Systematic evaluation of the maxillofacial region for injuries following trauma involving the face and associated structures

1. SYSTEMATIC CLINICAL EXAMINATION IN
MAXILLOFCIAL TRAUMA
Dr Arjun Shenoy

2. Contents
• Extraoral examination
Inspection
- scalp
- Ear, Eyes, Nose
- Middle third of the face
- Lower third of face
• Extraoral palpation

3. • Intraoral examination.
- Inspection
- Palpation
• Percussion and Auscultation
• Conclusion
• References.

4. General examination
 Nervous system
• Orientation
• Memory
Respiratory system & CVS
Chest & Abdomen.

5. FORCES

6. Biomechanics of the midface
• midface equates to a tent, where the tent poles represent the bony
midface and the tarpaulin represents the overlying soft tissues.
• vectors of the midface address all three dimensions ie, vertical,
sagittal, and transverse,

7. Extraoral examination
Inspection.
• Face – washed with warm saline/water
• Cleaning of dried blood clots/ scabs
• Check for – presence of edema, ecchymosis, deformity,
facial asymmetry.
• Bleeding areas, CSF leak.
• Associated soft tissue injury.

8. ESSENTIALS
• Examination gloves
• Single-use tongue blades
• Examination light
• Visual chart
• Nasal speculum (in case of need for nasal
examination)

9. Scalp & skull
• Lacerations &
contusions.
• Depressed # of the skull
• Battle’s sign.
Ecchymosis near mastoid
process

10. Eyes.
• Examine for debris / broken
glass pieces
• Lacerations
• Corneal Abrasions & Scleral
tears
• Circumorbital Edema &
Ecchymosis
• Examine for movements of the
eye in all GAZES & patency of
optic & occulomotor nerve

11. Classification of eyelid lacerations
partial thickness full thickness
canalicular system canalicular system
involved not involved

12. full thickness + inferior canalicular disruption

13. Racoon eyes.

14. • Subconjunctival Ecchymosis–
• Flame shaped hemorrhage with posterior limit not seen .
( Suspect # of the orbital walls )

15. Globe position-
Simple testing of pupil axis is provided using a straight
instrument.
The examiner should include an examination from above

16. … and below to evaluate facial symmetry.
The illustration shows a posttraumatic asymmetry of globe
protrusion (left enophthalmos)

17. Hertel exophthalmometer
• This instrument is only reliable to measure the sagittal globe
position correctly in a side-to-side comparison.
• Note: Evaluation for enophthalmos in the acute setting is
unreliable because of orbital edema or if the lateral orbital rim is
not intact and displaced

18. Naugle exophthalmometer
• In case of acquired or congential asymmetry of the lateral
orbital rims a Hertel exophthalmometer is misleading.
• Naugle exophthalmometer is preferred since the referring
structure is not the lateral orbital rim but the frontal and
infraorbital structures.

19. Pupillary reaction
A light is used to assess pupillary reaction

20. • The illustration shows the optic nerve with impingement of
the optic nerve at the orbital apex. There is no indirect light
reaction of the unaffected right eye (Marcus Gunn pupil).
• Note: The indirect light reaction is more reliable than the
direct pupillary reaction to detect posttraumatic optic nerve
lesions.

21. Ear
• Lacerations of auricle, external auditory
canal, tympanic membrane.
• Check for bleeding & foreign bodies
• Check for any CSF Ottorrhea
• Check for any Blood discharge
Dislocated condylar neck may # EAM

22. • Examine for laceration or collapse of the external canal.
• Examine the tympanic membrane for rupture or a
hemotympanum.
• Note: Blood in the ear canal may indicate skull base fractures or
external auditory canal lesion resulting from a condylar fracture.

23. • Note: Make sure the patient can hear with both ears
• Examine for a hematoma of the auricular cartilage. If there is a
hematoma it needs to be drained and a ‘through-and-through’
bolster dressing is recommended. This is to prevent the
permanent deformity of a cauliflower ear, with a possible
compromise of the external canal.

