The Head and Face Chapter 27

Preventing Injuries to the Head, Face, Eyes, Ears, Nose, and Throat Wearing proper protective equipment Instruct proper techniques of wearing the head and face equipment Instruct proper techniques of usage of head and face equipment

Anatomy of the Head meninges Skull (comprised of 22 bones) Scalp Brain http://www.gwc.maricopa.edu/class/bio201/skull/skulltt.htm Scalp http://www.lrc.bcm.tmc.edu/courses/anatomy/bigheadneck/headneck22.html Brain http://www.pbs.org/wnet/brain/3d/index.html meninges cerebrospinal fluid

Assessing Head Injuries History Observation Palpation (skull, cervical region) Special Test Eye function (PEARL, tracking, vision blurred) PEARL (pupils equal and reactive to light) Dilated or irregular: Accommodation to light Eyes track smoothly (nystagmus:involuntary back and forth or up and down motion indicates cerebral involvement) Vision blurry

Special Tests (continued) Balance Test (Rhomberg’s; variations?) Rhomberg’s:eyes closed, stand with hands at side; variations include single leg balance and tandem (heel toe) stance BESS (balance error scoring system): variations in stance and regaining lost balance Coordination Test (“DUI”, heel toe walk) Inability to perform indicates cerebrum injury Cognitive Test (counting backwards, months of the year, etc Neuropsychologiccal Assessments: SAC(Standard Assessment of Concussion) Others?

Assessing the Unconscious Athlete First priority to deal with life threatening injuries Breathing in particular Always suspect cervical injury Spine Board If no life threatening injury suspected: Note length of time unconscious and do not remove if not necessary

Recognition and Management of Specific Head Injuries Skull Fracture Etiology: blunt trauma Symptoms and Signs:headache, nausea, defect, blood from ear, nose, raccoon eyes(eechymosis around eyes) or battle’s sign(ecchymosis behind ears); straw colored fluid in ear canal or mouth Management Cerebral Concussion Defn: immediate or transient posttraumatic impairment of neural function Etiology: direct blow (coup or contrecoup) Symptoms and Signs (headache, tinnitus, nausea, etc) Management: return to play?

Concussions 2 primary symptoms: disturbances in LOC and posttraumatic amnesia Retrograde: nothing right before injury Anterograde :no memory of events after injury Galscow Commas Scale Classifications Based primarily on length of LOC LOC appears in less than 10% of mild head injuries More recent classifications account for ability to concentrate, attention span difficulties, balance and coordination problems

Determining when to return Dilemma If LOC, remove from competition Some tests say that even with mild injury (bell rung) that cognitive function does not return for 3-5 days Should not return until all symptoms have subsided (conservative) Returning too early increases risk of second impact syndrome

Post Concussion Syndrome Etiology: unknown Poorly understood condition following concussion Etiology: unknown Symptoms and Signs: headache, lack of concentration, anxiety, vision problems, etc Management: treat symptoms; do not allow return Second Impact Syndrome Etiology: rapid swelling and herniation of brain from 2nd injury before all symptoms have resolved; minor blow may causes this; brain autoregulation is disrupted Greater likelihood in athletes 20 or younger Symptoms and Signs: initially looks minor but within 15secs to mins, rapidly worsens (dilated pupils, loss of eye movement, LOC, respiratory failure); 50% mortality Management: Prevent it; tx within 5 mons. Of dramatic life saving measures

Etiology:Intracranial bleeding; impact with immoveable object Cerebral Contusion Etiology:Intracranial bleeding; impact with immoveable object S/S:vary; LOC then alert and talking but have headaches, nausea and dizziness Management: refer – CT or MRI Epidural Hematoma Etiology:tear of meningeal arteries; direct blow or fracture S/S: created very fast; usually LOC; regained and then gradual digression; will go as far as convulsions, decrease in respirations and pulse Management: life threatening; refer for surgical relief

Subdural hematoma Etiology:venous bleed into subdural space from acceleration/deceleration forces S/S:slow onset of symptoms; LOC not required, headaches, dizziness, nausea, sleepy; increases intracranial pressure Management:life threatening Migraine headaches Etiology: unknown but appear to be vascular related S/S: flashes of light, blindness in half field of vision Management: prevent (meds) Scalp injuries Etiology: blunt or penetrating trauma (laceration, abrasions, contusions, hematomas) S/S: bleeding Management: clean areas (why is this difficult)

