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Systematic Assessment of the

P a t i e n t w i t h F a c i a l Tr a u m a
Deepak G. Krishnan, DDS

KEYWORDS
 Facial injury  Trauma  Assessment  Treatment  Intervention

KEY POINTS
 The systematic assessment of patients with facial injuries is the culmination of wisdom from trials
and errors, audits of failures and successes, careful and mindful reflection of current practice, and a
willingness to change.
 Emerging technology has positively impacted the practice of management of facial trauma.
 A systematic evaluation and physical examination of the trauma victim remain the gold standard
and the first step toward effective care.

Traumatic injuries affect thousands of individuals  Severe injuries: pose an immediate threat to
and account for billions of dollars in direct and in- life. These injuries represent more than 50%
direct expenditures annually. More than 9 people of traumatic deaths. These patients will pre-
die every minute from injuries and violence ac- sent with a major disruption of their vital phys-
cording to the World Health Organization. In the iologic function and will benefit from acute
last 2 decades or so, a system-wide improvement intervention.
in assessment, resuscitation, and management of  Urgent injuries: these patients usually present
trauma has improved overall outcomes, thus with stable vital signs but have injuries grave
reducing the impact of traumatic injuries on the so- enough that require an intervention, but are
ciety as a whole. Dissemination of this information not usually life-threatening.
from the developed to the developing world has  Nonurgent injuries: most common injuries,
had a positive impact.1 fortunately. These patients do not present
The committee on Trauma of the American Col- with an immediate threat to life, but generally
lege of Surgeons established Advanced Trauma require an intervention after a thorough evalu-
Life Support (ATLS) in 1980 and has since devel- ation and possibly observation.
oped, refined, and defined a system for accurate
and systematic assessment of injury based on ASSESSMENT PRINCIPLES IN TRAUMA
protocols. Approximately 25% to 30% of deaths
caused by trauma can be prevented when this The principles in systematic assessment of the
systematic and organized approach is used.2–5 trauma patients as outlined by the ATLS protocols
The main goal of a systematic initial assessment are as follows1:
of a trauma patient is to recognize the patient with  Preparation and transport
severe life-threatening injuries, establish treatment  Triage
oralmaxsurgery.theclinics.com

priorities, and manage them efficiently and aggres-  Primary survey (ABCDEs)
sively. Toward this, at presentation, all trauma in-  Resuscitation
juries can generally be divided into the 3 following  Adjuncts to primary survey and resuscitation
categories: including monitoring and radiography

Disclosures: The author has nothing to disclose.


Department of Surgery, Division of Oral/Maxillofacial Surgery, University of Cincinnati College of Medicine,
University of Cincinnati Medical Center, 200 Albert Sabin Way, ML 0461, Cincinnati, OH 45219, USA
E-mail address: gopaladk@ucmail.uc.edu

Oral Maxillofacial Surg Clin N Am 25 (2013) 537–544


http://dx.doi.org/10.1016/j.coms.2013.07.009
1042-3699/13/$ – see front matter Published by Elsevier Inc.
538 Krishnan