24. • Bolster suture are used in a ‘through-and-through’ manner to
prevent reaccumulation of the hematoma
• Many different materials can be used as a bolster dressing. In
this case, dental rolls have been used

25. BATTLES SIGN
• Post Auricular Bruising
• Base of Skull Fracture
OR
• condyle impacts above into the MCF fracturing the
mastoid process )

27. FRONTO-NASOETHMOIDAL REGION
• NOE complex fractures involve the medial vertical (nasomaxillary)
buttresses of the facial skeleton

28. IN CASE OF FRACTURE IN NOE
• swelling and pain in the medial canthal area.

29. Intercanthal distance
• in Caucasians more than 35 mm intercanthal distance is considered
abnormal.
• illustration demonstrates widening on the left with the medial
canthus positioned lateral to the position of the lateral nasal alar
margin

30. • NOE fractures are most commonly classified according to Markowitz
BL, Manson PN, Sargent L, et al (1991)
• Type I
• Type II
• Type III
• These can be unilateral or bilateral injuries.
• Plast Reconstr Surg. 87(5):843-53:

31. Type I
• In unilateral Markowitz type I fractures, there is a single large NOE
fragment bearing the medial canthal tendon.
• The nasal bone may also be involved and, in cases of comminution,
may not provide adequate dorsal support to the nasal bridge.

32. Unilateral Type II
• In unilateral type II fractures, there is often comminution of the
NOE area, but the canthal tendon remains attached to a fragment of
bone, allowing the canthus to be stabilized with wires or a small
plate on the fractured segment

33. Unilateral Type II + Involvement of the nasal bone
• The nasal bone may also be involved and, in cases of comminution,
may not provide adequate dorsal support to the nasal bridge.

34. Bilateral type II fracture with nasal bone
involvement
• bone grafting of the nasal dorsum may be necessary

35. Type III
• In type III fractures, there is often comminution of the NOE area (as
in type II fractures) and a detachment of the medial canthal tendon
from the bone.

36. Type III + Involvement of the nasal bone

37. Bilateral type III fracture with nasal bone
involvement

38. Nose.
• Uni/bilateral epistaxis.
• CSF rhinorrhea – tram line effect
& halo effect
• Deviation, asymmetry of nose.

39. CSF RHINNORHEA
• Leakage of CSF from the nose due to fractured cribriform plates of
ethmoid bone , generally with Le-Fort 2 & 3 fractures
• Tram Line Effect
• Patient complains of salty taste in throat ( post nasal leak of CSF)
• Warn patient not to blow nose vigorously (traumatic aerocele) and
raise head ( will increase ICP )

40. CSF leak (clinical sign: straw-colored or clear nasal drainage)
• Tilt test with positive halo sign (as illustrated)
• CT scan with thin coronal cuts (0.5 mm) of the cribriform plate
• Comparison of the concentration of glucose between fluid and
patient’s serum
• Laboratory analysis for beta-transferrin

41. • Traumatic telecanthus.
- Nasal fracture
- Lefort III fracture
Saddle Nose - Depressed Nasal
Bridge due to # of the nasal bones
Traumatic Telecanthus & Mongoloid
Inclination of Palpebral Fissure.
( # of the frontal process of the
maxilla to which palpebral ligaments
are attached )
Normal Intercanthal Distance = 3 – 3.5
Cm

42. • BALLOON FACIES -Circumorbital
• Edema
• PANDA FACIES - Circumorbital
• Ecchymosis
• Vertical lengthening of the face
( downward & backward rotation of # rd maxilla )
• Sensory loss in region supplied by V2 branches
• Surgical Emphysema ( Air entering from nose leaks through
fractured Maxilla/Zygoma/Naso-ethmoid regions to tissues )

43. • Nasal inspection using a speculum with appropriate light
(headlights are recommended) allows for examination of
the nasal cavity.
• It is very important to rule out a septal hematoma, as this
has to be drained to avoid an infection which can result in
septal perforation. Nasal packing or splints should be
inserted to prevent recurrence of hematoma.

