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Christine Huang, MD, Assistant Professor, Department of Emergency Medicine, Indiana University, Indianapolis, IN
Aaron Leetch, MD, Assistant Professor, Departments of Emergency Medicine and Pediatrics; Program Director, Combined Emergency Medicine & Pediatrics Residency, University of Arizona, Tucson
Steven M. Winograd, MD, FACEP, Mt. Sinai Queens Hospital Center, Jamaica Queens, NY; Assistant Clinical Profesor of Emergency Medicine, Mt. Sinai Medical School, New York City; Assistant Clinical Professor of Emergency Medicine, NYiTCOM, Old Westbury, NY
Facial trauma is uncommon in children. However, the unique features of these injuries, as well as the assessment and management considerations to minimize radiation exposure and ensure optimal cosmetic outcome, require an awareness of the diagnostic and therapeutic approach in pediatric patients. The authors provide an overview of orofacial, eye, and ear trauma in children.
— Ann Dietrich, MD, FAAP, FACEP, Editor
Trauma is a leading cause of morbidity and mortality in children, with pediatric head trauma accounting for a large proportion of these injuries.1 Facial trauma is a smaller proportion of these injuries, although the diagnostic, treatment, and social management surrounding these injuries can be quite complex. Concerns regarding radiation exposure, surgical management, and aesthetic outcome are common questions for both the emergency department (ED) provider and the child’s guardian. This article describes the recognition and management of common facial trauma that ED providers may encounter in pediatric patients.
Only a minority of children who sustain facial injuries will have a concurrent facial fracture, although incidence increases with age.2 Facial fractures are less common in young children than in older adolescents and adults because children have proportionally smaller faces compared to their skulls, underdeveloped sinuses, large facial fat pads, unerupted teeth, and flexible bones. When fractures do occur, most commonly they are the result of motor vehicle collisions, followed by sports-related injuries, falls, bicycle accidents, and assaults.3,4 Additionally, ED providers always should consider nonaccidental trauma.
The most common facial fractures in children are nasal bone, maxillary bone, and other orbital wall fractures. Other fracture sites include the mandible, zygomatic arch, alveolar ridge, hard palate, and mid-face. (See Figure 1.)
The physical exam in children who have sustained facial fractures almost always is abnormal, although the findings are nonspecific. Inspection of the face may reveal an asymmetry, deformity, laceration, bruising, or swelling. Hematomas noted in the nose or mouth also may be a presenting sign. Palpation may detect points of tenderness, instability, numbness (nerve injury), or crepitus (subcutaneous emphysema). Visualization of the tympanic membranes is important to evaluate for otorrhea and hemotympanum, which may indicate a temporal bone or basilar skull fracture. However, a widened inter-canthus distance (telecanthus) may indicate a mid-face fracture. Le Fort fractures rarely are seen in children younger than 10 years of age. (See Table 1.) However, when present, these represent an urgent surgical case and require fixation during that visit.
Plain radiographs rarely are useful in identifying and differentiating facial fractures. Therefore, when there is a concern for underlying facial fractures, computed tomography (CT) generally is considered the diagnostic modality of choice for most facial fractures.5 Furthermore, a three-dimensional reconstruction can be created to provide additional details of the fracture for future surgical management.
Management of facial fractures is typically conservative.6 Facial fractures that do not result in functional impairment or significant cosmetic disfigurement rarely require surgical intervention. Most nondisplaced fractures are managed as outpatient, although consultation with local facial plastic surgery or otolaryngology specialists is recommended. Practices vary by region. Fractures that are displaced, comminuted, or unstable often require operative management. Although uncommon, Le Fort mid-face fractures require open reduction and internal fixation. (See Figures 2 and 3.)
