorough exploration should be performed.
Tips:
- Small laceration (less than 2cm) with only minimal gapping can be left alone.
- Wound will become uncomfortable, covered with fibrous tissue in 48 hours. Instruct patients to rinse with lukewarm water, half strength hydrogen peroxide, or chlorhexidine oral rinse four times daily
- If there is continued bleeding, wound edges fall between chewing surface, or the wound is gapping, consider repair with 5-0 absorbable sutures.
- Don’t worry about repairing frenulum lacerations
- If dental fractures are involved, explore the wound thoroughly with gloved finger looking for dental fragments. Deep wounds or those in question should have imaging to rule out retained tooth fragments.
Tongue Lacerations
Goals: Repair lacerations at high risk of impairing function
Importance: The tongue heals rapidly and most simple, small lacerations will heal well on their own. Wounds to consider for repair include: large lacerations > 1.5cm, extending and passing through muscle layers, large flaps, split tongue lacerations.
Tips:
- Anesthesia can be obtained with direct local infiltration of lidocaine without epinephrine.
- Use absorbable sutures (i.e. 4-0 chromic gut or Vicryl).
- Sutures should be placed with large bites to include both the mucosa and muscle of the tongue.
- An assistant should be utilized to help pull out the tongue using dry gauze or a towel clip. You may also consider placing an anchoring suture (leaving the tails long) to gain control of the tongue.
- Instruct patients to rinse with lukewarm water, half strength hydrogen peroxide, or chlorhexidine oral rinse four times daily to prevent infection.
Lip Lacerations
Goals: It’s all about the vermillion border, must line this up properly.
Importance: The casual observer can appreciate a vermillion misalignment of even 1mm. These lacerations are particularly known for causing significant cosmetic deformity, so meticulous repair should be undertaken with a low threshold to consult a specialist for repair.
Tips:
- Anesthesia should preferentially be obtained via nerve block to avoid distortion of lip anatomy. This is accomplished by either an infraorbital nerve block for the upper lip or a mental nerve block for the lower lip.
- Place your first suture at the vermillion border. Consider using a marking pen to help you line up suture. Once proper alignment is obtained, 6-0 non-absorbable monofilament can be used to closer remainder of laceration. Note: If the mucosal border is violated, this should also be meticulously aligned.
- If you have a through and through laceration involving the orbicularis oris muscle, you can place 5-0 absorbable suture through the muscle, ideally through the fibrous muscle sheath to ensure anchoring. The remainder of the repair should proceed with 6-0 non-absorbable suture for the skin and exposed lip and 5-0 absorbable suture for the mucosal surface. Note: Consultation should be considered for any through and through laceration if there are high expectations for excellent cosmetic result.
Expert Commentary
The ear can seem like an intimidating area for procedures for the emergency physician due to the relative infrequency of these presentations. The concepts, however, are somewhat straightforward as excellently articulated by Dr. Reuter. A key to these procedures is adequate anesthesia. Since direct infiltration may be difficult and deforming in certain areas of the ear, I recommend a ring block of the ear when direct infiltration is not a good option. This provides anesthesia to the entire ear (except the concha and external auditory canal), which has innervation from four separate sensory nerves.
Use a 10mL syringe and a long 25 or 27 gauge needle. Lidocaine with epinephrine can be used (but for direct ear infiltration do not use epinephrine!). Disinfect the skin. Insert the needle just inferior to the attachment of the earlobe to the head, not into the earlobe itself. Advance the needle to the tragus, aspirating while advancing. Inject 2-3mL while withdrawing towards the puncture site. Without removing the needle, redirect and advance posteriorly along the posterior auricular sulcus, aspirating as you advance. Inject 2-3mL while withdrawing the needle. Remove the needle and repeat the technique superior to the ear, inserting just superior to the attachment of the tragus to the scalp. Remember all the infiltration is to the subcutaneous tissue of the head, not the ear cartilage. The superficial temporal artery is medial to the ear and would need constant direct pressure for at least 20 minutes if punctured.
Rapid follow up, preferably within 24 hours, is highly recommended after a mastoid dressing is placed to check the dressing and to ensure re-accumulation of the hematoma has not occurred.
I’ve always taken a minimalist approach to intraoral wounds. They seem to heal so well with little intervention. I typically inspect the wound and ask myself if I think it is large enough to get food fragments lodged within the wound. If so, then I recommend closure. The key is to avoid closing tooth fragments in a wound. This is a surefire recipe for disaster. Imaging in the ED for intraoral wounds is often impractical since plain films are not sensitive in this area and CT requires time and radiation. While films from a dental clinic may have utility, by then a tooth fragment has been closed in a wound so it is too late. So when teeth are not intact, intraoral wounds must be explored thoroughly! The grating of a metal probe against the fragment may be your only clue! If CT is ordered for evaluation of other facial injuries, go back and look at the images around the wound yourself. If you feel comfortable that a foreign body has been ruled out, then antibiotics are not necessary. The ability of the oral mucosa to avoid infection in the setting of a bacterial environment may seem difficult to believe but is remarkable.
The same advice regarding unaccounted-for tooth fragments pertains to tongue and lip lacerations as well. For tongue lacerations, the anchoring suture technique to obtain control of the tongue is especially useful in pediatrics. It is hard for those critters to keep their tongues still and they will curiously move their tongues all over to feel what is going on. Sedation may be necessary.
Matt Levine, MD
Assistant Professor
Director of Trauma Services, Department of Emergency Medicine
Northwestern Memorial Hospital
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References
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