 Consideration for the need for patient transfer may or may not be readily apparent at primary sur-
 Secondary survey—head-to-toe evaluation, vey. The ATLS approach is applied regardless of
patient history the anatomic presentation. For instance, a patient
 Adjuncts to secondary survey—special inves- that presents with a gunshot wound to the face
tigations, such as computed tomographic and neck would have his maxillofacial injuries
(CT) scanning or angiography addressed on presentation to the trauma bay
 Continued postresuscitation monitoring and according to ABCDEs of primary survey: Airway
ongoing reevaluation maintenance with cervical spine protection,
 Definitive care Breathing and ventilation, Circulation with hemor-
rhage control, Disability and neurologic status,
Over time, this system of assessment and inter- and Exposure, environmental control.
vention has seen the development of trauma Similarly, a patient with multiple injuries, in-
scores, identification of factors highly correlated cluding long-bone injuries, sternal and possibly
with life-threatening injuries, identification of intracranial injuries, may not have a nasal fracture
anatomic factors correlated with high mortality, identified until the secondary survey is completed
simple reproducible systems of assessment, and and adjunctive investigations are completed.
development of protocols of treatment based on If the patient’s maxillofacial injuries are second-
collective wisdom, experience, and observational ary and the patient has been stabilized, it always
studies. All aspects of treatment both clinical and helps to obtain a history of the presenting condi-
medico-legal have had a positive evolution within tion and a brief review of systems from either the
this system. Despite this systematic reproducible patient or a representative.
methodology of assessment, the incidence of The pneumonic AMPLE serves as an easy tem-
missed injuries following trauma continues to be plate while obtaining the history of the patient:
reported as between 4% and 65%.
Although most maxillofacial injuries (other than  A, Allergies
penetrating wounds to neck or other life-  M, Medications
threatening injuries) are identified and addressed  P, Pregnancy, past illnesses
following the primary survey and resuscitation ef-  L, Last meal
forts following the ATLS protocol, the same princi-  E, Events related to admission
ples of this protocol are often applied in the early
assessment and treatment planning of these in- In the alert patient, it also helps immensely to
juries as well.6 obtain a review of pertinent systems: continued
Accordingly, facial injuries could be addressed headache, nausea, and vomiting following the
based on the urgency to treat. injury may suggest neuro-trauma; double vision,
blurry vision, headache, and so on might suggest
 Severe facial injuries: those that require imme- ocular or orbital injuries; a clear discharge from
diate and often resuscitative treatment. These nose or ears may suggest a base of skull frac-
injuries could include injuries to the airway, in- ture; complaints of lack of sensation on the
juries causing severe hemorrhage, cranial in- face may indicate an underlying facial skeleton;
juries including facial injuries, ophthalmologic a change in bite and limited mouth opening sug-
traumatic emergencies, and severe facial gest a fracture of the maxilla or mandible, and
soft tissue injuries, including special struc- hoarseness or stridor may suggest laryngeal
tures such as ducts or nerves whereby acute fracture.
intervention would presumably yield better The systematic assessment of the patient with
outcomes. facial trauma should follow the same principles
 Urgent facial injuries: facial injuries that can of primary survey, intervention, secondary survey,
often wait a few hours until the trauma team and definitive care.
has completed their primary survey and suc-
cessful resuscitation. These injuries are often AIRWAY WITH CERVICAL SPINE PROTECTION
soft tissue injuries or contaminated wounds.
 Nonurgent facial injuries: injuries that may be Penetrating neck trauma, complex multiple facial
addressed safely in a delayed manner, such soft tissue, and bony injuries of the maxillofacial
as most facial fractures. skeleton necessitate immediate intervention to
protect the anatomic airway. Foreign bodies,
It is not the goal of this article to summarize the gastric content regurgitation, and tracheal or
detailed ATLS protocol for the multisystem evalu- laryngeal fractures may not be dramatically
ation in a trauma patient. However, polytrauma pa- apparent. Whenever possible, an endotracheal
tients often present with maxillofacial injuries that intubation is preferred and attempted and a
Systematic Assessment of the Patient 539

