Eye, Facial, and Dental Trauma in Sports James McKinley MD University of Texas Health Center at Tyler.

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1 Eye, Facial, and Dental Trauma in Sports James McKinley MD University of Texas Health Center at Tyler

2 Introduction  Epidemiology  On-field assessment  Nasal injuries  Ear injuries  Dental injuries  Eye injuries

3 Epidemiology  Maxillofacial injuries – 4 -18% of all reported athletic injuries.  Boys 2-3 times more injuries than girls in like sports (esp. under 15 yrs.).  1962- face masks and mouth guards mandatory in football (dramatic decline in maxiillofacial injuries)  Baseball – now 40% of sports related facial injuries

4 Epidemiology  50% involve mouth and teeth.  50% divided among eye, ear, nose, face.  Low speed injuries – (elbow or fist) usually cause soft tissue injuries (lacerations, contusions).  High speed injuries – (balls, pucks, sticks) most likely to cause fractures of face/teeth.

5 On–field assessment  ABC’s – avulsed tooth, blood, mouth guard may obstruct airway.  C-spine precautions in unconscious athlete.

6 On-field assessment- History  How did the injury occur?  Associated injuries (neck, c-spine)?  LOC, altered mental status, other symptoms of concussion?  Can you bite down gently, do teeth mesh normally (jaw fracture)?

7 On-field Exam  Facial symmetry, bruising, swelling.  Palpate orbital rims, nasal bones, upper and lower jaws, TMJ areas for tenderness, crepitus, step-off.  Palpate the upper and lower jaw, teeth, intraorally.  Assess stability of mid-face, grasping and pulling forward two front teeth.  Inspect nares for hematomas, CSF leak (ring test)

8 Diagnostic Imaging  X-rays-facial series and Panorex view of mandible.  CT scan if fracture suspected.

9 Return to play  Decision based on results of history and physical.  Presence of suspected fracture, active bleeding, airway obstruction, LOC, or visual difficulty should preclude return to play.

10 Nasal Injuries

11  Most commonly injured structure on the face.  Lateral blows-simple fractures, deviated to one side.  Direct blows-may cause comminuted fractures of bone and cartilage.

12 Nasal Fracture - symptoms  “Crack”, epistaxis, tearing, pain.  Inability to breath through a nostril may indicate septal hematoma

13 Nasal Fracture - Exam  Usually a clinical diagnosis-deformity.  Internal nasal exam-septal hematoma, CSF leak.  Palpate the nose for crepitus, tenderness.  X-rays not helpful in making treatment decisions.

14 Nasal Fracture - Treatment  It’s possible to reduce a displaced fracture (relatively painless if immediate).  Swelling often hides deformity; may take 5-7 days to decide if reduction necessary.  Reduction becomes much more difficult after 10-14 days.  Avoid return to play for a week, protective gear for at least 4 weeks.

15 Nasal Fracture

16 Septal Hematoma  Usually associated with nasal fracture (rare)  Accumulation of blood between the cartilage and mucoperichondrium.  Prone to abscess formation and pressure necrosis of the septum – “saddle nose”

17 Septal Hematoma - Symptoms  Similar to nasal fracture  Nasal obstruction  Pain

18 Septal hematoma - Exam  Bluish bulge from the nasal septum that obstructs the nares.

19 Septal Hematoma - Treatment  Prompt aspiration is critical  Followed by bilateral nasal packing for several days.  Prophylactic antibiotics

20 Epistaxis  Minor or major trauma to nose.  Can be associated with nasal mucosal dryness.  Anterior – 95% of nosebleeds (Kiesselbachs plexus on anterior septum)  Posterior – usually not from trauma, but requires more aggressive intervention.

21 Epistaxis - Symptoms  Posterior bleeds drain down into throat.  Anterior bleeds drip from nostrils, usually easily stopped with pressure.  Profuse bleeds with fracture – anterior ethmoid artery, require reduction of fracture with packing.

22 Epistaxis - Exam  Look for site of bleeding.  Anterior – usually visualized.  Posterior – usually not.

23 Epistaxis - Treatment  Sit forward, extend neck, gently blow one nostril at a time (remove clots).  Pinch the anterior nose between the thumb and index finger 2 – 5 minutes for anterior bleed.  If pain/fracture prevent pinch, apply ice to back of neck (reflex vasoconstriction) and nasal packing.

24 Epistaxis - Treatment  Nasal packing – can use petroleum jelly gauze or commercial pack (nasal tampon) – can be soaked in neo- synephrine to cause vasoconstriction.  Silver nitrate stick may also be used (ouch).

