Pediatric Head and Neck / Facial Trauma

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Pediatric Head and Neck / Facial Trauma

Pediatric Otolaryngology
Author Credentials 

William O. Collins, MD
Associate Professor
Department of Otolaryngology
University of Florida College of Medicine
Gainesville, FL

Module Summary

With advancing age, patients will have progressively different patterns of facial trauma injuries. In young children, the proportionately larger skull and high riding larynx, lead to a higher incidence of intracranial trauma and relatively fewer bony facial or cervical injuries. As the face grows in proportion to the intracranial vault, combined with increasing sports and other activities in older children, more facial skeleton trauma occurs.  Evaluation of the critically injured patient, including management & stabilization, is important before turning attention to the definitive management of facial trauma. An understanding of the complex interactions of the different parts of the craniofacial skeleton is critical to choosing the right surgical techniques based on the pattern of injury and patient’s age.

Module Learning Objectives 
  1. Review the incidence of facial trauma in the pediatric patient population.
  2. Describe the common patterns of pediatric facial trauma based on anatomic differences in children compared to adults.
  3. Explain the algorithm for emergency management of a pediatric patient with head and neck trauma.
  4. Describe surgical management of pediatric facial trauma.

Anatomy

Learning Objectives 

To describe common head and neck anatomic differences between children and adults.

References 
  1. Koltai PJ. Craniofacial Skeletal Trauma in Childhood. In Practical Pediatric Otolaryngology. Ed. Cotton RT, Myer CM. Lippincott-Raven Publishers. Philadelphia, PA. 1999: p. 729-758

Pathogenesis

Learning Objectives 

To describe how anatomic differences in the craniofacial skeleton lead to particular injury patterns in pediatric patients.

References 
  1. Boyette JR. Facial Fractures in Children. Otolaryngol Clin North Am. 2014;47(5):747-761.
  2. Chapman VM, Fenton LZ, Gao D, Strain JD. Facial Fractures in Children: Unique Patterns of Injury Observed by Computed Tomography. J Comput Assist Tomogr. 2009;33:70-72.

Incidence

Learning Objectives 

To know the incidence and epidemiology of facial trauma in pediatric patients.

References 
  1. Boyette JR. Facial Fractures in Children. Otolaryngol Clin North Am. 2014;47(5):747-761.

Patient Evaluation

Learning Objectives 

To describe an evaluation & treatment algorithm for management of pediatric patients suffering from head and neck trauma:

  • Emergency management, including establishment of a secure airway.
  • Definitive, long term management, including the timing of surgical repair.
References 

 

  1. Koltai PJ. Craniofacial Skeletal Trauma in Childhood. In Practical Pediatric Otolaryngology. Ed. Cotton RT, Myer CM. Lippincott-Raven Publishers. Philadelphia, PA; 1999: p. 729-758
  2. Boyette JR. Facial Fractures in Children. Otolaryngol Clin North Am. 2014;47(5):747-761.
  3. Losee JE, Afifi A, Jiang S, et al. Pediatric Orbital Fractures: Classification, Management, and Early Follow-Up. Plast Reconstr Surg. 2008;122(3):886-897.
  4. Koltai PJ, Amjad I, Meyer D, Feustel PJ. Orbital Fractures in Children. Arch Otolaryngol Head Neck Surg. 1995;121:1375-1379.
  5. Ferreira PC, Amarante JM, Silva PN, et al. Retrospective study of 1251 maxillofacial fractures in children and adolescents. Plast Reconstr Surg. 2005;115(6):1500-1508.
  6. Smartt JM, Low DW, Bartlett SP. The pediatric mandible: II. Management of traumatic injury or fracture. Plast Reconstr Surg. 2005;116(2):e28-e41.

Imaging

Learning Objectives 

To describe common imaging modalities and their role in the evaluation of pediatric facial trauma:

  • Plain Xrays
  • CT scanning
  • MRI imaging
References 
  1. Chapman VM, Fenton LZ, Gao D, Strain JD. Facial Fractures in Children: Unique Patterns of Injury Observed by Computed Tomography. J Comput Assist Tomogr. 2009;33:70-72.
  2. Koltai PJ. Craniofacial Skeletal Trauma in Childhood. In Practical Pediatric Otolaryngology. Ed. Cotton RT, Myer CM. Lippincott-Raven Publishers. Philadelphia, PA. 1999: p. 729-758

Treatment

Learning Objectives 

To describe a comprehensive treatment strategy to manage pediatric patients suffering from facial trauma:

