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Fig. 11.27: Maxillary fracture
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Examination of Jaw
medial tilt or lateral tilt. Infraorbital nerve may get
compressed or branches of superior dental nerve may
get torn.
Unstable fracture with r otation around horizontal axis
with medial tilt or lateral tilt.
Comminuted fracture extending into the floor of the
orbit.
Fracture of the zygomatic arch causes a localised
depression of the arch which displaces medially and
tends to impinge on the coronoid process of the
mandible.
‘Blow-out’ fracture of the orbit is due to direct blunt
trauma on the eyeball causing depressed comminuted
271
A
C
Figs 11.28A to D: Le Fort classification—different types and also dentoalveolar fracture. A—dentoalveolar;
B—Le Fort I; C—Le Fort II; D—Le Fort III (Refer Table on Pg. 270 for details).
B
D
272
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SRB’s Clinical Surgery
fracture of the orbital floor with herniation of the orbital
fat into the antrum.
Enbloc dislocation of zygomatic bone medially/
inferiorly/postero-laterally (Figs 11.29A to C).
into the antrum; Diplopia is due to entrapment of the
inferior rectus muscle preventing upward rotation of
the eyeball while looking up; Trismus with marked
restriction of the lateral movements; Epistaxis,
lowering of pupil level; Infraorbital ecchymosis of
the orbit is called as Panda sign.
Investigations—30° occipitomental X-ray is commonly used but often obliquity of X-ray may be
increased to 60°. In X-ray, findings observed are—
Fracture line near infraorbital foramen, zygomatic arch
and lateral wall of the antrum; Orbital floor line for
fracture; Opacity in the antrum due to blood. CT scan
is done to see orbital depression and herniation of
orbital fat.
A
C
Figs 11.29A to C: Diagrams showing different types of
zygomatic fractures.
Clinical Features
B
Swelling and bruising in the cheek with sub conjuctival
haemorrhage; Flattening of the cheek prominence; Step
in the margin of the bony orbit at the infraorbital
foramen; Sensory loss over the supply of the branches
of the superior orbital nerve— teeth on the affected
area are anaesthetic on percussion; Sensory loss over
the supply of the infraorbital nerve usually over
infraorbital region, upper lip and alar region of the
nose – common; Enophthalmos is due to herniation
of the orbital fat across the fracture floor of the orbit
Fracture of the Mandible
Types (Fig. 11.30)
I. At the neck of the condyle as it is the weakest point.
The condyle is displaced in front and medially
often with dislocation. Painful jaw movement is
the clinical feature. It may be unilateral or
bilateral.
II. At the angle of the mandible: If fracture is
upwards and inwards, it is impacted and undisplaced. So it is a favourable fracture. If fracture
is downwards and outwards, it gets displaced and
so it is an unfavourable fracture. It needs open
reduction using wires.
Fig. 11.30: Types of mandibular fractures.
Examination of Jaw
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Other classifications
Classification of the fracture mandible
Depends on the type Depending on the anatomical site (Fig. 11.31)
• Simple • Dentoalveolar fracture
• Compound • Condylar fracture
• Comminuted • Coronoid fracture
• Pathological • Fracture ramus of the mandible
• Green stick fracture in children • Fracture angle of the mandible
• Fracture in the body of the mandible
• Symphyseal region fracture
Dentoalveolar fracture
Features Management
• Horizontal fracture below the alveolar margin • Look for other injuries in face
• Dentoalveolar segment will be freely mobile • X-ray face to see injuries
• Tooth may get split vertically / horizontally • Dentoalveolar segment reduction and placing jaws in
central occlusion position
• Derangement in occlusion and alignment • Stabilization using interdental wires or arch bars
• Gingival laceration • Liquid diet for 3-4 weeks
• Bleeding
• Infection and late osteomyelitis of mandible
is called as Coleman’s sign. Difficulty in opening the
mouth, speech and swallowing; anaesthesia of the
lower lip due to compression of inferior dental nerve;
deranged dental occlusion; step deformity; blood
stained saliva is common as often mandibular fracture
is of compound type because mucoperiosteum is
adherent to mandible (Fig. 11.32).
273
Fig. 11.31: Different sites of fracture mandible.
III. Fracture near the mental foramen through the
canine fossa. This fracture causes displacement.
Such bilateral fractures can cause pull on digastric
and geniohyoid muscles precipitating fall of
tongue backwards which will block the airway.
Guardsman fractur e is direct fracture of symphysis
and indirect fractures of both the condyles of the
mandible. In olden days guards of queen who are in
attention position used to faint and fall forward to
get these fractures.
Clinical Features
Pain and tenderness in the lower jaw with bruising
over the surface. Haematoma in the floor of the mouth
Complications of fracture mandible: Obstruction of
the airway; Osteomyelitis of the mandible; Trismus;
Speech disturbances.
.
Fig. 11.32: Unreduced and reduced fractures of the
mandible.
