Key Points

  • Clinical examination for orthognathic surgery.

  • Head and neck examination.

  • Examination of cutaneous lesions.

  • Examination of salivary glands.

  • Examination for facial pain including TMJD.

  • Trauma exam.

16.1 Orthognathic

  • Position: Clinical Frankfort Plane horizontal to floor/lips at rest.

Lateral View

  • Facial 1/3.

  • Frontal bossing, nasal shape, nasofrontal, nasolabial, labiomental, cervicofascial.

  • Dorsum/tip of nose.

  • Maxilla concave/convex.

  • Paranasal hollowing.

  • Gross skeletal pattern.

Frontal View

  • Facial 1/3: Medial canthus to alar base.

  • Facial 1/3: Upper face height/lower face height.

  • Brow/tip: Aesthetic lip.

  • Contributes—nasal/dental upper and lower/chin point = feel TMJ/check for deviations—asymmetry.

  • Upper lip length.

  • Incisors show at rest/dynamic.

  • Dental centrelines.

  • Intraoral examination: OH/incisors (overjet/overbite/openbite), molars, missing/crowding, wisdom teeth.

16.2 Head and Neck Exam

  • Firstly, check the primary site, FNE where appropriate.

  • FNE

    • Head level.

    • Spray: Lidocaine 5%/Phenylephrine 0.5% Nasal Spray.

    • Focus and white balance.

    • Nasal floor.

    • Soft palate/Eustachian tube.

    • Fossa of Rosenmuller.

    • Posterior wall.

    • Vallecula, vocal cords

      • Lip compensatory and drooling.

      • Tongue mobility, speech, swallowing, mastication.

      • Oral health and radiation caries/mucositis.

      • Dental status—e.g. problems with denture/obturators.

      • Mouth opening: Measure with Willis gauge.

      • Speech intelligibile—understood over phone.

      • Drooling.

      • Diet—PEG/RIG.

      • Appearance—facial nerve (MMN).

      • Sensation—Von Frey filament (nylon).

      • Weight—malnutrition.

Neck Exam—Primary Drainage Areas

  • Under lower border.

  • Facial lymph nodes.

  • Sternomastoid—fingers.

Shoulder

  • Stand behind—abduct to 90°.

  • Can they take bra off.

  • Comb back of head.

  • Hand—radial site.

  • Scar—contraction/hypertrophic.

  • Skin graft.

  • Tendon exposure.

  • Loss of sensation over first dorsal interosseous.

  • Function: grip/pain.

  • Median/ulnar nerve.

Scapula

  • Shoulder function.

DCIA

  • Sensation cutaneous nerve.

Fibular

  • Wound healing.

  • Hammer knee—flexor hallucis.

  • Sensation—lateral sural cutaneous nerve: posterior/lateral leg gait.

  • Foot drop—common peroneal nerve: wasting of anterior tibial and peroneus muscles.

  • Pulses—dorsalis pedis.

Look

  • Muscle wasting.

  • Hair.

  • Scar.

  • Foot drop.

  • Skin graft.

Feel

  • Swelling.

  • Warmth.

  • Tenderness.

  • Sensation.

  • Pulses—posterior tibial.

  • Tendon expose.

Move

  • Knee: Joint—flexion/extension.

  • Ankle: Plantarflexion/eversion/dorsiflexion.

  • Gait: Foot drop.

  • Toe: Hammer toe.

New Oral SCC

  • Introduction.

  • Patient demographics.

  • History of lesion—duration/growth/change of colour or pigmentation/bleeding/pain/previous surgery.

QOL Issues

  • Speech, swallowing, taste, checking change in nerve sensation—trigeminal.

  • Any other lesions of face/head/neck.

Miscellaneous History

  • Industrial chemicals.

  • Haematological conditions.

  • Immunosuppression.

  • Head and neck irradiation.

Past Medical History

  • Especially with regards to intended surgery.

  • Previous surgery—bleeding.

  • Pulmonary, cardiovascular fitness, exercise tolerance (claudication/vascular disease).

Social

  • Smoking/occupation/alcohol/living circumstances/support.

Clinical Examination—Inspect with Features

  1. (a)

    Appearance, location, texture, size (with ruler), proximity to surrounding structures, thickness.

  2. (b)

    Trismus—whole oral cavity.

  3. (c)

    Head and neck exam/neck nodes.

  4. (d)

    FNE.

  5. (e)

    Examination around possible donor site.

