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386
13 History andExamination ofMaxillofacial Trauma
– Orbital fracture/blow out fracture
Redness or bleeding in the conjunctiva
of the eye.
Numbness in the forehead and eyelids—This is due to injury to the supratrochlear and supraorbital nerve in
fracture of upper margin of orbit.
Numbness in cheek or upper lip/teeth—
This is due to injury to the infraorbital
nerve in blowout fracture.
Facial numbness near injury.
Blurry, decreased or double vision
(diplopia).
Difculty in moving eyes left, right, up
or down—This is due to entrapment of
orbital muscles.
Swollen forehead or cheek or swelling
below the eyes.
Sunken or bulging eyeballs.
A black eye.
Limitation of upward gaze movement.
Orbital compartment syndrome—This
syndrome may occur from acute haemorrhage causing soft tissue swelling,
severe implosion of the orbit by inwardly
rotated bone fragments causing tissue
impaction, or even orbital emphysema.
This is most commonly caused by injury
to either the infraorbital artery or the
anterior or posterior ethmoid arteries.
Associated symptoms are epistaxis,
watery nasal discharge and loss of
vision.
History of fall, high-velocity wallrelated sport injury, trafc accidents and
interpersonal violence.
– Mid-face (maxillary/Le Fort) fracture:
Le Fort 1—Swelling of upper lip and
laceration, increased vertical height of
the face, epistaxis, malocclusion, dental
fracture, and ecchymosis is present in
the buccal sulcus beneath each zygomatic arch.
Le Fort 2—Gross oedema over the
middle third of the face (Moon faces),
B/L circumorbital ecchymosis,
increased height of the face, epistaxis,
infraorbital nerve hypoesthesia, orbital
haematoma, globe rupture or impingement and optic nerve damage.
Le Fort 3—Enophthalmos, Moon faces,
B/L circumorbital ecchymosis, subconjunctival haemorrhage, diplopia,
restricted eye movement, epistaxis,
anosmia, CSF rhinorrhoea.
– Mandible fracture
Pain at fracture site or movement of the
mandible.
Bruising and swelling along the mandible or below the ear.
Malocclusion—Unable to bring the
teeth together properly.
Bruising under the tongue—This almost
always indicates a mandible fracture.
Trismus—inability to open the mouth
properly or restricted mouth opening.
Numbness in the lower lip or chin
(altered sensation).
Difculty in chewing, eating, or
speaking.
Tooth/teeth may be Loose, broken, or
missing.
Pain in the cheek and face while opening the mouth.
Bleeding from the mouth.
Aggravating factors of pain are swallowing, talking and mouth opening/
closing.
History includes time, cause, type of
trauma, other injury, vomiting and
unconsciousness.
Examination ofPatient withMaxillofacial
Trauma
• General examination—The patient has to be
examined to know the Glasgo coma scale, the
general status of patients, any signs of hypovolemic shock, respiration, blood pressure
and pulse.
• Systemic examination—CNS and function
of the cranial nerve such as altered sensation,
pupillary reex, visual changes, facial nerve
function, trigeminal nerve function, respiratory, cardiovascular system, abdomen, and
13.1 Maxillofacial/Facial Trauma
387
other areas of head and neck, cervical vertebra., should be examined.
• Local examination of maxillofacial trauma/
face
• Inspection:
– General inspection of the face (Extraoral
Inspection): The examination of the face
should begin from the upper face to the
lower face in a systematic fashion. An
overall inspection of the face will reveal
any asymmetry, contusions, swelling, or
haemorrhage. The debris must be cleared
before a thorough inspection of the face of
a patient.
– The examination of the face after the pri-
mary inspection should be completed and
encompass the following details:
The location and extent of facial
injuries
The total number of facial structures
injured, i.e. skin, soft tissue and bone.
The bony fracture or loss and number of
bone fractures and number of fractures
in a bone.
Any loss of skin and soft tissue.
Dentoalveolar injuries and status of
occlusion.
