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374
Exclusively in the parotid.
Mostl
Der
e entrapped in
ly
C
May be multiple in one parotid gland or bilateral
Common neoplasm in both adults and children
The most common cander in pa
y glands
Tw
High grade - aggr
metastasiz
spread haematogenously to the lung, liver, bone.
Lo
12 History andExamination ofSalivary Gland Diseases…
12.2.2 Characteristics ofWarthin’s
Tumour (Fig.12.5)
y in men & more common in smokers.
ived from salivary duct cells that ar
mph nodes during embryonic development.
Very slow growing
onsists of large cystic spaces
Fig. 12.5 Characteristic features of Warthin’s tumour
Fig. 12.6 Characteristic
features of
mucoepidermoid
carcinoma
12.2.3 Characteristics
ofMucoepidermoid Tumour
ofSalivary Gland (Fig.12.6)
Colour atlas of Salivary gland diseases
o grades- Low grade & High grade
w grade
very slow growing
non-metastasizing
generally behave like a benign tumor**
essive growth and invasion
widespread metastasis and death
rotid and minor salivar
e to cervical lymph nodes
12.2 Histopathological Classication of Salivary Gland Tumours
375
12.2.4 Submandibular Gland Disease
(Fig.12.7a–e)
a
c d
Fig. 12.7 Diseases of submandibular gland and triangle. (a) Sialadenitis, (b) Stone in submandibular duct, (c) Ludwigs
angina, (d) Abscess in submandibular triangle, (e) Cyst in submandibular area
b
12.2.5 Parotid Gland Disease
(Fig.12.8a–c)
e
a b c
Fig. 12.8 Diseases of parotid gland. (a) Parotid abscess, (b) parotid tumour, (c) parotid tumour
376
ab
12 History andExamination ofSalivary Gland Diseases…
12.2.6 Minor Salivary Gland Disease
(Fig.12.9a, b)
Fig. 12.9 Diseases of minor salivary glands. (a, b) Pleomorphic adenoma over palate
History andExamination
ofMaxillofacial Trauma
13
13.1 Maxillofacial/Facial Trauma
13.1.1 Overview of Maxillofacial Fracture
Denition: Maxillofacial trauma refers to injury
to the face or jaw caused by physical forces, such
as a road trafc accident, rearm injury, ght,
human/animal bite, or burns. It includes injuries
to bony structures or soft tissue of the face.
13.1.1.1 Classication ofMaxillofacial
Trauma Based onSite
ofFracture
• Frontal bone and frontal sinus fracture:
The frontal bone forms most of the forehead
area. A high-impact injury to the forehead (i.e.
Road trafc accident (RTA), fall) results in
fracture of the frontal bone and/or frontal
sinuses. The fracture of the frontal bone
mostly occurs in the middle of the forehead
because the bone is the thinnest and weakest
at the middle. Fractures of the frontal bone
and the frontal sinuses (FSs) are relatively
uncommon comprising 5% of all maxillofacial injuries.
– Frontal sinus fracture:
Type 1—It is a fracture of the anterior
wall of the sphenoid sinus with or without frontal recess involvement, with a
Type 1 A—Isolated fracture of the anterior
wall of the frontal sinus without frontal
recess involvement without
displacement.
Type 1 B—Displaced fracture involving
the superior part of the anterior wall of
the frontal sinus without fracture of the
anterior wall of the frontal sinus with
frontal recess
Type 1 C—Frontal sinus fracture with bone
loss.
Type 1 D—Fracture of the inferior part of
the anterior table with injured nasofrontal duct.
Type 1 E—Entire anterior table is fractured
with injury to the nasofrontal duct.
variable displacement of fracture ranging from minimally displaced to
severely displaced.
Type 2—It is a fracture of the posterior
wall of the frontal sinus, with or without
cerebrospinal iud (CSF) rhinorrhoea
and with or without intracranial injury.
The posterior wall of the frontal sinus is
in direct contact with dura and thus
commonly associated with intracranial
injury.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2025
S. K. Kashyap, S. Sagar, Clinical Methods of Otorhinolaryngology, Skull Base & Head Neck
Surgery, https://doi.org/10.1007/978-981-96-1765-4_13
379
380
Type 2 A—Fracture of posterior wall of
frontal sinus with or without CSF
rhinorrhoea.