surgical airway is sought only when the endotra- malar/maxilla, or frontal/parietal bone fracture,
cheal intubation is not practical or possible. cervical spine injury ranged from 4.9% to 8.0%.
Bilateral mandibular body or parasymphysis In the setting of 2 or more facial fractures, the
fractures causing a flail segment that is pulled prevalence of cervical spine injury ranged from
back by the genial musculature in a supine patient 7.0% to 10.8%.9 All patients that require airway
can also cause airway embarrassment. Posi- intervention, regardless of concomitant maxillofa-
tioning the patient properly, and in dentate pa- cial injuries, must be assumed to have an unde-
tients, simply bridling a wire between teeth tected cervical injury, and care must be taken
stabilizing these segments may be simple and to avoid hyperflexion or hyperextension of the
effective interventions that assist in keeping the neck. Excessive movement of the neck can result
airway patent. in neuronal deficit and paralysis. The presence of
A typical chin lift or jaw thrust maneuver may not distracting injuries, especially in the head and
be easy in patients with mandibular fractures. neck, can often lead to missed cervical injuries.
Pain, dislodgment of loose teeth into the airway, A cervical collar is placed until a cervical injury is
a new hematoma formation,and so forth may be definitively cleared in secondary survey or during
risked when a broken jaw is manipulated. the hospital stay.
Although laryngeal fractures are rare, pain, stri- In patients with a cervical injury that has not
dor, odynophagia, hoarseness, hemoptysis, and been cleared, a trip to the operating theater for
subcutaneous emphysema are the common pre- surgery of the maxillofacial region would mean
senting symptoms in these injuries. The presence that this cervical collar should be temporarily
of stridor and hemoptysis are suggestive of major relieved, which is done by stabilizing the neck on
injury. Early surgical intervention is recommended either side with sandbags and taping the patient’s
for all major injuries to ensure a good outcome.7,8 head tightly to the operating table. Tilting the table
Not all of these patients require airway interven- is often needed instead of turning the patient’s
tion, but many do. head, should that be required.
Examination for a direct airway injury or a major
vascular injury in the neck is important before intu- BREATHING AND VENTILATION
bation in patients with facial trauma.
Endotracheal intubation is often performed ATLS suggests exposure of the neck and chest
orally with a rapid sequence tracheal intubation. and ensuring immobilization of the head and
Care must be taken to applying cricoid pressure neck. Tracheal deviation, signs of airway obstruc-
to prevent aspiration. tion, and subtle signs such as cyanosis of the lips
When routine intubation is not possible because suggestive of hypoperfusion are not to be missed.
of profuse hemorrhage, severe edema, or other Transient brain hypoxia can cause severe second-
inability to intubate, a surgical airway must be es- ary brain injury. Simple maneuvers such as stabi-
tablished. In the emergency setting, in an adult, a lizing the mandible can improve breathing and
cricothyroidotomy is preferred over a tracheotomy ventilation, preventing long-term hypoxia-related
because of its ease of performance and reduced neuro-deficits.
bleeding. Cricothyroidotomies however often
need to be converted to formal tracheotomies for CIRCULATION WITH HEMORRHAGE
the prolonged airway maintenance in a nonacute CONTROL
setting.
Anesthesiologists may be reluctant to pass na- As in primary survey for polysystem trauma, circu-
sotracheal tubes for intubating patients with mid lation is a priority only following stabilization of
face fractures. This reluctance is based on the pru- airway and ensuring breathing and ventilation.
dence of causing an inadvertent passage of tubes Structures of the head and neck are extremely
(nasogastric or suction catheters) intracranially vascular and can often cause significant extrava-
through an undetected skull base fracture. A care- sation of blood that can contribute to shock. An
ful evaluation of the patient’s CT scan for these assessment for bleeding should be systematic,
skull base fractures are important to alleviate complete, and thorough, addressing all evident
such unfounded fear. and occult bleeding from vessels of the maxillofa-
Care must be taken in ensuring that the cervical cial region.
spine is stable in these patients while attempting Occult bleeding could occur acutely or in a
airway stabilization. Many epidemiologic studies chronic manner from blood vessels of the neck,
have looked at the prevalence of cervical injury in especially at the base of the skull. The neck is
patients with maxillofacial trauma. In the setting divided into horizontal zones to help manage
of an isolated mandible, nasal, orbital floor, penetrating injuries (Fig. 1):
540 Krishnan