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Examination of
12
Salivary Gland
History
Swelling: Duration—progress, recent increase in size;
Pain, whether initially painless now has become
painful. Swelling of short duration with pain, trismus
could be due to acute parotitis. Often it is bilateral
in children due to viral cause (mumps). Bilateral
enlargement of parotid along with other salivary glands
and lacrimal gland is called as Mikulicz syndrome.
Excessive salivation, joint pain along with enlargement
of all salivary glands is called as Sjogren syndrome.
Pleomorphic adenoma is slow growing tumour of long
duration. Recent increase in size of swelling is
important which suggests malignant transformation
probably from a pre-existing pleomorphic adenoma.
Adenolymphoma is slow growing tumour from lower
pole of the parotid (Fig. 12.1).
Fig. 12.1: Typical parotid swelling—
pleomorphic adenoma.
Pain: Duration/type/severity/radiation should be
asked. Sudden onset of severe pain is a feature of
acute parotitis. Throbbing excruciating pain may be
a feature of parotid abscess. Colicky pain during meals
is a feature of salivary calculus with sialadenitis. Stone
is more common in submandibular salivary gland but
can also occur in parotid gland.
Fever is a feature of acute sialadenitis or abscess.
Acute sialadenitis with suppuration is common in
parotid. Parotid abscess is usually unilateral. Mumps
in children is bilateral. Neoplastic condition once
necrosed can cause fever.
Difficulty in opening mouth can occur in acute
parotitis, submandibular sialadenitis, and malignancy
extending into the soft tissues.
History of excess salivation during meals/more pain
during meals/swelling becoming more prominent
during meals should be asked. It is a feature of stone
in the salivary duct. Presence of sinus, its formation,
discharge, etc. should be asked. Discharge from sinus/
fistula is usually saliva. Its quantity, duration, colour
whether increases while taking food should be clarified.
Recent increase in size suggests malignant
transformation.
History of impairment of function like drooling
of saliva, inability to close eyes, tears in the eye,
asymmetry of face, difficulty in opening of the mouth
should be asked.
History suggestive of metastases in case of
malignant salivary tumours like of lungs, bone, brain
should be asked.
Past history of surgery for parotid or submandibular swellings should be asked. Recurrent parotid
tumours are known to occur in pleomorphic adenoma
and malignancies. Detailed history of surgery , its nature
of biopsy, postoperative management should be taken.
Examination of Salivary Gland
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Past history of radiotherapy in head and neck region;
past history of other malignancy in the body.
Personal history of alcohol intake is relevant in
bilateral parotid enlargement.
Local Examination
Inspection
Swelling is examined in detail. Position of the swelling
is noted. Parotid swelling is below, behind and in front
of the ear lobule. Parotid enlargement shows typically
raise in ear lobule. Normal hollow/depression just
below the ear lobule are obliterated. Size, shape, extent,
skin over the swelling should be inspected (Figs 12.2
and 12.3A and B). Skin is red and oedematous in
parotid abscess or inflammatory conditions. In salivary
calculus (submandibular calculus), swelling immediately becomes more prominent when lemon juice or
chocolates are given to the patient to drink or eat.
Deep lobe of parotid enlargement is checked by
inspecting the oral cavity for any bulge in the tonsil
and lateral wall of pharynx. Floor of the mouth should
be inspected for enlargement of deep lobe of the
submandibular salivary gland (Figs 12.4A to 12.5C).
Stenson’ s parotid duct should be inspected opposite
to 2nd upper molar tooth (Figs 12.6A and B). Cheek
should be retraced using spatula and light source to
inspect the duct properly . In suppurative parotitis pus
275
A
Fig. 12.2: Inspection of parotid should be done
carefully by holding the ear lobule.
B
Figs 12.3A and B: Typical parotid swelling with ear lobe
raised. Facial nerve should be tested by clenching the teeth.
may be seen gushing out of the duct orifice after gentle
pressure over the parotid gland. Blood in the duct
orifice (ampulla of duct) may be due to malignant
parotid tumour. Opening and course of the submandibular salivary duct (Wharton’ s) should be inspected
after raising the tip of the tongue over the palate. Duct
orifice may be inflamed and oedematous with discharging pus from it. Often stone may be visible in the
duct orifice. Orifice is situated on either side of the
frenum linguae. Duct with impacted stone blocks the
salivary flow and hence that side orifice looks dry
whereas normal side orifice looks wet due to normal
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SRB’s Clinical Surgery
A
Figs 12.4A and B: Deep lobe of the parotid should be inspected from inside.
A
B
B
C
Figs 12.5A to C: Inspection of submandibular salivary gland swelling.
Oral cavity is also should be inspected.
Examination of Salivary Gland
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A
B
Figs 12.6A and B: Stenson’s parotid duct should be
examined opposite 2nd upper molar.
