Facial Laceration Case File

Facial Laceration Case File

Eugene C. Toy, MD, Barry C. Simon, MD, Terrence H. Liu, MD, MHP, Katrin Y. Takenaka, MD, Adam J. Rosh, MD, MS

Case 12

A 32-year-old man, involved in a motor vehicle collision (MVC), is brought to the emergency department (ED). He lost control of his car and hit a utility pole with the front end of his car, while traveling at approximately 35 MPH. He was thrown against the windshield of the car, hitting his face and forehead against the windshield. There was no loss of consciousness. His blood pressure is 125/79 mm Hg, heart rate is 92 beats per minute, respiratory rate is 16 breaths per minute, and pulse oxygenation is 99% on room air. On examination, he has a 7-cm laceration on the right side of his face that courses from his right ear to just below the lower lip. He is alert and has no focal neurologic deficits on examination. When he is asked to smile, the right side of his mouth droops.

⯈ What is the most likely diagnosis?

⯈ What is the most appropriate therapy?

ANSWER TO CASE 12:

Facial Laceration

Summary: A 32-year-old man presents to the ED after a motor vehicle collision. There is no evidence of injury except for a 7-cm laceration on the right side of his face, which courses from his ear, to across the cheek, and ends just below the right lower lip. His neurologic examination is normal except for the inability to smile on the right side.

• Most likely diagnosis: Right facial nerve laceration
• Most appropriate therapy: Microsurgical repair of right facial nerve and closure of skin laceration

ANALYSIS

Objectives

1. Understand the critical structures that can be injured in facial lacerations.
2. Understand the need for tetanus immunization in trauma patients.
3. Know the basic principles of facial laceration repair.

Considerations

This patient suffered a laceration across his right cheek after being involved in a motor vehicle collision. The mainstay in trauma management includes managing the airway, breathing, and circulation (ABCs). Once the primary survey is complete, the physician then performs the secondary survey, which includes a head-to-toe physical examination that evaluates for non–life-threatening injuries. Any trauma to the head, face, or neck should raise concern for a cervical spine (C-spine) injury. If there is suspicion for a C-spine injury, the patient should be placed in a rigid cervical collar until either appropriate imaging can be performed or appropriate clinical evaluation completed. Facial trauma often results in bony injuries to the orbits and mandible. Injury to cranial nerves V and VII are common. The facial nerve (CN VII) exits the stylomastoid foramen and branches into motor and sensory branches to the temporal, zygomatic, buccal, and mental regions. Lacerations to the buccal branch are associated with injury to the parotid duct. Identification of a facial nerve injury is critical because delayed diagnosis results in poor outcome. Microsurgical techniques give fairly good results. After repair of the injury, the patient needs a tetanus immunization if the last time the patient received a tetanus vaccine was longer than 5 years ago.

Approach To:

Facial Lacerations

DEFINITIONS

FACIAL TRAUMA: Any soft or deep tissue injury secondary to physical force, burns, or foreign objects to the following structures: the scalp, forehead, nose, eyes, lips, cheeks, tongue, oral cavity, and jaw.

VERMILLION BORDER: The junction between the lip and facial skin. An injury to this area can result in a significant cosmetic defect if not repaired correctly.

AURICULAR HEMATOMA: Collection of blood in the ear that results from the traumatic interruption of the perichondrium and cartilage. If left untreated, it can evolve into a fibrous mass leaving the affected ear with a cauliflower-like appearance.

SADDLE NOSE DEFORMITY: Nasal injury secondary to the necrotic breakdown of the septal cartilage. It is caused by a traumatic injury to the nose resulting in a nasal septal hematoma. If the hematoma is left untreated, it separates the septal cartilage from its perichondrium depriving it of its nutrient supply.

TETANUS: An often fatal infectious disease caused by the bacteria Clostridium tetani, which usually enters the body through a puncture, cut, or open wound.

CLINICAL APPROACH

The basic approach to wound care includes assessment for other injuries, probing the depth of the wound, irrigation, a neurovascular examination, and deciding on whether primary closure is advisable (ie, leave open if infection is likely such as contamination or delay in presentation). The length of time the suture stays in place and the type of suture depends on the body location (Table 12–1). Additionally, the need to update the patient’s tetanus vaccination should be assessed.

