Face and Related Structure Pathologies Chapter 19 Face and Related Structure Pathologies

Clinical Anatomy Frontal bone Maxillary bone Nasal bone Zygomatic bone Alveolar process Temporal bone Zygoma Zygomatic arch Mandible Ramus Mandibular condylar processes Temporomandibular joint (TMJ) Coronoid process

Clinical Anatomy Temporomandibular joint anatomy Malocclusion Articular tubercle Articular eminence Glenoid fossa Posterior glenoid spine Articular disc Malocclusion Deviation in the normal alignment of two opposable tissues (e.g., the mandible and maxilla) Mastication Chewing of food

Clinical Anatomy Ear External ear Middle ear Inner ear Auricle (pinna) Cartilage External auditory meatus Middle ear Tympanic membrane (eardrum) Three bones Auditory ossicles, malleus, and incus Eustachian tube Inner ear

Clinical Anatomy Inner ear Cochlea Semicircular canals Vestibulocochlear nerve

Clinical Anatomy Nose Nasal bones Nasal bridge Nasal septum Nasal cartilage Frontal bones Maxillary bones Ethmoid bone Hard and soft palates Pharynx Mucosal cells Kiesselbach plexus

Clinical Anatomy Throat Larynx Thyroid cartilage Cricoid cartilage Cornua

Clinical Anatomy Mouth Vermillion border Oral vestibule Oral cavity Tonsils Adenoids Papillae Taste buds Lingual frenulum

Clinical Anatomy Teeth 32 teeth Tooth Upper and lower row Root Neck Cementum Periodontal ligaments Gums Neck Crown

Clinical Anatomy Teeth

Classification and Function of Teeth Type Number Function Incisors 4 Cutting Cuspids (Canines) 2 Tearing Bicuspids (Premolars) Crushing and grinding Molars 6

Clinical Anatomy Muscular anatomy Muscle of mastication Closing mouth Masseter Opening mouth Diagastric Mylohyoid Medial and lateral pterygoid Muscles of expression See Table 20-2 from text Bell’s palsy Bell’s palsy - Inhibition of the facial nerve secondary to trauma or disease, resulting in flaccidity of the facial muscles. In individuals suffering from Bell’s palsy, the face on the involved side appears elongated.

History Involving the ear Involving the nose Location of the pain Activity and injury mechanism Blunt trauma Upper respiratory infections Other symptoms Vertigo Nausea Vomiting Congestion Location of the pain Radiating? Onset Activity and injury mechanism Direct blow Spontaneous epistaxis Symptoms Pain Bleeding Medical history Prior nasal fracture

History Involving maxillofacial injuries Involving the throat Location of the pain Onset Acute Activity and injury mechanism Blunt trauma Bruxing Clenching or grinding of the teeth Symptoms Location of the pain Anterior (trauma) Deep (illness) Onset Activity and injury mechanism Symptoms Inability to speak or hoarse, raspy voice Respiratory distress

Inspection Ear Auricle Tympanic membrane Periauricular area Auricular hematoma Otitis externa Tympanic membrane Otoscope Distended Effusion Periauricular area Battle’s sign Enlarged lymph nodes

Using an Otoscope

Inspection Nose Alignment Epistaxis Septum and mucosa Eyes and face Have athlete view in mirror if unsure Epistaxis Septum and mucosa Otoscope or penlight Asymmetry or angulation Eyes and face Raccoon eyes (periorbital ecchymosis)

Inspection Throat Face and jaw Bleeding Respiration Ecchymosis Difficulty = medical emergency Thyroid and cricoid cartilage Deformity = medical emergency Face and jaw Bleeding Ecchymosis Fracture Mandible, nasal bone, maxilla, or zygoma Symmetry Deformity Swelling Eye movement symmetry? Muscle tone Paralysis Bell’s palsy

Inspection Oral cavity Lips Vermillion border laceration = referral Teeth Obvious or subtle fractures Tongue Lingual frenulum Gums Gingivitis—inflammation of the gums

Palpation Anterior structures Nasal bone Nasal cartilage Zygoma Maxilla TMJ Periauricular area External ear Teeth Mandible Hyoid bone Cartilages

Palpation

Palpation Lateral structures Temporalis Masseter Buccinator

Functional Assessment Tests for the ear Hearing Balance Tests for the nose Smell Tests for temporomandibular involvement Open and close mouth Lateral excursion

Selective Tissue Test: TMJ Range of Motion

Observation for Malocclusion of the Teeth (A) Normally, the mandible travels in a straight line. (B) Trauma to the temporomandibular joint or a fracture of the mandible causes the jaw to track laterally and results in a malalignment of the teeth.

