Although facial and neck trauma occurs frequently during childhood,
the small size, skeletal flexibility, and increased fatty tissue
in a child’s face mainly results in soft-tissue injuries.
Extensive soft-tissue laceration and fractures of the facial and
neck skeleton are comparatively uncommon. Such serious injuries
are not normally caused by childhood play but are usually the result
of motor vehicle accidents, animal-related trauma, or iatrogenic
Cervicofacial lacerations are most commonly caused by animal,
particularly dog, bites (see Chapter 116).14 The
peak incidence occurs in children less than 10 years of age who
may not anticipate an aggressive response and indeed may precipitate
an attack through either irritating the animal or invading its personal
space.15 The majority of such lacerations are usually
closed by special suturing techniques under conscious sedation,
though occasionally general anesthesia may be necessary if the defect
The nasal bones are the facial bones most frequently broken.
The acute identification of a nasal bone fracture in a child may
not be easy due to extensive facial swelling, which limits the examination.
Additionally, plain radiographs can be difficult to interpret. The
immediate evaluation should rule out gross disfigurement and the presence
of a septal hematoma. If the patient is stable, reexamination in
2 to 7 days once the swelling has resolved can better determine
nasal appearance and function. Concern in either respect should
lead to otolaryngologic referral.
An obviously displaced nasal fracture with cosmetic deformity
or functional compromise should be corrected as soon as possible,
usually by closed reduction under general anesthesia. In more complicated
fractures, or when fracture reduction has been delayed, a septorhinoplasty may
need to be performed at a later date.
Subluxation of the nose may be as a complication
of passage through the birth canal during delivery. This problem
often corrects itself. If breathing problems are present or if the
nose is markedly deformed, closed reduction in the neonatal period
Mandibular and Maxillary
Because a child’s jaw is less ossified than an adult’s,
mandibular fractures are infrequent. The majority of childhood mandibular
fractures involve the condyle.16 Such “greenstick” fractures
usually do not go through the growth plate. They usually heal rather
well without surgery and with minimal immobilization. More extensive
mandibular fractures require surgical reduction, with the approach
depending on the patient’s age, the localization of the
fracture relative to tooth eruption, and the child’s bite.
Because the maxilla in children is proportionately small, fractures
here are also uncommon. Midface fractures often occur in a setting
of significant trauma with associated orbital and/or nasal
involvement. Such children are also more likely to have associated
skull and cervical spine fractures.17
The preoperative evaluation of suspected mandibular and maxillary
fractures often requires plain dental radiographs and bone algorithm
computed tomography; magnetic resonance imaging may be necessary
if there is an associated skull fracture or suspected closed head
injury. Severe fractures may require securing the airway by endotracheal
intubation or tracheotomy. Surgical reconstruction may be staged,
with the ultimate goal of achieving good functional and cosmetic
Evaluation of orbital injuries should always involve ophthalmologic
consultation that assesses globe position, ocular motility, and
vision. The location of an orbital fracture—the zygoma,
above the eye, below the eye, or in the bones surrounding the eye
socket—varies depending on the mechanism of facial injury.
Potential complications of orbital fractures include enophthalmos, exophthalmos,
excessive tearing (epiphora), double vision due to oculomotor muscle
entrapment, and traumatic vision loss.18
Trauma to the temporal bone in children more commonly results
in fractures than any other area of the skull.19 The
primary cause is motor vehicle accidents, and the secondary causes
are falls or blunt trauma.20 Fractures to the temporal
bone may affect hearing, balance, and facial nerve function. Longitudinal
temporal bone fractures that parallel the petrous ridge typically
cause a conductive hearing loss as a result of hemotympanum, tympanic
membrane perforation, or ossicular damage. Sensorineural hearing
loss and vertigo are more common with transverse fractures that
run perpendicular or oblique to the petrous pyramid due to disruption
of the labyrinth or cochlea.21 Such transverse
fractures are more likely to result in cerebrospinal fluid otorrhea.22 Localizing
a temporal bone fracture is best accomplished with high-resolution
computed tomography. Surgical intervention is infrequently necessary,
as conductive hearing losses often spontaneously improve and sensorineural
hearing losses are often not correctable.
