CHAPTER 13
WOUNDS OF THE FACE
They are as frequent as the wounds of the skull. Although several of the regions of the face may be injured simultaneously, distinction should be made between the wounds of the nose, of the orbit and eye, of the ear, of the superior maxillary, of the mouth, of the inferior maxillary, each of which should be studied separately. Rifle fire that hits this region is antero-posterior, transverse, vertical, sometimes direct, sometimes oblique.
Wounds of the Nose.-The nose when struck by a sword or a large shell fragment may be partially or entirely severed from the face, together with a part of the superior maxilla. Bullets indent it, or more commonly perforate it. The damage is generally limited. Struck by antero- posterior or lateral firing at a short distance, the nose may be divided into several parts or split up.
The wounds heal without complications. Hydrogen peroxide (diluted by half) is one of the best antiseptics for these lesions, which usually suppurate. Even when they are very bruised, all osseous or cutaneous fragments must he carefully preserved ; they will be held in place by nasal tamponade.
In large traumatisms, autoplasty and prosthesis provide the surgeon with admirable expedients.
Wounds of the Orbit and of the Eye.-Direct lesions of the bones of the orbit are notches, indentations, perfora tions, with short, thin, and dry splinters. Indirect or extended lesions are fissures radiating from the base of the skull.
Bullets often pass through the orbit without touching the eye or the optic nerve. On other occasions this nerve, as well as the other nerves in its neighbourhood, is contused, indented, divided.
Rapid ecchymosis, palpebral swelling, occasionally exophthalmia, are the immediate signs of wounds of the orbit.
The evolution of these lesions is nearly always simple, and their dressing presents nothing particular. When infected, they may give rise to abscess of the orbit, and threaten the meninges.
An external incision gives issue to pus.
Of frequent occurrence, the injuries of the eye consist of contusions, with or without hernia of the iris, dislocation of the lens, detachment of the retina, tearing of the choroid, of slight or large wounds, of perforations, abrasions, rupture.
At first the diagnosis is either obvious or very obscure. In trying to localize it, one finds that functional troubles, diminution or loss of sight, can arise from very diverse causes.
Radiography will determine the presence and seat of metallic foreign bodies.
In some cases these wounds heal without complications; in others the cornea, the iris, the choroid, become inflamed. The vitreous becomes easily infected. Panophthalmia is common.
Sympathetic ophthalmia is frequent. It is one of the most serious complications of lesions of the eye. It appears sometimes very quickly, sometimes in the course of the year following the wound - a fact which must not be lost sight of by the skillful medical man.
Antiseptic dressings of iodoform ointment are used at first; certain lesions of the cornea, the iris, the sclerotic may need suturing. Immediate enucleation is the treatment of extreme irremediable wounds, or of those that a complicated by the presence of foreign bodies. It must not be forgotten that this is preferable to conservation by reason of its being less often followed by sympathetic troubles.
Wounds of the Ear.-They rarely are seen alone; most cases they are accompanied by concomitant lesions of the skull and of the face; they result from antero- posterior and transverse firing.
In artillery fire and explosions, ruptures of the tympanum (oozing of blood from the ear), concussion of and haemorrhage from the labyrinth, are by no means rare,
Bullets and shell fragments notch, perforate, partial destroy, the pinna ; gouge out and penetrate into the bony auditory canal or the mastoid process; invade the petrous bone as far as the interior of the cranium, and gouge or perforate the petrous bone itself. Wounds of the large vessels closely connected with the ear give rise to dangerous haemorrhage (internal carotid branches of the external carotid, internal jugular, transverse sinus); but even independently of any injury to the large vessels, external and buccal haemorrhage is frequent The loss of cerebro-spinal fluid, of broken-down cerebral pulp, implies some cerebral complication; lesions of the facial nerve, of the trigeminus, are revealed by their ordinary signs. Those of the facial are not rare.
Diminution or loss of hearing is nearly certain in deep wounds of the ear, and secondary psychic troubles occur pretty frequently. These wounds rarely remain aseptic they nearly always suppurate, and the pus may burrow even into the neck.
Treatment at first comprises instillations of carbolized glycerine and iodoform or iodine, the introduction of drain of aseptic or iodoform gauze, and bucco-pharyngeal disinfection. No splinters should be extracted, excepting those that are free; removal of adherent splinters would render the patient liable to dangerous haemorrhage.
Foreign bodies are subsequently taken away by the retro-auricular route after petro-mastoid clearing out.
Wounds of the Upper Maxillae. - On their edges the upper maxillae are notched; in their body they are perforated (bullets) or abraded with comminution (shell fragments), occasionally separated as a whole, and dislocated from the rest of the bones of the face, or separated one from the other in the middle line at the time they are perforated by bullets travelling with great velocity.
Injury of the alveolar border is complicated with dental traumatisms, fractures, tearing out, with propulsions of the teeth.
The splinters are generally short. Notwithstanding the communication of the osseous focus with the nasal fossae and the mouth, the evolution of these wounds is usually benign, even when there is extensive loss of substance with large external lesions.
The prognosis of these injuries is in the main not serious, provided the surgeon secure buccal antisepsis, the danger lying in the continual dropping into the buccal cavity of septic products arising from the seat of the fracture.
