Facial Pathologies and Related Special Tests Orthopedic Assessment III – Head, Spine, and Trunk...

Facial Pathologies Facial Pathologies and Related and Related Special TestsSpecial Tests

Orthopedic Assessment III Orthopedic Assessment III – Head, Spine, and Trunk – Head, Spine, and Trunk

with Labwith Lab

PET 5609CPET 5609C

Ear PathologiesEar Pathologies

Auricular Hematoma: Auricular Hematoma: “Cauliflower Ear”“Cauliflower Ear” MOI:MOI: Repeated blunt Repeated blunt

trauma or shearing trauma or shearing forces to external earforces to external ear

Pooling of blood between Pooling of blood between the skin and cartilage the skin and cartilage (cartilage deprived of (cartilage deprived of nutrition)nutrition)

Over time, hematoma can Over time, hematoma can scar - deformityscar - deformity

Inspection:Inspection: Red appearanceRed appearance Swelling of auricleSwelling of auricle EcchymosisEcchymosis


Auricular Auricular Hematoma:Hematoma: Palpation:Palpation:

Acute Injury: pain, Acute Injury: pain, confirm presence of confirm presence of hematomahematoma

Chronic Injury: Chronic Injury: hardened feelinghardened feeling

Functional/Functional/Neurological Tests:Neurological Tests:

Otoscope → check inner Otoscope → check inner earear

Hearing and BalanceHearing and Balance Note:Note: Rule out brain Rule out brain

trauma (blow to head)trauma (blow to head)

Ear PathologiesEar Pathologies Tympanic Membrane Tympanic Membrane

Rupture:Rupture: History:History:

Onset of SymptomsOnset of Symptoms → Acute → Acute PainPain → Severe pain in middle → Severe pain in middle

ear; radiating inward and ear; radiating inward and outwardoutward

MOI:MOI: Sudden change in air pressure Sudden change in air pressure

→ blunt trauma (slap to ear), → blunt trauma (slap to ear), blocked sneeze, mechanical blocked sneeze, mechanical intrusion (i.e. cleaning ear intrusion (i.e. cleaning ear with pen)with pen)

Tympanic membrane Tympanic membrane burstsbursts

Predisposing ConditionsPredisposing Conditions → → URI, otitis mediaURI, otitis media

Ear PathologiesEar Pathologies Tympanic Membrane Rupture:Tympanic Membrane Rupture:

Inspection:Inspection: Blood, fluid leaking from ear (fluid should Blood, fluid leaking from ear (fluid should

not be present in canal → immediate not be present in canal → immediate referral)referral)

Can signify skull fracture Can signify skull fracture Inspection with Otoscope:Inspection with Otoscope:

Cerumen – reddish-brown wax formed in auditory Cerumen – reddish-brown wax formed in auditory meatusmeatus

Functional Testing:Functional Testing: Hearing LossHearing Loss Valsalva maneuver may result in audible Valsalva maneuver may result in audible

escape of air from within inner earescape of air from within inner ear

Ear PathologiesEar Pathologies Tympanic Membrane Tympanic Membrane

Rupture:Rupture: Complications:Complications:

Permanent hearing loss Permanent hearing loss Ear infection (otitis media) Ear infection (otitis media)

Treatment:Treatment: Ruptured or perforated eardrum Ruptured or perforated eardrum

usually heals by itself within 2 usually heals by itself within 2 monthsmonths

Treatment: relieve pain, prevent Treatment: relieve pain, prevent infection (Antibiotics) infection (Antibiotics)

Surgical repair of the ear drum may Surgical repair of the ear drum may be neededbe needed

Prevention:Prevention: Keep ear dry and clean while it heals Keep ear dry and clean while it heals Prevent water entering the earPrevent water entering the ear Ear plugs while swimming. Ear plugs while swimming. Do not insert objects into the ear Do not insert objects into the ear

canalcanal

Ear PathologiesEar Pathologies Otitis Externa: “Swimmer’s Ear”Otitis Externa: “Swimmer’s Ear”

Infection of external auditory meatusInfection of external auditory meatus History:History:

Pain: constant, pressure, itchingPain: constant, pressure, itching MOI: Inadequate drying of ear canal (water sports)MOI: Inadequate drying of ear canal (water sports)

Excessive water exposureExcessive water exposure Water collects in the ear canal (trapped by wax) Water collects in the ear canal (trapped by wax)

