1. Facial Pathologies and Related Special Tests Orthopedic Assessment III – Head, Spine, and Trunk with Lab PET 5609C

2. Ear Pathologies Auricular Hematoma: “Cauliflower Ear” Auricular Hematoma: “Cauliflower Ear” MOI: Repeated blunt trauma or shearing forces to external ear MOI: Repeated blunt trauma or shearing forces to external ear Pooling of blood between the skin and cartilage (cartilage deprived of nutrition) Pooling of blood between the skin and cartilage (cartilage deprived of nutrition) Over time, hematoma can scar - deformity Over time, hematoma can scar - deformity Inspection: Inspection: Red appearance Red appearance Swelling of auricle Swelling of auricle Ecchymosis Ecchymosis

3. Ear Pathologies Auricular Hematoma: Palpation: Acute Injury: pain, confirm presence of hematoma Chronic Injury: hardened feeling Functional/Neurological Tests: Otoscope → check inner ear Hearing and Balance Note: Rule out brain trauma (blow to head)

4. Ear Pathologies Tympanic Membrane Rupture: Tympanic Membrane Rupture: History: History: Onset of Symptoms → Acute Onset of Symptoms → Acute Pain → Severe pain in middle ear; radiating inward and outward Pain → Severe pain in middle ear; radiating inward and outward MOI: MOI: Sudden change in air pressure → blunt trauma (slap to ear), blocked sneeze, mechanical intrusion (i.e. cleaning ear with pen) Sudden change in air pressure → blunt trauma (slap to ear), blocked sneeze, mechanical intrusion (i.e. cleaning ear with pen) Tympanic membrane bursts Tympanic membrane bursts Predisposing Conditions → URI, otitis media Predisposing Conditions → URI, otitis media

5. Ear Pathologies Tympanic Membrane Rupture: Tympanic Membrane Rupture: Inspection: Inspection: Blood, fluid leaking from ear (fluid should not be present in canal → immediate referral) Blood, fluid leaking from ear (fluid should not be present in canal → immediate referral) Can signify skull fracture Can signify skull fracture Inspection with Otoscope: Inspection with Otoscope: Cerumen – reddish-brown wax formed in auditory meatus Cerumen – reddish-brown wax formed in auditory meatus Functional Testing: Functional Testing: Hearing Loss Hearing Loss Valsalva maneuver may result in audible escape of air from within inner ear Valsalva maneuver may result in audible escape of air from within inner ear

6. Ear Pathologies Tympanic Membrane Rupture: Tympanic Membrane Rupture: Complications: Complications: Permanent hearing loss Permanent hearing loss Ear infection (otitis media) Ear infection (otitis media) Treatment: Treatment: Ruptured or perforated eardrum usually heals by itself within 2 months Ruptured or perforated eardrum usually heals by itself within 2 months Treatment: relieve pain, prevent infection (Antibiotics) Treatment: relieve pain, prevent infection (Antibiotics) Surgical repair of the ear drum may be needed Surgical repair of the ear drum may be needed Prevention: Prevention: Keep ear dry and clean while it heals Keep ear dry and clean while it heals Prevent water entering the ear Prevent water entering the ear Ear plugs while swimming. Ear plugs while swimming. Do not insert objects into the ear canal Do not insert objects into the ear canal

7. Ear Pathologies Otitis Externa: “Swimmer’s Ear” Otitis Externa: “Swimmer’s Ear” Infection of external auditory meatus Infection of external auditory meatus History: History: Pain: constant, pressure, itching Pain: constant, pressure, itching MOI: Inadequate drying of ear canal (water sports) MOI: Inadequate drying of ear canal (water sports) Excessive water exposure Excessive water exposure Water collects in the ear canal (trapped by wax) Water collects in the ear canal (trapped by wax) Resultant bacteria ( streptococcus, staphylococcus) /fungus growth Resultant bacteria ( streptococcus, staphylococcus) /fungus growth Predisposing Conditions: Psoriasis, eczema, oily skin, open wounds within ear; Overcleaning of external auditory canal Predisposing Conditions: Psoriasis, eczema, oily skin, open wounds within ear; Overcleaning of external auditory canal Inspection: Inspection: Redness, possible presence of clear discharge from middle ear Redness, possible presence of clear discharge from middle ear Palpation: ↑ pain with tugging on earlobe Palpation: ↑ pain with tugging on earlobe Treatment: Treatment: Prescription drops (acid-based) mixed with antibiotics or corticosteroids Prescription drops (acid-based) mixed with antibiotics or corticosteroids

