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Maxillofacial Injuries in Sports and Exercise

Maxillofacial Injuries in Sports and Exercise. Kevin deWeber, MD, FAAFP Director, Sports Medicine Fellowship. Adapted from: “Dude, he gave you a Facial!,” by Anthony Beutler,M.D. and Gary Ho, MD. “Professional athletes don’t wear mouthguards.”. Why aren’t they smiling?. Objectives.

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Maxillofacial Injuries in Sports and Exercise

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  1. Maxillofacial Injuries in Sports and Exercise Kevin deWeber, MD, FAAFP Director, Sports Medicine Fellowship Adapted from: “Dude, he gave you a Facial!,” by Anthony Beutler,M.D. and Gary Ho, MD

  2. “Professional athletes don’t wear mouthguards.” Why aren’t they smiling?

  3. Objectives • Briefly discuss scope of ENT injuries in sports • Briefly discuss on-field assessment of ENT injuries • Review common ENT injuries • PREVENTION IS KEY

  4. EpidemiologyScope of the problem • 18% of all athletic injuries • Boys: 3 times more facial injuries than girls • Most frequently associated sport: • Before 1964, Football • Now Baseball (40%)

  5. Epidemiology:Oral and Facial Trauma • 50 : 50 • 50% mouth & teeth • 50% ears, nose & face • Low Speed • elbows & fists • soft tissue lacerations & contusions • High Speed • balls, pucks, sticks • Bone / tooth fractures

  6. On Field Assessment • ABC’s always come FIRST • Airway • Breathing • Circulation • Don’t get distracted! • C-spine precautions

  7. On Field Assessment • Mechanism of Injury

  8. On Field Assessment • History • How? (MOI) • Other Injuries? • Other symptoms • Respiratory symptoms? • Concussion? • Symptoms • Leakage of fluid (LOF)? • Able to move jaw? • Teeth mesh normally?

  9. Sideline Examination • Risk of returning to play • Inspection • Obvious deformity • Asymmetry • Swelling • Bleeding, LOF • Otorrhea • Rhinorrhea • Ecchymosis • Raccoon’s eyes • Battle’s sign • Dysfunction • Neuro exam (esp EOM) • OP and dental exam

  10. Sideline Examination • Palpate • Orbital rims • Maxilla & malar areas • Zygomatic arches • Nasal bones • Midface stability • Jaw & alveolar ridges • Temporal mandibular joints • Teeth for dental trauma • Malocclusion • Special tests • Ring test for CSF • Septal hematoma • Hemotympanum

  11. Facial Fractures

  12. Diagnostic Imaging • Plain film x-rays • Facial series • Waters view (Occipitomental) • Caldwell (PA) view • Lateral • Submentovertex view • Lower face series • Panorex • Lateral oblique • Other views • CT Scan – (Hi Res)

  13. Common Injuries • Nasal Injuries • Ear Injuries • Mouth Injuries • Teeth Injuries • Eye Injuries

  14. Nasal Injuries • Most commonly injured structure of the face • Fractures • Septal deviation • Epistaxis • Septal hematoma • Saddle deformity

  15. Nasal Fracture Swelling Ecchymosis Deviated appearance Epistaxis Crepitus to palpation Indentation to palpation

  16. Nasal Fracture Management • Exam: septal hematoma, midfacial injuries • Preferable to reduce quickly after injury • If not, wait 5-7 days for decision • Local, general or moment anesthesia • Manipulation after 10 days is very difficult

  17. Epistaxis

  18. Epistaxis • Anterior • 95% • Kiesselbach’s plexus • Traumatic • Visualizable • Squeeze & Pack • Profuse anterior bleeding after fracture • Anterior ethmoid laceration • Needs reduction, packing, consult and admission

  19. Epistaxis • Posterior • 5% • Larger vessels • Atraumatic • Nonvisualizable • Consult & Admit

  20. Epistaxis Management Compression, ice, nasal spray Epistaxis Locate site Anterior (95%) Posterior (5%) Anterior packing Posterior packing ENT consult Anterior cautery / QR powder Surgery Posterior packs/surgery Admit

  21. Epistaxis Management

  22. Epistaxis Management

  23. Epistaxis Management

  24. Epistaxis Management • Insert 12-16 F catheter with 30cc balloon until tip is visible in posterior pharynx • Slowly inflate with 15cc saline and pull anteriorly to set against choanae. • Secure with umbilical clamp • Place anterior nasal pack