that requires immediate attention. Large scalp lac-


erations could cause significant blood loss and
must be stabilized expeditiously.12 Repaired scalp
lacerations often require a pressure dressing to
prevent a hematoma in the acute after-repair
phase. This is especially true in patients who are
pharmacologically anti-coagulated or have a
Zone III bleeding disorder.
Lacerations to the muscles of the cheek and
tongue cause a significant amount of blood loss.
Zone II
Pressure application, primary repair, and tempo-
rary packing help to reduce the blood loss.
Zone I Bleeding from broken ends of bones, especially
of the mandible, can be stopped by pressure
packing or by placing a bridle wire or temporary
maxilla-mandibular fixation until the definitive
treatment.
Epistaxis in facial trauma can impair visualiza-
Fig. 1. Zones of the neck. (From Townsend CM, tion of the airway, impede a proper examination,
Beauchamp RD, Evers BM, et al. Sabiston textbook of cause obstruction of airway, and lead to shock
surgery. Philadelphia: Elsevier; 2008. p. 490; with and aspiration. Epistaxis can be fatal. Mid facial
permission.) trauma can cause significant epistaxis that needs
to be recognized and managed efficaciously.
 Zone 1: horizontal zone extending superiorly Most emergency rooms are equipped with pack-
from sternal notch to cricoid cartilage. ing materials for both anterior and posterior
 Zone 2: horizontal zone extending from nose. Packs are at risk of being left in for
cricoid cartilage to inferior border of mandible. prolonged periods of time and can cause serious
 Zone 3: horizontal zone from inferior border of infections. Posterior nasal packs can be inadver-
mandible to base of skull. tently shoved into the cranial cavity if the patient
has a skull base fracture. Often, the reduction of
Traditionally, the platysma had been considered facial fractures will allow for control of the peri-
the barrier for penetrating neck injuries. The stan- nasal hemorrhage.
dard of care was neck exploration for those in- Proper visualization of facial lacerations often
juries that penetrated the platysma. However, requires concomitant control of bleeding. Simple
improvements in imaging technology, particularly injections of local anesthetic solution with vaso-
CT angiography, have altered the management constrictors or pressure packing help stop most
of patients with penetrating neck injuries. Although bleeding. In addition, small hand-held mono-polar
some centers still advocate routine exploration for cautery devices assist in hemostasis. Most emer-
all zone 2 neck injuries penetrating the platysma, gency rooms also carry silver nitrate sticks that
many civilian centers in the United States have could be useful in intra-oral bleeding (Fig. 2).
adopted a policy of selective exploration based
on clinical and radiographic examination.10
Occasionally, closed tight spaces in the base of
the skull, infratemporal region, and so forth, can
cause delayed bleeding or formation of pseudo-
aneurysms that can cause a shunting effect and
hemodynamic instability. Interventional radiology
techniques have again become the treatment mo-
dality of choice for these.11
Lacerations of the face are hard to miss and are
often superficial and, if deep, readily accessible to
repair and control of bleeding. Scalp lacerations,
especially of the posterior scalp, are notoriously
missed and, if left exposed to bleed or form large
hematomas, can cause future infection. A system- Fig. 2. Hand-held electro-cautery unit and silver
atic examination of the patient’s scalp often re- nitrate sticks—good local measures for control of
veals a missed occult source of serious bleeding bleeding in the acute trauma setting.
Systematic Assessment of the Patient 541

DISABILITY (NEUROLOGIC AND FUNCTIONAL Patients that wear contact lenses must have
EVALUATION) them removed at examination. Prolonged reten-
tion of these in patients that are intubated or with
During the primary survey, a Glasgow Coma Scale low levels of consciousness can cause severe
establishes a baseline neurologic status for the corneal injuries.
patient. During the secondary survey and later, The skin of the scalp and face and neck must be
this is reassessed constantly using a simple inspected for embedded foreign bodies and dirt or
AVPU method: debris. These foreign bodies could become future
A—Patient is awake, alert, and appropriate sources for infection.
V—Patient responds to voice
P—Patient responds to pain SYSTEMATIC CLINICAL EXAMINATION OF THE
U—Patient is unresponsive FACIAL TRAUMA PATIENT