Gargling or, better still, very frequent irrigations by large glassfuls during the first days, besides those taken immediately before any food or drink, are to be preferred to a drain of antiseptic gauze.
Hydrogen peroxide is excellent in these cases. In its absence we can employ potassium permanganate solution (1 in 4,000), boric or iodized solutions, even simple boiled water. Some wounded men are quite capable of doing their irrigation themselves both by day and by night.
The diet should be liquid, at least for the first days. The liquid food should be introduced behind the dental arches through an india-rubber tube supplied with a small funnel.
A bandage to support the chin, ligation of the teeth, suturing, will all help to keep the loose fragments in place. Not one of these last should be sacrificed even if they are very loose. At the rear, in severe cases, these first means will be replaced by provisional intrabuccal prosthetic apparatus.
The slightest portion of the soft parts covering the superior maxillae that have been lacerated by bullets or shell fragments should be preserved. Median or lateral losses of substance on the roof of the hard palate are generally repaired by prosthetic apparatus.
Wounds of the Inferior Maxilla. -The inferior maxilla, a compact bone, presents lesions comparable to those of the diaphysis. The borders are gouged, furrowed by oblique fissures, with cuneiform direction of the grooves. Perforations are complicated by radiated
X-shaped fissures, like perforations of the diaphysis. The line of fracture is rarely simple, and represented by one or two vertical or oblique lines. The teeth are fractured, pushed or propelled out of their alveolar cavities. Splinters are relatively not very extensive; they are maintained in position by the thick periosteum, the mucous membrane, and the attachments of the muscles, they may, however, be displaced.
Nearly always there is no displacement of the large fragments. Sometimes they tilt inwards, exceptionally out. wards; most frequently forwards and downwards through the action of the genio-hyo-glossus and genio-hyoid muscles. In some cases there is overlapping.
Fragments of large. projectiles occasion contusions, simple fractures after tangential contact, or else partial or total abrasions of the body of the maxilla. When the lesion involves the body of the bone, the result is a large buccal hiatus, open in front, invaded by the tongue, which hangs out in front of the neck. With less severe injuries and separation of the genio-hyo-glossi, the tongue rather tends to drop back into the larynx.
Very different from the injuries of the superior maxilla, which in the majority of cases are benign, those of the inferior maxilla must always be looked upon as grave. Local infection is the rule; pus accumulates and remains in the buccal floor, and is continually being swallowed. Purulent general infection is very frequent. Osteitis or necrosis of fragments, both long and difficult to repair, at times osteomyelitis - such are the consequences of localized infection.
Treatment must fulfil three conditions.-
(1) It must secure incessant disinfection of the mouth; (
(2) facilitate easy draining for septic fluids to the outside of the mouth;
(3) obtain immobilization of the fragments.
1. All we have said regarding disinfection of the mouth in reference to the superior maxilla is applicable to the inferior.
2. Inclining the head forward; in case of need, an incision made under the maxilla, insuring permanent intra- and extra-buccal drainage, realizes the second condition.
3. As for immobilization, it is attained either by fastening the teeth together by ligatures, or by maintaining the inferior maxilla against the superior by means of a chin bandage. By inserting between the dental arches a flat but thick piece of cork hollowed into a double groove, or a slab of guttapercha, thus leaving a free space between the maxillae, we facilitate buccal disinfection, and at the same time maintain coaptation of the fragments. Direct suturing has its advocates, but it should mainly be used in simple fractures.
We must respect splinters that have not been moved, even when they are only very slightly adherent, in order to avoid consecutive deviations towards the buccal axis. Fragments that have been pushed forward, like a free tooth, must be removed.
Haemorrhage, a quite frequent complication, is arrested at first by compression, then by ligation. As to foreign bodies, which usually cause a great deal of irritation, they must be removed at an early period.
Subsequently loss of substance is filled up by prosthesis, and deviations are corrected by apparatus, which make good in the necessary places the damage that the maxilla has suffered (Preterre).
Wounds of the Tongue and the Buccal Floor.- Bullets striking the tongue produce furrows, setons, cul-de-sac wounds, or total perforations. They generally bring with them splinters or teeth that have been detached from the maxilla, especially from the inferior maxilla.
These wounds are sometimes complicated by abundant hemorrhage, and, if they frequently end without septic accidents, yet on other occasions, though far more rarely nowadays with the present small bullets, they give rise to abscesses of the buccal floor, to septicemia caused by the patient swallowing the intrabuccal fluids, and finally to glossitis.
The most common treatment required by wounds of the tongue is, in case of severe haemorrhage, obturation of the buccal wound by tamponade or suturing; uninterrupted detersion of the mouth, relief by incisions of all constriction in the wound, and search for foreign bodies which may be lodged in the tongue, if we find there is glossitis, which causes so much trouble in deglutition and respiration; also median or lateral incision of the buccal floor, which should include the whole mylo-hyoid band, in order to give issue to the fluids of the cellular sublingual tissue; also angular sterno-mastoid incision to open up the peripharyngeal collections.
Wounds of the lips and cheeks present no special particularities. Strips of flesh from the lips, even when very much contused, must be carefully preserved. Lesions of Stenon's duct are exceptional.