SYSTEMATIC CLINICAL EXAMINATION IN MAXILLOFCIAL TRAUMA

Dr Arjun Shenoy

Contents

• Extraoral examination

Inspection - scalp

- Ear, Eyes, Nose

- Middle third of the face

- Lower third of face

• Extraoral palpation

• Intraoral examination.- Inspection

- Palpation

• Percussion and Auscultation

• Conclusion

• References.

General examination

Nervous system• Orientation

• Memory

Respiratory system & CVS

Chest & Abdomen.

FORCES

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,

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.

ESSENTIALS

• Examination gloves

• Single-use tongue blades

• Examination light

• Visual chart

• Nasal speculum (in case of need for nasal examination)

Scalp & skull

• Lacerations & contusions.

• Depressed # of the skull

• Battle’s sign.

Ecchymosis near mastoid process

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

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.

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

• 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 SIGN

• Post Auricular Bruising

• Base of Skull Fracture

OR

• condyle impacts above into the MCF fracturing the mastoid process )

FRONTO-NASOETHMOIDAL REGION

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

IN CASE OF FRACTURE IN NOE

• swelling and pain in the medial canthal area.

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

• 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:

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.

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

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.

Bilateral type II fracture with nasal bone

involvement

• bone grafting of the nasal dorsum may be necessary

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.

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 )

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

• 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 face• Bilateral circumorbital ecchymosis, gross edema –

‘Moon face.’

• Lengthening of middle third of the face – ‘Dish face deformity.’

Panda facies

• Vero-1965

• Bilateral circumorbital ecchymosis

• Localized to orbicularis oculi region.

• Maximum effect- 24-48 hrs.

EXAMNATION MANDIBLE • Inspect for Asymmetry and deviation • of mandible

• Lacerations

• Condylar depression( the condyle can be dislocated anterior to thearticular eminence )

• Trismus & Jaw Movements

• Palpate the symphysis , inferior Border and ramus of the mandiblefor step deformity.

• PARADE GROUND FRACTURE – Bilateral parasymphysial with Bilateral Condylar fracture.

Extraoral palpation

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.

Extraoral palpation

• Gentle 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 →infrorbital rim → zygomaxillary suture

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

Zygomatic Examination

• Unilateral epistaxis

• Depressed malar

prominence

• Subcutaneous

emphysema

• Orbital rim step-off

• Altered relative pupil

position

• Periorbital ecchymosis

• Subconjunctival

hemorrhage

• Infraorbital

hypoesthesia

TMJ PALPATION

TMJ Dislocation

Symptoms

• Patient presents with mouth open, cannot close

mouth or talk well

• Can be misdiagnosed as psychiatric or dystonic

reaction

• Mandible

- Areas of tenderness,

step deformity.

- Abnormal mobility.

- Inferior border continuity.

- Angle of mandible.

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.

• Illustration shows the palpation of the nose

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

IN CASE OF FRACTURE IN NOE

• swelling in the medial canthal area and pain and crepitation with palpation.

PALPATION OF NOSE

• simple 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:

• Pain

• Bleeding

• Swelling

• Compromised nasal airway

• Crepitation

• Palpable 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 trauma

• If 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 delayed

INTRA-ORAL EXAMINATION

Intraoral examination

Inspection.

• Mouth opening

• Gagging of occlusion

• Lacerations

• Ecchymosis

EXAMINATION OF PALATE

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

• Blood Clots / Avulsed teeth

• ECCHYMOSIS/HEMATOMA in –

Buccal Sulcus at buttress region Sublingual region Greater palatine foramen

• Step Defects in Occlusion

• GAGGING OF OCCLUSION

• 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.

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

GAGGING OF OCCLUSION DUE TO FRACTURED CONDYLE

Intraoral palpation

• Buccal & lingual sulcus –tenderness, alteration in contour, crepitus

• Mandible palpation

• Mobility of maxilla

Differentiating Leforts

Pull forward on maxillary teeth

• Lefort I: maxilla only moves

• Lefort 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.

AUSCULTATION

PERCUSSION• Percussion - Loss of Normal resonance of the

• Maxillary Sinus ( CRACKED TEACUP SOUND )

TESTS

Acuity testing

Visual field testing

Visual field testing

Testing of ocular motility

Examine the patient to check the extraocularmuscle (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 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.

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 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.

• 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.

REFERENCES

• Fractures of the Facial Skeleton, Peter Banks

• Oral and Maxillofacial Trauma, 4th Edition,RaymondFonseca, H. Dexter Barber, Michael Powers,David E. Frost

• Online resource- Science-direct