Irrigation

When the decision to suture is made, a stepwise preparation must take place. All wounds must first be irrigated and explored for foreign bodies and environmental debris. Proper irrigation can significantly reduce the risk of wound infection. High-pressure and large-volume irrigation remains the gold standard to reduce or eliminate particulate matter and bacterial loads from the wound. This is usually established with a 35- to 60-mL syringe and 16- to 19-gauge catheter using constant hand pressure. This generates a pressure of 5 to 8 psi, which is adequate to irrigate a wound. Sterile saline is the most commonly used irrigant. Application of povidone iodine, hydrogen peroxide, and detergents should be avoided because of their toxic effects on tissue.

Anesthesia

Once irrigation is complete and the wound is examined, anesthesia should be administered. Delaying anesthesia until irrigation is completed allows the patient to reveal any sensation of a retained foreign body that might dislodge during irrigation. Local anesthetics are divided into two major groups, amides and esters. Although it is rare, some patients are allergic to anesthetics. However, if a patient is allergic to one class, the other class can be safely administered. It is thought that the allergy is to the preservative in the anesthetic, rather than the anesthetic itself (Table 12–2).

Local anesthesia can be attained in many ways including injection directly into the wound, topical application, or by a nerve block. The most common method is local infiltration. Several techniques are available to reduce pain experienced by the patient during injection. These include using smaller gauge needles, injecting at a slow rate, infiltrating the wound edge instead of surrounding skin, adding sodium bicarbonate to the anesthetic solution at a 1:10 dilution, and warming the solution. Some authors recommend first applying topical anesthetic. This is particularly useful in the pediatric population. Initially TAC (tetracaine, 0.25%-0.5%; adrenaline, 0.025%-0.05%; cocaine, 4%-11%) was commonly used, but was associated with seizure, arrhythmia, and cardiac arrest. LET (lidocaine, 4%; epinephrine, 0.1%; tetracaine, 0.5%) is generally safer than TAC and is used for anesthesia of the face and scalp. EMLA (eutectic mixture of local anesthetics) consists of lidocaine and prilocaine and is also commonly used. Because of the possibility for systemic absorption of lidocaine and tetracaine, these anesthetics should be avoided in large wounds and mucus membranes.

Epinephrine is added to many anesthetic solutions. This augments hemostasis and prolongs the duration of action of the anesthetic by decreasing systemic absorption through local vasoconstriction. Although it is controversial, it is recommended to avoid injecting solutions with epinephrine into sites such as digits, the tip of the nose, ears, and penis due to the risk of necrosis.

Suture Placement

To reduce scarring, sutures on the face should be placed approximately 1 to 2 mm from the wound edge and 3 mm apart. Cosmesis is less of a concern with other body areas.

Wound Closure

Once the wound is irrigated, explored, and anesthetized, closure can begin. Below are several methods and approaches for wound closure depending on the site of injury; addressing proper methods to examine specific areas and appropriate closure techniques.

Scalp and Forehead

These lacerations are usually caused by a combination of blunt and sharp trauma. Careful inspection of the wound is critical, with care to palpate for depressed skull fractures, and assess the integrity of the galea aponeurosis, which covers the periosteum. Repair usually follows the skin lines for the best cosmetic result. The scalp should be closed with a 4-0 monofilament suture of different color than the patient’s hair or staples can be used. Sutures and staples should be removed after 7 to 10 days. Because scalp lacerations can be associated with significant hemorrhage, rapid closure with staples may decrease the blood loss. If the galea is involved, it should be repaired with long-lasting absorbable suture material (eg, Vicryl, Monocryl). Closing the galea helps to control heavy bleeding associated with scalp wounds and limits the spread of potential infection. Forehead lacerations should be repaired in layers. The skin should be approximated with 6-0 nonabsorbable interrupted sutures, and removed after 5 days. Care should be taken to precisely approximate hair lines.

Eyelids

The eyelid is thin and delicate and is functionally and cosmetically important. Because of the risk of periorbital trauma, the emergency physician should have a low threshold to refer to an oculoplastic specialist or ophthalmologist for evaluation and repair. This includes lacerations to upper and lower lid margins and those involving the lacrimal duct. Any laceration medial to the puncta should be highly concerning for a canicular system injury. Staining the laceration with fluorescein dye can be used to determine damage to the canaliculus. In addition, damage to the levator palpebrae superioris muscle should be ruled out with traumatic lacerations of the upper lid. This commonly manifests as ptosis. A majority of eyelid lacerations can be managed without suture repair, including lacerations that are superficial and involve less that 25% of the eyelid. When sutures are indicated, repair is generally undertaken with 6-0 or 7-0 interrupted sutures, with care to stay superficial; the suture is removed after 3 to 5 days.

