Abstract
A summary of clinical examinations of the head and neck.
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Key Points
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Clinical examination for orthognathic surgery.
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Head and neck examination.
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Examination of cutaneous lesions.
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Examination of salivary glands.
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Examination for facial pain including TMJD.
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Trauma exam.
16.1 Orthognathic
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Position: Clinical Frankfort Plane horizontal to floor/lips at rest.
Lateral View
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Facial 1/3.
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Frontal bossing, nasal shape, nasofrontal, nasolabial, labiomental, cervicofascial.
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Dorsum/tip of nose.
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Maxilla concave/convex.
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Paranasal hollowing.
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Gross skeletal pattern.
Frontal View
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Facial 1/3: Medial canthus to alar base.
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Facial 1/3: Upper face height/lower face height.
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Brow/tip: Aesthetic lip.
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Contributes—nasal/dental upper and lower/chin point = feel TMJ/check for deviations—asymmetry.
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Upper lip length.
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Incisors show at rest/dynamic.
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Dental centrelines.
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Intraoral examination: OH/incisors (overjet/overbite/openbite), molars, missing/crowding, wisdom teeth.
16.2 Head and Neck Exam
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Firstly, check the primary site, FNE where appropriate.
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FNE
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Head level.
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Spray: Lidocaine 5%/Phenylephrine 0.5% Nasal Spray.
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Focus and white balance.
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Nasal floor.
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Soft palate/Eustachian tube.
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Fossa of Rosenmuller.
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Posterior wall.
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Vallecula, vocal cords
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Lip compensatory and drooling.
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Tongue mobility, speech, swallowing, mastication.
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Oral health and radiation caries/mucositis.
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Dental status—e.g. problems with denture/obturators.
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Mouth opening: Measure with Willis gauge.
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Speech intelligibile—understood over phone.
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Drooling.
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Diet—PEG/RIG.
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Appearance—facial nerve (MMN).
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Sensation—Von Frey filament (nylon).
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Weight—malnutrition.
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Neck Exam—Primary Drainage Areas
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Under lower border.
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Facial lymph nodes.
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Sternomastoid—fingers.
Shoulder
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Stand behind—abduct to 90°.
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Can they take bra off.
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Comb back of head.
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Hand—radial site.
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Scar—contraction/hypertrophic.
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Skin graft.
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Tendon exposure.
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Loss of sensation over first dorsal interosseous.
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Function: grip/pain.
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Median/ulnar nerve.
Scapula
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Shoulder function.
DCIA
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Sensation cutaneous nerve.
Fibular
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Wound healing.
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Hammer knee—flexor hallucis.
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Sensation—lateral sural cutaneous nerve: posterior/lateral leg gait.
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Foot drop—common peroneal nerve: wasting of anterior tibial and peroneus muscles.
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Pulses—dorsalis pedis.
Look
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Muscle wasting.
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Hair.
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Scar.
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Foot drop.
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Skin graft.
Feel
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Swelling.
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Warmth.
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Tenderness.
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Sensation.
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Pulses—posterior tibial.
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Tendon expose.
Move
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Knee: Joint—flexion/extension.
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Ankle: Plantarflexion/eversion/dorsiflexion.
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Gait: Foot drop.
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Toe: Hammer toe.
New Oral SCC
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Introduction.
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Patient demographics.
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History of lesion—duration/growth/change of colour or pigmentation/bleeding/pain/previous surgery.
QOL Issues
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Speech, swallowing, taste, checking change in nerve sensation—trigeminal.
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Any other lesions of face/head/neck.
Miscellaneous History
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Industrial chemicals.
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Haematological conditions.
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Immunosuppression.
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Head and neck irradiation.
Past Medical History
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Especially with regards to intended surgery.
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Previous surgery—bleeding.
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Pulmonary, cardiovascular fitness, exercise tolerance (claudication/vascular disease).
Social
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Smoking/occupation/alcohol/living circumstances/support.
Clinical Examination—Inspect with Features
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(a)
Appearance, location, texture, size (with ruler), proximity to surrounding structures, thickness.
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(b)
Trismus—whole oral cavity.
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(c)
Head and neck exam/neck nodes.
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(d)
FNE.
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(e)
Examination around possible donor site.
16.3 Cutaneous Lesion
Introduction
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Patient demographics.
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Age/occupation.
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History—lesion
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(a)
Duration, growth, change in colour/pigmentation, bleeding, previous surgery on lesion.
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(b)
Any other lesions—head/face/neck/body.
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(c)
Any other lumps/bumps.
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(a)
History Of
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Sun exposure/sunscreen usage/hat-wearing.
Miscellaneous History
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Related to aetiology—industrial chemicals, hereditary conditions, burns, ulcers, scars, immunosuppression.
