Begin the examination by viewing the patient from the front. Facial elongation occurs with high-grade LeFort fractures. Then view the face from above looking down (bird's-eye view) and from below up (worm's-eye view). These perspectives reveal subtle asymmetries. Because posttraumatic Bell palsy occurs with fractures of the temporal bone, test the muscles of facial expression. Ask patients to smile, frown, whistle, raise their brows, and close their eyes tightly. Look for ecchymosis around the eyes (raccoon eyes) and over the mastoid area (Battle sign) for associated basilar skull fracture. These findings usually develop over several hours and are often absent on admission, despite serious facial trauma.
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