Step ladder deformity on occlusion and/
or at the site of fracture
Inspection for asymmetry—
Lengthening or shortening, broadening
of face and laceration
Facial swelling—Facial swelling may
hide the underlying fracture.
Restricted mouth opening—It is indicative of fractured zygomas or fractured
mandible.
– Symmetry of face—A balanced appear-
ance to one’s face has a positive effect on
mental health. The two halves of the face
should perfectly match for a balanced face
and an emotionally balanced and happy
person. If there is disparity between two
halves of body, it termed as assymetry. It
can be either congenital or acquired. The
common cause of acquired facial asymmetry is maxillofacial trauma.
Parade ground fracture (guardsman
fracture)—This is dened as having
parasymphyseal with a condylar fracture on both sides. Both fractures are
comminuted with a large fractured segment displaced inferiorly.
Moon face—This includes B/L circumorbital ecchymosis; gross oedema presents in Le Fort 2 fracture, Le Fort 3
fracture and naso-orbito-ethmoid
fracture.
Dish face deformity—This is dened
as the lengthening of the middle third of
face caused by Le Fort III of maxilla.
Panda facies—This is dened to have
B/L circumorbital ecchymosis localized
to the orbicularis oculi region and present in fracture maxilla Le Fort 2 and 3.
Racoon eye or face—Periorbital ecchymosis, bruising and discolouration
around a person’s eyes that resemble the
dark circles around a raccoon’s eyes due
to skull base fracture, nasoethmoid fracture and zygomaticomaxillary fracture.
Bucket handle fracture—There are B/L
parasymphyseal fractures; the fractured
segment may displace posteriorly due to
genioglossus. The tongue falls back and
may cause respiratory construction.
– Facial proportion
Horizontal third: Da Vinci divided the
face into equal horizontal thirds
(Fig.13.6a).
• Inspection of the upper part of the
face: The upper third of the face
measures from the trichion (midpoint
of the hairline) to the glabella (area
above the nose and between the eyebrows). The upper part of the face to
be inspected for:
Subcutaneous emphysema
Superior orbital rim step
deformity
388
13 History andExamination ofMaxillofacial Trauma
Fig. 13.6 (a) Shows
horizontal third and (b)
shows lateral/vertical
fth of the face
Depressed deformity of the fron-
tal area
Symmetry of forehead on
frowning
• Inspection of the mid part of the
face—The middle third of the face
measures from the glabella to the
subnasale (where the nasal septum
meets the upper lip). This part of the
face needs to be inspected for various
parameters.
Deformity of the nose—lateral
deviation, depression.
Facial swelling (oedema, haema-
toma, emphysema) and deformity.
Displacement of the globe
(hyper-, hypo-, eno-, exophthalmos).
Displacement of the MCT.
Compromised/reduced ocular
motility—This may be due to entrapment of muscle and tendon.
Altered relative position of pupil.
Malar attening or prominence.
• Inspection of lower part of face—
The lower third of the face is measured from the subnasale to the
menton (the most inferior point of
the chin). The lower part of the face
is to be inspected for various
parameters.
Occlusal disturbance—anterior
bite, open bite and open deformities.
a b
Step deformity on the occlusal
surface or inferior border of the
mandible
Symmetry of angle of mouth
Step ladder deformities
Restricted mouth opening
Deviation of the mandible to one
side on the opening of the mouth.
Vertical fth: In the vertical plane, the
neoclassical canon divides the face into
equal fths. The two lateral fths on
either side extend from the lateral helix
of the ear to the exocanthus of the eye.
The two middle one-fth represent eye
ssures. The one medial fth, which is
the distance between the medial canthi
of the eye, corresponds to the width of
the nose (Fig. 13.6b). These areas are
inspected for telecanthus and widening
of the face.
– Intraoral inspection
The oral cavity should be inspected for
malocclusion, any lacerations, foreign bodies, dentoalveolar damage, an anterior open
bite or shift of midline hard palate—palatal
haematoma/laceration/step ladder
deformities.
