This lecture by Dr. Hempre provides a detailed, systematic guide to the history taking and clinical examination essential for maxillofacial surgery practice. The presentation emphasizes the importance of a thorough general medical history, noting high-risk conditions like diabetes and the use of anticoagulants, which directly impact surgical planning. A significant portion of the lecture is dedicated to the comprehensive physical examination, focusing on the systematic testing of all twelve cranial nerves (including specific tests for vision, ocular motility, sensory perception, and motor functions like facial symmetry and tongue movement). Furthermore, the guide covers palpation techniques for identifying and differentiating cervical lymph node pathology (inflammatory vs. malignant) and provides a structured approach to assessing patients with suspected facial bone trauma, detailing how to check for fractures (mandible, zygoma, Le Fort) and associated neurological deficits.
The Systematic Examination in Maxillofacial Surgery
0:37 General and Special Medical History: Emphasizes collecting the reason for the visit, cardinal symptoms, previous diagnostics (x-rays, forms), and prior therapy.
2:01 Key Systemic Risks: Physicians must know if a patient has diabetes (affects wound healing, risk of unconsciousness) or heart problems (delaying surgery for 6 months post-heart attack) or if they are taking anti-coagulants (risk of bleeding).
3:38 Systematic Overview: Reviewing all body systems (cardiovascular, respiratory, gastrointestinal, endocrine, neurological) is necessary. The speaker highlights that mental health status should be considered before large operations.
5:24 General Examination: Starts with assessing the patient's general appearance, age, vigilance, orientation, and vital parameters (pulses, blood pressure). Skin coloration (e.g., yellowish skin suggests liver issues) and hygiene are important hints.
8:48 Palpation of Sinuses and Nerves: Percussion of the maxillary facial wall can hint at sinus inflammation. Palpating the nerve exit points of the trigeminal nerve (V) helps diagnose inflammation.
9:21 Temporomandibular Joint (TMJ) Examination: The TMJ must be palpated at rest and during function, noting the normal mouth opening of about 40 mm.
11:18 Examination Using Senses: The medical examination should involve inspecting (size, color, surface), listening, touching, and smelling (noting that the sense of taste is no longer used, referencing historical diabetes diagnosis).
14:43 Palpation and Consistency: Palpation should assess consistency (elastic, hard, bone hard) and displaceability (versus skin/base). Key Takeaway: Lymph nodes that are painful often indicate an inflammatory process, while non-painful, slowly growing nodes raise suspicion of a tumor.
16:18 Carotid Triangle Warning: Pain and inflammation in the carotid triangle area are a very bad sign, indicating inflammation spreading down the vessels toward the mediastinum (requiring immediate hospitalization).
17:20 Defining Sensory Loss: It is crucial to explain the difference between analgesia (lack of pain, achieved via local anesthesia) and anesthesia (lack of all sensitive qualities) to patients so they are not surprised if they feel pressure during a procedure.
24:02 Cranial Nerve Assessment: The lecture extensively reviews the testing protocol for all 12 cranial nerves:
24:08 Olfactory (I): Tested with odorous substances.
24:29 Optic (II) & Eye Movement Nerves (III, IV, VI): Tested by visual acuity, visual field, and tracking a finger (looking for eye mobility issues common in zygoma fractures).
29:48 Trigeminal (V): Sensory testing (sharp/blunt, temperature) and motor testing (contraction of masticatory muscles).
33:07 Facial (VII): Tested by lifting eyebrows, frowning, and eye closure (trying to gently open the lids). Differentiation of peripheral palsy (all three branches affected) from central problems. Notes lagophthalmos (Bell’s phenomenon), where the eye cannot close, risking corneal damage.
38:13 Glossopharyngeal (IX) and Vagus (X): Tested together for taste, gag reflex, and soft palate movement. Lesions result in loss of gag reflex and an open nasality (speech disorder).
42:18 Hypoglossal (XII): Tested by tongue movement; a unilateral palsy causes the tongue to point toward the affected side.
45:00 Lymph Node Palpation Technique: Using four fingers together, gently direct the patient’s head to the side being palpated to reduce tension, allowing better assessment of nodes along the mandibular edge and neck triangles.
46:50 Intra-Oral Findings: Inspecting mouth opening (normal distance 40 mm), and palpating salivary glands/ducts to check for normal saliva flow (or stones/hardening). Takeaway: Leukoplakia requires monitoring; malignant ulcers demand immediate action.
50:09 Fracture Patient Assessment: Key steps include checking for disrupted occlusion, measuring reduced mouth opening, checking for abnormal mobility/crepitation, and palpating typical fracture sites (zygomatic crest, orbital frame).
54:11 Le Fort Mobility Test: Testing the mobility of the maxilla by grasping the frontal teeth (if intact) and attempting to move the structure, while stabilizing the head.