8. Ear Pathologies Otitis Externa: Otitis Externa: Prevention: Prevention: Decrease exposure to water Decrease exposure to water Ear plugs (if prone to infection) Ear plugs (if prone to infection) Swimmer's ear drops or alcohol drops (Swim- EAR®) used in the ear after water exposure followed by drying the ear with a hair dryer held at arms length Swimmer's ear drops or alcohol drops (Swim- EAR®) used in the ear after water exposure followed by drying the ear with a hair dryer held at arms length Do not insert instruments, scratch, or use cotton swabs in the ears. Do not insert instruments, scratch, or use cotton swabs in the ears.

9. Ear Pathologies Otitis Media: Infection or inflammation of the middle ear Often begins when infections (viral or bacterial) that causes URI spread to the middle ear History: Pain/pressure within ear Irritability, difficulty sleeping, fever Fluid draining from the ear Loss of balance Hearing difficulty

10. Ear Pathologies Otitis Media: Otitis Media: Inspection: Inspection: Otoscope → fluid build-up / reddened, bulging tympanic membrane Otoscope → fluid build-up / reddened, bulging tympanic membrane Functional Testing: Functional Testing: Hearing Hearing Weber Test Weber Test Treatment: Treatment: Oral antibiotics Oral antibiotics Decongestants and antihistamine medications Decongestants and antihistamine medications

11. Nasal Pathologies Nasal Fractures: Nasal Fractures: History: History: Onset: Acute (most commonly fractured facial/skull bone) Onset: Acute (most commonly fractured facial/skull bone) Pain: Bridge of nose and cartilage, frontal and zygomatic bones Pain: Bridge of nose and cartilage, frontal and zygomatic bones MOI: Direct blows MOI: Direct blows Inspection: Inspection: Possible deformity Possible deformity Bleeding Bleeding Ecchymosis (raccoon eyes) Ecchymosis (raccoon eyes)

12. Nasal Pathologies Nasal Fractures: Nasal Fractures: Palpation: Palpation: Pain Pain Crepitus Crepitus Note: Any patient suffering a nasal fracture needs to be screened for injury to the eyes/head Note: Any patient suffering a nasal fracture needs to be screened for injury to the eyes/head

13. Nasal Pathologies Repeated Nasal Trauma: Repeated Nasal Trauma: Saddle-Nose Deformity: Saddle-Nose Deformity: Necrosis of nasal cartilage Necrosis of nasal cartilage Collapsed bridge of nose Collapsed bridge of nose

14. Nasal Pathologies Repeated Nasal Trauma: Repeated Nasal Trauma: Deviated Septum: Deviated Septum: Nasal Septum - thin wall inside your nose that separates right and left nasal cavities Nasal Septum - thin wall inside your nose that separates right and left nasal cavities Ideally, septum is situated in the center of your nose Ideally, septum is situated in the center of your nose 80 percent of people have a septum that is displaced to one side (one nasal passage smaller than the other) 80 percent of people have a septum that is displaced to one side (one nasal passage smaller than the other) Septum significantly off- center (deviated septum) Septum significantly off- center (deviated septum)

15. Nasal Pathologies Deviated Septum: Deviated Septum: Blockage of one side of your nose – reduced air flow Blockage of one side of your nose – reduced air flow Signs and Symptoms: Signs and Symptoms: Difficulty breathing Difficulty breathing Nasal congestion Nasal congestion Nosebleeds Nosebleeds Frequent sinus infections Frequent sinus infections Causes: Causes: Can be present at birth Can be present at birth Result of injury Result of injury Treatment: Treatment: Medication, Surgery Medication, Surgery