• Palpation
– General palpation of the face and maxil-
lofacial area: Palpation of the entire face
will delineate any step deformity and cause
an instability of the underlying skeleton. A
13.1 Maxillofacial/Facial Trauma
389
top-down approach to palpation makes
the examination more efcient and focused.
The examiner should not be distracted by
the obvious injuries as this could mask less
obvious but more signicant injuries. Soft
tissue injuries should be noted, any vital
structures within range should be tested
and cranial nerves should be examined for
any decits (Fig.13.7). There are two components of palpation extraoral and
intraoral.
– External Palpation of face—The exam-
iner rst stabilizes the head of the patient
with the left hand and palpation to be done
with the right hand. A gentle but rm pressure is applied to elicit tenderness, to check
step deformity, for abnormal mobility and
any crepitation.
Palpation of upper face
• Step ladder deformity: over supraorbital margin and frontal region.
• Hypoesthesia, anaesthesia and paraesthesia of the supraorbital area.
• Crepitation: over frontal region and
supraorbital region.
Palpation of middle face
• Complete ocular exam—The eye
should be examined for visual acuity, visual eld testing, pupillary
reexes, light perception and extraocular movements. If there is any
concern for ocular injury, an ophthalmologic consultation is
recommended.
• Bow string test—The eyelid to be
grabbed between the thumb and
index nger or skin of the medial
canthal area to be held with forcep
and pulled laterally while the MCT
area is palpated to detect movement
of fracture segments. A lack of resistance or movement of the underlying
bone is indicative of a fracture
(Fig.13.7f, q).
• Forced duction test—This is a simple test done to test the function of
the extraocular muscle (EOM) that
can be used to differentiate between
EOM weakness (i.e. paresis) and
restriction (e.g. entrapment, enlargement, inltration, or brosis of muscle). The eye ball is rst anaesthetized
by instilling 2% xylocaine, and bulbar sclera/conjunctiva is held with
plane forceps and moved in all directions to know any restriction of
movements (Fig.13.10).
• Palpation of the maxilla and infra-
orbital margin—This area is
palpated for tenderness, crepitation
and step ladder deformity.
• Palpation of zygoma—The zygomatic area should be palpated for
tenderness, depression and crepitation (Fig.13.7).
• Palpation of the nose—The nose is
palpated for irregularity of bony
vault of crepitation and tenderness
(Fig.13.7).
• Anterior rhinoscopy is done for internal assessment of the nasal cavity.
• Sensation over the infraorbital area—
A light touch is checked with a wisp
of cotton.
• Peri orbital area—This area is palpated for palpable bony fragments,
crepitation and dislocated bony
contour.
• Intercanthal distance—The intercanthal distance is measured from one
medial palpebral angle to the other,
which is approximately 29–34mm in
adult women and 29–36mm in adult
men, but it can vary considerably.
The normal intercanthal distance is
approximately equal to the width of
the palpebral aperture or half the
interpupillary width. Telecanthus, or
dystopia canthorum, refers to the
increased distance between two
medial canthi while the inter- -
pupillary distance is normal.
Telecanthus resulting from traumatic
injury to the nasal-orbital-ethmoid
390
13 History andExamination ofMaxillofacial Trauma
a
d
g
b c
e
h i
f
j k l
Fig. 13.7 Examinationof a patient of maxillofacial
trauma (t op-down approach for general palpation of the
face) (a–c) palpation of orbital margin, (d) palpation of
the zygoma, (e) palpation of the nose, (f) bow string test,
(g) palpation of frontal bone, (h–j) Intraoral palpation, (k
and l) examination for movement of upper jaw, (m–p)
extraoral palpation, (q) bow string test, (r–t) examination
for abnormal movement of upper jaw
13.1 Maxillofacial/Facial Trauma
mn o
pq
391
rst
Fig. 13.7 (continued)
(NOE) complex is termed traumatic
telecanthus (Fig.13.8).