Type 2 B—Fracture associated with dis-
placed fragment without CSF leak.
Type 2 C—Fracture associated with bone
loss with CSF leak.
Type 2D—Fracture with extensive bone
loss with CSF leak.
Type 3—It is a fracture of both walls of
the frontal sinus. This is a combination
of Type 1 and Type 2 frontal sinus
surgery.
Type 4—It is a severe fracture involving
other bones of face like the nose, ethmoid and orbit.
– Frontal bone fracture: These fractures are
more common in the mid part of the frontal
bone.
• Nasal bone fracture: Nasal bone fractures are
classied into three types (Fig.13.1):
– Type I—Simple fracture with no
displacement.
– Type II—Simple fracture with displace-
ment/with no telescoping.
IIA—Unilateral nasal bone fracture
with displacement but no septal
fracture.
IIAs—Unilateral nasal bone fracture
with displacement and septal fracture.
13 History andExamination ofMaxillofacial Trauma
IIB—Bilateral nasal bone fracture with
displacement but no septal fracture.
IIBs—Bilateral nasal bone fracture with
displacement with septal fracture.
– Type III—Comminuted fracture of nasal
bone with telescoping or depression of
dorsum.
• Nasoethmoid fracture: The most commonly
used classication of naso-orbital-ethmoid
(NOE) fracture is the Markowitz and
Manson classication. It is based on the status of the central fragment and medial canthal
tendon (MCT). NOE complex fractures are
classied into three types (Table 13.1 and
Fig.13.2).
• Zygomatic complex fracture: The zygomatic
bone is located in the lateral and upper part of
the face. It has a maxillary process inferiorly
which forms a zygomaticomaxillary complex
(ZMC) made up of zygomatic bone and maxillary bones: superiorly it has a frontal process
which articulates with the frontal bone and
posteriorly it articulates with the temporal
bone to form the zygomatic arch. The fracture
of this complex may range from isolated onecomponent fracture to tetrapod fracture
(Table13.2 and Fig.13.3).
• Orbital fracture/orbital rim fracture/blow-
out fracture/direct orbital oor fracture: It
is a fracture of one of the bones of the orbit. It
is caused by blunt force trauma to the eye. The
entrapment of muscle causes oculocardiac
reex which may result in nausea, vomiting
Type I II As II Bs Ty pe III
Fig. 13.1 Classication of nasal fracture
II A
II B
13.1 Maxillofacial/Facial Trauma
Table 13.1 Types of nasoethmoid fracture
Type of nasoethmoid
fracture Description
Class 1/Type I Type 1: It is a simple fracture of the naso-orbital-ethmoid (NOE) region. It involves a
single, noncomminuted, central fragment without disruption of the medial canthal tendon.
The MCT is attached to a relatively large ‘central fragment’ of fractured bone. These
fractures may be unilateral or bilateral
Class 2/Type II Type 2: It is a complete fracture of the naso-orbital-ethmoid (NOE) region. It involves
multiple comminuted bones external to the insertion of the MCT without its disruption. The
MCT maintains continuity with a relatively large fracture segment of bone because the
fracture line does not extend to the bone immediately underlying the canthal insertion. It
may be unilateral or bilateral
Class 3/Type III This is a bilateral and complete fracture of the nasoethmoid region. It involves multiple
comminuted bones beyond the insertion of the MCT with or without disruption. In this,
MCT is either attached to a small fragment of bone or avulsed
a b c
381
Fig. 13.2 Nasoethmoid fracture (classes 1–3). (a) Class 1, (b) class 2, (c) class 3
and bradycardia, especially in paediatric
patients (Table13.3).
• Maxillary (Le Fort or Mid-face) fracture:
Classication of Rene (Table 13.4 and
Fig.13.4)
• Mandible fracture
– Classication according to the site of
fracture
Sub-condylar fracture: The fracture
line is below the attachment of the
382
Table 13.2 Types of zygomaticomaxillary buttress/zygomatic fracture
Type A: Injuries are isolated to one component of the zygomatic bone. A1—zygomatic arch fracture, Type A2—
lateral orbital wall fracture, and Type 3—Inferior orbital rim fracture.