25 Nasal packing

26 Epistaxis - Treatment  Failure to control bleeding usually indicates posterior bleed, or laceration of anterior ethmoid artery, often need ENT consult/hospitalization.  Foley catheter for emergency hemostasis.  Petroleum jelly to septal mucosa both nares twice daily for anterior bleed, atraumatic.

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28 Auricular Hematoma  Contusion or trauma to ear  Bleeding between auricular cartilage and skin  Can cause pressure necrosis and scarring, “cauliflower ear”.

29 Auricular Hematoma

30 Symptoms  Pain, swelling, tenderness.  Well-defined hematoma forms after a few hours.

31 Treatment  Initial – ice, pressure dressing, vaseline to hot spots on ear to prevent friction.  Prompt, sterile aspiration with a 20 gauge needle.  Prophylactic antibiotics for seven days.  Compression to prevent reoccurrence for 7-10 days.  Sutures around dental rolls or button, cast from gauze soaked in flexible colloidin with pressure dressing. Or repeated aspiration (poor cosmetic).

32 Ear Laceration  Cosmetic deformity if extends through cartilage.  Examine closely for cartilage involvement.  Look for avulsion of the pinna.

33 Treatment  Approximate cartilage with fine absorbable sutures prior to skin closure.  Wheal of lidocaine (no epi) around entire base of ear will anesthetize all but external canal and concha.  Prophylactic antibiotics to prevent chondritis, a devastating complication.

34 Tympanic Membrane Rupture  Slap to side of head.  Barotrauma – scuba diving.  Fall during water skiing or surfing

35 symptoms  Sudden and painful “pop”.  Minor bleeding.  Usually a sudden unilateral hearing loss.  Associated vertigo and nausea if cold water enters ear (labyrinth stimulation).

36 Examination  Blood in the external canal.  Hole in TM usually easily visualized with an otoscope.

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38 Treatment  90% heal without intervention in 8 weeks.  Frequent re-examination to document healing.  Avoid nose blowing, sneeze with an open mouth for a few weeks.  Antibiotic drops (cortisporin Otic Suspension) if infection suspected, blood in canal (favors bacterial growth), or contamination suspected (lake water).

39 Follow Up  Formal hearing test for large ruptures (>25% of TM) within 2-3 days to rule out nerve injury (sensorineural loss).  Ear protectors should be worn in contact sports to prevent recurrence.

40 Otitis Externa  Infection of external auditory canal.  Pseudomonas, proteus, e. coli, fungi.  After prolonged water exposure (swimming sports).  Higher incidence in fresh water, poorly chlorinated water.  Scratching or probing the ear canal may predispose.

41 Symptoms  Pain, increased with manipulation of the auricle.  Associated watery to purulent discharge and hearing loss (conductive).

42 Exam  External canal is swollen and edematous, TM normal or not visualized.  Fungal – canal lining may appear fuzzy with black specks, odor may be present.

43 Treatment  Clear ear canal so drops can penetrate.  Antibiotic drops usually sufficient, oral antibiotics for severe, recalcitrant cases.  A cotton wick placed in the canal (24-48 hrs) will help drops penetrate if there is a lot of swelling.  Use topical antifungal solution/lotion if fungus.  Prevent recurrence with 5 drops of 50/50 mixture of white vinegar and rubbing alcohol after swimming.

44 Lip Lacerations  Compression of lip onto teeth with trauma.  Look for associated dental trauma.  Bleed profusely.  Most superficial mucosal lacerations heal without suturing, even tongue lac’s.  Deeper or through and through lac’s may need repair.

45 Lip Lacerations  Direct pressure to reapproximate wound edges and ice (vasoconstriction), can help control bleeding.  Lacerations that cross the vermilion border need careful repair to prevent cosmetic defect.  Consider prophylactic antibiotics and twice daily Chlorhexadine (.12%) rinses.

46 Temporomandibular Joint Dislocation  An athlete is struck with mouth open, or w/o trauma when mouth opens too wide (big yawn, shout).  Sx’s – unable to close mouth, at least moderate pain.  Exam – mandible dislocates anteriorly, then spasm pulls it superiorly.

47 TMJ Dislocation  Treatment – reduction by applying downward pressure (well padded thumbs) placed just posterior to the last lower molars, followed by slight posterior traction to lever the condyles back in place.  May need sedation.  Soft diet, avoid opening mouth wide for at least a week.

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49 Tooth Anatomy

50 Tooth Fracture  Small chip, or crack in enamel usually benign.  Sx’s – sensitivity to inhaled air indicates deeper injury into pulp or dentin.