Pupillary examination is a quick assessment of To minimize not finding injuries, and optimizing the
the cerebral function. Any changes in pupillary assessment in a busy trauma bay, a systematic
response indicates cerebral damage, optic nerve assessment pattern is recommended in examining
damage, or changes in intracranial pressure. In pa- patients with facial trauma. It is best to examine
tients with facial trauma, the ocular examination every patient the same way every time and record
goes beyond pupillary response. A palpation of the findings comprehensively every time to ensure
the globe for pressure, hard or soft, and ruling a thorough examination.
out an afferent pupillary defect, is an imperative For purposes of the physical examination, the
part of assessment. face and neck are divided into different zones
Facial injuries often cause cranial nerve trauma. and structures in each zone will be inspected
Facial lacerations can cause trauma to the facial and palpated and then correlated with findings of
nerve and its branches. Distal branches are often adjuncts such as a CT scan to formulate a diag-
not amenable to repair but the larger proximal nosis of the patient’s injuries.
branches could be attempted to be primarily anas-
Soft Tissues
tomosed with micro-neuro-surgical repair. Lacera-
tions of the face lateral to a line drawn Injuries to the soft tissues of the face may be the
perpendicular to the outer canthus of the eye most apparent trauma on the patient as the exam-
should be examined for parotid duct injury. Pri- iner begins assessment. The soft tissue wounds
mary repair of this must be attempted on detection must be qualified and quantified by location,
of the same. depth, and layers of involvement, involvement of
vital or crucial structures, and treatment rendered.
EXPOSURE Superficial wounds often do not require any more
treatment than cleansing and dressing. Deeper
Patients that present with a helmet (sports- wounds might require repair with varying levels
related or motorcycle-related) should have the of complexity either in the emergency room setting
helmet removed while the head and neck are or in an operation theater. Scalp wounds may be
held in a neutral position using a 2-person tech- easy to miss in patients with thick hair or if the
nique. The American College of Surgeons pro- wounds are in the back of the head on a patient
vides a poster entitled, “Techniques of Helmet lying supine. Oral wounds require special atten-
Removal from Injured Patients” (www.facs.org/ tion; muscles may require reapproximation before
trauma/publications/helmet.pdf). mucosa. Bleeding control is an essential part of
Dentures and other removable appliances that wound repair, as discussed earlier.
may not have caught the attention of the resusci- Often facial lacerations serve as excellent ac-
tating team may become evident on secondary cess for repair of underlying fractures. Definitive
survey by the practitioner assessing facial injuries. repair of such lacerations may be deferred until
These devices must be removed, preserved, and fracture repair; however, cleaning and decontami-
could be potentially used in repair of fractures nating these wounds serve better results in the
when patient is stable. Avulsed teeth must be ac- future.
counted for. Aspiration should be considered a Soft tissue injuries involving eyelids, external
potential in the unconscious patient and the ear, lacrimal system, parotid duct, nerves, and
routine chest radiograph must be checked for vessels require specialized attention and repair. If
aspirated teeth. Subluxed teeth must be consid- the laceration is in the vicinity of such structures,
ered a potential aspirate and must be stabilized careful attention must be paid during assessment
or removed. to the patency and integrity of these structures.
542 Krishnan