Type B: Fractures involve all four buttresses of zygomatic bones (i.e. classic tetrapod fracture)
Type C: Injuries are complex fractures with comminution of the zygomatic bone itself
Zygomaticomaxillary and zygomaticotemporal buttresses are the commonest site compared to the
zygomaticofrontal buttress. The zygomaticofrontal buttress is the strongest of the four ZMC buttresses
Table 13.3 Types of orbital fracture
Type of fracture Description
Orbital rim This fracture is located on the outer edges of the eye socket and only caused by a large
amount of force. The causes of orbital rim fractures are often car accidents. It often
accompanies other injuries of the head and face. This fracture may present as isolated
medial rim, superior rim, lateral rim and inferior rim fracture and may present as an
irregular contour along the edge of orbit
Blowout fracture/
orbital oor fracture
Compound fracture This includes fracture of the orbital rim, oor, maxilla and the ZMC zygomaticomaxillary
A blowout fracture is also known as a fracture of the oor of the orbit or inner wall. This
may be caused by a blow or trauma to the orbital rim. This blow to the orbit pushes the
bones back, causing the bones of the orbital oor to fracture downward
complex, resulting in abnormalities in biting or chewing
13 History andExamination ofMaxillofacial Trauma
Fig. 13.3 Various types of zygomaticomaxillary fracture
joint capsule and in general devoid of
ankylosis
Symphyseal fracture: A symphyseal
fracture is a midline mandibular fracture
between the central incisors.
Parasymphyseal fracture: The fracture
line runs between the lateral incisor and
canine tooth.
Body fracture: It results in a attened
appearance of the face with a fracture
line that runs anywhere between the
canine and last molar.
Angle fracture—Angle is a common
site for fracture because this is an anatomically weak area and further weakened by an unerupted third molar. This
occurs in a triangular area between the
anteroinferior and posterosuperior
attachment of the masseter on the
mandible.
13.1 Maxillofacial/Facial Trauma
Table 13.4 Classication of Le Fort fracture
Name of fracture Denition
Le Fort 1 It is a horizontal fracture of the maxilla in which the fracture line passes through the upper
alveolar ridge, lateral nose and inferior wall of the maxillary sinus. It separates the teeth
from the upper face and is also known as low-level fracture, Gurian’s fracture, oating
maxilla, or horizontal fracture of the maxilla
Le Fort 2 It is a pyramidal fracture of the maxilla in which the base is at the teeth and the apex is at
the nasofrontal suture. The fracture line passes through the posterior alveolar ridge, lateral
walls of maxillary sinuses, inferior orbital rim and nasal bones, and the uppermost fracture
line can pass through the nasofrontal junction or the frontal process of the maxilla. It is also
known as mid-level fracture or pyramidal fracture
Le Fort 3 It is a transverse fracture of the maxilla in which the fracture line passes through the
nasofrontal suture, maxillo- frontal suture, orbital wall and zygomatic arch/zygomaticofrontal
suture. It is also known as suprazygomatic fracture, high-level fracture, or craniofacial
disjunction
383
Fig. 13.4 Classication showing types of Le Fort fracture 1–3
Coronoid fracture—This is a fracture of
the coronoid process which is located at
superior aspect of ramus.
Ramus fracture: The fracture line runs
either horizontally or vertically.
– Classication according to muscle force
Horizontally favoured fracture—The
fracture reduced biomechanically by
temporalis and masseter muscle.
Horizontally unfavoured fracture—The
displacement of the fracture segment
increased by masseter and temporalis
muscle.
Vertically favoured fracture—The pull
vector of pterygoid muscle promotes
the reduction of the fractured
segment.
Vertically unfavoured fracture—The
pterygoid muscle tends to displace the
fracture segment.
– Classication according to number of frac-
tures (Fig.13.5):
Class I—Single condyle
Class II—Fracture at angle/ramus/
coronoid
Class II C—Class II and condyle
Class III—Body/para symphysis/
symphysis
Class IIIC—Class III and condyle
384
Fig. 13.5 Classication/types of mandibular fracture
13 History andExamination ofMaxillofacial Trauma
Class IV— > 1 fracture not including
condyle
Class IV C—Class IV and condyle
Class V—Bilateral condyle +/− other
fractures
• Pan-facial fracture—Pan-facial bone frac-
ture term is used when a facial fracture
involves the upper, middle and lower thirds of
the face.
