Facial Pathology

1. Facial Pathology UE

2. Hx ear • Location of pain: • Direct blow • Pressure in the middle or inner ear indicate an infection or tympanic membrane rupture. • MOI: • Blunt trauma to auricle • Tympanic membrane rupture from slapping blow to the ear. • Object entering external auditory canal. • URI – infection to middle ear. • Other symptoms: tinnitus, dizziness. Ear congestion due to infection (pressure).

3. Hx nose • LOP – over nose but may radiate throughout the eyes, face, and forehead. • Onset: almost always acute. • If insidious usually some sort of infection or disease. • MOI – direct blow. Spontaneous epistaxis may occur in a hot, dry enviornment. • Symptoms: pain, bleeding, r/o concussion. • Previous Hx: Fx’s may result in deformity.

4. Hx throat • LOP • Acute = anterior portion of neck • Deep w/in neck = illness, infection • Onset – usually acute. • If insidious r/o illness or infection • MOI – usually direct blow • Symptoms: inability to speak. Respiratory distress. Hoarse voice.

5. Hx facial • LOP – normally the exact site of pain can be located. Dental injuries usually can be pinpointed to one or more teeth. • Onset- usually acute onset from direct trauma. Except for non-athletic dental problems. • MOI – direct blow from blunt object. Lacerations to lips/tongue from self-biting. • Other symptoms: vision impairment (Fx of facial bones). Pain and/or clicking in TMJ.

6. Inspection • Ear – inspect outer ear for signs of damage. • Middle and inner ear use otoscope. • Cauliflower ear – hematoma to auricle from repeated direct blows. • Nose: • Alignment & Symmetry. Have pt. look into a mirror. • Epistaxis – nosebleed. • Septum & mucosa – use otoscope • Racoon eyes.

7. Inspection • Throat: • Respirations – respiratory distress • Thyroid & cricoid catilage – swelling & deformity (medical emergency). • Face & Jaw: • Bleeding – facial lacerations result in profuse bleeding. • Ecchymosis • Symmetry – compare bilaterally. Check eye movements. • Muscle tone – unilateral paralysis = Bell’s palsy.

8. Inspection • Oral cavity: • Lips: lacerations • Teeth: inspect for chips, luxations. Can use penlight and dental mirror. • Tongue • Lingual frenulum – under tongue, can be lacerated secondary to tooth Fx’s. • Gums

9. Palpation • Nasal bone • Note painful areas and/or crepitus • Nasal cartilage • From the bridge of the tip of nose, should align with center of the bridge. • Zygoma • Maxilla

10. Palpation • TMJ • Palpate for subluxation and crepitus. • Open jaw and stick fifth finger in external auditory canal. • Periauricular area • r/o Fx – temporal bone & mastoid process. • External ear • Auircle – hard nodules & cauliflower ear. • Pain associated with a middle or inner ear infection is increased by tugging on the earlobe.

11. Palpation • Teeth • Palpate with caution • Gentle pressure to check tooth’s attachment. • Mandible • Hyoid bone – have patient swallow

12. Functional testing • Ear • Hearing • Balance • Nose • Smell • TMJ • ROM – two knuckle test • Malocclusion – tracking. Watch pt. open and close mouth, look for lateral tracking. • Neuro = cranial nerves

13. Auricular hematoma

14. Tympanic membrane rupture • Relatively rare in athletics. • Usually occurs from sticking object into ear to clean out wax (cerumen). • Must use otoscope to view. • Must refer if confirmed. • Does not heal adequately. May require surgery.

15. Tympanic membrane rupture

16. Otitis externa (swimmer’s ear) • Infection of external auditory meatus. • Prevalent in swimmers • Caused by inadequate drying of the ear canal. The dark, damp, environment increases bacterial growth and fungus resulting in an inflammatory condition. • Can be caused by overcleaning (i.e q-tips or chemicals) which removes the wax. • Symptoms: constant pain and pressure, itching. Hearing deficit and dizziness.

17. Otitis externa (swimmer’s ear) • Canal appears red, clear discharge may be resent form middle ear. Tugging on earlobe may increase pain. • Tx: antibiotic ear drops. OTC meds for drying post swimming (solution).

18. Otitis externa

19. Otitis media • Inflammation of the ears mucous membranes, blocking eustachian tubes and increasing pressure in the inner ear. • URI, airplane travel, and seasonal allergies may predispose to infection. • Pt. may report pain and pressure within the inner ear. • Inspection reveals fluid buildup and an opaque, reddened, and possibly bulging tympanic membrane. • May result in hearing loss – Weber’s test, vibration hear louder in the affected ear. • May lead to tympanic membrane rupture. • TX: oral antibiotics. OTC’s decongestants and antihistamines for symptoms.

20. Nasal injuries • Most common are Fx’s & nosebleeds. • Fx’s don’t always produce deformity, may be more subtle. • Racoon eyes. • Saddle-nose-deformity: repeated nasal trauma resulting in necrosis to the cartilage. Bridge collapses. • Deviated septum: usually congenital, but can result from injury. Can be confirmed through otoscope.