Tetanus vaccination status should be checked Eyes and Orbit


and dosing regimen followed.
Inspection
Inspection of the orbit and the eyes can be chal-
Frontal Region lenging in patients with facial injuries. Early edema
Inspection in the peri-orbital area and neurologic impairment
The forehead and frontal region are inspected may make a thorough examination difficult.
for lacerations, contusions, or step deformities. The inspection of position and alignment of eyes
In an awake and alert patient, loss of sensation must be grossly examined. Increased orbital vol-
of the skin over the forehead must be checked. ume from orbital fractures can cause the sinking
In patients with thick hair, lacerations in the scalp of the contents of the orbit, causing enophthalmos
or within the eyebrows must be inspected. Pre- and vertical dystopia. An increase in orbital volume
vious injuries such as scars should also be can cause exophthalmos, suggestive of a foreign
inspected. body or a retrobulbar hematoma. Edema might
obscure these findings in an acute setting.
Palpation The eyelids should be inspected for evident lac-
Obvious or subtle step deformities should be erations, or previous scarring, in addition to ectro-
palpated. In an awake or responsive patient, pain pion, entropion, or ptosis. Inspection of the
on palpation should be checked as well as for conjunctiva and sclera will disclose conjunctivitis,
crepitus. chemosis, and subconjunctival hemorrhage, all in-
dicatiing orbital and/or ocular trauma. In addition,
Ear blood in the anterior chamber of the eye or
hyphema is an important finding.
Inspection
Inspection of the pupils is important to test due
Obvious signs of lacerations or deformities should
to the pathways involved. They are innervated by
be inspected and also signs of previous injuries,
both the sympathetic and the parasympathetic
such as a cauliflower ear deformity. A speculum
systems and can give a general indication of the
examination following cleaning of the external
neurologic condition. Normal pupillary response
auditory canal for blood, debris, and cerumen
and reactivity to light tests sensory and motor
will allow for inspection of the tympanic mem-
function of the eyes. Afferent pupillary defects or
brane. Hemorrhage or cerebrospinal fluid (CSF)
Marcus Gunn pupil is tested with the swinging
otorrhea may indicate base of skull or temporal
flashlight test. Pupillary size is noted. Miosis refers
bone fractures. Integrity of the tympanic mem-
to pupillary diameter less than 2 mm and mydriasis
brane is important to record.
or a “blown pupil” may be suggestive of orbital
Battle sign or postauricular ecchymosis may be
trauma, head injury, or drugs. Anisocoria or un-
suggestive of temporal or skull base fractures
equal pupillary diameter may be suggestive of
(Fig. 3).
actual globe injury. Epiphora in the medial canthus
Formal conductive and neurosensory examina-
may suggest injury or disruption of the lacrimal
tion may not be practical in a busy trauma bay.
drainage apparatus.
However, an ear examination is not complete
In patients who are awake and responsive to
without at least a cursory whispering test and
commands, it helps to check range of motion of
loss of hearing may indicate cranial nerve VIII
the extraocular muscles of the eyes. Extraocular
damage.
muscles are tested for movement in an H pattern.
Examination would reveal entrapment of muscles
in between fracture fragments of the orbit. In addi-
tion to causing diplopia, prolonged entrapment
may lead to necrosis and permanent mobility
restriction.

Palpation
Palpation of the globes for pressure of the con-
tents can often reveal retro-bulbar hematoma, or
other causes for proptosis. Palpation of the orbital
rims will elicit step deformities suggestive of frac-
ture and displacement of the orbital skeleton.
Edema may confound findings initially and, as
Fig. 3. Battle’s sign: postauricular ecchymosis. with anything in trauma, repeated examination
Systematic Assessment of the Patient 543