Resultant bacteria (Resultant bacteria (streptococcusstreptococcus, , staphylococcus)staphylococcus) /fungus growth/fungus growth

Predisposing Conditions: Psoriasis, eczema, oily skin, open Predisposing Conditions: Psoriasis, eczema, oily skin, open wounds within ear; Overcleaning of external auditory canalwounds within ear; Overcleaning of external auditory canal

Inspection:Inspection: Redness, possible presence of clear discharge from Redness, possible presence of clear discharge from

middle earmiddle ear Palpation: Palpation: ↑ pain with tugging on earlobe↑ pain with tugging on earlobe Treatment:Treatment:

Prescription drops (acid-based) mixed with antibiotics or Prescription drops (acid-based) mixed with antibiotics or corticosteroidscorticosteroids


Otitis Externa:Otitis Externa: Prevention:Prevention:

Decrease exposure to Decrease exposure to waterwater

Ear plugs (if prone to Ear plugs (if prone to infection) infection)

Swimmer's ear drops or Swimmer's ear drops or alcohol drops (Swim-alcohol drops (Swim-EAR®) used in the ear EAR®) used in the ear after water exposure after water exposure followed by drying the followed by drying the ear with a hair dryer ear with a hair dryer held at arms length held at arms length

Do not insert Do not insert instruments, scratch, or instruments, scratch, or use cotton swabs in the use cotton swabs in the ears. ears.


Otitis Media:Otitis Media: Infection or Infection or

inflammation of the inflammation of the middle earmiddle ear

Often begins when Often begins when infections (viral or infections (viral or bacterial) that causes URI bacterial) that causes URI spread to the middle earspread to the middle ear

History:History: Pain/pressure within earPain/pressure within ear Irritability, difficulty Irritability, difficulty

sleeping, fever sleeping, fever Fluid draining from the ear Fluid draining from the ear Loss of balance Loss of balance Hearing difficultyHearing difficulty

Ear PathologiesEar Pathologies Otitis Media:Otitis Media:

Inspection:Inspection: Otoscope → fluid Otoscope → fluid

build-up / reddened, build-up / reddened, bulging tympanic bulging tympanic membranemembrane

Functional Testing:Functional Testing: HearingHearing Weber TestWeber Test

Treatment:Treatment: Oral antibioticsOral antibiotics Decongestants and Decongestants and

antihistamine antihistamine medicationsmedications

Nasal PathologiesNasal Pathologies Nasal Fractures:Nasal Fractures:

History:History: Onset: Acute (most Onset: Acute (most

commonly fractured commonly fractured facial/skull bone)facial/skull bone)

Pain: Bridge of nose Pain: Bridge of nose and cartilage, frontal and cartilage, frontal and zygomatic bonesand zygomatic bones

MOI: Direct blowsMOI: Direct blows Inspection:Inspection:

Possible deformityPossible deformity BleedingBleeding Ecchymosis (raccoon Ecchymosis (raccoon

eyes)eyes)

Nasal PathologiesNasal Pathologies

Nasal Fractures:Nasal Fractures: Palpation:Palpation:

PainPain CrepitusCrepitus

Note:Note: Any patient Any patient suffering a nasal suffering a nasal fracture needs to fracture needs to be screened for be screened for injury to the injury to the eyes/headeyes/head


Repeated Nasal Repeated Nasal Trauma:Trauma: Saddle-Nose Saddle-Nose

Deformity:Deformity: Necrosis of nasal Necrosis of nasal

cartilagecartilage Collapsed bridge Collapsed bridge

of noseof nose


Repeated Nasal Repeated Nasal Trauma:Trauma: Deviated Septum:Deviated Septum:

Nasal SeptumNasal Septum - thin wall - thin wall inside your nose that inside your nose that separates right and left separates right and left nasal cavities nasal cavities

Ideally, septum is Ideally, septum is situated in the center of situated in the center of your noseyour nose

80 percent of people have 80 percent of people have a septum that is a septum that is displaced to one side (one displaced to one side (one nasal passage smaller nasal passage smaller than the other)than the other)

Septum significantly off-Septum significantly off-center (deviated septum)center (deviated septum)

Nasal PathologiesNasal Pathologies Deviated Septum:Deviated Septum:

