Evaluation of the Face and Related Structures ATTR 322 Krzyzanowicz- Spring ‘13

Objectives Understand bony and soft tissue anatomy of the eye, skull and teeth Describe common injuries to the eye, face and cranium Demonstrate the proper evaluation of the eye, face and cranium to include Neurological evaluation (derm/myo and cranial nerve) Palpation Referral techniques for immediate care Utilize EBP principles' in evaluation techniques

Note The material in this lecture is out of the Magee- Orthopedic Physical Assessment 5th ed. text It is in the Freel library Chapters 19 and 20 in the Starkey text cover the head and face but not in as much detail as the Magee text

Cranial Nerve Function Refer to handout (table 21-4 p. 883 Starkey text) You need to know these and how to evaluate any face or head injury using these nerves Eye injuries- II, III, IV, VI Balance- VIII Speaking/hearing- VIII, IX, X, XII Facial expression- V, VII, XII Smelling- I Shoulder shrug- XI

Introduction Bony anatomy Soft tissue anatomy Injuries can be gruesome “easy” bony anatomy Soft tissue anatomy Skin, eyes, nose, ears

Applied Anatomy (bone) Cranium vault Skull One frontal Two sphenoid Two parietal Two temporal (weakest) Once occipital (strongest)

Applied Anatomy (bone) Facial Bones Mandible (lower jaw) Maxilla (upper jaw) Nasal Palatine, lacrimal, zygomatic (cheeks) and ethmoid (orbital) bones

Eye Injuries are usually due to direct blow, impalement or chemical invasion Ophthalmologist intervention typically needed Racquet sports, boxing and golf Highest incidences of catastrophic eye injuries

Eye Bony Anatomy Eye-except for its anterior aspect sits in an orbit Orbital margin is composed of the: Frontal bone Zygomatic bone Maxillary bone Orbit’s roof Medially Lacrimal, ethmoid, maxillary and sphenoid bone

Eye Bony Anatomy

Eye Structures Mass of the eye is a fibrous, fluid filled structure referred to as the globe Sclera Pupil Iris Conjuntiva Cornea Retina Optic nerve

Visual Acuity Snellen eye chart 20/20 vision Able to red the letters on the 20 foot line of an eye chart when standing 20 feet from the chart Myopia- nearsightedness- see objects close to you Hypermetropia- farsightedness

Clinical Examination of the Eye Blunt trauma Result in injury to globe, laceration or fracture Infections, allergies, diseases, brain trauma Led to dysfunctions of the eye Past medical Hx Prior visual assessment- where can this be found? Nystagmus? General health such as diabetes?

Clinical Examination of the Eye Current History Location and symptoms photophonia? c/o “something in my eye” or “scratchiness” can be a foreign body, displaced contact lens or a corneal abrasion Injury mechanism Table 19-3 (Starkey text) p. 822 Chemicals Biology or chemistry labs

Clinical Examination of the Eye Inspection Discoloration- “black eye” Gross deformity Eyelids Cornea- hyphema? Conjunctiva- q-tip method Pupil Palpation Around the orbit Nasal and zygomatic bones

Eyelid injury

Clinical Examination of the Eye Visual assessment Snellen eye chart 20/20 vision ideal; diplopia? PEARL Pupils equal and reactive to light Penlight Eye motility Stargaze pattern Neurological testing Cranial nerves III, IV, VI- more on this later

Orbital Fractures MOI: blow to the periorbital area Tx Deformity usually occurs Blowout fractures- medial wall or floor Blow-up fractures-orbital roof Globe may be sunken and displaced Vision could be compromised Tx Refer to E.D. or Ophthalmologist Usually do a CT scan

Orbital Fracture

Corneal Abrasions MOI: fingernail (very common), turf- scratches the cornea Blinking increases P!, sensation of foreign body Eye will water to wash away particles Sharp, stabbing P! in eye Vision may be blurred Tx Fluorescein strip with cobalt blue light Dye the eye- can see the abrasion Antibiotic drops and/or a patch

Hyphema Blood in the anterior chamber of the eye Usually from blunt eye trauma Patching of the eye Immediate referral to E.D. Rest, medicine to decrease intraocular pressure

Conjunctivitis “Pink eye” Viral or bacterial infection of the conjunctiva Waking in the morning and eyelids stick together Eye burns and itches Red and swollen Water discharge usually is pink eye (viral)- eyedrops Yellow or green discharge bacterial infection Highly contagious!

