Summary
Soft tissue injuries of the head and neck are usually caused by blunt or penetrating trauma and require careful clinical assessment. Imaging may be required to rule out fractures and other complications. Initial management of all head and neck injuries follows the Advanced Trauma Life Support (ATLS) protocol and includes addressing life-threatening conditions, such as airway compromise and bleeding. Once initial management has been concluded and complications have been ruled out, open head and neck wounds are managed similarly to other acute open wounds.
For other soft tissue injuries of the neck, see also “Neck sprains,” “Blunt neck injuries,” and “Penetrating neck injuries.”
Etiology
- Physical assault
- Falls
- Sports injury
- Motor vehicle crash
- Animal bite
Approach
Follow the ATLS algorithm in any patient with suspected severe head injury.
Significant trauma [2][3]
- Ensure C-spine immobilization until vertebral fractures or dislocations are excluded.
- Anticipate the need for difficult airway management. [4]
- Assess for signs of TBI and begin TBI management.
- Evaluate for and perform diagnostics for facial fractures or skull fractures as clinically indicated.
- Assess for traumatic eye injuries and ear injuries.
Red flags for a difficult airway include oropharyngeal bleeding, expanding hematomas, and/or significant distortion of the mouth, oropharynx, and/or upper neck. [5]
Open wounds [5][6][7]
- Begin hemostatic control (e.g., apply pressure dressing to scalp wounds, control epistaxis).
- Assess for embedded foreign bodies and associated injuries.
- Consult a specialist prior to wound closure for:
- Fractures
- Neurovascular injury (e.g., of the facial nerve)
- Ductal injury (e.g., parotid or submandibular)
- Concern for significant cosmetic or functional impairment
- Provide management of head and neck wounds.
Obtain specialist consult for any wound complicated by fractures, damage to subdermal structures (e.g., cranial nerves, glands, ducts), or significant cosmetic or functional impairment. [5]
All patients
- Consider additional urgent diagnostics in trauma patients as clinically indicated.
- Provide acute pain management and consider ice packs to treat swelling.
- Manage associated injuries (e.g., replantation of avulsed teeth, reduction of nasal fractures).
Wound management
For basic principles of wound care, see “Management of open wounds.” See sections on “Facial wounds,” “Scalp lacerations,” and “Neck wounds” for specific considerations.
Hemostatic measures [6][7][8]
- Control any active bleeding.
- Begin with local pressure and local anesthetic with epinephrine. [9][10][11]
- Consider placing one or two figure of eight sutures over superficial venous bleeding or bleeding from a retracted vessel.
- Consider clamping and ligating larger (> 2 mm), well-visualized vessels using fine-point hemostats and 5-0 absorbable sutures.
- Reserve electrocautery for injured blood vessels with uncontrolled bleeding.
Wound irrigation and debridement
- Use large-volume normal saline (0.5–1 L) for grossly contaminated wounds.
- Avoid antiseptic solutions (e.g., chlorhexidine).
- Manually remove any residual foreign bodies.
- Embedded particulate matter : Gently scrub the wound with a sponge or surgical brush after applying topical anesthesia.
- Limit tissue debridement to obviously nonviable tissue.
Anesthesia and supportive care
- Administer local anesthesia for wound repair.
- Consider field block to minimize distortion of wound edges.
- For children: Consider EMLA or procedural sedation.
- Administer tetanus prophylaxis and antibiotics for acute open wounds as indicated.
Wound closure
- Abrasions can be treated with a thin layer of antibiotic ointment.
- Consider tissue adhesive for small superficial lacerations.
- For nongaping wounds, use a single layer of nonabsorbable sutures.
- For gaping wounds (i.e., deeper than the dermis), perform layered closure.
- Consider secondary wound closure for grossly contaminated wounds or wounds older than 12 hours. [12][13][14]
- See also “Closure of acute open wounds.”
Follow-up
- Nonabsorbable facial sutures are typically removed after 3–5 days.
- See also “Follow-up” in “Management of open wounds.”
Facial wounds
Eyebrow lacerations [5][6][7]
- Examine sensory functions of the supraorbital and supratrochlear nerves. [6]
- Perform layered wound closure.