51 Tooth Fracture  Enamel only – uniform color at fracture site.  Dentin – yellowish color at site.  Dental pulp – pink or red pulp at fracture site.  Use finger pressure against tooth to expose larger, partial fracture.

52 Treatment  Enamel – require only smoothing of rough edges.  Dentin – should be seen by dentist within 24 hours.  Pulp – usually need urgent referral, root canal and cap.

53 Avulsed Tooth  Hold tooth by crown, avoid touching the root. Clean debris with sterile saline, or water.  Re-implantation within 30 minutes – 90% chance of saving tooth (>6 hrs, virtually no chance). Make sure tooth orientation is correct.  Bite down on gauze or wet tea bag to hold tooth in place.  If unable to re-implant, tooth should be transported in buccal vestibule, milk, or saline.

54 Avulsed Tooth  Should see dentist within few hours for more permanent bracing, and x-rays to rule out other fractures.  Prophylactic antibiotics (pen VK) and tetanus immunization.  Can’t find tooth? CXR to R/O aspiration (requires bronchoscopy).  Mouth guards will prevent most sports related dental injuries.

55 Eye Injuries

56 Ocular Injuries  Consider ocular injury in any athlete with facial trauma.  2/3 pt’s with facial fractures sustain some degree of ocular injury.  Non-ophthalmologist should be able to recognize ocular injuries, provide basic treatment, and decide when emergency consultation is required.

57 History  Present – Injury time and mechanism, visual acuity and light perception immediately after injury.  Past – pre-injury visual status, prior trauma, medical conditions.  Pertinent ROS – visual acuity, pain, photophobia, diplopia, flashing lights, tearing, headache, nausea.  Medications – aspirin, anticoagulants.  Glasses, contacts.

58 Ocular Examination  Compare to uninvolved eye.  Visual acuity – read text, count fingers, light perception. Single, most important test.  Pupils – round, symmetric, and reactive?  Extra-ocular movements–full, symmetric?  Visual fields – are they full?

59 Ocular Examination  Condition of lids, conjunctiva, sclera, signs of perforation.  Anterior chamber – look for blood (hyphema).  Cornea – fluorescein stain to identify epithelial defects.  Fundoscopic exam – is red reflex present?  Other – slit lamp, intraocular pressure.

60 Chemical Burn  True ocular emergency – rare in sports (chalk or field dust).  Acids – localized, precipitation of proteins.  Alkali – worse, saponification of tissues.  Exam – a white eye indicates necrosis of blood vessels, worse prognosis.

61 Chemical Exam - Treatment  Irrigate first, Examine later! – Direct relationship between the duration of exposure and the severity of injury.  Preferred irrigation solution is normal saline or Ringer’s lactate, but non-sterile water is acceptable. Irrigate to a pH of 7.4 regardless of the volume of saline required. Do not try to neutralize acid with base, or vice – versa.  Bucket/tub of water will suffice in a pinch.

62 Chemical Burn - Treatment  Identify and remove any particulate matter (evert lids).  May use Opthaine or tetracaine to numb. Use antibiotic drops after, and a cycloplegic to help with pain.

63 Corneal Abrasion  Common in basketball, from fingernail (or stick)  Symptoms – Sharp pain, photophobia, foreign body sensation, tearing.  Exam – Check visual acuity, fluorescein stain and examine with cobalt blue light, flip lid, examine for foreign body.

64 Corneal Abrasion

65 Treatment  Not a contact wearer – antibiotic ointment (sulfacetamide or erythromycin QID) +/- pressure patch.  Contact wearer – anti-pseudomonas coverage (tobramycin or ciprofloxacin QID) and no patch (due to increased risk of infection).  Cycloplegic agent for comfort (cyclopentolate 1-2%).  Chronic use of topical anesthetics will interfere with epithelial healing, should not be prescribed for home use.  Recheck eye in 18-36 hrs. to document healing.

66 Corneal or Conjunctival Foreign Body  Commonly from dust, metal fragments.  Sx’s – Pain, photophobia, and tearing, also foreign body sensation.  Exam – Document visual acuity, check for conjunctival injection, eyelid edema, anterior chamber reaction (use topical anesthetic if needed.  Evert lids, look for FB on cornea or conjunctiva.  Consider x-ray if high speed metallic FB suspected (grinding) to have entered globe.