13.1.1.2 Classication ofType
ofFracture (Table13.5)
Symptomatology/Chief Complaints/
History ofMaxillofacial Trauma/Injury
• General symptoms of maxillofacial trauma
– Trouble with chewing, eating or speaking.
– Pain at the fracture site, while opening the
mouth, on chewing and on movement of eye.
– Teeth: Loose, broken, or missing; ill-tting
teeth or denture; missing teeth.
– Swelling: whole face, forehead, eye, nose,
periorbital area, infraorbital area and mandible area.
– Bleeding: Epistaxis, bruising, oral bleeding
and conjunctival haemorrhage.
– Orbital symptoms: black eye, blurred
vision, decreased mobility of eye, loss of
vision, diplopia, enophthalmos, proptosis,
double vision and subconjunctival
haemorrhage.
– Nasal symptoms: blocked nose, burn, red-
ness and blister.
– Depression of malar eminence.
– Changes in feeling/numbness over the face,
forehead, infraorbital area and over the
chin.
– Deformed or uneven face or facial bones.
– Trismus: Inability to open the mouth
caused by haematoma, fracture or disloca-
tion of the mandible or zygomatic arch,
temporomandibular joint (TMJ) contusion,
intraarticular bone islands/foreign bodies,
displaced meniscus and direct injury to
muscles of mastication.
– Face: facial widening and facial lengthening.
– Facial deformities and laceration over the
face.
13.1 Maxillofacial/Facial Trauma
Table 13.5 Types of fracture
Findings Type of fracture
The fracture without a break in the skin mucosa or periodontal membrane Simple or closed fracture
There is a connection between the jaw bone and the environment Compound or open
Only one side of the jawbone is fractured while the other part is bent Greenstick
Fracture due to pre-existing bone disease Pathological fracture
Two or more distinct fractures in one bone Multiple fractures
One section of bone is driven by force into another section Impacted fracture
Fracture due to bone atrophy Atrophic
Fracture in a bone located away from the injury site Indirect
Fracture with additional tissue or structural injury Complicated (complex)
Fracture with bone splinters or crushed bone Comminuted fracture
385
– H/o animal bite or hit, excessive bleeding,
previous disease, high-impact accidents,
such as road trafc accidents, sports injuries,
workplace accidents, falls and interpersonal
trauma like ghting or domestic violence.
• Symptomatology of fracture/trauma of spe-
cic area
– Nasal fracture
Nasal pain
Swelling over the nose
Nose bleeds (epistaxis)
Bruising around the nose
Difculty breathing through the nose—
It may be due to obstruction of one or
both nostrils or a deviated septum.
Nasal deviation or deformity
Associated symptoms: watery nasal discharge and other injuries like cranial
injury.
– Nasoethmoid fracture
Gross facial oedema—It may show
rstly in the early stage of fracture of
the NOE region.
Ophthalmic symptoms include diplopia,
telecanthus, enophthalmos, epiphora
and shortened palpable ssure.
Nasal symptoms include retrusion of the
nasal bridge, anosmia caused by damage to the cribriform plate and nasal
congestion secondary to septal haematoma or bony/cartilaginous deformity.
Cerebrospinal uid leak (CSF)—It may
or may not be present.
– Forehead (frontal bone/frontal sinus)
fracture
The forehead may appear inverted
(pushed inward)
Paraesthesia/anaesthesia over the
forehead
Pain around the sinuses
Injuries to the eyes (vision problem)
CSF rhinorrhoea
Involvement of the brain (neurological
decit)
Haemorrhage (nasal bleeding)
Laceration over the forehead
– Zygomatic fracture (cheek bone and
upper jaw)
Pain, oedema and ecchymosis of the
cheek and eyelids are the most common
symptoms associated with zygomatic
bone fracture.
Flatness of the cheek
Decit/altered sensation underneath the
eye on the affected side
There may be problems in vision.
Pain with jaw movement
Oedema of cheek
Ecchymosis of the cheek and eyelids
Trismus
Severe pain if associated with visual
loss or ophthalmoplegia may indicate
retrobulbar haemorrhage.
Anaesthesia or paraesthesia of the
cheek, nose, upper lip and lower eyelid
due to infraorbital nerve injury.