Blunt trauma to the eye results in transmission of forces posteriorly and may cause a “blowout” fracture of the orbital wall. Orbital roof fractures are more common in children younger than 5 years of age, while orbital floor fractures are more common in older children (after facial growth and pneumatization of the sinuses occur).7 Signs of an orbital wall fracture include restricted extraocular motion (due to muscle entrapment), diplopia, pain with eye movement, enophthalmos (i.e., sunken eyeball), periorbital ecchymosis, lid edema, and subconjunctival hemorrhage. Orbital roof fractures may be complicated by communication with the intracranial cavity. Orbital floor fractures may be complicated by injury to the infraorbital nerve. CT of the head or face with orbital cuts is the test of choice for identification of an orbital wall fracture. Fractures can be subdivided into location and prognostic severity8:
Ophthalmology consultation is required. Often, operative repair is delayed seven to 10 days to allow swelling to subside. However, if there are acute complications, such as entrapment, vision loss, increased intraocular pressure (IOP), intracranial extension, or nerve injury, operative management may be emergent. Generally, nondisplaced Type 1 and 2 fractures can be managed on an outpatient basis. Type 3 and 4 fractures should be managed urgently during that visit, and Type 5 fractures constitute an ophthalmologic emergency.
Nasal fractures are the most common pediatric facial fractures.9 Deformity of the nose is the most common and specific clue to the presence of a nasal fracture. Other physical exam findings that may suggest a nasal fracture include swelling, bruising, epistaxis, and lacerations. In addition, visualization of the nasal septum may show evidence of deformity, mobility, and hematoma.
Not all cases of nasal fracture need to be evaluated with radiological imaging. Isolated nasal fractures may be diagnosed on physical exam alone and referred for outpatient follow-up. However, if there is concern for additional associated facial fractures, then a facial CT is indicated. Ultrasound also has been shown to be useful in the diagnosis of nasal fractures in adults and may have a role in cooperative children.10
Typically, nonemergent, displaced fractures may be reduced acutely or after resolution of edema several days later.11 Initial conservative management includes ice, nasal decongestants, and epistaxis control. Outpatient subspecialty referral three to five days after the injury facilitates better anatomic visualization while allowing for reduction, if necessary.12 In most cases, anatomic realignment and fixation are achieved under general anesthesia by closed reduction. As in adults, septal hematoma requires immediate drainage to prevent septal cartilage necrosis, saddle-nose deformity, or potential mid-face growth retardation.
A septal hematoma can be a significant complication of a nasoethmoid fracture and requires immediate intervention.11 Signs of a septal hematoma include unilateral nasal obstruction and a bluish, bulging mass overlying the nasal septum. Management involves emergent evacuation, which relieves pressure and prevents septal erosion and deformity.
Mandibular fractures are the most common facial fractures requiring hospitalization.4 A mandibular fracture can be classified based on location of the fracture on the mandible, listed in order of frequency: condyle, body, angle, symphysis, coronoid, ramus, and alveolar ridge. (See Figure 4.)
Examination of the mandible begins with evaluation for signs of swelling, bruising, tenderness, bony discontinuity, laceration, and drooling. The presence of malocclusion, crepitus, and trismus also should be assessed. Inspection of the oral cavity may reveal bleeding from the mouth, exposed bone, injured teeth, or sublingual hematomas. Occasionally, fractures to the body of the mandible may cause injury to the inferior alveolar nerve, resulting in complaints of ipsilateral numbness of the skin overlying the mandibular body and chin, as well as the ipsilateral mandibular teeth. In cooperative children, the ability to bite and hold a tongue blade in both sides of the jaw can be a good screening test for mandibular fracture.13
Options for imaging suspected mandibular fractures include plain film series, panoramic X-ray, and CT scan.14 Unfortunately, panoramic X-rays are not available universally and requires a patient to sit steady in an upright position. CT scan has become the standard imaging modality, providing significantly more anatomical detail, although at the expense of added radiation exposure. If not available or not clinically feasible, plain radiographs (posterioranterior, lateral oblique, towne occipitofrontal, mandibular occlusal, and dental views) may be used.