PMH
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Previous surgery/bleeding, also with regards to intended surgery.
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Medication: Aspirin/warfarin.
Social History
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Smoking (lip), alcohol, occupation (sun exposure/industrial chemicals), living circumstances, social support.
Family History
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Melanomas, non-melanoma skin cancer, immunosuppression, other cancers in family.
Examination—Wash Hands/Gloves
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Inspection.
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Palpation—determine attachment to underlying structures.
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Examine nerve/vital structures affected—e.g. trigeminal/facial nerve.
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Measure—lesion using ruler.
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Examination.
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Surrounding skin for laxity.
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Head and neck for other lesions.
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Regional nodes.
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Neck/pre- and post-auricular—donor site.
16.4 Salivary Gland
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Patient demographics.
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History of lesion
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Duration, growth, previous surgery on lesion, pain, infections, swellings with food, previous stone history.
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Change in sensation—trigeminal nerve.
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Change in facial movements—facial nerve.
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Any other lesions in other salivary glands.
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History/PMH/medication, especially xerostomia
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Antihistamines.
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Antidepressants.
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Antihypertensives.
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Social history
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Smoking/alcohol.
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Social circumstances.
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Support.
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Examination
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Inspection of lesion with description of features
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Appearance.
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Location.
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Texture.
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Size measured with a ruler.
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Proximity to surrounding structures.
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Palpable thickness.
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Trismus.
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Comprehensive examination of oral cavity.
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Bimanual palpation.
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Examination of nerves or other vital structures that may be affected—e.g. trigmenial, facial, hypoglossal, lingual.
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Examination of head and neck for other lesions.
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Examination of regional nodes—systematic examination from level 1–5 and include post auricular nodes.
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Any masses should be characterized by size, shape, mobility, consistency and proximity to adjacent structures.
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Include thyroid and parotid glands.
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16.5 TMJ/Facial Pain
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Nature of patient’s complaints
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Nature, intensity, location, duration, onset. Aggravating or relieving factors.
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Other symptoms/parafunction.
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Headaches, neuralgia, bruxism, clenching, clicks, crepitus, locking, dislocation.
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PMH
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Arthritis, joint surgery, other chronic pain, facial skeletal surgery, bone pain, IBS etc.
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Medication
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Pain killers (history of analgesics, antidepressants/benzodiazepines).
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Family/social history
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Family—children, stress, anxiety, depression.
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Examination
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(a)
Inspection: Abnormal asymmetry.
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(b)
Jaw opening: Maximal (measure), protrusion, lateral excursion.
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(c)
Palpate TMJ: Feel crepitus/clicking.
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(d)
Palpate muscles: Lateral and medial pterygoids, masseters, temporalis, suprahyoid—test power, check accessory muscles (scalp/neck/back).
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(e)
Examine dentition: Occlusion/centric relationship—check canine guidance.
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(f)
Cranial nerves: Auriculotemporal, facial nerves.
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(g)
Otoscopy/auscultation of ear and joints.
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(a)
Trauma Examination
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Extraoral examination.
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Intraoral examination.
Extraoral examination: Remove and clear debris, photographs, if open fractures cover with betadine soaked dressing, systematic examination.
Systematic Examination:
Skull base and cranial vault: Laceration, contusions, Battle’s sign (ecchymosis post auricular/astoid region), open/depressed skull fractures.
Midface
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Eyes: Pupil (size, reaction), visual acuity, eye movement, circumorbital oedema, subconjunctival haemorrhage, proptosis, dystopia/globe position (Hertel exophthalmometer), laceration of eye lid, corneal abrasions.
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Ear: Laceration, bleeding, otorrhoea, haematoma of auricular cartilage.
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Pain/swelling medial canthal region: check for depression, intercanthal distance, check for NOE fracture.
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Bony deformity: Zygomatic arch/body, infraorbital rim, infraorbital hypoaesthesia, check for Le fort fractures.
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Nose: Shape, nose bleed, rhinorrhoea (halo sign/beta-transferrin), septal haematoma, air entry.
Mandible: Look for asymmetry, deviation, dislocation, trismus, reduced jaw movement, ecchymosis, laceration. Palpate over TMJ region.
Dental alveolar and intraoral examination: Malocclusion, loss of dentition, laceration, ecchymosis, mobile mandibular and maxillary segments, position of the tongue.
Le Fort Fractures:
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Le Fort I: Only maxillary movement.
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Le Fort II: Movement maxilla & base of nose.
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Le Fort III: Movement of midface.
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Ahmed, A., Farook, S., Perry, M. (2023). Clinical Examinations. In: Oral and Maxillofacial Surgery. Springer, Cham. https://doi.org/10.1007/978-3-031-25473-4_16
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DOI: https://doi.org/10.1007/978-3-031-25473-4_16
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