Facial Pathology

UE
Hx ear
 Location of pain:
 Direct blow
 Pressure in the middle or inner ear indicate an infection or
tympanic membrane rupture.
 MOI:
 Blunt trauma to auricle
 Tympanic membrane rupture from slapping blow to the ear.
 Object entering external auditory canal.
 URI – infection to middle ear.
 Other symptoms: tinnitus, dizziness. Ear congestion
due to infection (pressure).
Hx nose
 LOP – over nose but may radiate throughout
the eyes, face, and forehead.
 Onset: almost always acute.
 If insidious usually some sort of infection or
disease.
 MOI – direct blow. Spontaneous epistaxis
may occur in a hot, dry enviornment.
 Symptoms: pain, bleeding, r/o concussion.
 Previous Hx: Fx’s may result in deformity.
Hx throat
 LOP
 Acute = anterior portion of neck
 Deep w/in neck = illness, infection
 Onset – usually acute.
 If insidious r/o illness or infection
 MOI – usually direct blow
 Symptoms: inability to speak.
Respiratory distress. Hoarse voice.
Hx facial
 LOP – normally the exact site of pain can be
located. Dental injuries usually can be
pinpointed to one or more teeth.
 Onset- usually acute onset from direct
trauma. Except for non-athletic dental
problems.
 MOI – direct blow from blunt object.
Lacerations to lips/tongue from self-biting.
 Other symptoms: vision impairment (Fx of
facial bones). Pain and/or clicking in TMJ.
Inspection
 Ear – inspect outer ear for signs of damage.
 Middle and inner ear use otoscope.
 Cauliflower ear – hematoma to auricle from
repeated direct blows.
 Nose:
 Alignment & Symmetry. Have pt. look into a
mirror.
 Epistaxis – nosebleed.
 Septum & mucosa – use otoscope
 Racoon eyes.
Inspection
 Throat:
 Respirations – respiratory distress
 Thyroid & cricoid catilage – swelling & deformity
(medical emergency).
 Face & Jaw:
 Bleeding – facial lacerations result in profuse
bleeding.
 Ecchymosis
 Symmetry – compare bilaterally. Check eye
movements.
 Muscle tone – unilateral paralysis = Bell’s palsy.
Inspection
 Oral cavity:
 Lips: lacerations
 Teeth: inspect for chips, luxations. Can use
penlight and dental mirror.
 Tongue
 Lingual frenulum – under tongue, can be
lacerated secondary to tooth Fx’s.
 Gums
Palpation
 Nasal bone
 Note painful areas and/or crepitus
 Nasal cartilage
 From the bridge of the tip of nose, should
align with center of the bridge.
 Zygoma
 Maxilla
Palpation
 TMJ
 Palpate for subluxation and crepitus.
 Open jaw and stick fifth finger in external auditory
canal.
 Periauricular area
 r/o Fx – temporal bone & mastoid process.
 External ear
 Auircle – hard nodules & cauliflower ear.
 Pain associated with a middle or inner ear
infection is increased by tugging on the earlobe.
Palpation
 Teeth
 Palpate with caution
 Gentle pressure to check tooth’s
attachment.
 Mandible
 Hyoid bone – have patient swallow
Functional testing
 Ear
 Hearing
 Balance
 Nose
 Smell
 TMJ
 ROM – two knuckle test
 Malocclusion – tracking. Watch pt. open and close
mouth, look for lateral tracking.
 Neuro = cranial nerves
Auricular hematoma
Tympanic membrane rupture
 Relatively rare in athletics.
 Usually occurs from sticking object into
ear to clean out wax (cerumen).
 Must use otoscope to view.
 Must refer if confirmed.
 Does not heal adequately. May require
surgery.
Tympanic membrane rupture
Otitis externa (swimmer’s ear)
 Infection of external auditory meatus.
 Prevalent in swimmers
 Caused by inadequate drying of the ear canal.
The dark, damp, environment increases
bacterial growth and fungus resulting in an
inflammatory condition.
 Can be caused by overcleaning (i.e q-tips or
chemicals) which removes the wax.
 Symptoms: constant pain and pressure,
itching. Hearing deficit and dizziness.
Otitis externa (swimmer’s ear)
 Canal appears red, clear discharge may
be resent form middle ear. Tugging on
earlobe may increase pain.
 Tx: antibiotic ear drops. OTC meds for
drying post swimming (solution).
Otitis externa
Otitis media
 Inflammation of the ears mucous membranes, blocking
eustachian tubes and increasing pressure in the inner ear.
 URI, airplane travel, and seasonal allergies may predispose to
infection.
 Pt. may report pain and pressure within the inner ear.
 Inspection reveals fluid buildup and an opaque, reddened, and
possibly bulging tympanic membrane.
 May result in hearing loss – Weber’s test, vibration hear louder
in the affected ear.
 May lead to tympanic membrane rupture.
 TX: oral antibiotics. OTC’s decongestants and antihistamines for
symptoms.
Nasal injuries
 Most common are Fx’s & nosebleeds.
 Fx’s don’t always produce deformity, may be more
subtle.
 Racoon eyes.
 Saddle-nose-deformity: repeated nasal
trauma resulting in necrosis to the cartilage.
Bridge collapses.
 Deviated septum: usually congenital, but can
result from injury. Can be confirmed through
otoscope.
 Management
 Control bleeding and
refer to a physician for X-
ray,examination and
reduction
 Uncomplicated and
simple fractures will pose
little problem for the
athlete’s quick return
 Splinting may be
necessary
 Deviated Septum
 Etiology

