Although detailed evaluation of the extent of facial trauma is usually delayed until the secondary survey, 25–35 % of patients with penetrating injuries to the face will require an emergent airway. Oral intubation is always preferred over nasal intubation in the setting of midface instability, cerebrospinal fluid leak, and basilar skull fracture in order to avoid cranial intubation. Success rates of 85 % have been reported in large series of patients sustaining penetrating facial trauma. As mentioned in the introduction to this chapter, early elective intubation should be considered if the potential for deterioration of airway patency is high such as in intraoral bleeding and edema, gunshot wounds to the mandible, and close-range shotgun wounds. Additionally, brisk hemorrhage from lacerations to the face, scalp, and underlying structures should be identified and controlled with direct pressure during the initial evaluation.

There is no universal approach to the diagnosis and classification of penetrating facial trauma, but several authors have described schema to identify the location of the external wound and predict underlying structures at risk. The original designation of three zones of the face included everything below the hairline to the superior orbital rim (Area 1), the midface from the superior orbital rim to the upper lip extending laterally to the preauricular area (Area 2), and the lower face from the upper lip to the hyoid bone (Area 3). The use of this system directed further diagnosis and management of injuries based on the identifiable injuries on screening physical examination. Additionally, particular attention was paid to the injuries posterior to the angle of the mandible, as this location was associated with a higher incidence of vascular injury due to the proximity of the carotid artery and jugular vein, but these are really Zone III neck injuries (see Sect. 26.2.3). This approach has been generally supplanted by a more simple two-area designation of the midface and mandible; this is largely due to the fact that significant Area I injuries are intracranial and not truly facial injuries, as well as to avoid the confusion due to the nomenclature and overlap with the previously named three zones of the neck. In the newer designation, the midface includes the area from the supraorbital rim superiorly to the oral commissure inferiorly to the external auditory meatus laterally, and the mandible designates the area below the oral commissure, but not including Zone III of the neck.

Although useful for the description of findings during the secondary survey, these anatomic schemas do not reliably distinguish between the extent and severity of injury, as the path of projectiles is largely unpredictable. External and intraoral examinations are often insufficient to identify the trajectory and extent of penetrating injury, particularly if concomitant neck or head injury is suspected, and additional diagnostic modalities must be employed. Plain radiographs are of little use today, as CT with reconstructed multidimensional views facilitates a detailed analysis of the path of the projectile and the scope of the tissue damage, including possible intracranial and cervical spine involvement. Three-dimensional bony reconstructions of the face are regarded by many surgeons as essential tools for planning operative reconstruction of facial fractures. Associated vascular injury can be quickly identified using CT angiography, including evaluation of the cerebral circulation, and may assist in planning angiographic intervention of vessels notoriously difficult to expose surgically.

The mechanism of injury also bears importance in the evaluation. In general, the degree of soft tissue loss and overall structural disruption is greater in ballistic injuries than that seen in stabbings, and knife lacerations to vascular structures or nerves may be amenable to primary repair. Gunshot and close-range shotgun blasts are commonly associated with fractures and tissue loss due to their substantial kinetic energy and may leave behind significant shrapnel and bony fragmentation. Shotgun injuries are more commonly spread across multiple areas and have a high incidence of globe injury. Although low velocity, objects such as knives have unpredictable depth of penetration. If the stab wound implement is still present in the wound at the time of evaluation, it should remain in situ until after any diagnostic studies are performed and the patient is in the operating room. Vascular control can be temporarily obtained endovascularly either before or in conjunction with the operative exposure.

Timing of repair of soft tissue injury depends on the complexity of the injury and degree of contamination. The majority of low-energy wounds are simple lacerations, which should be cleansed and closed primarily in layers within 24 h of injury. Heavily contaminated wounds and large avulsion injuries, however, may be packed and treated with sequential debridement before undergoing delayed closure—particularly if they have already failed a primary closure attempt. For large, complex soft tissue defects that require graft or flap closure, delayed management may be beneficial to allow for wound bed conditioning or for complete demarcation of necrosis or nonviable tissue, as is often the case in high-velocity ballistic wounds.

Damage to specialized organs of the face requires evaluation by surgical subspecialists. Ocular and intracranial penetration necessitates early ophthalmological and neurosurgical consultation. Particularly with fractures to the facial bones and involvement of the sinuses, multidisciplinary evaluation and coordinated treatment by craniofacial reconstructive specialists is recommended to obtain the best long-term cosmetic and functional outcomes. Special attention should be paid to meticulous realignment of the eyelids, nasal alar rims, auricular helical rims, and oral stoma. Patients who present with obvious facial paralysis should be assumed to have sustained direct injury to one or more branches of the facial nerve. If the wound is posterior to the lateral canthus, a local exploration with primary nerve repair is considered the treatment of choice. In cases of blast trauma, the nerve is debrided beyond the visible injury, and nerve grafting should be strongly considered. Delayed onset of paralysis suggests post-injury nerve edema that may resolve without intervention. The parotid duct is commonly injured in association with buccal branch of the facial nerve injuries due to the proximity of these structures. Additional signs of parotid injury include clear fluid draining from a cheek wound or sialocele formation. As the parotid duct rarely heals or recanalizes without intervention, repair over a stent is recommended.