Jaw/Teeth, Ear, Nose, and Throat Evaluation

Temporomandibular Joint (TMJ) TMJ is a synovial articulation between the mandibular condylar process and temporal bone Pathology can result in malocclusion Cause HA, cervical muscle strain, muscular weakness TMJ is necessary for communication and mastication Articular disk located between the two bones which can be damaged causing TMJ symptoms

TMJ

The Teeth 32 permanent teeth Each row is formed by four different types of teeth (table 20-1 p.840 Starkey) Each tooth has a root, neck and crown

Clinical Examination of Maxillofacial Injuries Hx Location of P! Dental (tooth) P! TMJ- catching, locking which chewing? Migraine HA’s? Onset Acute fx vs. dental caries Bruxism Grinding of the teeth

Clinical Examination of Maxillofacial Injuries Inspection Bleeding- facial and tongue lacerations bleed profusely Ecchymosis Symmetry Malocclusion? Lips- cuts? Teeth- chipped, fractures, etc?

Clinical Examination of Maxillofacial Injuries Palpation Maxilla Mandible Zygoma TMJ Teeth (glove up)

Facial Fractures Mandibular Fx Zygoma fx 2nd most common facial fx Result of high-velocity impact to the jaw P! in the jaw that’s increased with opening or closing of mouth Crepitus may be felt, tongue blade test Zygoma fx Direct blow to the cheek and inferior periorbital area P!, discoloration, depression of the zygomatic arch Malalignment of the eyes Step-off deformity

Mandible & Zygoma fx’s

Facial Fractures Maxillary Fractures LeFort Fractures Tend to occur concurrently with nasal fractures P! mid-portion of the face Ecchymosis, swelling and crepitus is common LeFort Fractures System used to classify mid-face fractures Unusual in athletics due to the extreme high impact forces needed 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

LeFort Fracture

Tooth Injuries Fractures Range from simple chips of the crown to full avulsions of the crown from its roots Class I- chip fx’s, subtly noticed during eating, drinking or talking Class II, II, IV- more easily recognized seconardy to pain, sensitivity to extreme temps of food/drink, obvious deformity Refer to oral surgeon/dentist!

Tooth Injuries Tooth luxations Tooth being avulsed from the socket to being driven into the bone Intruded tooth- depression into the alveolar process of the next tooth Extruded tooth- partially withdrawn from the bone and may be tilted anteriorly, posteriorly or twisted Tooth avulsion- the intact tooth being displaced from the alveolar process Dental emergency Fracture of the tooth’s root can also lead to luxation

Tooth Fractures Tooth luxations

TMJ Dysfunction Broad term that encompasses P!, decreased ROM, and audible noises Typically insidious onset, but prior hx of injury may be identified in hx taking process Acutely, TMJ is included when a direct blow is received across the chin or jaw What sports? S&S Clicking or clunking (disk subluxation) Lock jaw P! while chewing, talking HA, earache, dizziness Tx Tough What do you think?

TMJ Dislocation Observable displacement of the mandible on the maxilla MOI: direct blow to move the mandible laterally, getting punched Upper and lower teeth are malaligned, movement of the jaw is significantly impaired Malocclusion of teeth, deformity, inability to swallow* How would you treat this?