16. Throat Pathologies Throat Trauma: Throat Trauma: History: History: Onset – acute Onset – acute Pain: Anterior neck, increased during swallowing or taking deep breaths Pain: Anterior neck, increased during swallowing or taking deep breaths MOI: Blow to anterior neck MOI: Blow to anterior neck Inspection: Inspection: Bruising, swelling Bruising, swelling Mouth/throat – possible bloody septum Mouth/throat – possible bloody septum Patient: coughing (attempting to clear airway) / altered voice Patient: coughing (attempting to clear airway) / altered voice Palpation: Palpation: Point tenderness, crepitus, displacement of cartilage Point tenderness, crepitus, displacement of cartilage Treatment: Treatment: Immediate referral / Monitor vital signs Immediate referral / Monitor vital signs

17. Facial Fractures Mandibular Fractures: Mandibular Fractures: History: History: Onset: Acute Onset: Acute Pain: Ramus or mental protuberance of mandible Pain: Ramus or mental protuberance of mandible MOI: Direct blow MOI: Direct blow Inspection: Inspection: Swelling, gross deformity Swelling, gross deformity Malocclusion of teeth Malocclusion of teeth Palpation: Palpation: Tenderness, crepitus Tenderness, crepitus

18. Facial Fractures Mandibular Fractures: Functional Tests: Pain with opening/closing mouth Lateral tracking of mandible Neurological Tests: Cranial Nerves V, VII Special Tests: Tongue Blade test Treatment: Referral

19. Facial Fractures Zygoma Fractures: Zygoma Fractures: History: History: MOI: Direct blow to cheek or inferior periorbital area MOI: Direct blow to cheek or inferior periorbital area Pain: Injury site, possibly ↑ with eye movement Pain: Injury site, possibly ↑ with eye movement Inspection: Inspection: Subconjunctival hematoma Subconjunctival hematoma Periorbital swelling Periorbital swelling Palpation: Palpation: Tenderness at zygomatic arch, lateral eye socket Tenderness at zygomatic arch, lateral eye socket Treatment: Treatment: Referral Referral

20. Facial Fractures Maxillary Fractures: Maxillary Fractures: History: History: May occur concurrently with nasal fracture May occur concurrently with nasal fracture Pain: Midpoint of face Pain: Midpoint of face Inspection: Inspection: Ecchymosis Ecchymosis Swelling Swelling Palpation: Palpation: Pain and crepitus Pain and crepitus Treatment: Treatment: Referral Referral

21. Facial Fractures LeFort Fractures: Midface fracture LeFort Fractures: Midface fracture MOI: High-impact forces MOI: High-impact forces Automobile accident Automobile accident Unusual in athletics Unusual in athletics Inspection: Inspection: Upper teeth/face can be displaced forward Upper teeth/face can be displaced forward Classification: Classification: I – maxilla I – maxilla II – maxilla and nasal II – maxilla and nasal III – crosses zygomatic and orbital bones III – crosses zygomatic and orbital bones

22. Dental Conditions Dental Injuries: Rates Dental Injuries: Rates Female athletes: Female athletes: 1.5% - softball 1.5% - softball 7.5% - basketball 7.5% - basketball Male athletes: Male athletes: Basketball (highest) Basketball (highest) Ice hockey Ice hockey Lacrosse Lacrosse Football Football Soccer Soccer Baseball Baseball Volleyball Volleyball ADA: Universal National System (1-32)

23. Dental Conditions Tooth Fracture: Classifications (Ellis System) Tooth Fracture: Classifications (Ellis System) Class I – enamel only Class I – enamel only Class II - enamel and dentin Class II - enamel and dentin pain to touch and sensitivity to air. pain to touch and sensitivity to air. Class III – enamel, dentin, pulp Class III – enamel, dentin, pulp Pain with manipulation, air, and temperature. Pain with manipulation, air, and temperature.