Palatal injuries are common in children, often occurring when
a child is running or playing with something in the mouth like a
pencil, toothbrush, or stick. Lacerations on the hard and soft palate,
tongue, and buccal mucosa usually heal spontaneously; larger lacerations
may require suturing. Palatal and oropharyngeal lacerations that
extend laterally pose potential injury to the great vessels, necessitating hospitalization
for observation and MRI angiographic evaluation if worrisome neurological signs
or symptoms develop (see also Chapters 371 and 375).23
Both auricular and external ear canal (EAC) lacerations are common.
Potential complications include secondary infection in the short
term and narrowing (stenosis) of the EAC in the long term. Tympanic
membrane tears (perforations) can result from puncturing the eardrum
with sharp or blunt objects such as bobby pins and Q-tips or from
sudden pressure changes such as those experienced from injury during
diving or water-skiing. Such perforations cause a conductive hearing
loss. Spontaneous healing often occurs; if not, a tympanoplasty
may be required (see also Chapter 269).
Neck and Laryngotracheal Trauma
Penetrating neck injuries may be intentional or unintentional.
The objects causing these injuries can be divided into stabbing
instruments and projectile instruments, each having specific characteristics
that affect surgical findings. For example, stab wounds typically
have a 10% higher rate of negative exploration than injuries from
The evaluation of a patient with penetrating neck trauma always
should start with advanced trauma life support (ATLS), a paradigm
that begins with a directed primary survey emphasizing airway, breathing,
and circulation (ABC). Once stabilized, a secondary survey that
includes a complete history and thorough physical examination should
be performed. In few other regions of the body are so many vital
structures located in so small an area. The sternocleidomastoid
muscle delineates the posterior and anterior regions of the neck. Most
of the vital structures are located in the anterior or lateral regions.
Penetrating injuries are those that violate the platysma muscle.
Such injuries and those that cross the midline have the greatest
potential for damage.
Tracheobronchial and esophageal injuries resulting from penetrating
trauma may have a mortality rate as high as 20%.25 Traumatic
cervical esophageal injuries can result in devastating complications.
Leakage of saliva and gastroesophageal fluid contents can produce
early suppurative infection and an intense necrotizing inflammatory
response in the neck and mediastinum. The overall mortality rate
increases when esophageal injuries are not diagnosed within 12 hours.26 Diagnostic
testing needed to ascertain the level and degree of injury includes
direct hypopharyngoscopy and esophagoscopy, computed tomography,
and contrast barium esophagraphy.
Laryngeal injury can occur from both anterior and posterior neck
trauma. Airway compromise is the biggest immediate concern secondary
to soft tissue swelling, vocal cord paralysis, and hematoma formation.
Immediate treatment for traumatic laryngeal airway obstruction often
requires a tracheotomy; endotracheal intubation is often not possible
and may be contraindicated.
A long-term consequence of airway trauma may be narrowing (stenosis)
of the airway, requiring future surgical reconstruction. The areas
most prone to stenosis are the subglottis, the anterior and posterior
commissure, and the tracheotomy site.27
While external causes of tracheal trauma in children have been
associated with the escalating use of skateboards, minibikes, motorcycles,
and motor vehicles, most injuries to the airway are the result of
internal trauma.28 The primary culprit is endotracheal
intubation with a tube that is too large and fits snugly. Many critically
ill children are salvaged through prolonged respiratory support,
only to develop laryngotracheal stenosis. In adults and older children,
the glottic opening represents the smallest diameter of the airway,29 whereas
in small children and infants, the cricoid ring is the narrowest
section of the airway. Surgical reconstruction is often required
(see also Chapter 371).