Airway injury, Ocular injury and neurovascular tissue damage, burns is all a spectrum of pediatric soft tissue injury complex. Soft tissue injuries to the head and neck area in children are challenging to manage, because these injuries significantly affect the child’s overall health and development. Management of such injuries requires a multidisciplinary approach involving surgical and nonsurgical interventions and close collaboration among health care professionals, parents, and caregivers. This article reviews the various causes of injuries, specific considerations for each region of the head and neck, and approaches to the surgical management of soft tissue injuries in pediatric patients, including surgical and adjuvant therapies. Specific anatomic regions reviewed include the scalp/forehead, periorbital region, nose, cheeks, lips, ears, and neck/airway.Laceration repair in the growing pediatric populations may require revisions in the future. Facial soft tissue injuries are prone to poor cosmesis as in many occasions as may be constrained by available surgical specialists, thus proper multispecialty team approach along with surgical alignment and symmetry should be considered comprehensively.
Key points
- •
Pediatric soft tissue injuries may be severe but often present without an underlying fracture because of the significant pliability of the growing facial skeleton.
- •
Pediatric facial nerve and salivary duct injuries are similarly common like adult penetrating soft tissue injuries.
- •
Ocular and lacrimal system injuries are to be suspected in children and injury severity is higher compared with adults.
- •
Animal bites in children have a propensity to cause injury in the periocular subsite, another common cause being motor vehicle accidents.
- •
Airway examination and evaluation in children especially in penetrating injuries should be similar to adults; literature is sparse but injury sequela are commonly seen.
Introduction
Soft tissue injuries to the head and neck area in children is particularly challenging to manage, because these injuries can significantly affect the child’s overall health and development. The management of such injuries requires a multidisciplinary approach involving surgical and nonsurgical interventions and close collaboration between health care professionals, parents, and caregivers. In this article, we review the various causes of injuries, specific considerations for each region of the head and neck, and approaches to the surgical management of soft tissue injuries in pediatric patients, including pharmacologic and nonpharmacologic therapies.
This article focuses on soft tissue injuries, and reviews specific anatomic regions. These include the scalp/forehead, periorbital region (eg, eyebrows, globe, canaliculi, lacrimal system), nose, cheeks, lips, ears, and neck/airway.
General Principles of Wound Management
The mechanisms of injuries in the pediatric population mimic those of adults and include motor vehicle accidents, trauma, assault, accidental injuries, falls, and others. Although most facial injuries in the pediatric population present without an underlying fracture, soft tissue injuries may be more severe in the pediatric population. Incomplete ossification of children protects the pediatric facial bones from fracture, , suggesting that blunt trauma may produce more devastating soft tissue injuries but without an underlying fracture. With increasing age, however, the risk for fracture increases by 14% with each additional year. , Nevertheless, clinical judgment and cause of injury should dictate the need for further imaging.
Facial injuries involve critical functional and esthetic considerations. Careful inspection should assess the involvement of the dermis, subcutaneous fat, musculature, nerves, and ducts. Findings should be documented. All wounds should be generously irrigated to prevent local infection and poor wound healing. Generally, layered closure with attention to the alignment of skin edges, hairlines, creases (nasolabial folds), and so forth should be considered. Underlying structures involving nerves, lacrimal system, and so forth should be adequately reviewed before repair. Advanced Trauma Life Support principles on trauma management are followed in extensive facial injuries, because airway, brain, and cervical spine injuries are correlated with trauma patterns. Isolated and single subsite facial injuries may not mandate a comprehensive trauma survey.
For the pediatric patient, compliance with repairing injuries in the emergency department may be complex and require treatment in the operating room. For wounds less than 4 cm in length and 0.5 cm in width, tissue adhesives (eg, Dermabond) may be an equivocal alternative to repairing superficial linear lacerations. Additionally, tissue adhesives in these wounds can result in similar cosmetic outcomes when compared with wounds closed by sutures. This is favorable in fearful patients with minor wounds that do not necessarily require general anesthesia for management.