22. Management • Control bleeding and refer to a physician for X-ray,examination and reduction • Uncomplicated and simple fractures will pose little problem for the athlete’s quick return • Splinting may be necessary

23. Deviated Septum • Etiology • Compression or lateral trauma • Signs and Symptoms • Bleeding and in some instances a septal hematoma • Athlete will complain of nasal pain • Management • At the site of the hematoma, compression will be required (and if present, drained immediately) • Following drainage, a wick is inserted to allow for further drainage • Packing will be necessary to prevent a return of the hematoma • A neglected hematoma will result in formation of an abscess along with bone and cartilage loss and deformity

24. Nosebleed (epistaxis) • Etiology • Result of a direct blow, a sinus infection, high humidity, allergies, a foreign body or some other serious facial injury • Signs and Symptoms • Generally bleeding from the anterior aspect of the septum • Generally presents with minimal bleeding and resolves spontaneously • More severe bleeding may require more medical attention

25. Management • W/ acute bleeding, sit upright w/ a cold compress over the nose, pressure on the affect nostril and the ipsilateral carotid artery • Also gauze between the upper lip and gum - limits blood supply • If bleeding does not cease in 5 minutes, an astringent or styptic may need to be applied along with a gauze/cotton nose plug to encourage clotting • After bleeding has ceased, the athlete can return to play but should be reminded not to blow the nose under any circumstances for at least 2 hours after the initial insult

26. Facial Fx’s • Mandibular Fx’s: 2nd most common facial Fx behind nasal Fx’s. • High velocity impact to the jaw. • Have pt. bite down to confirm. Crepitus might be felt. • Tongue blade test.

27. Mandible Fx’s

28. Recognition and Management of Specific Facial Injuries • Mandible Fractures • Etiology • Direct blow (generally fractures at frontal angle) • Signs and Symptoms • Deformity, loss of occlusion, pain with biting, bleeding around teeth, lower lip anesthesia • Management • Temporary immobilization w/ elastic wrap followed by reduction and fixation

30. Zygoma Fx’s • Direct blow to the cheek. • Pain @ site of injury • Eye movements increase pain • Subconjunctival hematoma and periorbital swelling • Step-off deformity may be present on palpation.

31. Zygomatic complex (cheekbone) fracture • Etiology • MOI = direct blow • Signs and Symptoms • Deformity, or bony discrepancy, nosebleed, diplopia, and numbness in cheek • Management • Cold application to control edema and immediate referral to a physician • Healing will take 6-8 weeks and proper gear will be required upon return to play

32. Maxillary Fractures

33. Mandibular Dislocation • Etiology • Involves TMJ joint • MOI is generally a side blow to an open mouth • Signs and Symptoms • Dislocated jaw presents in locked-open position w/ ROM minimal along w/ poor occlusion • Management • Cold application, elastic wrap immobilization and reduction • Follow-up w/ soft diet, NSAID’s and analgesics w/ a gradual return to activity 7-10 days following acute period • Can be recurrent or result in malocclusion, or TMJ dysfunction

34. Temporomandibular Joint • Sprains • Cartilage Tears • subluxation or dislocation • TMJ dysfunction

35. Tempromandibular Joint Dysfunction • Etiology • Disk condyle derangement (disk is positioned anteriorly) • Signs and Symptoms • Headaches, earaches, vertigo, inflammation, neck pain, muscle guarding and trigger points • Hyper- or hypomobility, muscle dysfunction, limited ROM, clicking and popping • Management • Treat with custom designed, removable mouth piece • Treat problem w/ either strengthening or stretching • If corrective measures fail, referral to a dentist will be necessary

36. Dental Injuries • Tooth Fracture • Class I-IV • Class I- Enamel Fracture • Class II- Dentin Fracture • Class III- Pulp Fracture • Class IV- Root Fracture

37. Tooth Fractures • Etiology • Impact to the jaw, direct trauma • Signs and Symptoms • Uncomplicated fractures produce fragments w/out bleeding • Complicated fractures produce bleeding, w/ the tooth chamber being exposed w/ a great deal of pain • Root fractures are difficult to determine and require follow-up w/ X-ray

38. Tooth Fractures (continued) • Management • Uncomplicated and complicated crown fractures do not require immediate attention • Fractured pieces can be placed in a bag and and if not sensitive to air or cold, follow-up can wait for 24-48 hours • Bleeding can be controlled via gauze • Cosmetic reconstruction of tooth • In instances of root fractures, the athlete can continue to play but must follow-up immediately following competition • Tooth repositioning may be required, along with bracing and the use of mouthpieces in the future • Mandibular fractures and concussions must also be ruled out

39. Tooth Subluxation, Luxation and Avulsion • Etiology • Direct blow • Signs and Symptoms • Tooth may be slightly loosened, dislodged • When subluxed tooth may be loose w/in socket w/ little or no pain • With luxations, no fracture has occurred, however, there is displacement • W/ an avulsion, the tooth is completely knocked from the oral cavity • Management • For a subluxed tooth, referral should occur w/in the first 48 hours • With a luxated tooth, repositioning should be attempted along w/ immediate follow-up • Avulsed teeth should not be re-implanted except by a dentist (use a Save a Tooth Kit, milk or saline)

40. Tooth Injury Classification

41. Facial Lacerations • Etiology • Result of a direct impact, and indirect compressive force or contact w/ a sharp object • S&S • Pain, substantial bleeding, • Management • Apply pressure to control bleeding • Referral to a physician will be necessary for stitches

42. Ear pathology • Impacted Cerumen • Etiology • Excessive wax may accumulate, clogging the ear canal • Signs and Symptoms • Degree of muffled hearing or hearing loss • Generally little or no pain because no infection is involved • Management • Initial attempts should be made to irrigate the canal with warm water • Do not try to remove with cotton swab, as it may increase the degree of impaction • May require physician removal with a curette