KIN 191B – Advanced Assessment of Upper Extremity Injuries Face and Eye Anatomy, Evaluation and Injuries

Anatomy Facial anatomy Bony anatomy Temporomandibular joint Ear Nose Mouth, teeth and throat Muscular anatomy Eye anatomy Bony anatomy Globe Muscular anatomy

Facial anatomy

Bony anatomy

Temporomandibular joint

Ear

Nose

Mouth, teeth and throat

Muscular anatomy

Eye anatomy

Bony anatomy

Globe

Muscular anatomy

Facial Anatomy

Bony Anatomy Frontal bone Maxillary bone Inferior orbit, nasal cavity, oral cavity Upper row of teeth Nasal bone Zygomatic bone/arch/process Gives shape to cheeks Mandible Moveable portion of jaw, TMJ articulation Lower row of teeth

Frontal bone

Maxillary bone

Inferior orbit, nasal cavity, oral cavity

Upper row of teeth

Nasal bone

Zygomatic bone/arch/process

Gives shape to cheeks

Mandible

Moveable portion of jaw, TMJ articulation

Lower row of teeth

Face – Bony Anatomy

Temporomandibular Joint (TMJ) Synovial joint between temporal bone and mandible (condyle) Articular disc at joint enhances nature of articulation Movement at joint necessary for communication and mastication Injury often presents with malocculsion of teeth

Synovial joint between temporal bone and mandible (condyle)

Articular disc at joint enhances nature of articulation

Movement at joint necessary for communication and mastication

Injury often presents with malocculsion of teeth

TMJ Anatomy

Ear Anatomy External ear Auricle (pinna) – cartilaginous funnel of sounds External auditory meatus (canal – transmits sounds to middle ear) Middle ear Tympanic membrane (ear drum) Ossicles – malleus, incus, stapes (vibration) Eustachian tube – connects middle ear to nasal passage (pressure regulation, illness) Inner ear Cochlea – propagates sounds to brain via CN VIII Semicircular canals – filled with fluid, process body and head movements to brain, maintains balance

External ear

Auricle (pinna) – cartilaginous funnel of sounds

External auditory meatus (canal – transmits sounds to middle ear)

Middle ear

Tympanic membrane (ear drum)

Ossicles – malleus, incus, stapes (vibration)

Eustachian tube – connects middle ear to nasal passage (pressure regulation, illness)

Inner ear

Cochlea – propagates sounds to brain via CN VIII

Semicircular canals – filled with fluid, process body and head movements to brain, maintains balance

Ear Anatomy

Nasal Anatomy Proximal 1/3 of nose is bone Distal 2/3 comprised of cartilage Nasal septum separates nostrils Nostrils allow passage of air into pharynx and ultimately to trachea Mucosal cells warm and humidify air Nasal hairs trap foreign particles

Proximal 1/3 of nose is bone

Distal 2/3 comprised of cartilage

Nasal septum separates nostrils

Nostrils allow passage of air into pharynx and ultimately to trachea

Mucosal cells warm and humidify air

Nasal hairs trap foreign particles

Nasal Anatomy

Mouth, Throat and Teeth Mouth Oral vestibule (between lips and teeth) and oral cavity (between teeth and throat) Tongue – skeletal muscle, sense of taste Throat (larynx) Thyroid and cricoid cartilages Hyoid bone Teeth 32 permanent teeth (pulp, dentin, enamel) Root, neck and crown per tooth

Mouth

Oral vestibule (between lips and teeth) and oral cavity (between teeth and throat)

Tongue – skeletal muscle, sense of taste

Throat (larynx)

Thyroid and cricoid cartilages

Hyoid bone

Teeth

32 permanent teeth (pulp, dentin, enamel)

Root, neck and crown per tooth

Mouth Anatomy

Throat Anatomy

Muscular Anatomy Muscles of mastication Masseter – primary muscle for clenching jaw or chewing Multiple muscles responsible for mouth opening Muscles of expression Responsible for movement of lips, cheeks, nose, eyebrows and forehead Lack of symmetrical movement indicative of Bell’s palsy (cranial nerve deficit)

