return to: Facial Fracture Management Handbook

by Dr. Gerry Funk

Head and Neck Trauma Exam

The following is a general outline for a comprehensive head and neck examination in the trauma patient with facial fractures. It is helpful to have a methodical approach in order to avoid missing any pertinent findings. If the patients condition does not permit any aspect of the examination that should be documented.

Remember the ABC of emergency care, HAS THE C-SPINE BEEN CLEARED? KNOW THIS BEFORE YOU BEGIN.

Head: Examine the scalp and palpate the skull for any fractures. The posterior skull is frequently overlooked.

Eyes: Record an objective measure of visual acuity (most frequently done with a near card), extra ocular movements (percentage of normal), proptosis and enophthalmos (recorded in mm). Assess medial canthal ligament integrity and medial canthal angle. A blunted medial canthal angle suggests rupture of the medial canthal tendon. Measure the intercanthal distance, the normal is roughly half the interpupillary distance or the same as the palpebral fissure width or approximately 30-35 mm. Check the pupillary reaction to light and test for an afferent pupillary defect. The afferent pupillary defect is present when light in the eye does not provoke a brisk pupillary contraction because the injured optic nerve does not conduct the afferent signal to the brain normally (the Gunn pupil). The eye will contract consensually. If light is alternately thrown into the normal and injured eye (the swinging flashlight test) the normal eye will constrict when the light is upon it, however when light is then shined into the injured eye instead of remaining contracted the injured eye dilates. This abnormal response occurs because the afferent signals are not traveling in a normal fashion from the eye to the brain. A complete APD is present when the injured eye will not react to light at all. A relative APD indicates a less severe injury in which the eye slowly reacts to light and appears to rapidly accommodate. A relative APD will also usually result in an abnormal swinging flashlight test. Total ophthalmoplegia (inability to move the eye) together with ptosis and numbness in the distribution of V1 indicate a superior orbital fissure syndrome. If decreased vision and an APD are also present this is an orbital apex syndrome. If a ruptured globe is suspected from the history or due to severely decreased vision and a small appearing globe do not further manipulate the eye. Blood in the anterior chamber should be noted.

Ears: Evaluate the hearing grossly and inspect the tympanic membrane. Hemotympanum or a torn tympanic membrane may be suggestive of skull base fractures as is a Battle's sign (hemorrhage over the mastoid). If there is any abnormality perform tuning fork tests to rule out or in a conductive or sensorineural hearing loss.

Nose: Examine the external contour of the dorsum; is it deviated or midline? Determine if there has been bony or cartilaginous deformation. Examine the septum for hematoma.

Oral cavity: Examine the occlusion. Is there a crossbite, anterior open bite or do the teeth occlude in the patients normal bite. Are any teeth avulsed, luxated or fractured? Does the patient notice a difference in the occlusion? Measure the maximal incisor opening (normal range 3.5 to 5.0 cm). Is there evidence of swelling or potential swelling that may compromise the airway, especially the floor of the mouth? Look for lacerations of the lips and buccal mucosa. Gingival lacerations and tears suggest possible underlying bony trauma.

Pharynx/Larynx: Is the airway adequate? Do you need to look at it again in an hour? Does the patient need a tracheostomy urgently? Note any swelling or blood in the pharynx. Is there blood coming from the larynx or trachea? The flexible laryngoscope is usually the best way to examine a trauma patients hypopharynx and larynx. Do the cords move normally, is the glottis tilted, does the patient have evidence of laryngeal trauma (torn vocal cord, hematoma of the vocal cord, laryngeal edema)?

Neck: Is there a history of neck trauma? Is the neck tender to motion? Palpate the cartilaginous and bony structures ( hyoid, thyroid and cricoid cartilage, and trachea) for tenderness and the presence of step off's. How easy would it be to perform a tracheostomy on the patient if needed? Would it be better to do it early than late? Is there any evidence of penetrating trauma? Is there increasing swelling or crepitance?

Bony face: Start from above and work down. Palpate the forehead especially if there is a laceration to exclude a frontal sinus fracture. Palpate the orbital rims for step off's. Are the malar eminences symmetric? Are the zygomatic arches up? Is the midface mobile? To check midface mobility grasp the hard palate and stabilize the nasal dorsum. If the patient clearly has a mobile midface DO NOT manipulate it any further, you may cause optic nerve trauma if there is a high Le Fort II or III fracture. Write for no midface manipulation in the chart. Is the mandible stable? Is it tender to manipulation? No tenderness to firm downward pull on the symphysis will essentially exclude a significant mandible fracture.

Soft tissue: If swelling precludes an accurate bony exam record this. Record lacerations and severe abrasions. If lacerations are present in the region of the parotid duct, a lacrimal probe should be used to rule out injury to it at the time that the wound is closed.

Cranial nerves: Most are checked with the above exam but CN VII function is important to record specifically. If temporal bone fractures are present or if there is a laceration over the course of the facial nerve be sure to note facial motion. The sensory function of CN V is very important to record preoperative, many facial fracture patients will have an injury to CN V (V1 for frontal sinus fractures, V2 for all midface fractures, and V3 for mandible fractures).