Recognition and Management of Specific Head Injuries Dental Injuries Anatomy(pg 801) gum, crown, root, dentin, pulp Prevention Tooth Fracture Etiology: impact Symptoms and Signs: varies Management: refer Tooth Subluxation, Luxation, Avulsion Etiology: impact Symptoms and Signs:loose or dislodged Management Subluxation: refer within 24 hours If possible, put back in normal position Avulsed tooth should be rinsed only and placed in Save-A –Tooth, milk or saline Sooner it is re-implanted the better

Facial Anatomy Bones Muscles TMJ Carry over form skull Maxillary, mandible(supports teeth, larynx, trachea, upper airway, upper digestive tract) Muscles TMJ Joint capsule Meniscus between mandibular condyle and temporal bone

Facial Injuries Fractures Madibular Zygomatic complex (cheekbone) Etiology: collision sports; direct blow; 2nd most common S/S: deformity, inability to bite normally, bleeding of gum, inability to fell lower lip Mange: temp. immobilize and refer; fixation approx 4-6 weeks Zygomatic complex (cheekbone) Etiology: 3d most common; direct blow S/S: deformity on cheek region; epistaxis (nosebleed), diplopia (double vision) Mange: refer; healing takes 6-8 weeks

Facial Injuries TMJ Facial Laceration Etiology:disk – condyle derangement (disk moves anteriorly or stability problems at the joint (too much or too little) S/S: headache, ear ache, neck pain and muscle guarding; may report pain and clicking when jaw moves Mange:if cause is hypermobilty, strengthen ; hypomobility corrected with joint mobilizations; treat pain PRN; severe = dental referral Facial Laceration Etiology:direct impact or indirect compressive force S/S: Mange: sutured require referral Special considerations: eyebrows?

Nasal Injuries Nasal Fracture Deviated Septum Etiology: most common fx to face; direct blow from front or side S/S: profuse hemorrhage, deformity, mobility or crepitus on palpation Manage: control bleeding; refer for x-ray and reduction Deviated Septum Etiology: compression and lateral trauma S/S; bleeding, septal hematoma, deformity; painful Manage: apply compression at site of hematoma (these are drained surgically), then nose packed and drainage allowed to continue. If this is mismanaged, the hematoma can complicate healing and cause difficult to correct deformities

Nasal Injuries Epistaxis Etiology: direct blow resulting in contusion S/S: nose will bleed; usually stops; some will cauterize to prevent future problems Manage: site upright with cold compress; may place gauze between lip and gum (direct pressure to arties supplying nasal mucosa); if doesn’t stop, try styptic solution on hemorrhage point; may “plug” nose with guaze

Ear Injuries Auricular Hematoma (cauliflower Ear) Etiology: Compression or shearing injury that causes subcutaneous bleeding into auricular cartilage S/S: deformity due to accumulation of fluid / hematoma / coagulation results in keloid (elevated, nodular) This can only be removed through surgery. Manage:to prevent, ear headgear, apply lubricant to ear of those predisposed; immediate application of cold pack will reduce hemorrhage

Ear Injuries Otitis Externa (swimmers ear) Infection in ear canal caused by bacteria; athlete will complain of pain, itching, and partial hearing loss Prevention: clean and dry ears, do not stick objects in ear, avoid drastic environmental exposures Otitis Media (inner ear infection) Accumulation of fluid in middle ear caused by local and systemic infection results in intense pain, hearing loss, fever, headache, nausea Treat with antibiotics

Eye injuries Orbital Fractures Foreign Body in eye Etiology: Direct Blow to orbit S/S: diplopia, restricted movement, hemorrhage Mange: refer for x-ray; antibiotics prophylatically Foreign Body in eye Severe cases: when the object cannot be wiped away or washed out, close eye, cover with patch and refer to doctor for further treatment

Retinal Detachment Acute conjunctivitis Sty (Hordeolum) Blow to the eye; separate retina from eth pigment; more common among nearsighted athletes S/S: painless, speaks floating before eye, flashes of light, burred vision Management: immediate referral to ophthalmologist Acute conjunctivitis Etiology: bacteria or allergens; irritations S/S: swelling of eyelid, discharge, itching, burning Mange: highly infectious Sty (Hordeolum) Infection of eyelash follicle or sebaceous gland; usually caused by organism that is spread by rubbing or dust particles S/S: erythema of eye; localizes to pustule in a few days Manage: hot, moist compresses and ointment; if reoccurs, refer t o ophthalmologist