• Bimanual test: An instrument to be
placed in the nose and push laterally in the medial canthal area to
test for instability and crepitation,
which suggests an unstable NOE
fracture.
• Lower part of face
Examination of mandible—The
lower part of the face is to be
examined for tenderness, crepitation and step ladder deformity
along the border of mandible.
Abnormal movement of mandible—Hold the two sides of sus-
392
Fig. 13.8 Intercanthal distance, interpupillary distance
and outer canthal distance
pected fracture site and move in
opposite directions.
Crepitation—The abnormal
movement is associated with
crepitation. It is the crackle sound
felt during movement.
• Other examinations
Examination of airway and circulation should have the highest
priority.
Neurological examination—This
part of the examination includes
the consciousness of the patient,
higher function, cranial nerve
examination and Glasgow coma
scale.
Examination of ear—The ear
should be examined for bleeding,
laceration external auditory canal
(EAC), rupture tympanic membrane and watery ear discharge.
Facial nerve examination—Facial
nerve examination is done.
Examination of neck and cervical
spine—The neck should be examined for any laceration, bleeding,
or fracture of the cervical spine.
Tests for CSF rhinorrhoea—The
nose should be examined for
watery nasal discharge.
– Intraoral palpation
Tenderness in gingiva buccal sulcus,
gigivo-labial sulcus—This is done by
13 History andExamination ofMaxillofacial Trauma
putting a nger in these sulcus and
applying rm but gentle pressure.
• Abnormal mobility of upper or lower or
both alveolus.
Mobility of maxilla—It is tested by
grasping the anterior alveolar arch and
forward while stabilizing the head with
the other hand (Fig.13.7).
• Lefort 1—Only maxilla move
• Lefort 2—Maxilla and base of nose
move
• Lefort 3—Whole face move
Abnormal mobility of mandible—The
examiner holds the fractures segment
with different hands and moves them in
opposite directions (Fig.13.7).
Crepitation—This is a crackling sound
heard on the movement of fracture
segments if there is a displaced fracture
or loose bony segment.
Laceration—All sites of oral cavity to
be checked.
Avulsed teeth/loose teeth/missing
teeth—It is indicative of alveolar fracture (Fig.13.7).
13.2 Examination ofSpecic Area
1. Examination of orbit and eye: The bony
framework of the orbit is formed by frontal,
ethmoidal, sphenoid, zygomatic and lacrimal
bones. The ocular injury can be associated
with mid face fracture, tripod fracture and/or
nasoethmoid fracture.
(a) Surgical anatomy of orbit: Medial wall
is formed by frontal process of maxilla,
lacrimal bone and lamina papyracea of
the ethmoid bone. The sphenoid bone
forms the posterior wall and houses the
orbital canal. The superior orbital ssure
housing cranial nerves III, IV, V and VI
located lateral to orbital canal. The lateral
wall is formed by zygomatic bone.
Superior and inferior borders are the frontal and maxillary bones. There are six
muscles located around the globe of the
eye and attached to it.
13.2 Examination ofSpecic Area
393
(b) Inspection of eyeball, and orbit
• Vision/visual acuity
– Normal
– Altered vision
Decrease vision—Retrobulbar
haematoma
Only Light perception—Patient
can only tell about the light and
dark or day and night caused by
mechanical ocular trauma.
Only nger counting—
Retrobulbar haematoma and
optic neuropathy.
No vision—Retrobulbar haematoma, traumatic optic neuropathy, carotid-cavernous stula,
damage to visual pathway, intra
sheath haematoma, penetrating
injury to orbit and orbital
emphysema.
• Position of eyeball or pupillary level
– Displaced inferiorly—Inferior dis-
placement is due to entrapment of
tissue in minimally displaced linear/trapdoor/blowout fractures of
oor of orbit.
– Anteriorly—This is also known as
proptosis or exophthalmos occult
orbital fracture.