Nose

The nose is commonly injured, and is the most common fracture in victims of domestic violence. It is the focal point of the face, thus it is important to ensure proper management of nasal lacerations for optimal cosmesis. Inspection for the depth of injury is important. Infection can occur when all of the layers are penetrated or when cartilage is exposed. Septal trauma may lead to hematoma formation, which can lead to necrosis of the septum or chronic obstruction of the nasal passageway. Untreated hematoma separates the septal cartilage from its perichondrium depriving it from the nutrient supply. The septal cartilage can necrose resulting in a saddle nose deformity. Therefore, septal hematomas require drainage. Anesthesia in this area is difficult because of the tightness of skin over the cartilage, but can be obtained via a dorsal nerve block. Injection directly into a wound can distort wound edges for repair and is extremely uncomfortable, as well. Epinephrine must be avoided in this area. Topical lidocaine is generally helpful. Cartilage lacerations should be repaired with 4-0 or 5-0 absorbable sutures, and the skin closed with 6-0 nonabsorbable suture for 3 to 5 days. Lacerations to the nasal alae are usually complex and difficult to anesthetize; these wounds often require consultation of a plastic or ear, nose, and throat (ENT) surgeon.

Lips

The junction between the skin and the red portion of the lip, the vermillion border, is of vital cosmetic importance. Additionally, the orbicularis oris muscle that surrounds the mouth is critical for facial expression, speech formation, and the retention of saliva. Lacerations involving the lip that do not cross the vermillion border can be closed in layers with 6-0 nonabsorbable suture and left in place for 5 days. If the vermilion border is disrupted, the first stitch in repair should exactly approximate the border using 6-0 nonabsorbable suture. This first suture needs to be precise, because even a 1-mm discrepancy is noticeable (Figure 12–1). A plastic surgeon can be consulted for these injuries. Regional anesthesia is helpful, because local anesthetic infiltration can obscure the anatomy. The most common regional blocks include the mental nerve block and infraorbital block for the lower and upper lip, respectively. All intraoral wounds are dirty wounds and are at high risk for infection. Therefore, prophylactic penicillin or clindamycin is indicated.

Figure 12–1. Lip laceration crossing the vermillion border. The first step is to approximate the

vermillion-skin junction, the orbicularis muscle is then approximated and, finally, the skin is

repaired.

Ears

In patients with trauma to the ear region, the physician should evaluate the patient for a basilar skull fracture or tympanic membrane rupture. After inspection, cotton can be placed into the ear canal during irrigation of any lacerations. Regional auricular block is effective, and again, epinephrine should be avoided. Lacerations of the ear should be approached with the following goals: cosmesis, avoidance of hematoma, and prevention of infection. Repair of lacerated ear tissue should mirror its symmetric counterpart as much as possible for the best cosmetic results. Superficial lacerations should be repaired with 6-0 nonabsorbable sutures, and removed in 5 days. Meticulous hemostasis is important to prevent hematoma formation. If an auricular hematoma is present, and is left unaddressed, the ear is prone to abnormal cartilage production and subsequent calcification commonly referred to as a “cauliflower ear.” Auricular hematoma, avulsed tissue, or crushed cartilage is probably best handled by a plastic surgeon or otolaryngologist. Any cartilage that is exposed should be covered to reduce infection, erosive chondritis, and subsequent necrosis. If a plastic surgeon or otolaryngologist are unavailable, small superficial lacerations should be repaired with uninterrupted sutures. Sutures should be placed in the skin surrounding these wounds paying special attention to avoid suturing the ear cartilage, which could lead to avascular necrosis. After the laceration is repaired, a pressure dressing should be applied to help prevent the formation of an auricular hematoma.

Cheeks and Face

Lacerations of the cheek and face should be repaired after investigating the vital structures in the region such as the facial nerve and parotid duct (Figure 12–2). Generally, a 6-0 monofilament interrupted suture technique is appropriate for repair. Sutures are removed after 5 days. Simple lacerations (<2 cm) isolated to the buccal cavity typically do not need closure. These areas are highly vascularized and heal well without sutures. Proper irrigation is important to prevent complications of infection. Lacerations in the buccal cavity greater than 2 cm have the propensity to collect food, which can lead to infection. These typically require closure. Absorbable 5-0 sutures are preferred. As stated above, all intraoral wounds are dirty and are at high risk for infection. Therefore, prophylactic penicillin or clindamycin is indicated.