and secondary surveys may help unfold injuries management. These septal hematomas can de-
that were not apparent at first presentation. tach the perichondrium from the septal cartilage,
thus strangulating its blood supply, and can
Naso-orbito-ethmoid Region possibly cause septal necrosis, leading to loss
of septal support and resulting in a saddle nose
The naso-orbito-ethmoid (NOE) region must be
esthetic deformity. A simple lance and drain or
included in the examination, right after examining
needle decompression with or without packing
the eyes and orbits.
or splinting will help manage this problem when
Inspection identified. Active CSF rhinorrhea must be exam-
Peri-orbital ecchymosis and circumorbital edema ined when base of skull fractures are suspected.
giving the patient an appearance of raccoon eyes
Palpation
is a hallmark of NOE fractures. Subconjunctival
Nasal bones must be palpated for obvious mobility
hemorrhage is often seen as well. NOE fractures
and crepitus.
with displacement can cause depression of the
nasal projection. Disruption of the medial canthal
ligament attachments can cause telecanthus and Zygomatic o-maxillary Complex
blunting of the medial palpebral fissures. Inter-
Inspection
canthal distance measurement is an imperative
Peri-orbital edema and ecchymosis, obvious facial
part of the examination. Racial differences in
asymmetry, and malar depression with or without
norms should be considered for this measure-
difficulty to open the mandible wide may be hall-
ment but, in general, the intercanthal distance
marks of zygomatico-maxillary complex fractures.
should be about 50% of the interpupillary dis-
Acute edema may obscure malar flattening. Malar
tance. Loss of volume of the orbit from the
depression and asymmetry may be more evident
medial orbital/ethmoid fractures can cause
when examined from a bird’s eye view as opposed
enophthalmos.
to frontal view.
Palpation
Palpation
Mobility and crepitus of the NOE complex is the
Step deformities at the orbital rim may be part of
hallmark of this fracture. Mobility may be tested
the zygomatico-maxillary complex fracture. Exam-
with an instrument inserted in the nose with its
ination from the bird’s eye view along with palpa-
tip placed deep to the medial orbital area and
tion of the arches may demonstrate malar
the fingers and thumbs of the other hand support-
depression and asymmetry more readily, even in
ing the NOE region. Moving the instrument will
the face of mild to moderate edema of the region.
then generate movement of the medial canthal
and NOE complex. In addition, a “bowstring” test
can elicit movement of medial tendon when Maxillo-mandibular Structures
tugging on the lateral canthal tendon.
Oral examination and examination of the maxilla,
mandible, and dento-alveolar structures should
Nasal Skeleton
be performed last in the systematic evaluation to
The nasal skeleton would be the next logical area avoid contamination of saliva to other facial
on the face to examine. Nasal complex requires wounds.
good lighting, suction, and a nasal speculum to
illuminate and examine properly. Inspection
Obvious lacerations in the peri-oral region or within
Inspection the oral cavity must be examined for debris, con-
Obvious deformities and lacerations are noted; taminants, and loose teeth. In awake and respon-
the depth of these lacerations must be examined, sive patients, the maximum incisal opening should
and involvement of cartilage must be noted. be checked with the patient opening voluntarily;
Nasal deformities must be examined facing the any deviations while opening may be suggestive
patient, from a worm’s eye view and from a bird’s of location of fractures of the mandible.
eye view. Intranasal examination must be per- Ecchymosis in the buccal vestibules or floor of
formed after cleaning out dried blood, CSF, and the mouth often indicates a fracture of a bone
debris, with good lighting and using a nasal spec- nearby.
ulum. Intranasal examination should focus on Evaluation of the occlusion is performed with
obvious lacerations, septal fractures, perfora- care and can often be suggestive of the location
tions or hematomas, and sources of bleeding. of the fracture as well, which could be a challenge
Septal hematomas require early recognition and in orally intubated patients.
544 Krishnan

Palpation audits of failures and successes, careful and mind-


Palpation for step deformities and obvious tender- ful reflection of current practice, and a willingness
ness and mobility indicate fractures. Mobility of the to change. Emerging technology has positively
maxillary complex indicates a disjunction of the impacted the practice of management of facial
maxilla from the remaining facial skeleton. De- trauma. Regardless, a systematic evaluation and
pending on the level of this disjunction, the area physical examination of the trauma victim remain
of mobility may vary. For instance, in Le Fort I level the gold standard and the first step toward effec-
fractures, only the dento-alveolar segments of the tive care.
maxilla may elicit mobility, whereas in Le Fort II
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