Muscles of mastication

Masseter – primary muscle for clenching jaw or chewing

Multiple muscles responsible for mouth opening

Muscles of expression

Responsible for movement of lips, cheeks, nose, eyebrows and forehead

Lack of symmetrical movement indicative of Bell’s palsy (cranial nerve deficit)

Facial Muscles

Eye Anatomy

Eye Anatomy Bony anatomy Globe Muscular anatomy

Bony anatomy

Globe

Muscular anatomy

Bony Anatomy Superior – frontal bone Lateral – zygomatic, frontal and spehnoid bones Inferior – zygomatic and maxillary bones Floor – add palatine bone Medial – lacrimal, ethmoid, maxillary and sphenoid bones Posterior – sphenoid bone

Superior – frontal bone

Lateral – zygomatic, frontal and spehnoid bones

Inferior – zygomatic and maxillary bones

Floor – add palatine bone

Medial – lacrimal, ethmoid, maxillary and sphenoid bones

Posterior – sphenoid bone

Bony Anatomy

Globe Sclera Visible white layer of the eye Pupil Dark, central aperture Separates anterior from posterior chamber Iris Pigmented contractile tissue controlling pupil size Conjunctiva Mucous membrane lining globe, eyelids and socket

Sclera

Visible white layer of the eye

Pupil

Dark, central aperture

Separates anterior from posterior chamber

Iris

Pigmented contractile tissue controlling pupil size

Conjunctiva

Mucous membrane lining globe, eyelids and socket

Globe Cornea Transparent anterior covering of eye Focuses light as it enters eye Lens Focuses light onto retina at back of eye Suspended by ligaments from ciliary body Retina Rods/cones are photoreceptors Optic nerve transmits impulses to brain

Cornea

Transparent anterior covering of eye

Focuses light as it enters eye

Lens

Focuses light onto retina at back of eye

Suspended by ligaments from ciliary body

Retina

Rods/cones are photoreceptors

Optic nerve transmits impulses to brain

Globe Anatomy

Muscular Anatomy 6 total muscles control eye movements Rectus muscles rotate eye toward contracting muscle Inferior, superior, medial and lateral Inferior and superior oblique muscles allow for torsion/rotation of the eye

6 total muscles control eye movements

Rectus muscles rotate eye toward contracting muscle

Inferior, superior, medial and lateral

Inferior and superior oblique muscles allow for torsion/rotation of the eye

Eye Muscles

Visual Acuity

Visual Acuity Utilization of Snellen eye chart 20/20 vision is “normal” (emmetropia) Myopia Nearsightedness, light focused anterior to retina Hypermetropia Farsightedness, light focused posterior to retina

Utilization of Snellen eye chart

20/20 vision is “normal” (emmetropia)

Myopia

Nearsightedness, light focused anterior to retina

Hypermetropia

Farsightedness, light focused posterior to retina

Snellen Eye Chart

Evaluation of Facial Injuries

Facial Evaluation History Anatomy specificity Inspection Anatomy specificity Palpation Special tests Discussed with pathologies

History

Anatomy specificity

Inspection

Anatomy specificity

Palpation

Special tests

Discussed with pathologies

History - Ear Location of pain Internal pain indicative of infection and/or tympanic membrane injury External pain typically due to trauma Etiology Typically blunt force trauma Tympanic membrane more susceptible secondary to infection, foreign objects or pressure changes Related symptoms Tinnitus, dizziness, congestion

Location of pain

Internal pain indicative of infection and/or tympanic membrane injury

External pain typically due to trauma

Etiology

Typically blunt force trauma

Tympanic membrane more susceptible secondary to infection, foreign objects or pressure changes

Related symptoms

Tinnitus, dizziness, congestion

History - Nose Location of pain Generally localized, may involve other facial structures, esp. eyes Etiology Typically blunt force trauma May be secondary to illness and/or environment Typical symptoms Pain, bleeding (epistaxis), associated head injury Relevant medical history Prior injuries/conditions which may affect anatomy or symptom presentation