The appropriate surgical subspecialty should be consulted to guide management.14 Conservative management for nondisplaced fractures includes a soft mechanical diet and pain management. Operative repair is necessary for any notable malocclusion or limited mobility. Immobilization of mandibular fracture can be accomplished in a variety of ways. Before tooth eruption, a splint may be placed. After tooth eruption, the teeth themselves may be used as anchors for fixation. If there is significant instability, open reduction and fixation may be required. Bleeding from a tooth near a mandibular fracture or sinus fracture should be managed as an open fracture, and antibiotics should be administered.15
Dental injuries are a common occurrence during childhood and adolescence. They can cause significant and long-lasting cosmetic, functional, and financial impact. Appropriate initial management may reduce these negative sequelae.
The management of dental injuries depends on whether the tooth involved is part of the primary or permanent dentition. Tooth eruption and exfoliation occurs in a predictable manner. (See Table 2.) In general, all teeth in children 5 years of age and younger usually are primary. Children 13 years of age and older generally have all permanent teeth.
Dental trauma may be classified further by the anatomical location and nature of the injury.16 The simple anatomy of a tooth includes the crown (the visible portion of the tooth covered by enamel), the root (the deeper portion of the tooth inserted into the alveolar bone), and the cementum (the bony material that secures the tooth root to the periodontal ligament and alveolar bone). Injuries can occur at any of these sites and may be fractures (see Table 3), root fractures, or luxations (see Table 4). In addition, the surrounding mandibular bone may be involved (alveolar ridge fractures).
The crown of a tooth includes the enamel as well as deeper structures called the dentin and pulp. Injuries to the crown always involve the enamel but also may extend into the dentin and pulp. One traditional manner by which to describe crown fractures is the Ellis fracture classification. Ellis I fractures involve only the enamel. Ellis II fractures extend into the dentin. Finally, Ellis III fractures involve all three structures (enamel, dentin, and pulp). However, this simplified method of describing fractures actually is not used by dentists, who classify fractures as complicated (exposed pulp) and uncomplicated (pulp not exposed).14
Injuries isolated to the enamel (Ellis I) usually are painless unless associated with a luxation injury. Sharp edges of a chipped tooth may require smoothing by a dentist to prevent soft tissue injury. Dentin has a yellowish appearance, and when exposed (Ellis II) causes sensitivity to temperature and touch. The pulp is highly vascularized (central artery) and, therefore, appears pink or red and usually bleeds when exposed (Ellis III). Pulp injuries also usually are very painful. Preservation of the pulp is the key prognostic indicator in crown fractures, as pulp involvement increases the risk for infection and tooth necrosis.
Uncomplicated crown fractures involve only the enamel and dentin (Ellis I and II). Management of these injuries focuses on controlling pain and protecting the pulp. Bacterial and chemical access to the pulp through the fracture site may result in complications such as infection and pulp necrosis, although these are uncommon. Creating a protective barrier in the ED against microbial and chemical invasion, as well as exposure to temperature and touch, may help prevent further damage and provide pain control until the patient can follow up with a dentist for definitive management within a few days. The most commonly available chemical agent for this purpose is a calcium hydroxide composition. Also, 2-octyl cyanoacrylate has been shown to be helpful and may be available more readily in most EDs. Complicated root fractures (Ellis III) have a higher risk of pulp necrosis and require more urgent follow-up for pulp capping or pulpectomy (i.e., root canal).
Roots develop two to three years after tooth eruption. Fracture of the root may be located in the coronal, midroot, or apical regions. Root fractures with displacement often require urgent dental consultation for splinting.
Dental concussions refer to teeth that are painful but neither loose nor displaced. Pain usually results from minor injury to the periodontal ligament. Subluxations may occur in any direction or plane. Dental concussions and subluxations rarely are dental emergencies. Serious long-term injury to primary or permanent teeth is unlikely and, therefore, outpatient follow-up is recommended. However, if there is significant tooth mobility, then dental consultation should be considered for splinting or possibly tooth extraction.