  25. Epistaxis Management • QR Powder • Hydrophilic polymer • Absorbs H2O from blood  polymer swells • Potassium salt • Binding agent forms artificial scab

  26. Septal Hematoma • Collection of blood b/w cartilage septum & muco-perichondrium • Most often associated with fracture • Dx: grape-like, blue bulge that obstructs nares • Left untreated: can cause “saddle nose” deformity

  27. Septal Hematoma • Treatment • Prompt aspiration / drainage to prevent saddle nose • Packing / splinting • Prophylactic anitbiotics • Tetanus prn

  28. Nasal Injuries

  29. Common Injuries • Nasal Injuries • Ear Injuries • Mouth Injuries • Teeth Injuries • Eye Injuries

  30. Ear Problems

  31. Auricular Hematoma(“Wrestler’s Ear”)

  32. Auricular Hematoma • Trauma causes bleeding between skin and cartilage • Fluctuant bluish swelling in auricle • Untreated  • Pressure necrosis • Fibroneocartilage formation • Unsightly scarring • Tx: prompt drainage

  33. Auricular Hematoma Needle Drainage • Need to be promptly aspirated • Have done up to 10 days out • 20 gauge needle • Sterile conditions • +/- Prophylactic antibiotics

  34. Auricular HematomaClot Evacuation • After evacuation, apply compression for 7-10 days to prevent hematoma recurrence

  35. Auricular hematoma Unreliable techniques for compression:

  36. Auricular Hematoma • Best technique for compression: • Sutured tubular gauze • Allows quick return to play • Need to protect it!

  37. Perichondritis is bad. Sterility is important. Poor cosmesis is bad. Headgear is important. Auricular Hematomacomplications

  38. Y O U M A K E T H E C A L L OR

  39. Auricular Laceration • Key is to look for cartilage involvement • Anesthesia: no epi • Repair cartilage first w/ 5/6-0 suture • Then repair skin • Tetanus +/- oral abx

  40. Thermal Injuries of Auricle • Frostbite • Avoid refreezing • Rewarm • Avoid rubbing • Protect • Blister management • Abx / Td prn • Nutrition & hydration • Sunburn • Pain relief • Moisturizers, ointments • Blister management • Abx / Td prn • Nutrition & hydration

  41. Tympanic Membrane Rupture • Mechanism of injury • Barotrauma • Percussive blow or slap to side of head • Explosions • Travel at altitude • Diving • Boxing, wrestling, martial arts • Water skiing • Surfing • Wake Boarding

  42. Tympanic Membrane Rupture • Symptoms • Painful “pop” • Minor bleeding • Unilateral hearing loss • Can have vertigo &/or nausea • Exam • Otoscopic exam

  43. Tympanic Membrane Rupture • Usually no treatment needed, except re-exam • Oral abx if a/w infection • Avoid valsalva and pressure changes (no diving) • Swimming OK • Protect w/ custom plugs • 90% heal in 8 weeks • Refer to ENT if not healed by 3 months • Large ruptures >25% • consider hearing screen to r/o sensorineural hearing loss

  44. Otitis Externa • Infection of external auditory canal: • Pseudomonas • E. coli • Proteus • Staphylococcus • Fungus • Swimmers • Other water sports • Pain with auricle movement • Red, swollen EAC +/- exudate

  45. Otitis Externa • Bacterial Tx: abx ear drops • Buffered acetic acid qid x10d • Cortisporinotic • Ciprofloxacin otic • Systemic abx? • Fungal (black dots, fuzz) • Tx: antifungal ear drops • 1% tolnaftate drops Ear wicks are beautiful things, but hard to find

  46. OtitisExterna Prevention ? Cotton w/ petroleum jelly during swimming

  47. Nasal Injuries • Ear Injuries • Mouth Injuries • Teeth Injuries • Eye Injuries

  48. Lip Lacerations • Compression of lip on teeth • Look for associated dental and other bony injury

  49. Lip Lacerations • Mucosa-only lacs heal well w/o sutures • Deep or thru & thru lacerations require layered repair • Vermilion border: approximate border FIRST, then repair remainder (consider referral) • Prophylactic abx or chlorhexidine rinse bid

  50. Tongue lacerations • Irrigate, remove foreign bodies • Repair muscle with 3-0 absorbable if deeper than 5mm • Repair mucosa if still necessary, absorbable is fine

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