Location of pain

Generally localized, may involve other facial structures, esp. eyes

Etiology

Typically blunt force trauma

May be secondary to illness and/or environment

Typical symptoms

Pain, bleeding (epistaxis), associated head injury

Relevant medical history

Prior injuries/conditions which may affect anatomy or symptom presentation

History - Throat Location of pain External is generally trauma related Internal is generally systemic in nature Etiology Typically blunt force trauma Related symptoms Dyspnea, respiratory distress Difficulty speaking

Location of pain

External is generally trauma related

Internal is generally systemic in nature

Etiology

Typically blunt force trauma

Related symptoms

Dyspnea, respiratory distress

Difficulty speaking

History - Maxillofacial Location of pain Generally at site of injury due to etiology Etiology Typically blunt force trauma Related symptoms Visual impairment Difficulty with eye movements Malocclusion of teeth/TMJ injuries

Location of pain

Generally at site of injury due to etiology

Etiology

Typically blunt force trauma

Related symptoms

Visual impairment

Difficulty with eye movements

Malocclusion of teeth/TMJ injuries

Inspection

Inspection - Ear Auricle Contusion, laceration, avulsion Auricular hematoma (cauliflower ear) Tympanic membrane Utilize otoscope, also inspect meatus Should be shiny, translucent and smooth Periauricular area Battle’s sign (basilar skull fracture)

Auricle

Contusion, laceration, avulsion

Auricular hematoma (cauliflower ear)

Tympanic membrane

Utilize otoscope, also inspect meatus

Should be shiny, translucent and smooth

Periauricular area

Battle’s sign (basilar skull fracture)

Tympanic Membrane

Inspection - Nose Alignment Asymmetry may be due to fracture and/or swelling Epistaxis May or may not be associated with fracture or trauma Septum Deviation indicative of septal injury Eyes/face “ Raccoon’s eyes” often associated with nasal fracture

Alignment

Asymmetry may be due to fracture and/or swelling

Epistaxis

May or may not be associated with fracture or trauma

Septum

Deviation indicative of septal injury

Eyes/face

“ Raccoon’s eyes” often associated with nasal fracture

Insepction - Throat Thyroid and cricoid cartilages Appreciate normal location and appearance May be compromised with swelling Can compromise airway – must be treated as medical emergency

Thyroid and cricoid cartilages

Appreciate normal location and appearance

May be compromised with swelling

Can compromise airway – must be treated as medical emergency

Inspection – Face/Jaw Bleeding Facial lacerations tend to bleed significantly Ecchymosis Around eyes from contusion and/or fracture Around tooth “socket” with contusion/fracture Symmetry Identify bony prominences and compare bilaterally Muscle tone Ability to move jaw and create facial expressions

Bleeding

Facial lacerations tend to bleed significantly

Ecchymosis

Around eyes from contusion and/or fracture

Around tooth “socket” with contusion/fracture

Symmetry

Identify bony prominences and compare bilaterally

Muscle tone

Ability to move jaw and create facial expressions

Inspection - Mouth Lips Often lacerated with dental injuries Teeth Inspect for fractures/avulsion/subluxation Tongue Often lacerated with dental injuries or head trauma Gums Inspect for lacerations, ecchymosis, abcess

Lips

Often lacerated with dental injuries

Teeth

Inspect for fractures/avulsion/subluxation

Tongue

Often lacerated with dental injuries or head trauma

Gums

Inspect for lacerations, ecchymosis, abcess

Palpation

Primary Palpable Structures Nasal bone/cartilage Zygomatic arch Maxilla Temporomandibular joint Periauricular area (mastoid processes) Auricle Teeth Mandible Hyoid bone Cricoid cartilage Thyroid cartilages

Nasal bone/cartilage

Zygomatic arch

Maxilla

Temporomandibular joint

Periauricular area (mastoid processes)

Auricle

Teeth

Mandible

Hyoid bone

Cricoid cartilage

Thyroid cartilages

Special Tests

Special Tests Specific tests discussed with pathologies Neurological function generally associated with cranial nerve evaluation Vascular assessment generally performed via skin color and temperature

Specific tests discussed with pathologies

Neurological function generally associated with cranial nerve evaluation

Vascular assessment generally performed via skin color and temperature

Facial Pathologies

Facial Injuries Ear Nose Throat Facial fractures Dental injuries Temporomandibular joint injuries Lacerations