67 Corneal metallic Foreign Body

68 Treatment  Cornea – Topical anesthetic and remove with needle tip (18 gauge) or foreign body spud. Need to remove rust ring with drill.  Conjunctiva – Topical anesthesia and remove with saline irrigation and cotton tipped applicator. Sweep the conjunctival fornices with a cotton tipped applicator soaked in anesthetic.

69 treatment  After successful, removal of a corneal FB, apply antibiotic ointment, cycloplegic, and pressure patch. Re-examine in 24 hrs.

70 Subconjunctival Hemorrhage  Very common after blunt trauma (also spontaneously in adults, not kids).  Often asymptomatic, occasionally irritation or “heavy feeling”.  Examine for FB or globe rupture.  No specific treatment required, reassure, most resolve within two weeks.

71 Subconjunctival Hemorrhage

72 Conjunctival Laceration  History of ocular trauma.  May need fluorescein stain to show a subtle tear.  Often see associated conjunctival hemorrhage.  Do complete ocular exam (consider Ophthalmology consult) exclude scleral laceration, ruptured globe, conjunctival or intraorbital FB.  Apply antibiotic ointment and pressure patch 24 hours.  Large lacerations (1.5 cm) may need sutures (8-0 vicryl), but most heal without them.

73 Lid Lacerations  Sharp or blunt trauma, from eyeglass lens.  Sx’s – pain, bleeding around eye.  Exam – Depth of penetration (into fat?) and location (middle one third may involve lacrimal system.  Complete ocular exam – r/o globe rupture.

74 Lid Lacerations - Treatment  Clean (betadine), local anesthetic, irrigate with saline, explore for FB, topical anesthetic and eye shell, repair with 5-0 absorbable suture, antibiotic ointment BID.  Refer to Ophthalmology if the lid margin involved (may get notch), canaliculus involved (may need tear duct stent), or extends into subcutaneous fat.

75 Orbit Fracture (Blowout Fracture)  Usually involve the orbital floor.  Fractures that extend to orbital rim often have associated facial bone fractures (malar, maxillary, naso-orbital, and frontal bone). Defect created by fracture can allow orbital contents to displace into the maxillary sinus, causing extra-ocular muscle damage or entrapment.

76 Orbital Fracture - symptoms  Pain, especially with upward gaze.  Diplopia.  Eyelid may swell when nose is blown.

77 Orbital Fracture - Exam  Restricted extra-ocular movements (especially upward or lateral).  Exophthalmos initially due to hemorrhage and edema, enophthalmos later.  Local tenderness, crepitus, step-off.  Hypesthesia in infraorbital nerve distribution, ipsilateral cheek and upper lip.

78 Orbital Fracture

79  Facial x-rays to include lateral, Water’s, Caldwell, and optic canal views. May see obscured maxillary sinus.  Tomograms may be helpful.  CT scan can help differentiate orbital edema/hemorrhage with out fracture.

80 Orbital Fracture - Treatment  Apply ice packs.  Avoid nose blowing.  Nasal decongestant (if needed) and oral antibiotic.  Operative versus non-operative management depending on severity.

81 Hyphema  Trauma causes bleeding into the anterior chamber of the eye.  Important to determine/quantify vision loss at time of injury.  25% bleed again at 3-5 days after injury.  Decreasing vision over time suggests recurrent or continued bleeding.

82 Hyphema - Symptoms  Pain  Photophobia  Vision often normal, unless bleeding is large.

83 Hyphema - Exam  Complete eye exam.  Blood in anterior chamber (may be black or red).  Check intraocular pressure (glaucoma is a common complication). Recheck pressure in 6 months.  Slit lamp exam may show turbid microscopic hyphema before it settles. These can rebleed.

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85 Hyphema - Treatment  Discuss with ophthalmologist urgently, many will admit to hospital for observation.  Strict bed rest, elevate HOB 30 degrees.  Eye shield at all times.  Re-examine daily.  Measures are to reduce the risk of rebleed.

86 Hyphema - Treatment  Atropine 1% drops TID helps pain.  No ASA, anticoagulants.  Consider hospitalization if poor visual acuity, increased intraocular pressure, or large initial hyphema size > 1/3 – ½ anterior chamber).

87 Ruptured Globe  Most common sites are near limbus, old wounds, under muscle insertions.  Sx’s – pain, blurred vision  Exam – boggy edema, severe subconjunctival hemorrhage, hyphema, irregular pupil, shallow anterior chamber, intraocular contents (dark brown or black tissue) on ocular surface, lids, or cheek.

88 Ruptured Globe

89 Ruptured Globe - Treatment  If eye visibly ruptured, call ophthalmologist emergently.  Transfer patient in upright or supine position (avoid prone or head down).  Eye shield (not pressure patch).  Definitive treatment includes surgical exploration, repair, primary enucleation.