Intrusion injuries are unique because they potentially can damage the periodontal ligament and underlying structures. A primary tooth that intrudes and affects underlying structures should be extracted. If there is no concern for damage to the underlying structures, then the tooth may be allowed to re-erupt spontaneously. In the case of a permanent tooth, spontaneous re-eruption may be allowed for teeth with incomplete root formation. Repositioning is required for teeth with complete root formation.
Extrusion injuries and lateral luxations require dental consultation. In the case of a primary tooth, extraction may be performed if exfoliation is predicted to be imminent. In the case of extrusion of a permanent tooth, dental consultation may be required for splinting.
Avulsion injuries are the most serious dental trauma and, in the case of permanent teeth, constitute a true dental emergency. Sometimes imaging is necessary to differentiate avulsion from severe intrusion. Reimplantation of primary teeth is not recommended; however, permanent teeth should be reimplanted as quickly as possible. The viability of the tooth depends on the health of the periodontal ligament. Preserving the ligament may be accomplished by suspending the tooth in cell culture media (e.g., Hank’s solution) or milk (preferably chilled) as quickly as possible after avulsion. Normal saline and saliva are not ideal, but are preferable to dry storage. Reimplantation is performed by rinsing off the tooth (without scrubbing) and then placing it into the socket with slow and steady pressure. Gently aspirating any blood clots from the socket may facilitate reinsertion. Patients may be given prophylactic oral antibiotics after successful reimplantation, although this practice is unproven except in patients at risk for developing subacute bacterial endocarditis from the transient bacteremia that may result.
Many dental injuries are associated with alveolar ridge fractures. Loose and laterally subluxated teeth may be an indication of an injury to the surrounding bone. Alveolar ridge fractures require dental consultation for tooth repositioning and splinting. Patients also should be given a course of prophylactic oral antibiotics.
Ocular trauma is common in
childhood and is the leading non-congenital cause of blindness in children younger than 20 years of age.17 (See Table 5.) Sports-related eye injuries are common because children and adolescents are more prone to these high-risk activities. It is important to document a thorough eye exam in patients presenting with ocular trauma.
Visual Acuity: This may be accomplished with finger counting at 6 feet, the Allen or “E” chart, or a standard eye chart, depending on the age of the child. If the child wears corrective lenses, perform the exam with the child wearing his or her glasses. If the glasses have been lost or damaged, correct refractive error by having the child look through a pinhole.
Pupils: Note pupil reactivity (direct and indirect), accommodation, size, and shape. Post-traumatic mydriasis may occur with direct blows to the eye.
Extraocular Movement: Limited extraocular movement is usually due to muscle entrapment associated with blowout fractures. Further imaging will be required to assess for associated fractures.
Position of the Globe: Enoph-
thalmos or exophthalmos may indicate underlying orbital fracture or hemorrhage.
Integrity of the Orbital Rims: Palpation of the bony orbital rims may identify tenderness, step-offs, or crepitus associated with fractures.
Slit Lamp Exam: Look for foreign bodies. The lens should be transparent, and the margins should not be visible. Check the cornea and anterior chamber for depth, flare and cells, and red blood cells.
Fundoscopic Exam: Check the posterior chamber and retina for signs of vitreous hemorrhage or detachment, retinal hemorrhage or detachment, and papilledema.
Fluorescein Dye with Cobalt Blue Filter: Look for epithelial disruption, linear streaks on epithelium, which suggests a foreign body embedded under eyelid, and Seidel sign, which suggests globe rupture with vitreous fluid leakage.
Intraocular Pressure: IOP may be increased or decreased. Normal IOP is between 15 and 20. Increased IOP may help identify retrobulbar hemorrhage but is unlikely to be sufficiently sensitive alone to exclude the diagnosis. Do not measure IOP if globe rupture or penetrating ocular trauma is suspected.
