Examination of patients with midfacial post traumatic deformities

Before assessing the individual deformity the patient's medical history should be considered. This could reveal the description of the original fractures and previous treatment provided. Pre-injury occlusion and ocular anomalies should be noted.

A systematic evaluation of the craniofacial hard and soft tissues should be performed. Appropriate consultation should be considered when indicated eg. ophthalmology, neurosurgery, orthodontic, etc.

Routine documentation with pictures is made.

The following instruments are recommended:

• Examination gloves
• Single-use tongue blades
• Examination light
• Visual chart
• Nasal speculum (in case of need for nasal examination)

When examining for facial asymmetry, a frontal view together with both profiles, a worm's and a bird's eye inspection is needed.

A preinjury photograph may be helpful to assess the extent of the secondary deformity.

Inspection of all facial units must be done both statically and dynamically.

Existing scars or previous incisions should be considered when planning the approach.

Forehead and eyebrow symmetry and motility are examined. Scars and their quality are investigated. Deformities such as bone depressions are assessed.

The clinician should evaluate the patient with the head in a neutral position. This allows precise evaluation of gross eye symmetry, pupillary line, facial midline, symmetry of palpebral fissures, intercanthal distance, and position of eyelid margins.

Abnormal findings including external/internal canthal dystopia, telecanthus, ectropion, entropion, ptosis, etc. should be noted.

External canthal dystopia

Ectropion

Entropion

Ptosis

Facial nerve function is assessed. Voluntary and involuntary corneal blinking and eyelid closure confirm strength and symmetry of the orbicularis function.

The illustration shows a patient presenting with weakness of the orbicularis function on the left side.

The eye examination should include gross visual acuity with attention to preexisting conditions (optical correction by glasses or contact lenses or ocular disorders such as cataract, glaucoma, and retinal disorders can compromise basic visual acuity testing), visual field testing, ocular motility, binocular vision, globe position, pupillary reaction, intraocular pressure testing.

Acuity testing

Visual field testing

Examine the patient to check the extraocular muscle (EOM) are functioning properly.

If the extra ocular movements (EOM) are abnormal, the surgeon should rule out muscular entrapment. It is recommended to perform the forced duction test under sedation, local, or general anesthesia.

Evaluation of mid pupillary axis is provided with a straight instrument. Additional comparison of light reflexes might be useful.

The examiner should include an examination from above and below to evaluate facial symmetry.

The illustration shows a posttraumatic asymmetry of globe position.

Hertel exophthalmometer
This instrument is only reliable to measure the sagittal globe position correctly in a side-to-side comparison if the lateral orbital rim is intact and not displaced. In these cases, the amount of en- or exophthalmos can reliably be measured.

Naugle exophthalmometer
In case of acquired or congential asymmetry of the lateral orbital rims a Hertel exophthalmometer is misleading (see above). In these cases, a Naugle exophthalmometer is preferred since the referring structure is not the lateral orbital rim but the frontal and infraorbital structures.

A light is used to assess pupillary reaction.

Candidates for secondary orbital surgery should undergo a complete ophthalmological investigation including fundoscopy (assessing both anterior chamber and retina), ocular pressure assessment, visual field and diplopia evaluation using Hess charts.

Examination of the nose starts with inspection for swelling or asymmetry, followed by palpation. Characteristic signs for posttraumatic nasal deformities are:

• Flattening of the nasal dorsum
• Widening of the intercanthal distance
• Foreshortening of the nose
• Compromised nasal airway
• Palpable bony dislocation

A CT scan will show the flaring of the nasal bones.

If there is an epiphora it would be advisable to assess the status of the lacrimal pathways prior to surgery. This is typically examined by an ophthalmologist.

The workup of patients with posttraumatic deformities of the maxilla should basically follow the guidelines for orthognathic patients.

In addition, look for:

Unstable fragments, fistulae, loose teeth etc.

This CT shows a deformity resulting from a panfacial fracture in which the maxilla has been telescoped.

Examine the function of the sensory nerves of the face (supraorbital nerve, infraorbital nerve, and mental nerve).

Examine the function of the motor nerves of the face (frontal (temporal), zygomatic, buccal, marginal mandibular, and the cervical branch of the facial nerve). The most important branches to check are the zygomatic and the marginal mandibular.

Illustration shows injury to the zygomatic branches of the facial nerve resulting in inability to close the eye.

Illustration shows the absence of function of the depressor muscles, resulting in asymmetry of the lower lip and demonstrating left facial nerve dysfunction (marginal branch).

Illustration shows injury to the left temporal branch resulting in significant brow ptosis and possible visual field impairment with upward gaze.

The midface and frontal cranium should be palpated to detect bony irregularities, step-offs, and sensory disturbances.

The illustrations show the step-wise examination of the midfacial skeleton around the orbital rims looking for step-offs, irregularities and/or asymmetries.

Illustration shows the palpation of the nose.

Illustration shows the palpation in the region of the zygomatic complex and zygomatic arch.