Clinical Evaluation in Maxillofacial Trauma

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Dr Arjun ShenoyContentsExtraoral examination Inspection scalpEar, Eyes, NoseMiddle third of the faceLower third of faceExtraoral palpation

Intraoral examination.InspectionPalpation

Percussion and AuscultationConclusionReferences.

General examination Nervous systemOrientationMemory

Respiratory system & CVS

Chest & Abdomen.FORCES

Biomechanics of the midfacemidface 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,

Extraoral examinationInspection.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.

ESSENTIALSExamination glovesSingle-use tongue bladesExamination lightVisual chartNasal speculum (in case of need for nasal examination)

Scalp & skull Lacerations & contusions.Depressed # of the skull

Battles sign. Ecchymosis near mastoid process

Eyes.Examine for debris / broken glass pieces


Corneal Abrasions & Scleral tears

Circumorbital Edema & Ecchymosis

Examine for movements of the eye in all GAZES & patency of optic & occulomotor nerve

Classification of eyelid lacerations partial thickness full thickness

canalicular system canalicular system involved not involved

full thickness + inferior canalicular disruption

Racoon eyes.

Subconjunctival Ecchymosis

Flame shaped hemorrhage with posterior limit not seen . ( Suspect # of the orbital walls )

Globe position-

Simple testing of pupil axis is provided using a straight instrument.

The examiner should include an examination from above

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

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

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.

Pupillary reactionA light is used to assess pupillary reaction

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.

EarLacerations 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

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.

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.

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

BATTLES SIGNPost Auricular Bruising

Base of Skull Fracture ORcondyle impacts above into the MCF fracturing the mastoid process )


NOE complex fractures involve the medial vertical (nasomaxillary) buttresses of the facial skeleton

IN CASE OF FRACTURE IN NOEswelling and pain in the medial canthal area.

Intercanthal distancein 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

NOE fractures are most commonly classified according to Markowitz BL, Manson PN, Sargent L, et al (1991)

Type IType IIType III

These can be unilateral or bilateral injuries.

Plast Reconstr Surg. 87(5):843-53:

Type IIn 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.

Unilateral Type IIIn 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

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

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

Type IIIIn 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.

Type III + Involvement of the nasal bone

Bilateral type III fracture with nasal bone involvement

Nose.Uni/bilateral epistaxis.

CSF rhinorrhea tram line effect & halo effect

Deviation, asymmetry of nose.

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 )

39CSF 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 plateComparison of the concentration of glucose between fluid and patients serumLaboratory analysis for beta-transferrin

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

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 )

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.

This clinical photograph shows septal hematoma.

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.

Middle third of faceBilateral circumorbital ecchymosis, gross edema Moon face.

Lengthening of middle third of the face Dish face deformity.

Panda facies

Vero-1965Bilateral circumorbital ecchymosisLocalized to orbicularis oculi region.Maximum effect- 24-48 hrs.

EXAMNATION MANDIBLE Inspect for Asymmetry and deviation of mandible


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.

Extraoral palpation

Fracture palpationThe 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 examiners contralateral hand can provide movements which can be assessed.Extraoral palpationGentle but firm pressure.

Depression over forehead.

Areas of tenderness, step deformity, abnormal mobility.

Supra-orbital rim

frontozygomatic suture

zygomatic butress

zygomatic arch

infra orbital rim

zygomaxillary suture

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

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

Zygomatic ExaminationUnilateral epistaxisDepressed malar prominenceSubcutaneous emphysemaOrbital rim step-offAltered relative pupil positionPeriorbital ecchymosisSubconjunctival hemorrhageInfraorbital hypoesthesiaTMJ PALPATION

TMJ DislocationSymptoms

Patient presents with mouth open, cannot close mouth or talk well

Can be misdiagnosed as psychiatric or dystonic reactionMandible

- Areas of tenderness, step deformity.

- Abnormal mobility.

- Inferior border continuity.

- Angle of mandible.

Bow string testFingers 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.

Illustration shows the palpation of the nose

Bimanual palpationinstrument 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

IN CASE OF FRACTURE IN NOEswelling in the medial canthal area and pain and crepitation with palpation.

PALPATION OF NOSEsimple method to gather information on the function of the internal patency of the nose.

Examination of the nose starts with inspection for swelling or asymmetry, followed by palpation. Characteristic signs for nasal fractures are:

PainBleedingSwellingCompromised nasal airwayCrepitationPalpable bony dislocation

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

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

Neck examinationPalpate the posterior neck for any signs of cervical spine trauma

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

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 delayedINTRA-ORAL EXAMINATION

Intraoral examinationInspection.

Mouth opening

Gagging of occlusion



EXAMINATION OF PALATENote: Palatal hematoma and/or palatal lacerations can be noted in the sagittally split palate.

Blood Clots / Avulsed teeth


Buccal Sulcus at buttress region Sublingual region Greater palatine foramen Step Defects in Occlusion


Anterior open bite & Shift of midline


Bilateral parasymphysial # where the anterior segment is pulled lingually & down by the mylohyoid & digastric respectively , and the postr fragment pulled vertically upwards.

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


Intraoral palpationBuccal & lingual sulcus tenderness, alteration in contour, crepitus

Mandible palpation

Mobility of maxilla

Differentiating LefortsPull forward on maxillary teeth

Lefort I: maxilla only movesLefort II: maxilla & base of nose move:Lefort III: whole face moves:

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

testing for mobility of the central midface

testing for mobility of the midface.


PERCUSSIONPercussion - Loss of Normal resonance of the Maxillary Sinus ( CRACKED TEACUP SOUND )

TESTSAcuity testing

Visual field testing

Visual field testing

Testing of ocular motility

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

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

Gross digital intraocular pressure testingThis 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.

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.

Sensory exam of the faceIllustration shows injury to the zygomatic branches of the facial nerve resulting in inability to close the eyeExamine 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.

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

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

REFERENCESFractures 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