  • Emergency evaluation and stabilization of the acutely injured pediatric patient
  • Timing and techniques for definitive repair
References 
  1. Koltai PJ. Craniofacial Skeletal Trauma in Childhood. In Practical Pediatric Otolaryngology. Ed. Cotton RT, Myer CM. Lippincott-Raven Publishers. Philadelphia, PA; 1999: p. 729-758
  2. Boyette JR. Facial Fractures in Children. Otolaryngol Clin North Am. 2014;47(5):747-761.
  3. Losee JE, Afifi A, Jiang S, et al. Pediatric Orbital Fractures: Classification, Management, and Early Follow-Up. Plast Reconstr Surg. 2008;122(3):886-897.
  4. Koltai PJ, Amjad I, Meyer D, Feustel PJ. Orbital Fractures in Children. Arch Otolaryngol Head Neck Surg. 1995;121:1375-1379.
  5. Ferreira PC, Amarante JM, Silva PN, et al. Retrospective study of 1251 maxillofacial fractures in children and adolescents. Plast Reconstr Surg. 2005;115(6):1500-1508.
  6. Smartt JM, Low DW, Bartlett SP. The pediatric mandible: II. Management of traumatic injury or fracture. Plast Reconstr Surg. 2005;116(2):e28-e41.

Surgical Therapies

Learning Objectives 

To describe surgical strategies for repair of:

  • Mandibular fractures
  • Midface fractures
  • Nasal fractures
  • Zygomaticomalar complex fractures
  • Nasoethmoidal complex fractures
  • Orbital fractures
References 
  1. Boyette JR. Facial Fractures in Children. Otolaryngol Clin North Am. 2014;47(5):747-761.
  2. Losee JE, Afifi A, Jiang S, et al. Pediatric Orbital Fractures: Classification, Management, and Early Follow-Up. Plast Reconstr Surg. 2008;122(3):886-897.
  3. Koltai PJ, Amjad I, Meyer D, Feustel PJ. Orbital Fractures in Children. Arch Otolaryngol Head Neck Surg. 1995;121:1375-1379.
  4. Ferreira PC, Amarante JM, Silva PN, et al. Retrospective study of 1251 maxillofacial fractures in children and adolescents. Plast Reconstr Surg. 2005;115(6):1500-1508.
  5. Smartt JM, Low DW, Bartlett SP. The pediatric mandible: II. Management of traumatic injury or fracture. Plast Reconstr Surg. 2005;116(2):e28-e41.

Staging

Learning Objectives 

To classify pediatric facial trauma injury patterns:

  • Midface fractures according to the LeFort classification scheme.
  • Nasoethmoidal complex injuries
References 
  1. Losee JE, Afifi A, Jiang S, et al. Pediatric Orbital Fractures: Classification, Management, and Early Follow-Up. Plast Reconstr Surg. 2008;122(3):886-897.

Case Studies

  1. A 3 year old male is involved in a motor vehicle accident, and suffers extensive trauma. He is noted on CT scan to have a mandible fracture. What type of dentition would you expect this child to have? What would be the indications for operative intervention in a pediatric patient with a mandible fracture? What are the surgical options for repair?
  2. A 10 year old female is hit in the face with a softball. She develops immediate peri-orbital swelling. What aspects of the physical examination would be critical to ascertain if she has suffered any bony trauma to her orbit?  What patterns of injury would you expect to most likely occur with blunt orbital trauma in a pediatric patient? What would be the indications for surgical repair of orbital bony fractures? What are the surgical approaches used to access the orbit?

Complications

Learning Objectives 

To describe potential complications of pediatric facial trauma, which are particularly unique to pediatric patients:

  • Dental injury to unerupted teeth
  • Facial growth abnormalities
  • Long term use of rigid, permanent plates for fixation vs. bioresorbable plates
References 
  1. Koltai PJ. Craniofacial Skeletal Trauma in Childhood. In Practical Pediatric Otolaryngology. Ed. Cotton RT, Myer CM. Lippincott-Raven Publishers. Philadelphia, PA. 1999: p. 729-758

Review

Review Questions 
  1. What are the most common mechanisms by which children suffer trauma to their facial skeleton?
  2. What anatomic and physiologic properties are unique to children that explain their pattern of facial trauma injuries?
  3. What are the indications for surgical repair of pediatric facial trauma of the midface? Orbit? Mandible?
  4. How do facial growth patterns factor into surgical decision making?
Resources 

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  1. Annual Meeting Webcast (AMW):