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

2. 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

3. 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

4. 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

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

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

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

8. 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

9. 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

10. Eye Bony Anatomy

11. 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

13. 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

14. 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?

15. 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

16. 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

17. Eyelid injury

18. 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

19. 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

20. Orbital Fracture

21. 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

22. 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

23. 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!

24. Jaw/Teeth, Ear, Nose, and Throat Evaluation

25. 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

26. TMJ

27. 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

28. Clinical Examination of Maxillofacial InjuriesHx
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

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

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

31. 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

32. Mandible & Zygoma fx’s

33. 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

34. LeFort Fracture

35. 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!

36. 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

37. Tooth Fractures
Tooth luxations

38. 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?

39. 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?

40. 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

41. Ear Anatomy

42. 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

43. 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

45. 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

46. 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)

47. 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

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

49. 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

50. 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

52. 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

53. 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)

54. 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!

55. 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?

56. 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

57. 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