Eyelids: Note any lid swelling or lacerations. Evert the eyelid to check for foreign bodies. Do not evert the eyelid if globe rupture or penetrating ocular trauma is suspected, as this may increase the IOP.
Conjunctiva: Note any injection. The presence of a ciliary flush (perilimbal injection) may indicate the presence of a traumatic iritis. Check for chemosis and subconjunctival hemorrhage, which may be associated with globe rupture.
Horner’s Syndrome: The combination of ptosis, miosis, and anhydrosis is suggestive of disruption of the sympathetic pathway.
Ultrasound: Ultrasound is a useful tool to assess for ocular foreign bodies, retinal detachment, vitreous hemorrhage/detachment, or globe rupture.
A retrobulbar hemorrhage is a time-sensitive emergency and can rapidly lead to compression of the optic nerve, resulting in irreversible vision loss.18 Although relatively uncommon with isolated orbital fractures, retrobulbar pain, pupillary deformity, and vision changes are the most common symptoms. Proptosis (an afferent pupillary defect), chemosis, and increased IOP are concerning signs that should be managed emergently with a lateral canthotomy.19
A hyphema is an accumulation of blood in the anterior chamber. It may layer inferiorly or diffusely spread out (microhyphema). Typically, it is caused by a tear in the iris root and bleeding from the arterioles supplying the iris. Signs of a hyphema include decreased vision, a poorly reactive pupil, and red blood cells layered in the anterior chamber. Complications include increased IOP caused by obstruction of the drainage of aqueous humor from the eye. Patients are at risk for rebleeding three to five days after the initial injury as a result of clot lysis and retraction.
Management involves supportive care with bed rest and elevation of the head of the bed to at least 30 degrees.20 Patients should be given an eye shield with holes to protect the eye. Patients may take acetaminophen for pain but should be
advised to avoid nonsteroidal anti-inflammatory drugs and aspirin. Patients require an ophthalmology consult and typically receive topical steroids (prednisolone acetate 1%) and topical anticholinergics (atropine 1%). Oral steroids may be prescribed if there is a high risk of rebleeding. Of all these treatments, oral aminocaproic acid has been shown to prevent rebleeding.21 Beta-blockers, carbonic anhydrase inhibitors, or alpha-agonists may be needed in cases of increased IOP. Surgical intervention may be required for increased IOP refractory to medication, corneal blood staining, or cases of hyphema in select sickle cell patients.
Corneal injuries are a common cause of pediatric eye complaints in patients presenting to the ED. Pain is the primary symptom. Other symptoms include tearing, photophobia, conjunctival injection, and foreign body sensation. Injury to the cornea is confirmed with the application of fluorescein dye and examination with a cobalt blue filtered light source. Areas of epithelial disruption will fluoresce brightly, and foreign bodies can be visualized easily. Linear streaks noted on the epithelium are suggestive of a foreign body embedded under the eyelid.
The mainstay of corneal abrasion management is pain control. Additional therapy may include cycloplegic medications and eye patching for comfort, and topical antibiotics for infection prophylaxis. If identified, superficial foreign bodies may be removed with irrigation, a moistened cotton swab, or the tip of a 25-gauge needle if the child is cooperative. Ophthalmology should be consulted for deeply embedded foreign bodies. Ulceration is a significant complication of corneal abrasions; therefore, ophthalmology follow-up within 24 hours is indicated.
As a result of blunt ocular trauma, the lens may become partially (subluxation) or completely (dislocation) detached. Patients complain of blurry vision and monocular diplopia. Examination may reveal that the lens borders are visible. Anterior lens dislocation may be complicated by acute glaucoma and requires emergent surgical intervention.
Blunt force trauma to the eye may result in inflammation of the iris and ciliary body. Patients may have a delayed (one to three days) presentation with photophobia, redness, and traumatic miosis. On slit lamp exam, flare and cells may be present in the anterior chamber. Ophthalmology should be consulted, and management includes the use of cycloplegic drugs to relax the iris and pain medications.