– Posteriorly—Enophthalmos
(sunken eye).
• Ocular mobility (movement of the
eyeball)
– Normal—Eye movement may be
voluntary or involuntary. Normally,
both eyes move synchronously and
symmetrical in the same direction.
– Restricted movement:
Upward restricted movement—
Blow out fracture (fracture of
oor or orbit)
Lateral restricted movement—
Nasoethmoid fracture
– Painful movement—The causes are
haematoma, fracture of the orbital
wall and orbital cellulitis.
– Convergence insufciency—
Nasoethmoid fracture.
• Visible step ladder deformity at orbit
margins—It is a sign of fracture.
• Telecanthus—It is suggestive of a
nasoethmoid fracture.
• Interpupillary distance—Increased
interpupillary distance indicates a
nasoethmoid fracture with fracture of
the frontal bar.
• Diplopia—It is due to altered globe
position due to fracture orbit, CNS
contusion, injury to CN III, IV and VI
nerve.
• Size of the eye:
– Exophthalmos—It is also known as
proptosis or bulging or protruding
eyeballs. It can be unilateral or
bilateral.
Unilateral—Haematoma,
abscess and orbital cellulitis.
Bilateral—Grave’s disease
– Enophthalmos—It is also known as
a shrunken eye that develops due to
posterior displacement of the eyeball. The causes are changes in the
volume of the orbit (fracture of the
orbital wall) relative to its contents
or loss of function of the muscle.
• Orbital emphysema—It is a collection of air within the eyelid or orbit
and may increase ocular pressure,
resulting in blindness. The common
cause is trauma and may be aggravated
by nose blowing, sneezing, or valsalva
manoeuvre.
• Retrobulbar haematoma—It is blood
collection in retrobulbar space, presented as eyelid swelling, ptosis, diplopia, headache, nausea, vomiting, eye
pain and periorbital ecchymosis.
• Fat protrusion from a periocular laceration, in the nasal cavity means orbital
penetration.
• An irregularly shaped pupil (corectopia), particularly a teardrop shape, is
indicative of anterior penetrating
injury.
• Orbital compartment syndrome:
This is due to acute haemorrhage in
394
13 History andExamination ofMaxillofacial Trauma
orbit due to injury to the infraorbital
artery, anterior ethmoidal artery, or
posterior ethmoidal artery. It is presented as soft tissue swelling, severe
implosion of the orbit by inwardly
rotated bone fragments causing tissue
impaction, or even orbital emphysema
that may lead to ophthalmic infarction
or even blindness.
• If an upper-eyelid laceration is present,
an examination of the eye both above
and below the cornea is to be done
because an upper-eyelid laceration
may penetrate the globe below the cornea. This is due to forced eyelid closure, and the Bell phenomenon causes
the eye to rotate upward.
• Racoon eye: Black and blue bruising
around the eyes is indicative of zygomatic fracture.
• Swelling of the forehead or cheek and
swollen skin under the eye.
• Conjunctival/subconjunctival haemorrhage—it is visible on the bulbar and
palpebral conjunctiva.
• Oedema and periorbital ecchymosis:
It is a sign of orbital fracture.
• Ecchymosis of sclera—The colour of
sclera is bright red due to the fracture
of the wall.
• Numbness of cheek and upper incisor
• Inspection of cornea—This is done to
assess corneal tear.
• Inspection of fundus—This is done to
assess the fundus.
• Pupillary examination—Size, shape
and pupillary reaction to be checked.
• Associated injury amnesia and cranial
nerve palsy.
• Pupillary light reex: An absent
reex can show damage to the afferent
or efferent nerve system.
• Upward gaze diplopia is most com-
mon secondary to entrapment of the
inferior rectus muscle and soft tissue
surrounding it.
(c) Palpation of orbit and eye
• Decrease or absence of sensation over
the injured side of the face, forehead
and eyelids.