TETANUS IMMUNIZATION

Tetanus is an acute, often fatal, but preventable disease caused by the gram-positive bacterium Clostridium tetani. The spores are ubiquitous in soil and animal manure. Contamination of a wound with C tetani, particularly in devitalized, crushed, or infected tissue, can lead to its proliferation and expression of the neuroexotoxin tetanospasmin. This powerful exotoxin acts on the motor endplates of skeletal muscle, the spinal cord, the sympathetic nervous system, and the brain, leading to generalized muscle rigidity, autonomic nervous system instability, and severe muscle contractions. The most common presentation of tetanus is muscle spasm of the masseter muscles, “lockjaw,” but the back, arms, diaphragm, and lower extremities can also be affected. The diagnosis is made clinically. In up to 10% of tetanus cases,

Figure 12–2. Anatomic structures of the cheek.

the patient does not recall a wound. The usual incubation period varies from 7 to 21 days, but can extend from 3 to 56 days.

Patients with tetanus should be admitted to the intensive care unit. Wound debridement, respiratory support as needed, and muscle relaxants or neuromuscular blockade may be helpful. Patients with tetanus should receive passive immunization with tetanus immunoglobulin (TIG) 3000 to 6000 units IM on the side opposite of the tetanus toxoid injection. It clearly reduces morbidity and mortality. Penicillin is usually given, but is of questionable efficacy.

Prevention of tetanus is accomplished with regular active immunization of all individuals. The dose of tetanus toxoid (TT) or diphtheria/tetanus toxoid (dT) is 0.5 mL IM regardless of age. Tetanus immunoglobulin (TIG) is given in patients with a possible tetanus exposure and have incomplete tetanus immunization (<3 injections). The dosage varies with age (Table 12–3). Tetanus immunoglobulin and tetanus toxoid should be administered in different body sites with different syringes.

Abbreviations: TDaP = tetanus, diphtheria, acellular pertussis; DTaP = diphtheria, tetanus, acellular pertussis; Td =

tetanus, diphtheria; TIG = tetanus immunoglobulin.

^aYes, if > 10 years since the last tetanus toxoid containing vaccine dose.

^bYes, if >5 years since the last tetanus toxoid containing vaccine dose.

Note: Please refer to CDC guidelines for more complete recommendations (CDC Health Information for International

Travel 2008, Chapter 4: Prevention of Specifi c Infectious Diseases).

COMPREHENSION QUESTIONS

12.1 An 18-year-old man was involved in an altercation at a local bar. He suffered a laceration of the scalp, neck, forehead, and upper lip. Which of the following is likely to be most challenging to repair from a cosmetic perspective?

A. Scalp

B. Neck

C. Forehead

D. Cheek

E. Upper lip

12.2 A 24-year-old woman was the victim of domestic violence and received treatment at the local emergency department for multiple contusions and lacerations of the face. Six months after treatment, she notices a defect of the nasal septum with communication between the right and left nasal passage way. Which of the following is the most likely diagnosis?

A. Physician use of epinephrine on the nasal septum

B. Patient use of cocaine

C. Hematoma of the nasal septum

D. Post-traumatic stress syndrome

12.3 A 48-year-old man was rock climbing when he slipped and suffered a laceration to his right lower leg. He put pressure on it, wrapped the area, and made his way to the ED. He recalls getting “all his shots” when he was a child, but doesn’t recall the last tetanus booster. Which of the following is the best choice regarding tetanus prevention?

A. Diphtheria toxoid/tetanus toxoids (DT) vaccine 0.5 mL IM

B. DT 0.5 mL IM and tetanus immune globulin (TIG) 250 units IM

C. DT 0.5 mL IM, TIG 250 units IM, and intravenous penicillin 600,000 units every 6 hours

D. Admit to the ICU to observe for muscle spasm and administer 2500 units TIG IM and 0.5 mL tetanus toxoid IM in the opposite deltoid muscles

12.4 An 18-year-old man presents to the emergency department complaining of right ear pain after sustaining a cut on his ear during a wrestling match. On examination, you note some swelling and exposed cartilage of the right upper ear. Which of the following is a correct statement?

A. Exposed cartilage should be left undressed and the patient should be discharged with follow-up.

B. Hemostasis and evacuation of an auricular hematoma should not be performed because it promotes infection.

C. When repairing an ear laceration, make sure to avoid placing sutures in the cartilage and only include the perichondrium when approximating the skin edges.