24. Dental Conditions Tooth Luxation: Tooth Luxation: Extrusive luxation: partially displaced from the socket Extrusive luxation: partially displaced from the socket Greatly increased mobility and radiographs show displacement Greatly increased mobility and radiographs show displacement Lateral luxation: tooth displaced laterally Lateral luxation: tooth displaced laterally Intrusive luxation: teeth forced into their sockets in an axial direction Intrusive luxation: teeth forced into their sockets in an axial direction Can be buried (no visibility) Can be buried (no visibility) Decreased mobility Decreased mobility

25. Intrusive LuxationLateral and extrusive luxation Avulsion and luxation Dental Conditions

26. Dental Caries: Cavities Dental Caries: Cavities Cause: Cause: Plaque – food, mucus, and bacteria that collect and harden on the exposed tooth (can harden into tartar) Plaque – food, mucus, and bacteria that collect and harden on the exposed tooth (can harden into tartar) Sugars, starches, acid-rich food, poor oral hygiene Sugars, starches, acid-rich food, poor oral hygiene Signs/Symptoms: Signs/Symptoms: As decay enlarges → heat/cold sensitivity, visible defect As decay enlarges → heat/cold sensitivity, visible defect

27. Dental Conditions Gingivitis: Inflammation of the gums Gingivitis: Inflammation of the gums Cause: Cause: Accumulation of plaque → bacteria released into gums Accumulation of plaque → bacteria released into gums Overbrushing can lead to inflammation Overbrushing can lead to inflammation Increased risk: Increased risk: Poor oral hygiene Poor oral hygiene Diabetes Diabetes Pregnancy, Birth control pills Pregnancy, Birth control pills Signs/Symptoms: Signs/Symptoms: Soreness, bleeding gums Soreness, bleeding gums Red and swollen gums Red and swollen gums Treatment: Treatment: Plaque, tartar removal (dental care) Plaque, tartar removal (dental care)

28. TMJ Pathology TMJ Dysfunction: TMJ Dysfunction: History : History : Onset: Acute, chronic Onset: Acute, chronic Pain: Area of TMJ; clicking/locking of joint Pain: Area of TMJ; clicking/locking of joint MOI: Blunt trauma to the mandible or progressive joint degeneration (i.e. punch – forces mandible laterally) MOI: Blunt trauma to the mandible or progressive joint degeneration (i.e. punch – forces mandible laterally) Inspection: Inspection: Swelling, Malocclusion of the jaw Swelling, Malocclusion of the jaw Palpation: Palpation: Point tenderness Point tenderness Clicking when mouth open/closed Clicking when mouth open/closed

29. TMJ Pathology TMJ Dysfunction: TMJ Dysfunction: Functional Tests: Functional Tests: Observation of jaw during opening/closing of mouth Observation of jaw during opening/closing of mouth Any deviation? Any deviation? Treatment: Treatment: Referral to physician Referral to physician Instruct athlete not to eat hard foods (↑ pain) Instruct athlete not to eat hard foods (↑ pain)

30. Dental Conditions

31. Special Tests Otoscope: Otoscope: Allows health care providers to see the outer and middle ear Allows health care providers to see the outer and middle ear Steps: Steps: Choose a speculum size appropriate for the patient’s canals Choose a speculum size appropriate for the patient’s canals Hold the otoscope in the hand of the same side as the ear you are examining Hold the otoscope in the hand of the same side as the ear you are examining

32. Special Tests Otoscope Use: (Steps continued) Otoscope Use: (Steps continued) Examine the good ear first: Examine the good ear first: Prevents spread of infection into unaffected ear Prevents spread of infection into unaffected ear You can see normal anatomy (for comparison) You can see normal anatomy (for comparison) Inspect the Eardrum: Inspect the Eardrum: Tympanic membrane should appear shiny, translucent, and smooth (without perforations) Tympanic membrane should appear shiny, translucent, and smooth (without perforations) Any suspected disruption, fluid, pus, debris seen → Medical referral Any suspected disruption, fluid, pus, debris seen → Medical referral