Ear

Nose

Throat

Facial fractures

Dental injuries

Temporomandibular joint injuries

Lacerations

Ear Injuries Auricular hematoma Tympanic membrane injury Otitis externa Otitis media

Auricular hematoma

Tympanic membrane injury

Otitis externa

Otitis media

Auricular Hematoma Often referred to as cauliflower ear Associated with blunt force trauma Bleeding between skin and underlying cartilage – if left untreated, will scar Often drained and casted for optimal resolution Must rule out associated head injury

Often referred to as cauliflower ear

Associated with blunt force trauma

Bleeding between skin and underlying cartilage – if left untreated, will scar

Often drained and casted for optimal resolution

Must rule out associated head injury

Auricular Hematoma

Tympanic Membrane Injury Most common mechanisms are penetration with foreign object, blunt force trauma or systemic infection Evaluate with otoscope – pull up on ear to straighten canal for easier viewing Excessive ear wax (cerumen) can obscure view of tympanic membrane Must be referred if obvious hole, bleeding or swelling/fluid accumulation on/near tympanic membrane

Most common mechanisms are penetration with foreign object, blunt force trauma or systemic infection

Evaluate with otoscope – pull up on ear to straighten canal for easier viewing

Excessive ear wax (cerumen) can obscure view of tympanic membrane

Must be referred if obvious hole, bleeding or swelling/fluid accumulation on/near tympanic membrane

Cerumen

Perforated Tympanic Membrane

Otitis Externa Commonly referred to as “swimmer’s ear” – outer ear infection (meatus) Ear pain and pressure May complain of dizziness and/or tinnitus Area is red and inflamed Must keep dry, often prescribed antibiotic ear drops for treatment

Commonly referred to as “swimmer’s ear” – outer ear infection (meatus)

Ear pain and pressure

May complain of dizziness and/or tinnitus

Area is red and inflamed

Must keep dry, often prescribed antibiotic ear drops for treatment

Otitis Externa

Otitis Media Middle ear infection – eustachian tubes become blocked and increase pressure on inner ear Often secondary to URI, air travel, environmental allergies Tympanic membrane may be red, opaque, demonstrate fluid and/or bulge Typically treat with antibiotics and may use decongestants or antihistamines for symptom relief

Middle ear infection – eustachian tubes become blocked and increase pressure on inner ear

Often secondary to URI, air travel, environmental allergies

Tympanic membrane may be red, opaque, demonstrate fluid and/or bulge

Typically treat with antibiotics and may use decongestants or antihistamines for symptom relief

Otitis Media

Nasal Injuries Nasal fracture Most commonly fractured facial bones Often presents with deformity but not requisite – may have crepitus Typically has associated epistaxis Septal deviation Viewed from inside nostrils with otoscope or penlight

Nasal fracture

Most commonly fractured facial bones

Often presents with deformity but not requisite – may have crepitus

Typically has associated epistaxis

Septal deviation

Viewed from inside nostrils with otoscope or penlight

Nasal Fracture/Deviated Septum

Throat Injuries May present with dyspnea, anxiety, dysphagia, laryngitis Must identify obvious deformity and refer immediately to avoid respiratory complications associated with swelling

May present with dyspnea, anxiety, dysphagia, laryngitis

Must identify obvious deformity and refer immediately to avoid respiratory complications associated with swelling

Facial Fractures Mandibular fracture Second most commonly fractured facial bone – tongue blade test Usually present with malocclusion May have difficulty opening and/or closing mouth Zygomatic arch fracture May present with step-off deformity or “blow-out” fracture (globe “sinks”) Eye movements may be compromised, especially upward rotation Usually periorbital swelling and globe irritation

Mandibular fracture

Second most commonly fractured facial bone – tongue blade test

Usually present with malocclusion

May have difficulty opening and/or closing mouth

Zygomatic arch fracture

May present with step-off deformity or “blow-out” fracture (globe “sinks”)

Eye movements may be compromised, especially upward rotation

Usually periorbital swelling and globe irritation

Mandible Fractures

Facial Fractures Maxillary fracture Often associated with nasal fracture Look for ecchymosis along gums/alveolar processes LeFort fracture classifications Type I – only maxilla fracture Type II – maxilla, nasal and suborbital fractures Type III – complete craniomaxillofacial separation