Ear Anatomy Composed of 3 sections External ear Middle ear Inner ear Cartilaginous tissue (auricle or pinna) funnel to the External auditory meatus Middle ear Tympanic membrane (eardrum)- like a microphone 3 small bones (malleus, incus and stapes) transmit the vibrations from tympanic membrane Eustachian tube- connects to nasal passages Inner ear Vibrations picked up by cochlea Transmitted to the vestibulocochlear nerve Assist with balance

Ear Anatomy

Clinical Examination of the Ear History Location of P!- direct blow? Infection? Activity- swimming, slapping blow? Other sx- dizziness, vertigo? Inspection Auricle- mike tysoned?, tympanic membrane (otoscope), battle’s sign, wrestlers? Palpation External ear

Auricular Hematoma “cauliflower ear”- repeated blunt trauma to the external ear, causing hematoma Pooling of blood between skin and cartilage separates the two, depriving the cartilage its nutrition P! in external and middle ear, ecchymosis and swelling of the auricle Can drain them, but usually come right back Headgear for wrestling

Tympanic Membrane Rupture “Ruptured eardrum” MOI: sudden change in air pressure on the tympanic membrane Blunt trauma, decreased ability to regulate inner ear pressure (flying?), infection Direct trauma- sticking a sharp object into the ear S&S Reddish-brown wax while observing with an otoscope Tinnitus, P! in the middle ear (often excruciating) Blood or fluid leaking from the ear Marked hearing loss dizziness

Otitis Externa “Swimmer’s ear” Infection of the external auditory meatus Caused by inadequate drying of the ear canal Overcleaning, undercleaning, narrow inner ear all predispose patient S&S Constant P! and pressure, itching in the ear Hearing deficit and dizziness Tx Antibiotics (drops or oral)

Otitis Media Upper respiratory infections, bacterial or viral invasions cause inflammation of ear’s mucous membranes Blocks Eustachian tubes, increased pressure within the ear URI’s, airplane travel, seasonal allergies predispose a patient S&S Inspection ear reveals fluid buildup, opaque reddened tympanic membrane Hearing loss Tx Antibiotics, Weber test

Nose Anatomy Paired wafer-thin nasal bones Form off the nasal bridge

Clinical Examination of the Nose History Location of pain, onset (acute) or URI Activity and MOI- direct blow or hot dry environment Epistaxis S&S Inspection Gross deformity Raccoon eyes Palpation Nasal bone, nasal cartilage, zygoma, maxilla

Nasal Fracture Most commonly fracture bone of the face MOI: direct blow to the nose S&S Bleeding almost immediately P! around the nose Possibly deformity Raccoon eyes Difficulty breathing Tx Tilt head forward, pinch the tip of the nose Pack nose with gauze or tampon that has been cut

Throat Anatomy Larynx is the most superficial and prominent structure of the throat Easily injured Hyoid bone Fractures when hanged Larynx and trachea are vital for living

Clinical Evaluation of the Throat History Location, onset (acute vs. sore throat), activity and MOI (struck with object?) S&S (inability to speak, breathe, voice, etc) Inspection Respirations (respiratory distress?) males vs. females? Children vs. adults? Palpation Hyoid bone Cartilage (Adam’s apple)

Throat Injury Trauma to this area often results in Respiratory distress, inability to speak and could include carotid sinus which results in loss of consciousness S&S P! while swallowing or taking a deep breath, ecchymosis, voice changes Tx Could be a medical emergency Airway management? This has happened! USC football player, multiple lacrosse players and baseball players!

On-Field Examination Lacerations Throat injuries Facial fx Control bleeding, properly clean wound (with gloves)- do they need sutures- how can you tell? Throat injuries Establish and maintain airway, activate EAP? Facial fx What about concussion? LeFort and other facial fx’s can compromise airway Spineboard? Philadelphia collar to stabilize jaw fractures E.D.- EMS or self-transport?

On-Field Examination TMJ injury (including dislocation) Nasal fx Triangular bandage, refer to E.D. or oral surgeon Nasal fx Control bleeding, splint using gauze/tampons Refer to E.D. Dental injuries Avulsed or luxated tooth- put in their own mouth! Can rinse with saline solution Reimplant into mouth- if not, store in whole milk or save-a-tooth Do not clean, sterilize or scrape the tooth besides saline

Review Most injuries to the face will be fractures/dislocations or lacerations Some can be life-threatening TMJ dislocation, throat injuries General Medical Conditions in the Athlete Entire course on general medical conditions such as infections, viruses, etc Make a list of referral specialties Dentistry, ENT, Opthalmogist, etc