33. Special Tests TMJ Palpation Test: (External) TMJ Palpation Test: (External) Procedure: TMJ is palpated while mouth is opened and closed Procedure: TMJ is palpated while mouth is opened and closed Positive Sign: Positive Sign: Asymmetry of movement Asymmetry of movement Clicking / Locking of joint Clicking / Locking of joint

34. Special Tests TMJ Palpation Test: (Internal) TMJ Palpation Test: (Internal) Positioning: Examiner places his fingers in the outermost portion of auditory canal (with rubber gloves on) Positioning: Examiner places his fingers in the outermost portion of auditory canal (with rubber gloves on) Procedure: Subject repeatedly opens/closes the mouth while examiner applies gentle pressure in an anterior direction Procedure: Subject repeatedly opens/closes the mouth while examiner applies gentle pressure in an anterior direction Positive Findings: Positive Findings: Pain, discomfort during opening/closing of mouth Pain, discomfort during opening/closing of mouth Asymmetry of movement Asymmetry of movement

35. Special Tests TMJ Range of Motion: TMJ Range of Motion: Patient Position: Seated or standing (examiner is positioned in front of subject) Patient Position: Seated or standing (examiner is positioned in front of subject) Procedure: Patient attempts to place as many flexed knuckles as possible between upper and lower teeth Procedure: Patient attempts to place as many flexed knuckles as possible between upper and lower teeth Positive Test: Patient unable to place a minimum of 2 knuckles within the mouth Positive Test: Patient unable to place a minimum of 2 knuckles within the mouth Decreased TMJ ROM Decreased TMJ ROM

36. Special Tests Weber Test: Weber Test: Tests for hearing loss Tests for hearing loss Otitis Media Otitis Media Procedure: Strike a tuning fork softly and place the vibrating fork on the middle of the patient’s forehead Procedure: Strike a tuning fork softly and place the vibrating fork on the middle of the patient’s forehead Ask patient if the sound is heard better in one ear or the same in both ears Ask patient if the sound is heard better in one ear or the same in both ears

37. Special Tests Weber Test: (continued) Weber Test: (continued) Positive Test: Athlete hears the vibration louder in the affected ear Positive Test: Athlete hears the vibration louder in the affected ear Reasoning: Conduction problem in affected ear masks the ambient noise of the room, while the well-functioning inner ear picks the sound up via the bones of the skull causing it to be perceived as a quieter sound in the unaffected ear Reasoning: Conduction problem in affected ear masks the ambient noise of the room, while the well-functioning inner ear picks the sound up via the bones of the skull causing it to be perceived as a quieter sound in the unaffected ear

38. Special Tests Tongue Blade Test: Tongue Blade Test: Possible mandibular fracture Possible mandibular fracture Position: Position: Patient seated with examiner standing in front Patient seated with examiner standing in front Procedure: Procedure: Tongue depressor is placed in patient’s mouth Tongue depressor is placed in patient’s mouth Patient attempts to hold the depressor in place, the examiner twists the tongue depressor Patient attempts to hold the depressor in place, the examiner twists the tongue depressor Positive Test: Positive Test: Patient unable to maintain a firm bite / Pain Patient unable to maintain a firm bite / Pain

39. Special Tests Chvostek Test: Facial Nerve Pathology Chvostek Test: Facial Nerve Pathology Positioning: Patient seated or standing Positioning: Patient seated or standing Procedure: Examiner taps over the masseter muscle and parotid gland Procedure: Examiner taps over the masseter muscle and parotid gland Positive Finding: Twitching of the facial muscles (masseter) Positive Finding: Twitching of the facial muscles (masseter) Special Consideration: Twitching of facial muscles may also be result of low calcium levels in the blood Special Consideration: Twitching of facial muscles may also be result of low calcium levels in the blood