• Orbital margins—Step ladder deformity of orbit margins—this is a sign of
orbital wall fracture. Palpation starts
from superior—lateral–inferior—
medial direction.
• Examination of medial canthal area
while pulling tarsus of lids—Sharp
angle in normal and round angle if
medial canthal ligament is not stable.
• Corneal reex: The corneal reex,
also known as the blink reex, is an
involuntary blinking of the eyelids
elicited by stimulation of the cornea
by touching with a wisp of cotton. This
reex is mediated by the nasociliary
branch of the ophthalmic branch (V1).
Sensing the stimulus on the cornea
only, these afferent bres reach to the
centre (nucleus) which is located in
the pons of the brainstem and afferent
bres carried by temporal and zygomatic branches of the facial nerve (CN
VII) to initiate a motor response
(Fig.13.9).
• Digital globe intraocular pressure
testing: Normal intraocular pressure
(IOP) ranges from 12 to 22mm Hg, on
average, but it may be higher if the
patient has H/O glaucoma, uses medi-
Fig. 13.9 Method of corneal reex
13.2 Examination ofSpecic Area
395
cine (e.g. steroids), or had recent surgery. If the patient’s history or
symptoms suggest that the IOP may be
high, two screening tests may be
useful:
– The ngertip test (digital palpa-
tion): Ask the patient to close her
or his eyes and look down. Place
the tips of both index ngers on
the closed upper eyelid. Keeping
both ngertips in contact with the
upper eyelid, apply gentle pressure through the closed eyelid,
rst gently pressing on the eye
with the right index nger, then
with the left and then with the
right again. A normal eye should
feel a bit like a tomato that is just
ripe: not solid, nor very soft.
Repeat on the other eye. It is
important to compare the two eyes
with one other. An eye with a very
high IOP will feel abnormally
hard and solid.
– Schiotz tonometry—The examin-
er’s hand should be washed and
dried; now, he stands upright,
behind the patient’s head, with
hands level with the head of the
patient. Now, instil 2% xylocaine
and wait for about 30 s. Ask the
patient to look at a xed object
directly above the eyes at the
patient’s thumb or nger which is
held directly in front of his or her
eyes. Now, gently open the eye of
the patient with the hand. Hold the
tonometer of 5.5g weight with the
other hand, place the plunger on the
central cornea and allow the disc to
lower gently onto the corneal surface. Note the scale reading. If the
scale reading is ‘2’ or less, remove
the tonometer, replace the 5 g
weight with the 7.5 g weight and
repeat the procedure. Note the scale
reading again and remove the
tonometer. Tell the patient not to
rub the eye.
• Trigeminal function assessment: This
is done by testing sensation in the
infraorbital region, corneal reex,
clinching of teeth, etc.
• Tenderness and step ladder at the infraorbital rim.
• Subcutaneous emphysema (indicates a
fracture of the maxillary sinus).
• Oculomotor function: This is checked
by the movement of the eye ball. The
entrapment of the inferior rectus muscle often occurs between fragments of
the lower orbit cause diplopia.
• Pupillary light reex: An absent reex
can show damage to the afferent or
efferent nerve system.
• Ophthalmological examination: The
penlight examination of the eye and ocular adnexa should be performed to look
for conjunctival hyperaemia, chemosis
and attening of the anterior chamber.
Clinical examination has to eliminate the
need for acute intervention under the
following conditions:
Large fractures with a high risk of
enophthalmos
Entrapment of infraorbital structures
Optical neuropathy
Orbital compartment syndrome
2. Examination of the patient with a nasal
fracture or signs of nasal fracture.
(a) Inspection
• Bruising or ecchymosis—Bruising on
inspection looks purplish discolouration of the skin caused by leakage of
blood from ruptured blood vessels.
• Twisted or crooked nose or indented
bridge—when the dorsum of the nose
is not in a continuous midline.
• Discolouration under the eyes (‘black
eyes’)
• Swelling of nose and surrounding
areas—This suggests either soft tissue
injury or fracture of the nasal bone.