 Compression or lateral trauma

 Signs and Symptoms

 Bleeding and in some instances a septal hematoma

 Athlete will complain of nasal pain

 Management

 At the site of the hematoma, compression will be

required (and if present, drained immediately)

 Following drainage, a wick is inserted to allow for

further drainage
 Packing will be necessary to prevent a return of the

hematoma
 A neglected hematoma will result in formation of an

abscess along with bone and cartilage loss and

deformity
 Nosebleed (epistaxis)
 Etiology
 Result of a direct blow, a sinus infection, high
humidity, allergies, a foreign body or some
other serious facial injury
 Signs and Symptoms
 Generally bleeding from the anterior aspect of
the septum
 Generally presents with minimal bleeding and
resolves spontaneously
 More severe bleeding may require more
medical attention
 Management
 W/ acute bleeding, sit upright w/ a cold compress over
the nose, pressure on the affect nostril and the ipsilateral
carotid artery
 Also gauze between the upper lip and gum - limits blood
supply
 If bleeding does not cease in 5 minutes, an astringent or
styptic may need to be applied along with a
gauze/cotton nose plug to encourage clotting
 After bleeding has ceased, the athlete can return to play
but should be reminded not to blow the nose under any
circumstances for at least 2 hours after the initial insult
Facial Fx’s
 Mandibular Fx’s: 2nd most common
facial Fx behind nasal Fx’s.
 High velocity impact to the jaw.
 Have pt. bite down to confirm. Crepitus
might be felt.
 Tongue blade test.
Mandible Fx’s
Recognition and Management
of Specific Facial Injuries
 Mandible Fractures
 Etiology
 Direct blow (generally
fractures at frontal angle)
 Signs and Symptoms
 Deformity, loss of occlusion,
pain with biting, bleeding
around teeth, lower lip
anesthesia
 Management
 Temporary immobilization w/
elastic wrap followed by
reduction and fixation
Zygoma Fx’s
 Direct blow to the cheek.
 Pain @ site of injury
 Eye movements increase pain
 Subconjunctival hematoma and
periorbital swelling
 Step-off deformity may be present on
palpation.
 Zygomatic complex
(cheekbone) fracture
 Etiology
 MOI = direct blow
 Signs and Symptoms
 Deformity, or bony
discrepancy, nosebleed,
diplopia, and numbness
in cheek
 Management
 Cold application to control
edema and immediate
referral to a physician
 Healing will take 6-8 weeks
and proper gear will be
required upon return to play
Maxillary
Fractures
 Mandibular Dislocation
 Etiology
 Involves TMJ joint
 MOI is generally a side blow to an open mouth
 Signs and Symptoms
 Dislocated jaw presents in locked-open
position w/ ROM minimal along w/ poor
occlusion
 Management
 Cold application, elastic wrap immobilization
and reduction
 Follow-up w/ soft diet, NSAID’s and analgesics
w/ a gradual return to activity 7-10 days
following acute period
 Can be recurrent or result in malocclusion, or
TMJ dysfunction
Temporomandibular Joint