277
Fig. 12.7: In submandibular salivary gland enlargement of
Wharton’s duct should be inspected by raising the tip of
the tongue over to palate.
Palpation
Swelling should be palpated like for any other
swelling—local rise of temperature (Fig. 12.8) tenderness; surface; consistency; mobility; curtain sign; skin
is free or not; extension to deeper plane; relation to
masseter and mandible. Curtain sign is—deep fascia/
parotid sheath is attached above to the zygomatic bone
and so swelling arising from parotid gland cannot be
moved up beyond zygomatic bone wherein deep fascia
acts like a curtain to prevent its further mobility.
salivary flow (Fig. 12.7). Two small dry swabs are
placed over the orifices on each side and patient is
asked to take stimulant like lemon juice; after a minute
swabs are taken out and inspected; swab on the side
with impacted orifice will be dry; swab over normal
orifice will be wet.
Skin over the swelling should be inspected. Redness
suggests sialadenitis. Sialadenitis is inflammation of
the salivary gland. Ulceration or fungation may develop
in advanced carcinoma parotid. Sinus or salivary fistula
should be inspected for discharge and location. If
parotid fistula is in masseteric relation then it is from
the gland; it will be premasseteric if it is from the
duct.
Inspection of neck region for enlarged cervical
nodes is also done.
Fig. 12.8: Temperature over the surface should be
checked.
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Swelling superficial to deep fascia can be moved
beyond the level of the zygomatic bone above. Initially
mobility of the swelling is checked in both directions;
then patient is asked to clinch the teeth so that masseter
gets contracted and mobility is checked again (Figs
12.9 and 12.11A and B). If mobility is restricted then
swelling is adherent to masseter muscle. Nonmobile
swelling means it is adherent to bone beneath. Whether
skin is adherent to swelling or not should be checked
(Figs 12.10A and B). Consistency is variable in
different conditions—pleomorphic adenoma is firm
but can be hard with smooth surface. Malignant
swellings often have nodular surface and hard
consistency; adenolymphoma (W arthin’ s) is smooth,
soft often fluctuant and usually not transilluminant.
Tenderness suggests that it could be abscess, necrosis
in a tumour or deeper infiltration. Scar, fistula on the
surface should be palpated.
A
Fig. 12.9: Lower margin of the enlarged parotid gland
should be assessed.
Submandibular salivary gland swelling also should
be examined similarly like any other swelling. Its
medial, posterior extension, relation of the swelling
to the lower margin of the body of the mandible should
be checked (Figs 12.12A to D). Submandibular
salivary gland enlargement occurs as a result of chronic
sialadenitis or neoplastic conditions. Its surface is
usually smooth whereas submandibular lymph node
enlargement is usually nodular. Best way of palpating
the submandibular salivary gland is by bidigital
palpation (Fig. 12.13). It confirms swelling as
B
Figs 12.10A and B: Checking the mobility and skin
fixation of the parotid swelling.
submandibular salivary gland and also deep lobe and
duct can be palpated. Duct is palpated from behind
forwards. First dentures if present should be removed.
Index finger of one hand is placed over the floor of
the mouth medial to alveolus and lateral to tongue
pushing the finger as deep as possible; fingers of other
hand are placed outside under the mandibular margin
to push the swelling upwards. By this way the finger
inside the oral cavity not only helps to feel the deep
lobe of the salivary gland which is deep to mylohyoid
muscle; but also the superficial lobe and often duct
Examination of Salivary Gland
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279
A
Figs 12.11A and B: Mobility of parotid swelling should be checked in two directions.
A
B
B
Figs 12.12A to D: Submandibular salivary gland palpation – skin fixity (pinching);
extent, margin and mobility. Fluctuation should be elicited in a soft swelling.
C
D
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SRB’s Clinical Surgery
be felt by bidigital palpation with index finger of one
hand placed inside the mouth in front of the tonsil
and behind the 3rd molar tooth and fingers of the other
hand placed outside behind the ramus of the mandible
(Figs 12.15A to 12.17).
Features of parotid swelling
Ear lobule raise
Swelling in parotid region
Swelling occupying the groove between posterior part
of the mandible and mastoid process
Moves upwards upto zygomatic bone—curtain sign
Fig. 12.13: Submandibular salivary gland bidigital
palpation.
Fig. 12.14: Parotid duct palpation.
can be better assessed by this method. Submandibular
lymph node is not bidigitally palpable as it is outside
the mylohyoid muscle, superficial to the gland. Stone
in the Wharton’s duct also can be palpated by this
method. Shape, size, consistency can be assessed by
this method.
A
Intra oral examination: Parotid duct should be
palpated using one finger inside the cheek and thumb
outside the cheek (Fig. 12.14). Duct can be better
felt when masseter is taut. Only anterior part of the
duct is felt. Enlarged deep lobe of the parotid can
B
Figs 12.15A and B: Palpation of deep lobe
of the parotid gland.
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