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 Skull (comprised of 22 bones)

– 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– 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

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 – 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

http://www.yahooligans.com/reference/gray/105.html

Facial Injuries Fractures

– Madibular• 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– 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

– 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– 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– 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