 Sprains
 Cartilage Tears
 subluxation or dislocation
 TMJ dysfunction
 Tempromandibular Joint Dysfunction
 Etiology
 Disk condyle derangement (disk is positioned
anteriorly)
 Signs and Symptoms
 Headaches, earaches, vertigo, inflammation,
neck pain, muscle guarding and trigger points
 Hyper- or hypomobility, muscle dysfunction,
limited ROM, clicking and popping
 Management
 Treat with custom designed, removable mouth
piece
 Treat problem w/ either strengthening or
stretching
 If corrective measures fail, referral to a dentist
will be necessary
Dental Injuries
 Tooth Fracture
 Class I-IV
 Class I- Enamel Fracture
 Class II- Dentin Fracture
 Class III- Pulp Fracture
 Class IV- Root Fracture
 Tooth Fractures
 Etiology
 Impact to the jaw, direct trauma
 Signs and Symptoms
 Uncomplicated fractures produce fragments w/out
bleeding
 Complicated fractures produce bleeding, w/ the
tooth chamber being exposed w/ a great deal of
pain
 Root fractures are difficult to determine and require
follow-up w/ X-ray
 Tooth Fractures (continued)
 Management
 Uncomplicated and complicated crown fractures
do not require immediate attention
 Fractured pieces can be placed in a bag and and if not
sensitive to air or cold, follow-up can wait for 24-48
hours
 Bleeding can be controlled via gauze
 Cosmetic reconstruction of tooth
 In instances of root fractures, the athlete can
continue to play but must follow-up immediately
following competition
 Tooth repositioning may be required, along with
bracing and the use of mouthpieces in the future
 Mandibular fractures and concussions must also
be ruled out
 Tooth Subluxation, Luxation and Avulsion
 Etiology

 Direct blow

 Signs and Symptoms

 Tooth may be slightly loosened, dislodged

 When subluxed tooth may be loose w/in socket w/ little or no pain

 With luxations, no fracture has occurred, however, there is

displacement
 W/ an avulsion, the tooth is completely knocked from the oral cavity

 Management

 For a subluxed tooth, referral should occur w/in the first 48 hours

 With a luxated tooth, repositioning should be attempted along w/

immediate follow-up
 Avulsed teeth should not be re-implanted except by a dentist (use a

Save a Tooth Kit, milk or saline)

Tooth Injury Classification
 Facial Lacerations
 Etiology
 Result of a direct impact,
and indirect compressive
force or contact w/ a sharp
object
 S&S
 Pain, substantial bleeding,
 Management
 Apply pressure to control
bleeding
 Referral to a physician will
be necessary for stitches
Ear pathology
 Impacted Cerumen
 Etiology
 Excessive wax may accumulate, clogging the ear canal
 Signs and Symptoms
 Degree of muffled hearing or hearing loss
 Generally little or no pain because no infection is involved
 Management
 Initial attempts should be made to irrigate the canal with
warm water
 Do not try to remove with cotton swab, as it may
increase the degree of impaction
 May require physician removal with a curette