Checklist

WIPER

• Good light source. The patient needs to be sitting with neck exposed to the clavicles. Necklaces and glasses must be removed.

• Examine the head from the front, from the sides and from above.

• Compare the left and right sides of the face.

• Look for deviation of midline structures.

Physiological parameters

General facial examination

• First, rule out

• airway compromise

• cervical spine injuries

• scalp, cranial or intracranial injuries

• major haemorrhage

• Facial appearance expression, symmetry, facial muscle palsy or congenital syndromes

• Nutritional status

Inspection

• Skin of all facial structures: scars, masses (tumours), defects (ulcers, lacerations, tissue loss), colour changes (cyanosis, ecchymoses, erythema, pallor)

• Scalp: lacerations, foreign bodies, haematomas, masses

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• Ears:

• mastoid bruising (Battle's sign) in skull base fractures

• auricle: lacerations, haematomas or avulsions

• external acoustic meatus: blood or CSF

• Eyes:

• periorbital ecchymoses (‘panda eyes’) in skull base fractures

• ‘sunken’ eye (enopthalmos) and diplopia in orbital floor fractures

• swelling of the eyelids

• symmetry of movement

• subconjunctival haemorrhage

• Nose:

• deformity or deviation from midline

• CSF leak

• bleeding

• septal haematomas

• Lips:

• lacerations, haematomas, masses, asymmetry of the mouth

• Parotid and submandibular glands:

• swelling

• Hard tissues:

• loss of bony contours or deformities of facial skeleton

• malocclusion of teeth, prognathism or retrognathism

Palpation

• Skin: temperature, tenderness.

• Soft tissues: tenderness, fluctuance, surgical emphysema:

• eyelids, nose, lips and cheeks

• submandibular region: induration (rule out Ludwig's angina or abscesses)

• Hard tissues: step deformities, irregularities, mobility or tenderness:

• supraorbital ridge and frontal bones

• inferior orbital ridge and lateral orbital ridge

• zygomatic arch

• ramus, angle and body of mandible

• nasal bone, midface, teeth

• Sensation:

• numbness in distribution of infraorbital nerve (cheek and upper lip) in orbital blow-out fracture or zygoma fractures

• numbness in distribution of inferior alveolar nerve (chin and lower lip) in mandibular fractures

• Sinuses: tenderness

• Salivary glands: parotid, submandibular for enlargement and tenderness.