44. This clinical photograph shows septal hematoma.

45. • Clinical photograph shows delayed drainage of
septal hematoma resulting in infection. This patient
did not present to the emergency room until 1
week following sustaining nasal trauma.

46. Middle third of face
• Bilateral circumorbital ecchymosis, gross edema –
‘Moon face.’
• Lengthening of middle third of the face – ‘Dish face
deformity.’

47. Panda facies
• Vero-1965
• Bilateral circumorbital
ecchymosis
• Localized to orbicularis
oculi region.
• Maximum effect- 24-48
hrs.

48. EXAMNATION MANDIBLE
• Inspect for Asymmetry and deviation
• of mandible
• Lacerations
• Condylar depression( the condyle
can be dislocated anterior to the
articular eminence )
• Trismus & Jaw Movements
• Palpate the symphysis , inferior
Border and ramus of the mandible
for step deformity.
• PARADE GROUND FRACTURE – Bilateral
parasymphysial with Bilateral Condylar
fracture.

49. Extraoral palpation

50. Fracture palpation
• The midface and frontal cranium should be palpated to
detect bony irregularities, step-offs, crepitus, and sensory
disturbances.
• It is crucial for decision making to ensure that one hand
stabilizes the skull so that the examiner’s contralateral hand
can provide movements which can be assessed.

51. Extraoral palpation
• Gentle but firm pressure.
• Depression over forehead.
• Areas of tenderness, step
deformity, abnormal mobility.
Supra-orbital rim
frontozygomatic suture

52. • zygomatic butress →
• zygomatic arch →
• infra orbital rim →
• zygomaxillary suture

53. Feel for STEP DEFORMITY in bone by palpating
starting from the :
Supra-orbital rim →frontozygomatic suture
→zygomatic butress →zygomatic arch →infr
orbital rim → zygomaxillary suture

54. • Illustration shows the palpation in the region of the
zygomatic complex and zygomatic arch.

55. Zygomatic Examination
• Unilateral epistaxis
• Depressed malar
prominence
• Subcutaneous
emphysema
• Orbital rim step-off
• Altered relative pupil
position
• Periorbital ecchymosis
• Subconjunctival
hemorrhage
• Infraorbital
hypoesthesia

56. TMJ PALPATION

57. TMJ Dislocation
Symptoms
• Patient presents with mouth open, cannot close
mouth or talk well
• Can be misdiagnosed as psychiatric or dystonic
reaction

58. • Mandible
- Areas of tenderness,
step deformity.
- Abnormal mobility.
- Inferior border
continuity.
- Angle of mandible.

59. Bow string test
• Fingers are used to grab the eyelid or a forceps to grab the skin in
the medial canthal area and pulled laterally
• the lid is pulled laterally while the tendon area is palpated to detect
movement of fracture segments. A lack of resistance or movement of
the underlying bone is indicative of a fracture.

60. • Illustration shows the palpation of the nose

61. Bimanual palpation
• instrument is placed in the nose and pushed laterally in the medial
canthal area to test for instability and crepitation, which suggests an
unstable NOE fracture

62. IN CASE OF FRACTURE IN NOE
• swelling in the medial canthal area and pain and
crepitation with palpation.

63. PALPATION OF NOSE
• simple method to gather information on the function of the internal
patency of the nose.

64. • Examination of the nose starts with inspection for swelling
or asymmetry, followed by palpation. Characteristic signs for
nasal fractures are:
• Pain
• Bleeding
• Swelling
• Compromised nasal airway
• Crepitation
• Palpable bony dislocation

65. • The nose can be retruded and impacted at the nasofrontal suture
area with lack of support for the nasal septum and cartilages.

66. • An undetected septal hematoma may also result in
the formation of neocartilage, resulting in a
widening of the septum and narrowing of the nasal
airways

67. Neck examination
Palpate the posterior neck for any signs of cervical
spine trauma

68. • anterior neck for signs of laryngeal trauma
• If a laryngeal fracture is suspected, CT of the neck
recommend.
• Examined for any significant penetrating neck trauma or
laceration.