Maxillary fracture

Often associated with nasal fracture

Look for ecchymosis along gums/alveolar processes

LeFort fracture classifications

Type I – only maxilla fracture

Type II – maxilla, nasal and suborbital fractures

Type III – complete craniomaxillofacial separation

LeFort Fractures

Dental Injuries Tooth fractures Ellis class I – chip fracture to tooth surface Ellis class II – fracture through enamel and dentin Ellis class III – fracture to pulp level Ellis class IV – fracture through pulp level at gum level Must refer to DDS for eval and treatment

Tooth fractures

Ellis class I – chip fracture to tooth surface

Ellis class II – fracture through enamel and dentin

Ellis class III – fracture to pulp level

Ellis class IV – fracture through pulp level at gum level

Must refer to DDS for eval and treatment

Tooth Fractures

Dental Injuries Tooth luxations Subluxation/extrusion Often heal well if stabilized in place Use mouthguard until evaluated by DDS Avulsion/dislocation Attempt to reimplant if whole – high success rate if done early on Rinse with saline if possible/necessary If can’t reimplant, store in milk, saline, saliva or emergency tooth kit and refer immediately

Tooth luxations

Subluxation/extrusion

Often heal well if stabilized in place

Use mouthguard until evaluated by DDS

Avulsion/dislocation

Attempt to reimplant if whole – high success rate if done early on

Rinse with saline if possible/necessary

If can’t reimplant, store in milk, saline, saliva or emergency tooth kit and refer immediately

Tooth Luxations

Temporomandibular Joint Injuries May include sprain, disc injury, subluxation or dislocation Dislocations obvious due to deformity Other conditions may present with pain and/or clicking on jaw movements or asymmetrical jaw movements Must differentiate from mandible fracture Tongue blade test

May include sprain, disc injury, subluxation or dislocation

Dislocations obvious due to deformity

Other conditions may present with pain and/or clicking on jaw movements or asymmetrical jaw movements

Must differentiate from mandible fracture

Tongue blade test

Lacerations Must stop bleeding and rule out underlying pathologies Want to refer for repair as soon as possible for best results Consider DDS, OMS or plastic surgeon for severe facial/oral laceration suturing

Must stop bleeding and rule out underlying pathologies

Want to refer for repair as soon as possible for best results

Consider DDS, OMS or plastic surgeon for severe facial/oral laceration suturing

Evaluation of Eye Injuries

Eye Evaluation History Inspection Periorbital area Globe Palpation Special tests Vision assessment Pupillary reaction Eye movements Neurological evaluation

History

Inspection

Periorbital area

Globe

Palpation

Special tests

Vision assessment

Pupillary reaction

Eye movements

Neurological evaluation

History Location of symptoms Photophobia is common “ Feels like foreign object” – corneal abrasion Itching – conjunctivitis and/or allergies Etiology Direct trauma to orbit and/or eye Foreign objects (dirt, sand, chlorine, etc.) Visual history Visual acuity, use of glasses/contact lenses

Location of symptoms

Photophobia is common

“ Feels like foreign object” – corneal abrasion

Itching – conjunctivitis and/or allergies

Etiology

Direct trauma to orbit and/or eye

Foreign objects (dirt, sand, chlorine, etc.)

Visual history

Visual acuity, use of glasses/contact lenses

Inspection Periorbital area Gross deformity (“blowout fracture”) or bleeding require immediate referral Periorbital hematoma (“raccoon’s eyes”) may indicate contusion, eye injury or fracture

Periorbital area

Gross deformity (“blowout fracture”) or bleeding require immediate referral

Periorbital hematoma (“raccoon’s eyes”) may indicate contusion, eye injury or fracture

Inspection Globe Eyelids – swelling, laceration, ecchymosis Cornea – best evaluated with flourescein and cobalt blue light Hyphema – blood in anterior chamber of eye Conjunctiva – irritation (allergies or foreign object) vs. subconjunctival hemorrhage Sclera – bleeding secondary to contusion Iris – should be symmetrical Pupil – PEARL, anisicoria, teardrop indicative of corneal laceration or ruptured globe