After establishing that the airway is not at risk, maxillofacial bony trauma does not generally pose an immediate threat to life. As such, delayed reconstruction up to 2 weeks after injury is an acceptable approach. At that time, post-injury edema has largely resolved and the reconstructive effort may be more straightforward. In cases of severe wound contamination or tissue loss, multiple-staged debridements and serial dressing changes may be required to prepare the recipient bed for grafting or implantation of prosthetic material. Prophylactic antibiotics with activity against oropharyngeal flora are commonly employed, especially when there is communication to the sinuses for fear of development of meningitis. Interestingly, several reports of patients with facial fractures and cerebrospinal fluid leak do not support this practice. Perioperative antibiotics at the time of facial fracture fixation are associated with a significant reduction in the incidence of surgical site infection. However, prolonged administration beyond 24 h does not confer additional protection in contaminated head and neck surgery and may be associated with higher incidence of infectious complications. Nevertheless, evidence is limited in severe facial trauma with heavily contaminated, multiple open fractures, where antibiotics outside the normal perioperative period may still confer a benefit. As foreign bodies and necrotic, contaminated tissue serve as a nidus for infection, early debridement and extraction of bullets, shrapnel, and debris is indicated. This is especially true for bullets as projectiles carry clothing and other debris along the projectile track. While knives and other sharp implements tend to breach clothing rather than drag it into the wound, irrigation and debridement of devascularized tissue is just as important in these wounds. Removal of fragments may not be possible due to the risk of damage to adjacent structures or the inaccessibility of the approach. There is no consensus as to the duration or appropriateness of antibiotic therapy in these circumstances, and delayed removal of debris may be required if infection develops. Timing of bony reconstruction is controversial, but earlier definitive treatment, including grafting and fixation, is possible in some patients and may result in fewer infectious complications.

The neck is anatomically unique. No other area of the body contains a focused collection of vital structures from the cardiovascular, respiratory, digestive, endocrine, and nervous systems. As such, the proper evaluation of penetrating trauma to the neck is crucial due to the consequences of missed injury that vary depending upon the structures affected. The zones of the neck are defined by anatomic features readily identified on physical examination. The caudal most zone is Zone I, spanning the area from the clavicle to the cricoid cartilage. Zone II is defined between the cricoid cartilage and the angle of the mandible. Above this, Zone III extends to the skull base. Reference to these zones provides a means to describe the location of penetrating injury and further implies the degree of difficulty of operative exposure required for adequate proximal and distal vascular control due to bony structures such as the clavicle, the angle of the mandible, and the skull base. Table 23.2 lists the major structures at risk for injury by zone.

Evaluation of the patient with suspected penetrating neck trauma begins, as always, with the airway. About 10 % of patients will present with a compromised airway; both direct and indirect airway obstruction must be considered. Any significant penetrating injury to the aerodigestive tract may compromise the airway due to fistula, obstruction, or, more commonly, hemorrhage into the trachea; these are indicators for mandatory neck exploration (Table 23.3). Alternatively, adjacent injury may progressively occlude the airway. Two main fascial layers, the superficial and deep cervical, envelope the contents of the neck, often limiting bleeding to the compartments defined by the fascia. While this generally prevents exsanguination from most penetrating wounds, the real danger is often airway compromise due to compression by expanding hematoma. Preemptive definitive airway control to prevent impending airway loss should be the rule, as an expanding hematoma can rapidly change a stable situation into a frantic struggle to obtain a patent airway (see previous Sect. 26.1.1). If the patient’s airway has already been secured by prehospital providers, information about the appearance of the airway on direct laryngoscopy should be obtained, particularly noting any physical findings present at the time and any changes that had occurred in the interim. Fiberoptic bronchoscopy may be employed to examine the proximal trachea by carefully withdrawing the endotracheal tube over the scope, but airway edema due to direct trauma or hematoma compression may demand tracheostomy prior to attempting this. CT of the neck is probably the best test in the intubated patient for detecting fractures of the larynx and to determine which patients should be managed operatively. If the airway is patent on arrival but a direct injury to the larynx is suspected, formal evaluation of the airway via direct or flexible fiberoptic laryngoscopy and flexible or rigid bronchoscopy may be undertaken in the operating room, where tracheostomy may be performed if indicated.