Sir, we would like to draw your readers' attention to a sign that we observed when working in the Philippines, and also in our home units: the tea towel sign of maxillofacial deformity. The two scenarios in which we have seen this sign are described below.

Oral and nasal competence is maintained by an intact dynamic muscular and mucosal seal. A competent oral sphincter and nasal aperture is imperative to the function of the oral cavity and nasopharynx.

This can be compromised by congenital or acquired craniomaxillofacial deformity. This seal can be, in part, restored by the positioning of a tea towel over the face.

In the developing world where oral and maxillofacial surgery is not freely and readily available many patients will use a tea towel or a bandana to cover their deformity. The tea towel has numerous functions including absorbing saliva and nasal secretions, preventing the drying out of the oral and nasal cavity and it allows alterations in voice. Furthermore the tea towel hides the deformity from view of the patient in the mirror and from other people. Many people without deformity in the developing world use face masks and bandanas to cover the entrance to their aerodigestive tract to prevent fumes and carbioniferous toxins entering. With this as an excuse many can secretly hide their deformity (Figs 1, 2, 3, 4).

Figure 1
figure 1

77-year-old man with destructive lesion of the left nasolabial region

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Figure 2
figure 2

Same man hiding deformity with a tea towel

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Figure 3
figure 3

7-year-old girl with a bilateral cleft lip and palate

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Figure 4
figure 4

Same girl hiding deformity with a tea towel

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In the developed world, a tea towel is normally held by a patient who has suffered severe trauma. Oral and maxillofacial and other facial reconstructive services are available to deal with most congenitial facial deformity. In this situation, as well as hiding the deformity, the tea towel soaks up blood, allows adequate pressure to prevent further bleeding and prevents drying of the oral and nasal mucosa.

The reasons for using a tea towel (or equivalent) to cover the face are multifactorial, nonetheless it can be a sign of untreated oral and maxillofacial deformity.