16.3 Cutaneous Lesion

Introduction

  • Patient demographics.

  • Age/occupation.

  • History—lesion

    1. (a)

      Duration, growth, change in colour/pigmentation, bleeding, previous surgery on lesion.

    2. (b)

      Any other lesions—head/face/neck/body.

    3. (c)

      Any other lumps/bumps.

History Of

  • Sun exposure/sunscreen usage/hat-wearing.

Miscellaneous History

  • Related to aetiology—industrial chemicals, hereditary conditions, burns, ulcers, scars, immunosuppression.

PMH

  • Previous surgery/bleeding, also with regards to intended surgery.

  • Medication: Aspirin/warfarin.

Social History

  • Smoking (lip), alcohol, occupation (sun exposure/industrial chemicals), living circumstances, social support.

Family History

  • Melanomas, non-melanoma skin cancer, immunosuppression, other cancers in family.

Examination—Wash Hands/Gloves

  • Inspection.

  • Palpation—determine attachment to underlying structures.

  • Examine nerve/vital structures affected—e.g. trigeminal/facial nerve.

  • Measure—lesion using ruler.

  • Examination.

  • Surrounding skin for laxity.

  • Head and neck for other lesions.

  • Regional nodes.

  • Neck/pre- and post-auricular—donor site.

16.4 Salivary Gland

  • Patient demographics.

  • History of lesion

    • Duration, growth, previous surgery on lesion, pain, infections, swellings with food, previous stone history.

    • Change in sensation—trigeminal nerve.

    • Change in facial movements—facial nerve.

    • Any other lesions in other salivary glands.

  • History/PMH/medication, especially xerostomia

    • Antihistamines.

    • Antidepressants.

    • Antihypertensives.

  • Social history

    • Smoking/alcohol.

    • Social circumstances.

    • Support.

  • Examination

    • Inspection of lesion with description of features

      • Appearance.

      • Location.

      • Texture.

      • Size measured with a ruler.

      • Proximity to surrounding structures.

      • Palpable thickness.

    • Trismus.

    • Comprehensive examination of oral cavity.

    • Bimanual palpation.

    • Examination of nerves or other vital structures that may be affected—e.g. trigmenial, facial, hypoglossal, lingual.

    • Examination of head and neck for other lesions.

    • Examination of regional nodes—systematic examination from level 1–5 and include post auricular nodes.

    • Any masses should be characterized by size, shape, mobility, consistency and proximity to adjacent structures.

    • Include thyroid and parotid glands.

16.5 TMJ/Facial Pain

  • Nature of patient’s complaints

    • Nature, intensity, location, duration, onset. Aggravating or relieving factors.

    • Other symptoms/parafunction.

    • Headaches, neuralgia, bruxism, clenching, clicks, crepitus, locking, dislocation.

  • PMH

    • Arthritis, joint surgery, other chronic pain, facial skeletal surgery, bone pain, IBS etc.

  • Medication

    • Pain killers (history of analgesics, antidepressants/benzodiazepines).

  • Family/social history

    • Family—children, stress, anxiety, depression.

  • Examination

    1. (a)

      Inspection: Abnormal asymmetry.

    2. (b)

      Jaw opening: Maximal (measure), protrusion, lateral excursion.

    3. (c)

      Palpate TMJ: Feel crepitus/clicking.

    4. (d)

      Palpate muscles: Lateral and medial pterygoids, masseters, temporalis, suprahyoid—test power, check accessory muscles (scalp/neck/back).

    5. (e)

      Examine dentition: Occlusion/centric relationship—check canine guidance.

    6. (f)

      Cranial nerves: Auriculotemporal, facial nerves.

    7. (g)

      Otoscopy/auscultation of ear and joints.

Trauma Examination

  • Extraoral examination.

  • 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

  • Eyes: Pupil (size, reaction), visual acuity, eye movement, circumorbital oedema, subconjunctival haemorrhage, proptosis, dystopia/globe position (Hertel exophthalmometer), laceration of eye lid, corneal abrasions.

  • Ear: Laceration, bleeding, otorrhoea, haematoma of auricular cartilage.

  • Pain/swelling medial canthal region: check for depression, intercanthal distance, check for NOE fracture.

  • Bony deformity: Zygomatic arch/body, infraorbital rim, infraorbital hypoaesthesia, check for Le fort fractures.

  • 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:

  • Le Fort I: Only maxillary movement.

  • Le Fort II: Movement maxilla & base of nose.

  • Le Fort III: Movement of midface.