90 Intraocular Foreign Body  Variant of ruptured globe.  Often secondary to high speed injury from grinding wheel.  Sx’s – may be minimal, pain or blurred vision.  Exam – entry wound through cornea or sclera. FB may be visible in ant. chamber, vitreous, or retina. Intraocular hemorrhage may obscure view, perform CT scan of orbit (not MRI).  Treatment – as per globe rupture – shield and refer to ophthalmology.

91 Retinal Detachment  May occur with blunt or penetrating trauma to eye, or indirect trauma to head.  Caused by the development of holes or tears within the retinal tissue.  Sx’s – begins as blind spot at edge of visual field. “lightening flashes” or “sparks” in visual field as it progresses. A “wavy black curtain” may encroach on central vision.

92 Retinal Detachment - Exam  Visual field defects.  Difficulty visualizing normal underlying vascular pattern with an ophthalmoscope.  Need to dilate the pupil to see early detachments that usually begin in the periphery of the retina.

93 Retinal Detachment

94 Retinal Detachment - Treatment  Urgent consultation with ophthalmologist.  Laser can seal holes and prevent progression.  Prognosis is poor once macula becomes involved.

95 Eye injuries - Prevention  Almost completely preventable with proper eye protection.  Eye exam and counseling should be part of PPE, especially in the functionally one eyed athlete.  Molded polycarbonate frames and lenses are suggested for contact lens wearers and those participating in high risk sports (racquet sports, hockey, baseball, basketball).

96 References  Davidson TN, Neuman TR. Managing Ear Trauma, Phys Sp Med, 22(7): 27-32,1994.  Dimeff RJ, Hough DO. Preventing Cauliflower Ear with Modified Tie Through Technique, Phys Sp Med, 17(3): 169-173, 1989.  Easterbrook M, et al. Assessment of Ocular Foreign Body Foreign Bodies, Phys Sp Med, 25(2): Feb 1997.  Josell SD, Abrams RG. Traumatic Injuries to the Dentition and its Supporting Structures, Ped Clinics N America, 29: 717,1982.  Kaufman BR, Heckler FR. Sports Related Facial Injuries, Clinics in Sports Medicine, 16(3):543-562,1997.  Kristensens, et al. Traumatic Tympanic Membrane Perforations; Complications in Management, Ear Nose and Throat Journal, 68:503- 516,1989.  Osguthorpe JD, Hoang G. Management of Patients with Facial Trauma and associated ocular/orbital injuries, Otolarngol Clin North America. 24(1): 79-91,1991.

97 References  Renner GJ. Management of Nasal Fractures, Otolaryngol Clin North Am, 24:195-213,1991.  Schelkun PH. Swimmer’s Ear: Getting Patients Back in the Water, Phys Sp Med, 19(7):85-90, 1991.  Schendel SA. Sport Related Nasal Injuries, Phys Sp Med, 18(10): 59-74, 1990.  Stackhouse T. On-site Management of Nasal Injuries, Phys Sp Med, 26(8):1998.  Weaver EM, Czibulka A, Sasaki CT. Acute Epistaxis: A Step by Step Guide to Controlling Hemorrhage; Consultant, March: 901- 916, 1999.  Vinger PF. A Practical Guide for Sports Eye Protection, Phys Sp Med, 28(6): 49-69, June 2000.  Zagelbaum BM. Treating Corneal Abrasions and Lacerations, Phys Sp Med, 25(3): March 1997.

98 Picture References  1) Septal Hematoma, entusa.com  2) Nasal Packing (balloon), shreyaas.net  3) Nasal Packing (pledgett), hydropore.com  4) Blue whale nose, geocities.com  5) nose protector, medcomedical.com  6) Dog Ears, ananova.com  7) Auricular Hematoma, visualsunlimited.com  8) Cauliflower Ear, longislandwrestling.org  9) TM Perforation, pedisurg.com  10) Jaw Dislocation, ncemi.org  11) Tooth Anatomy, mydr.com  12) Tooth Fracture, 32teethonline.com

99 Picture References  13) Eye Anatomy, macs.org/uk/detailed.html  14) Corneal Abrasion, opt.indiana.edu  15) Conjunctival Hemorrhage, opt.pcificu.edu  16) Blowout Fracture, aafp.org  17) Hyphema, varga.org  18) Globe Rupture, aafp.org  19) Retinal Detachment, avclinic.com  20) Retinal Detachment, siwofflowvision.com