1. The Head and Face
Chapter 27

2. 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

3. Anatomy of the Head meninges Skull (comprised of 22 bones) Scalp Brain
Scalp
Brain
meninges
cerebrospinal fluid

4. 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

5. 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?

6. 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

7. 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?

8. 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

9. 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

10. 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

11. 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

12. 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)

13. 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

14. 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

16. 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

17. 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?

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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