What ENT physical examination findings should be assessed in an adult or adolescent patient with facial or cervical trauma?

ENT Trauma Physical Examination Findings

Critical Initial Assessment

Before any facial examination, ensure airway, breathing, and circulation (ABC) are stabilized, as maxillofacial trauma can cause airway compromise through hemorrhage, soft-tissue edema, and loss of facial architecture from fractures. 1

Systematic Physical Examination Components

Inspection and Palpation

• Palpate all facial bones systematically for step-offs and crepitus, which indicate underlying fractures 1
• Assess for facial asymmetry, deformity, and lacerations through visual inspection 1
• Examine for tenderness to palpation, contusion, or edema over the frontal bone, which suggests frontal bone injury 2
• Evaluate for pain with upper jaw manipulation, pain overlying zygoma, facial elongation, or zygomatic deformity, all indicating midface injury 2, 1

Neurological Assessment

• Test infraorbital nerve sensation, as paresthesia suggests midface injury involving the zygomaticomaxillary complex 2, 1
• Perform complete cranial nerve evaluation to detect nerve injury from facial trauma 1

Ophthalmologic Examination

• Conduct full visual acuity testing and extraocular movement assessment in all patients with facial trauma 1
• Ophthalmology consultation is mandatory for all orbital fractures to assess visual acuity, extraocular movements, and globe integrity 1

Dental and Occlusion Assessment

• Evaluate dental occlusion to detect maxillary or mandibular fractures 1
• Assess for malocclusion, which strongly suggests midface injury 2, 1

Cerebrospinal Fluid Leak Detection

• Examine for cerebrospinal fluid leak through nasal or aural drainage, particularly with frontal bone or skull base fractures 1

Cervical Spine Evaluation

• Cervical spine clearance is essential before any facial manipulation, as 11% of mandibular fracture patients and 7-19% of patients with significant maxillofacial trauma have concomitant cervical spine injury 2, 1

Specific Injury Patterns and Associated Findings

Frontal Bone Injuries

• Tenderness to palpation, contusion, or edema over the frontal bone are the primary clinical indicators 2
• Displaced posterior table fractures may indicate underlying dural disruption 3

Midface Injuries

• Pain with upper jaw manipulation combined with infraorbital nerve paresthesia has high specificity for zygomaticomaxillary complex fractures 2
• Facial elongation suggests maxillary fracture (Le Fort patterns) 2
• Periorbital ecchymosis, enophthalmos, and facial asymmetry indicate severe maxillary injuries 2

Vascular Injury Signs

• Vascular soft signs were present in 57% of penetrating neck injury patients and require systematic assessment 4
• Complex skull fractures or scalp degloving are risk factors for blunt cerebrovascular injury (BCVI), which carries significant morbidity and mortality if missed 2

Critical Pitfalls to Avoid

• Never manipulate the cervical spine before clearance, as the incidence of concomitant cervical spine fractures is 11.3% in patients with maxillofacial injuries 2
• Do not rely on physical examination alone to rule out significant injury, as 68% of facial fracture patients have concomitant intracranial injury requiring CT imaging 1
• Recognize that the absence of soft signs does not exclude injury in penetrating trauma, though the negative predictive value is 98.7% 4

Immediate Management Considerations

• Elevate head of bed for acute maxillary fractures and implement sinus precautions 1
• Coordinate pain management for multiple painful injuries 1
• Obtain neurosurgery consultation when intracranial injury is present (68% of facial fracture patients) 1