Antibiotic Therapy
Soft tissue injuries of the face are common in children, with most being minor and requiring no more than simple wound care. Small superficial wounds do not require systemic oral antibiotics. But systemic oral antibiotics should be used in high-risk wounds, such as those contaminated with dirt or other foreign bodies, or in children with compromised immune systems. Additionally, tetanus prophylaxis should be administered for contaminated wounds according to local protocols. Even for clean wounds, however, tetanus toxoid should be administered if the patient has had three or fewer doses or it has been more than 10 years since the last immunization ( Figs. 1 and 2 ).
Scalp/forehead
Background and Anatomic Considerations
Head injuries are devastating and cause significant mortality. Pediatric head injuries can have a high case fatality rate of 3.74. Injuries to the scalp may result in traumatic brain injury and excessive blood loss, leading to subsequent hypovolemic shock. Injuries range from superficial abrasions to avulsions, often accompanied by skull fractures.
Pediatric skulls have open suture lines until undergoing ossification beginning approximately at 2 years of age. This is crucial because bones are freely mobile and may offer less brain protection against impact forces. Even puncture wounds from dog bites can often penetrate the soft tissue mantle and the underlying bones leading to an open injury.
The cause of most head injuries mimics those of the adult population and is secondary to motor vehicle accidents and falls. The prevalence of isolated scalp injuries without underlying fractures is unclear, because isolated studies are few ( Fig. 3 ).
The scalp is thick in infants and young children. This protects against injuries but is more susceptible to increased bleeding and swelling. The scalp comprises five layers, including the skin, subcutaneous tissue, galea aponeurotica (a dense fibrous layer), loose connective tissue, and the periosteum of the skull.
Rich arterial supply is from the external carotid artery branches, namely the superficial temporal, occipital, and posterior auricular arteries. However, its robust vascularity can lead to significant blood loss and hypovolemic shock if not controlled. The main vessels run along the galea aponeurotica, contributing to extensive blood loss because it is often disrupted.
The scalp is highly innervated and is supplied by branches of the trigeminal and cervical nerves. These sensory nerves travel through the subcutaneous tissue, which, when disrupted, can cause significant pain.
Hair typically obscures lacerations, making it difficult to assess the injury’s extent accurately. It also acts as a nidus for dirt and debris, increasing the risk of infection.
Management
As with any injury event, a focused examination and comprehensive history should be taken. Moreover, depending on the clinical presentation and cause of the injury, noncontrast computed tomography (CT) should be obtained to assess underlying fractures and intracranial injury. It may be difficult to thoroughly assess scalp wounds because of excessive hemorrhage, patient management, and the presence of hair and foreign bodies. Therefore, a thorough examination is best performed under general anesthesia before definitive management.
Because of the scalp’s highly vascular structure, uncontrolled hemorrhage can lead to hypovolemia and shock with more significant insults. Control of hemorrhage is crucial to prevent decompensation; arterial bleeds should be ligated timely, and compression should be applied through pressure dressings, and head wraps for hemostasis.
Simple lacerations may be repaired primarily in the emergency department under local anesthesia. However, most scalp wounds are difficult to examine because of the overlying hair and pain, so exploration may best be performed under general anesthesia. When exploring wounds and controlling bleeds, however, electrocautery should be used conservatively in the scalp to minimize damage to hair follicles and resultant alopecia. Complex and avulsive lacerations require repair under general anesthesia and may require local flaps or skin grafts. Tissue expanders may be used for significant avulsive injuries. However, animal models have shown that pressure can cause deformation and erosion in growing facial bones, so we recommend avoiding its use in children younger than 3.
Auricular
Background and Anatomic Considerations
Isolated ear injuries in the pediatric population are not well documented in the literature, although it accounts for 7% to 10% of emergency department visits yearly. Injuries range from localized cellulitis, lacerations, and partial to avulsive injuries. A dread complication of auricular trauma is a postinjury or postoperative hematoma, leading to subsequent ear deformity, commonly called “cauliflower ear.”
The ear canal is of external and internal contents. The external ear consists of elastic cartilage and acts as a hearing apparatus to direct acoustics through the middle ear for sound transmission by the inner ear. Blood supply to the ear is mainly from the superficial temporal artery and the posterior auricular artery, both arising from the external carotid artery. The neural sensation is from branches of the CN V, VII, and X and branches of spinal nerves C2 and C3.