D. Tetanus toxoid is not recommended for these types of injuries.

12.5 A 5-year-old boy is brought to the ED by his mom for a forehead laceration after hitting his head on the jungle gym. There was no loss of consciousness. The child is alert and active. He has a 3-cm forehead laceration which crosses the hairline. Which of the following is the most appropriate method of wound closure in this patient?

A. Shave the hair surrounding the laceration and close with interrupted sutures.

B. Close with staples.

C. Close with steri-strips.

D. Close with interrupted sutures.

ANSWERS

12.1 E. Lining up the vermillion border is by far the most challenging to repair because even a 1-mm discrepancy is noticeable. Injuries to the scalp usually can be repaired with sutures or staples, and are rarely cosmetically debilitating. Injuries to the neck, forehead, and cheek require approximation of wound edges to ensure appropriate wound healing; however, these lacerations do not require meticulous approximation as seen in repair of the vermillion boarder. It is important to point out to your patients that all laceration repairs will leave a scar.

12.2 C. The patient likely developed a septal hematoma, which caused necrosis to the septum and the subsequent communication between the nasal passageways. Cocaine is associated with septal perforation secondary to its vasoconstrictive properties. There is no indication that this patient used cocaine. The use of epinephrine on the nose is contraindicated because of the potential for necrosis. However, epinephrine is not associated with septal perforation. Although post-traumatic stress syndrome can be debilitating for patients, it does not cause septal perforation.

12.3 A. Because the patient likely received a full series of immunizations, but does not remember the last booster, he should receive tetanus toxoid 0.5 mL IM. TIG should be reserved for the following patients: those who do not know their immunization status or know that they never received the full series of three shots and sustained a contaminated wound. Admission to the ICU should be considered if the patient has signs of tetanus, such as muscle spasm or lockjaw.

12.4 C. Small superficial ear lacerations should be repaired with uninterrupted sutures. Do not place sutures in lacerated ear cartilage. Sutures placed in the skin surrounding these wounds in the cartilage should include the perichondrium (thin tissue layer overlying the cartilage). This method allows the approximation at the cartilage edges. Exposed cartilage should be covered or dressed to prevent infection and necrosis. Hemostasis and evacuation of an auricular hematoma is recommended to prevent the development of “cauliflower ear.” All patients with interruptions in the skin should be offered tetanus prophylaxis if their immunization status is not current.

12.5 D. Facial lacerations should be closed with a 6-0 nonabsorbable suture in interrupted fashion. Staples do not provide the desired cosmesis for a facial wound repair. Staples are more appropriate for scalp lacerations. Steri-strips can be used in very small skin openings with minimal tension. They will not provide the tensile strength required for this patient’s wound closure. Shaving surrounding hair increases the risk of infection and is not recommended.

CLINICAL PEARLS

⯈ The vermillion border must be precisely approximated because of its important cosmetic characteristics. Even a small discrepancy in lining up of the tissue is noticeable.

⯈ The facial nerve courses from the mastoid region across the cheek area and is prone to injury in facial lacerations. Care must be taken to identify an injury to the nerve to prevent permanent deformity.

⯈ Complex lacerations of the face, eye, ear, nose, and mouth, including lacerations associated with focal neurologic deficits (eg, facial droop or ptosis) should be cared for with expert consultation such as an ENT surgeon or ophthalmologist.

⯈ Meticulous hemostasis is important in repairing ear lacerations to avoid “cauliflower ear.”

⯈ Tetanus is an acute disease of wound contamination, which is largely preventable with immunization. All patients at risk for tetanus and not up- to-date on their tetanus vaccination should receive tetanus immunoglobulin or tetanus toxoid.

References

Brown DJ, Jaffe JE, Henson JK. Advanced laceration management. Emerg Med Clin N Am. 2007:25; 83-99. 

Brunicardi FC, Anderson DK, Billiar TR, et al, eds. Schwartz’s Principles of Surgery. 9th ed. New York, NY: McGraw-Hill; 2009. 

Kretsinger K, Broder KR, Cortese MM, et al. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid and acellular pertussis vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of TDaP among health-care personnel. MMWR Recomm Rep. Dec 15, 2006 Dec 15:55 (RR-17): 1-37. 

Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine. 5th ed. Philadelphia, PA: Saunders; 2010. 

Tintinalli JE, Kelen GD, Stapczynski JS, eds. Emergency Medicine. 7th ed. New York, NY: McGraw-Hill; 2004:302-304. 

Updated recommendatioms for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussic (TDaP) vaccine from the Advisory Committee on Immunization Practices, 2010. MMWR. January 14, 2011;60(01)13-15.

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