Blockage of one side of Blockage of one side of your nose – reduced air your nose – reduced air flowflow

Signs and Symptoms:Signs and Symptoms: Difficulty breathingDifficulty breathing Nasal congestionNasal congestion NosebleedsNosebleeds Frequent sinus Frequent sinus

infectionsinfections Causes:Causes:

Can be present at birthCan be present at birth Result of injuryResult of injury

Treatment:Treatment: Medication, SurgeryMedication, Surgery

Throat PathologiesThroat Pathologies Throat Trauma:Throat Trauma:

History:History: Onset – acute Onset – acute Pain: Anterior neck, increased during swallowing or Pain: Anterior neck, increased during swallowing or

taking deep breathstaking deep breaths MOI: Blow to anterior neckMOI: Blow to anterior neck

Inspection:Inspection: Bruising, swellingBruising, swelling Mouth/throat – possible bloody septumMouth/throat – possible bloody septum Patient: coughing (attempting to clear airway) / Patient: coughing (attempting to clear airway) /

altered voicealtered voice Palpation:Palpation:

Point tenderness, crepitus, displacement of cartilagePoint tenderness, crepitus, displacement of cartilage Treatment:Treatment:

Immediate referral / Monitor vital signsImmediate referral / Monitor vital signs

Facial FracturesFacial Fractures

Mandibular Mandibular Fractures:Fractures: History:History:

Onset: AcuteOnset: Acute Pain: Ramus or Pain: Ramus or

mental protuberance mental protuberance of mandibleof mandible

MOI: Direct blowMOI: Direct blow Inspection:Inspection:

Swelling, gross Swelling, gross deformitydeformity

Malocclusion of teethMalocclusion of teeth Palpation:Palpation:

Tenderness, crepitusTenderness, crepitus

Facial FracturesFacial Fractures Mandibular Mandibular

Fractures:Fractures: Functional Tests:Functional Tests:

Pain with Pain with opening/closing opening/closing mouthmouth

Lateral tracking of Lateral tracking of mandiblemandible

Neurological Tests:Neurological Tests: Cranial Nerves V, VIICranial Nerves V, VII

Special Tests:Special Tests: Tongue Blade testTongue Blade test

Treatment:Treatment: ReferralReferral

Facial FracturesFacial Fractures Zygoma Fractures:Zygoma Fractures:

History:History: MOI: Direct blow to cheek MOI: Direct blow to cheek

or inferior periorbital areaor inferior periorbital area Pain: Injury site, possibly Pain: Injury site, possibly

↑ with eye movement↑ with eye movement Inspection:Inspection:

Subconjunctival hematomaSubconjunctival hematoma Periorbital swellingPeriorbital swelling

Palpation:Palpation: Tenderness at zygomatic Tenderness at zygomatic

arch, lateral eye socketarch, lateral eye socket Treatment: Treatment:

ReferralReferral

Facial FracturesFacial Fractures Maxillary Fractures:Maxillary Fractures:

History:History: May occur May occur

concurrently with concurrently with nasal fracturenasal fracture

Pain: Midpoint of facePain: Midpoint of face Inspection:Inspection:

EcchymosisEcchymosis SwellingSwelling

Palpation:Palpation: Pain and crepitusPain and crepitus

Treatment:Treatment: ReferralReferral

Facial FracturesFacial Fractures

LeFort Fractures: LeFort Fractures: Midface fractureMidface fracture MOI:MOI: High-impact High-impact

forcesforces Automobile accidentAutomobile accident Unusual in athleticsUnusual in athletics

Inspection:Inspection: Upper teeth/face can Upper teeth/face can

be displaced forwardbe displaced forward Classification:Classification:

I – maxillaI – maxilla II – maxilla and nasalII – maxilla and nasal III – crosses zygomatic III – crosses zygomatic

and orbital bonesand orbital bones

Dental ConditionsDental Conditions Dental Injuries: Dental Injuries:

RatesRates Female athletes:Female athletes:

1.5% - softball1.5% - softball 7.5% - basketball7.5% - basketball

Male athletes:Male athletes: Basketball (highest)Basketball (highest) Ice hockeyIce hockey LacrosseLacrosse FootballFootball SoccerSoccer BaseballBaseball VolleyballVolleyball ADA: Universal

National System (1-32)

Dental ConditionsDental Conditions

Tooth Fracture: Tooth Fracture: Classifications (Ellis Classifications (Ellis System)System) Class IClass I – enamel only – enamel only Class IIClass II - enamel and - enamel and

dentindentin pain to touch and pain to touch and

sensitivity to air. sensitivity to air. Class IIIClass III – enamel, – enamel,

dentin, pulpdentin, pulp Pain with manipulation, Pain with manipulation,

air, and temperature.air, and temperature.