Neurological Testing Loss of hearing and smell Facial sensation Closed head trauma Facial sensation

Facial Pathologies and Related Special Tests Ear pathology Auricular hematoma Tympanic membrane rupture Otitis externa Infection of external auditory meatus “Swimmer’s ear” Otitis media Inflammation of the ear’s mucous membranes blocks the eustachian tubes and increases pressure in the inner ear Weber test

Facial Pathologies Nasal fractures Most common fracture of the face and skull Signs and symptoms Bleeding Deformity (preexisting?) Pain Ecchymosis (after some time)—“raccoon eyes” Tenderness to palpation (TTP) Deviated septum? Septal hematoma?

Facial Pathologies Throat injury Respiratory distress Inability to speak or a change in voice Loss of consciousness (trauma to carotid sinus) Bruising around the larynx Examine inside of mouth Bloody sputum Correct no deviations—immediately refer!

Facial Pathologies Facial fractures Mandibular fractures Zygoma fractures Maxillary fractures Le Fort fractures

Selective Tissue Test: Tongue Blade Test

Classification of Le Fort Fractures Type I fractures involve only the maxillary bone. Type II extend up into the nasal bone. Type III cross the zygomatic bones and the orbit. Sinus fluid may also be running from the nose.

Facial Pathologies Dental conditions Tooth fractures

Facial Pathologies Dental conditions Tooth luxations Intruded Extruded Avulsion

Facial Pathologies Temporomandibular joint dysfunction TMJ dislocation Pain (opening and closing mouth) Decreased ROM Audible noises TMJ dislocation MOI: Lateral blow Teeth malaligned Decreased jaw ROM

On-Field Evaluation of Injuries to the Face and Related Areas Lacerations Management Control bleeding Palpate for fracture Imbedded objects?—DO NOT REMOVE! Clean and dress wound RTP Facial laceration—referral (limit scars!) within 24 hours Throat laceration—immediate referral Avulsion laceration—clean area with sterile water, wrap in sterile gauze, put on ice, transport with athlete to medical facility for reimplantation

On-Field Evaluation of Injuries to the Face and Related Areas Laryngeal injuries Signs and symptoms Progressive swelling Crepitation Stridor—harsh, high-pitched sound resembling blowing wind that is experienced during respiration Blood exiting oral cavity Management Trouble breathing? Yes: Immediate stabilization and transport No: Sideline, put ice on anterior throat (lightly!)

On-Field Evaluation of Injuries to the Face and Related Areas Facial fractures Signs and symptoms Down athlete—possibly unconscious Management Obvious fracture? Maintain airway Philadelphia collar Transportation Stable fracture that doesn’t jeopardize airway? Move to sideline for further evaluation and treatment

On-Field Evaluation of Injuries to the Face and Related Areas Temporomandibular joint injuries Management Malooclusion? Immediate referral to physician or dentist Dislocation? Philadelphia collar—as long as it doesn’t cause pain Immediate referral

On-Field Evaluation of Injuries to the Face and Related Areas Nasal fracture and epistaxis Management Control bleeding Squeeze and tilt Ice pack Rolled gauze or tampon Rolled gauze between top lip and gums Palpate facial bones for tenderness and crepitus Ice Reduction—5 to 10 days following fracture

On-Field Evaluation of Injuries to the Face and Related Areas Dental injuries Management Luxated tooth Find tooth! Immediate reimplantation Tooth fracture If the rest are not loose, they may RTP—wearing a mouthpiece Follow up with dentist Anything beyond a class I fracture must be restricted from RTP

Emergency Management of Dental Injuries Rinse an avulsed tooth with water or saline solution before reimplanting. Allow the athlete to hold the tooth in its socket by biting on gauze. Make sure that the tooth is reimplanted in its proper orientation. If the tooth is not reimplanted immediately, store it in a secure biocompatible storage environment such as an emergency tooth-preserving system or in fresh whole milk in a plastic container with a tightly fitting lid.

Emergency Management of Dental Injuries Do not attempt to clean, sterilize, or scrape the tooth in any way other than as previously noted. Do not hold the tooth by the root. A replanted or loose tooth can be immobilized using aluminium foil. Transport the athlete and the tooth to a dentist as quickly as possible.