The posterior eye is less likely to be injured during ocular trauma; however, injury is more likely to result in irreversible vision loss. Symptoms of retinal and vitreous injury are similar and include painless visual loss, flashes of light, and floaters. However, in the event of vitreous hemorrhage or detachment, an afferent pupillary defect will not be present. Ultrasound can be useful in identifying these injuries. Management includes urgent consultation with an ophthalmologist. The presence of retinal hemorrhages in an injured infant always should raise suspicion for nonaccidental trauma.
A ruptured globe is rare and may be due to blunt or penetrating ocular trauma. Signs of a ruptured globe include decreased vision, extensive subconjunctival hemorrhage, limited ocular motility, an abnormally shaped pupil (often described as “teardrop pupil”), an afferent pupillary defect, extrusion of intraocular contents, and an abnormally deep anterior chamber.22 Other associated injuries may include lens dislocation, vitreous hemorrhage, hyphema, and corneal injury. Fluorescein exam may produce a waterfall or fountain-like effect from aqueous humor leaking out of the defect (Seidel sign). A ruptured globe requires emergent ophthalmology consultation and admission for acute surgical intervention. The patient should be given a protective eye shield, broad-spectrum antibiotics, tetanus prophylaxis, and an antiemetic agent (to prevent increases in IOP from emesis).
Perichondrial hematoma can result from blunt force trauma to the pinna. Accumulation of blood between the perichondrium and cartilage can result in permanent deformity, a “cauliflower ear.” This can be complicated further by avascular necrosis of the cartilage itself. Management of the perichondrial hematoma requires emergent evacuation of blood via needle aspiration before calcification of the blood occurs.23 After evacuation, a pressure dressing should be applied to prevent further accumulation of blood.
A laceration involving the cartilage requires repair.24 The cartilage and overlying skin are approximated and closed using absorbable sutures. Afterward, a pressure dressing should be applied to prevent accumulation of blood and formation of a hematoma.
Patients who present with traumatic otorrhea likely have serious underlying pathology.25 In the setting of trauma, clear fluid from the ear is presumed to be cerebrospinal fluid leakage through a perforated tympanic membrane. This may be a sign of a basilar skull fracture and warrants further investigation with a CT scan (with thin cuts through the basilar skull) and neurosurgical consultation. Initially, fractures may be managed conservatively, but refractory leaks may require surgical intervention. Patients should be advised not to blow their nose.
Hearing loss secondary to ear trauma may be due to temporal bone fractures or tympanic membrane perforation. Fractures of the temporal bone may require decompression if nerve injuries are suspected. Tympanic membrane perforations usually will heal without specific intervention within 10 to 14 days. If there is involvement of the round or oval window, then referral to an otolaryngologist is required for surgical intervention.
Although trauma is a leading cause of morbidity and mortality in children, facial trauma is far less frequent. However, there are unique considerations in the child and specific variations in imaging (minimize radiation exposure) and therapeutic strategies (primary vs. permanent teeth) to optimize outcome. Awareness of the typical pediatric injury patterns, diagnostic evaluation, and therapeutic interventions, as well as indications for consultation, optimize each child’s functional and cosmetic outcome.
Financial Disclosure: To reveal any potential bias in this publication, and in accordance with Accreditation Council for Continuing Medical Education guidelines, we disclose that Dr. Hocum (pharmacist reviewer) reports he is an employee of United Therapeutics. Dr. Dietrich (editor), Dr. Skrainka (CME question reviewer), Dr. Leetch (author), Dr. Huang (author), Dr. Winograd (peer reviewer), Ms. Coplin (executive editor), Ms. Mark (executive editor), and Ms. Hatcher (editorial group manager ) report no relationships with companies related to the field of study covered by this CME activity.