Tooth Luxation:Tooth Luxation: Extrusive luxation: Extrusive luxation: partially partially

displaced from the socket displaced from the socket Greatly increased mobility and Greatly increased mobility and

radiographs show displacementradiographs show displacement Lateral luxation: Lateral luxation: tooth displaced tooth displaced

laterally laterally Intrusive luxation: Intrusive luxation: teeth forced into teeth forced into

their sockets in an axial directiontheir sockets in an axial direction Can be buried (no visibility)Can be buried (no visibility) Decreased mobilityDecreased mobility

Intrusive Luxation

Lateral and extrusive luxation

Avulsion and luxation


Dental ConditionsDental Conditions Dental Caries: Dental Caries:

CavitiesCavities Cause:Cause:

Plaque – food, mucus, Plaque – food, mucus, and bacteria that and bacteria that collect and harden on collect and harden on the exposed tooth the exposed tooth (can harden into (can harden into tartar)tartar)

Sugars, starches, Sugars, starches, acid-rich food, poor acid-rich food, poor oral hygieneoral hygiene

Signs/Symptoms:Signs/Symptoms: As decay enlarges → As decay enlarges →

heat/cold sensitivity, heat/cold sensitivity, visible defectvisible defect

Dental ConditionsDental Conditions Gingivitis: Inflammation of the gumsGingivitis: Inflammation of the gums

Cause:Cause: Accumulation of plaque → bacteria released Accumulation of plaque → bacteria released

into gumsinto gums Overbrushing can lead to inflammationOverbrushing can lead to inflammation Increased risk:Increased risk:

Poor oral hygienePoor oral hygiene DiabetesDiabetes Pregnancy, Birth control pillsPregnancy, Birth control pills

Signs/Symptoms:Signs/Symptoms: Soreness, bleeding gumsSoreness, bleeding gums Red and swollen gumsRed and swollen gums

Treatment:Treatment: Plaque, tartar removal (dental care)Plaque, tartar removal (dental care)

TMJ PathologyTMJ Pathology TMJ Dysfunction:TMJ Dysfunction:

HistoryHistory:: Onset:Onset: Acute, chronic Acute, chronic Pain:Pain: Area of TMJ; Area of TMJ;

clicking/locking of clicking/locking of jointjoint

MOI:MOI: Blunt trauma to Blunt trauma to the mandible or the mandible or progressive joint progressive joint degeneration (i.e. degeneration (i.e. punch – forces punch – forces mandible laterally)mandible laterally)

Inspection:Inspection: Swelling, Malocclusion Swelling, Malocclusion

of the jawof the jaw Palpation:Palpation:

Point tendernessPoint tenderness Clicking when mouth Clicking when mouth

open/closedopen/closed

TMJ PathologyTMJ Pathology

TMJ Dysfunction:TMJ Dysfunction: Functional Tests:Functional Tests:

Observation of jaw Observation of jaw during during opening/closing of opening/closing of mouthmouth

Any deviation?Any deviation?

Treatment:Treatment: Referral to Referral to

physicianphysician Instruct athlete Instruct athlete

not to eat hard not to eat hard foods (↑ pain)foods (↑ pain)

Special TestsSpecial Tests

Otoscope:Otoscope: Allows health care Allows health care

providers to see the providers to see the outer and middle earouter and middle ear

Steps:Steps: Choose a speculum size Choose a speculum size

appropriate for the appropriate for the patient’s canalspatient’s canals

Hold the otoscope in the Hold the otoscope in the hand of the same side as hand of the same side as the ear you are the ear you are examiningexamining

Special TestsSpecial Tests Otoscope Use: (Steps Otoscope Use: (Steps

continued)continued) Examine the good ear Examine the good ear

first:first: Prevents spread of Prevents spread of

infection into unaffected infection into unaffected earear

You can see normal You can see normal anatomy (for comparison)anatomy (for comparison)