Management
Auricles have excellent vascularity, and trauma can result in residual injuries with noticeable effects, even when it is hanging on a very thin pedicle if appropriately closed. Another consideration is that vascular tissue must cover all cartilage to avoid necrosis, which may be difficult in complex lacerations where devitalized tissue is removed. Local flaps or skin grafting from the contralateral ear may be helpful in such situations. After inspection of cartilage involvement, a three-layer closure is performed of the posterior skin, cartilage, and anterior skin. Cartilage is closed with clear 4–0 PDS, posterior skin is closed with absorbable sutures, and anterior/visible skin is closed with 5–0 Prolene or nylon sutures and removed in 5 to 7 days along with the overlying bolster dressing.
Periorbital region (eyebrows, eyelids, canaliculi, lacrimal system)
Background
The periorbital region compromises vital substructures that demand careful consideration. This section is subdivided to address the eyebrows, eyelids/conjunctiva, orbital contents (globe, extraocular muscles, periorbital fat, neurovascular bundles), and canaliculi/lacrimal system. For this review, the nose is not considered part of the periorbital region and is discussed later in this review.
When fractures are present in the periorbital region, they are often accompanied by more severe soft tissue injuries when compared with those of adults. A study showed that 30% of patients with orbital fractures had concurrent periorbital and globe injuries. They were also more likely to suffer orbital roof fractures because of immature form of the frontal sinus. ,
Additionally, the injury pattern in this region differs between pediatric and adult populations. According to Hurst and colleagues, children were two times more likely to suffer a periorbital injury from dog attacks when compared with adults. Stature, safety habits, and often reckless play are attributable to the differences in injury patterns and mechanisms among the young. Moreover, compared with other regions of the face, injuries to the periorbital region were more likely to require surgical correction in the operating room. Nevertheless, the cause of periorbital injuries is diverse and includes animal bites, falls, assault, Gun shot wounds, and sports, the most common being motor vehicle accidents.
Orbital Contents Considerations and Management (Globe, Extraocular Muscles, Lacrimal Gland, Periorbital Fat)
Injuries can range from minor corneal abrasions to globe rupture, the most common cause of blindness from orbital trauma. Fractures are associated with ophthalmologic emergencies, such as retinal detachment, vitreous hemorrhage, and optic nerve compression. Open globe injuries are one of the most devastating but are fortunately rare. Generally, globe injury following orbital trauma ranges from 7.2% to 30%. Given the significant morbidity, however, any suspicion of globe injury should warrant immediate ophthalmology consultation because it can lead to permanent vision loss.
It is well established that the most common reason for emergent surgical intervention in the orbital region is inferior rectus muscle entrapment secondary to orbital floor fracture. Traumatic optic neuropathy can occur from any significant trauma to the orbits and is generally irreversible. Unfortunately, there is no substantial evidence that surgical intervention results in more favorable outcomes when compared with observation.
Eyebrows Considerations and Management
If poorly managed, lacerations and avulsions of the eyebrows can have devastating esthetic results. The goal of repairing the eyebrows is to align the brows to the contralateral brow symmetrically. Although contamination and avulsions may obscure the eyebrows, it is recommended to avoid shaving if possible. The brows should be closed in layers, with the deeper orbicularis oculi addressed first. Superficially, the superior border should be aligned first, because alignment issues are more noticeable than those of the lower border. If there are multiple injuries, it is advised to close the surrounding lacerations before closing the eyebrows to avoid tension that may distort the final esthetics.
Eyelids Considerations and Management
Special attention is needed in the management of eyelid injuries ( Fig. 4 ). Poor wound management may lead to ptosis, lid retraction, scleral show, or persistent deformity that may persist or worsen through adolescent growth. A retrospective review of eyelid lacerations in adults and children indicates that most complications are unrelated to the timing of repair, because many lacerations were repaired after 24 hours. Instead, complications, such as ptosis, lid retraction, and persistent deformity, were related to initial injury severity. The most common cause of eyelid injuries is not well established. In patients with dog bite injuries, however, eyelids were the most commonly injured in the periorbital region. As a general note, conjunctival injuries should be closed with knots away from the cornea to prevent irritation.