Do not shave eyebrows, as eyebrow hair is an important landmark for correct reapproximation and regrowth is unpredictable. [5][7]
Cheek lacerations [5][6]
- Consult a specialist in the presence of complications, e.g.:
- If no complications are present, proceed with wound closure:
- Perform layered closure (i.e., approximating mucosa, muscle, and skin).
- Ensure proper skin approximation along Langer lines of skin tension. [5]
Open wounds of the mouth [5][6][7]
- Consult plastic surgery, ENT, oral maxillofacial surgery, and/or dentistry if any of the following are present:
- Dental injuries or suspected mandibular fracture
- Suspected parotid duct or submandibular duct injury
- Large lip lacerations involving the vermilion border or > 25–30% of lip soft tissue
- Lacerations involving the oral commissures
- If missing or chipped teeth: Evaluate wounds for embedded tooth fragments (by inspection, probing, and/or soft-tissue x-ray).
- If no complications, proceed with wound closure.
Lip lacerations [5][6]
- Mark the vermilion border prior to infiltrating local anesthesia.
- Repair involved muscle with multiple layers to optimize cosmetic outcomes.
- Align the vermilion border with a single stitch using a nonabsorbable suture.
- Close the oral mucosa and vermilion with absorbable sutures.
Do not use tissue adhesive to repair lip lacerations. [5]
Oral mucosa and tongue lacerations [5][7]
- Close deep or gaping tongue lacerations with nonabsorbable sutures.
- For through-and-through oral lacerations:
- Close laceration in layers, from the mucosal side towards skin.
- Copiously irrigate the external wound after closing the mucosal layer to remove residual intraoral bacteria.
- Consider antibiotic prophylaxis (see “Antibiotics for open wounds”).
Small superficial tongue lacerations rarely require repair. [5][7]
Other anatomic locations [5]
-
Nasal lacerations
- Consider an absorbable subcuticular suture or tissue adhesive for wound repair.
- Repair through-and-through lacerations akin to lacerations of the oral mucosa.
- Forehead lacerations: Treat as any other facial wound.
- Eyelid lacerations: See “Traumatic eye injuries.”
- Ear lacerations: See “Ear injuries.”
Scalp lacerations
For scalp lacerations with underlying contusions or skull fractures, see also “Open head injuries” and “Traumatic brain injury.”
General measures [5][8]
- Prioritize hemostatic control for actively bleeding lacerations.
- Apply direct pressure and/or a pressure dressing.
- Consider irrigation with lidocaine PLUS epinephrine and/or ligation of visibly bleeding vessels.
- Expedite wound closure, e.g., with tissue staples.
- Consult neurosurgery if there is evidence of galea disruption and/or a skull fracture.
- Do not routinely shave the scalp prior to wound repair. [6]
- For uncomplicated lacerations, perform primary wound closure with staples, sutures, or hair apposition technique. [7]
Scalp lacerations can cause significant blood loss. In polytrauma, heavy scalp bleeding can be quickly controlled with staples or a tight dressing.
Use caution when manipulating scalp wounds with suspected underlying skull fractures to avoid pushing comminuted or depressed bone into the skull.
Hair apposition technique [7][15][16]
- Definition: a technique for primary closure of scalp wounds using strands of hair and tissue adhesive
- Indications: simple, superficial scalp wounds suitable for primary closure in adults and children
- Contraindications: actively bleeding, contaminated, or complex scalp wounds
-
Procedure: For pitfalls and postprocedural concerns, see also “Tissue adhesive.”
- Grasp several strands of hair from opposite sides of the wound using hemostats or gloved fingers.
- Cross and interlock the strands over the wound with a 180° or 360° twist without knotting the hair.
- Apply a drop of tissue adhesive over the base of the twist and allow it to dry.
- Repeat steps every 1–2 cm along the entire wound.
Neck wounds
- Suspected injury to deeper structures: Follow the approach to penetrating neck trauma.
- Simple superficial wounds: Follow the approach to management of head and neck wounds.
Suspect injuries to deeper structures of the neck if there are any soft or hard signs of penetrating neck injury (e.g., hemoptysis or subcutaneous emphysema), evidence of neurovascular injury, or violation of platysma.