The Head and Face

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 • 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

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 • 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. 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. 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 Recognition and Management of Specific Head Injuries

14. 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

16. 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

17. 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?

18. 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

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 • 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 • 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