69. laryngeal fracture
Placement of an endotracheal tube may be difficult
or dangerous if a patient has a large hematoma.
emergency tracheostomy should be considered.
Elective intubation for midface surgery should be
delayed

70. INTRA-ORAL EXAMINATION

71. Intraoral examination
Inspection.
• Mouth opening
• Gagging of occlusion
• Lacerations
• Ecchymosis

72. EXAMINATION OF PALATE
• Note: Palatal hematoma and/or palatal lacerations can be
noted in the sagittally split palate.

73. • Blood Clots / Avulsed teeth
• ECCHYMOSIS/HEMATOMA in –
Buccal Sulcus at buttress region
Sublingual region
Greater palatine foramen
• Step Defects in Occlusion
• GAGGING OF OCCLUSION

74. • Anterior open bite & Shift of
midline
• BUCKET HANDLE
FRACTURE
– Bilateral parasymphysial #
where the anterior segment is
pulled lingually & down by the
mylohyoid & digastric respectively
, and the postr fragment pulled
vertically upwards.

75. • Panfacial fracture showing characteristic anterior open bite
deformity which is commonly associated with Le Fort
fractures.

76. GAGGING OF OCCLUSION DUE TO FRACTURED CONDYLE

78. Intraoral palpation
• Buccal & lingual sulcus –
tenderness, alteration in
contour, crepitus
• Mandible palpation
• Mobility of maxilla

79. Differentiating Leforts
Pull forward on maxillary teeth
• Lefort I: maxilla only moves
• Lefort II: maxilla & base of nose move:
• Lefort III: whole face moves:

80. • Mobility of the midface may be tested by grasping the anterior alveolar
arch and pulling forward while stabilizing the patient with the other
hand.

81. • testing for mobility of the central midface

82. • testing for mobility of the midface.

83. AUSCULTATION
PERCUSSION
• Percussion - Loss of Normal resonance of the
• Maxillary Sinus ( CRACKED TEACUP SOUND )

84. TESTS

85. Acuity testing

86. Visual field testing

87. Visual field testing

88. Testing of ocular motility

89. Examine the patient to check the extraocular
muscle (EOM) are functioning properly.

90. If the extra ocular muscles (EOM) are not functioning properly
the surgeon should make sure that there is no entrapment of
the soft tissues. It is recommended to perform the forced
duction test under sedation, local, or general anesthesia

91. • Gross digital intraocular pressure testing
• This should include an examination of the anterior
chamber to rule out a hyphema.
• Severe exophthalmos due to retrobulbar bleeding
may need immediate surgical intervention to
decrease the intraorbital pressure.
• exophthalmos which is typical for carotid-cavernous-
sinus fistula.

92. Sensory loss.
• Anesthesia/ parasthesia over different parts of
face.
- Infraorbital nerve.
- Supraorbital nerve
- Break in continuity of inferior alveolar nerve.
- Facial palsy- peripheral branches, fractures of cranial
base involving facial canal.

93. Sensory exam of the face
• Illustration shows injury to the zygomatic branches of the facial nerve
resulting in inability to close the eye
• Examine the function of the sensory nerves of the face (supraorbital
nerve, infraorbital nerve, and mental nerve).
• Examine the function of the motor nerves of the face (frontal
(temporal), zygomatic, buccal, marginal mandibular, and the cervical
branch of the facial nerve). The most important branches to check are
the zygomatic and the marginal mandibular.

94. • Illustration shows the absence of function of the depressor muscles,
resulting in asymmetry of the lower lip.

95. • Illustration shows injury to the temporal branch resulting in
significant brow ptosis and possible visual field impairment
with upward gaze.

96. REFERENCES
• Fractures of the Facial Skeleton, Peter Banks
• Oral and Maxillofacial Trauma, 4th Edition,Raymond
Fonseca, H. Dexter Barber, Michael Powers,David E. Frost
• Online resource- Science-direct