Inspect the Eardrum:Inspect the Eardrum: Tympanic membrane Tympanic membrane

should appear shiny, should appear shiny, translucent, and smooth translucent, and smooth (without perforations)(without perforations)

Any suspected disruption, Any suspected disruption, fluid, pus, debris seen → fluid, pus, debris seen → Medical referral Medical referral


TMJ Palpation Test: TMJ Palpation Test: (External) (External) Procedure: TMJ is Procedure: TMJ is

palpated while palpated while mouth is opened mouth is opened and closedand closed

Positive Sign:Positive Sign: Asymmetry of Asymmetry of

movementmovement Clicking / Locking of Clicking / Locking of

jointjoint

Special TestsSpecial Tests TMJ Palpation Test: TMJ Palpation Test:

(Internal)(Internal) Positioning:Positioning: Examiner places Examiner places

his fingers in the outermost his fingers in the outermost portion of auditory canal portion of auditory canal (with rubber gloves on)(with rubber gloves on)

Procedure:Procedure: Subject Subject repeatedly opens/closes the repeatedly opens/closes the mouth while examiner mouth while examiner applies gentle pressure in an applies gentle pressure in an anterior directionanterior direction

Positive Findings:Positive Findings: Pain, discomfort during Pain, discomfort during

opening/closing of mouthopening/closing of mouth Asymmetry of movementAsymmetry of movement


TMJ Range of Motion:TMJ Range of Motion: Patient Position:Patient Position: Seated or standing Seated or standing

(examiner is positioned in front of (examiner is positioned in front of subject)subject)

Procedure:Procedure: Patient attempts to place as Patient attempts to place as many flexed knuckles as possible many flexed knuckles as possible between upper and lower teethbetween upper and lower teeth

Positive Test:Positive Test: Patient unable to place a Patient unable to place a minimum of 2 knuckles within the minimum of 2 knuckles within the mouthmouth Decreased TMJ ROM Decreased TMJ ROM


Weber Test:Weber Test: Tests for hearing loss Tests for hearing loss

Otitis MediaOtitis Media Procedure:Procedure: Strike a Strike a

tuning fork softly and tuning fork softly and place the vibrating place the vibrating fork on the middle of fork on the middle of the patient’s foreheadthe patient’s forehead

Ask patient if the sound Ask patient if the sound is heard better in one is heard better in one ear or the same in both ear or the same in both earsears

Special TestsSpecial Tests Weber Test: Weber Test:

(continued)(continued) Positive Test:Positive Test: Athlete Athlete

hears the vibration hears the vibration louder in the affected louder in the affected earear

Reasoning:Reasoning: Conduction Conduction problem in affected ear problem in affected ear masks the ambient noise masks the ambient noise of the room, while the of the room, while the well-functioning inner ear well-functioning inner ear picks the sound up via the picks the sound up via the bones of the skull causing bones of the skull causing it to be perceived as a it to be perceived as a quieter sound in the quieter sound in the unaffected earunaffected ear

Special TestsSpecial Tests Tongue Blade Test:Tongue Blade Test:

Possible mandibular fracturePossible mandibular fracture Position:Position:

Patient seated with examiner standing in Patient seated with examiner standing in frontfront

Procedure:Procedure: Tongue depressor is placed in patient’s mouthTongue depressor is placed in patient’s mouth Patient attempts to hold the depressor in Patient attempts to hold the depressor in

place, the examiner twists the tongue place, the examiner twists the tongue depressordepressor

Positive Test:Positive Test: Patient unable to maintain a firm bite / PainPatient unable to maintain a firm bite / Pain


Chvostek Test: Chvostek Test: Facial Facial Nerve PathologyNerve Pathology Positioning:Positioning: Patient Patient

seated or standing seated or standing Procedure:Procedure: Examiner taps Examiner taps

over the masseter muscle over the masseter muscle and parotid glandand parotid gland

Positive Finding:Positive Finding: Twitching of the facial Twitching of the facial muscles (masseter)muscles (masseter)

Special Consideration:Special Consideration: Twitching of facial Twitching of facial muscles may also be muscles may also be result of low calcium result of low calcium levels in the bloodlevels in the blood

Facial Pathologies and Related Special Tests Orthopedic Assessment III – Head, Spine, and Trunk...

Documents

Transcript of Facial Pathologies and Related Special Tests Orthopedic Assessment III – Head, Spine, and Trunk...