Globe

Eyelids – swelling, laceration, ecchymosis

Cornea – best evaluated with flourescein and cobalt blue light

Hyphema – blood in anterior chamber of eye

Conjunctiva – irritation (allergies or foreign object) vs. subconjunctival hemorrhage

Sclera – bleeding secondary to contusion

Iris – should be symmetrical

Pupil – PEARL, anisicoria, teardrop indicative of corneal laceration or ruptured globe

Eyelid Laceration

Corneal Abrasion

Hyphema

Conjunctivitis

Iris

Teardrop Pupil

Palpation

Primary Palpable Structures Orbital margin/rim Associated bony areas Frontal, temporal, nasal, zygoma Soft tissue and globe (through lids)

Orbital margin/rim

Associated bony areas

Frontal, temporal, nasal, zygoma

Soft tissue and globe (through lids)

Special Tests Vision assessment Snellen chart vs. available reading material Pupillary reaction PEARL – cranial nerve relevance Eye movements Cranial nerve relevance Potential for associated fracture Neurological evaluation Cranial nerve assessment

Vision assessment

Snellen chart vs. available reading material

Pupillary reaction

PEARL – cranial nerve relevance

Eye movements

Cranial nerve relevance

Potential for associated fracture

Neurological evaluation

Cranial nerve assessment

Eye Movements

Eye Pathologies

Eye Injuries and Conditions Orbital fractures Corneal abrasions and lacerations Iritis Detached retina Ruptured globe Conjunctivitis

Orbital fractures

Corneal abrasions and lacerations

Iritis

Detached retina

Ruptured globe

Conjunctivitis

Orbital Fractures Blunt force trauma, typically from object larger than orbit, may fracture it Most common is “blow out” fracture Inferior displacement due to fracture of floor of orbit May present with numbness due to neurological entrapment May present with inability to look upward due to entrapment of inferior rectus muscle

Blunt force trauma, typically from object larger than orbit, may fracture it

Most common is “blow out” fracture

Inferior displacement due to fracture of floor of orbit

May present with numbness due to neurological entrapment

May present with inability to look upward due to entrapment of inferior rectus muscle

Corneal Abrasion and Laceration Occurs either from foreign object beneath eyelid or from direct insult Often not grossly visible Complaints of “something in eye”, excessive tearing, etc. Treat with antibiotic drops, anesthetic drops and may patch Corneal lacerations often visible grossly – teardrop pupil is classic presentation

Occurs either from foreign object beneath eyelid or from direct insult

Often not grossly visible

Complaints of “something in eye”, excessive tearing, etc.

Treat with antibiotic drops, anesthetic drops and may patch

Corneal lacerations often visible grossly – teardrop pupil is classic presentation

Iritis Typically caused by trauma to eye resulting in inflammatory response in iris Most common symptoms are photophobia, abnormal/sluggish pupillary reaction May cause permanent pupil deformity

Typically caused by trauma to eye resulting in inflammatory response in iris

Most common symptoms are photophobia, abnormal/sluggish pupillary reaction

May cause permanent pupil deformity

Detached Retina Typically associated with jarring movement of head but may be secondary to sneeze Rupture of communication between retina and optic nerve May present with blind spots or halos and often note “curtain” falling over field of vision Typically requires surgical intervention

Typically associated with jarring movement of head but may be secondary to sneeze

Rupture of communication between retina and optic nerve

May present with blind spots or halos and often note “curtain” falling over field of vision

Typically requires surgical intervention

Detached Retina

Ruptured Globe Almost always associated with direct trauma to globe Severe pain and complete loss of vision Most common location of rupture is posterior so often hard to appreciate – look for black spots on sclera which are indicative of globe contents spilling outwardly

Almost always associated with direct trauma to globe

Severe pain and complete loss of vision

Most common location of rupture is posterior so often hard to appreciate – look for black spots on sclera which are indicative of globe contents spilling outwardly

Ruptured Globe

Conjunctivitis Viral or bacterial infection Often presents with discharge, eyelids stuck together in AM, itching and redness/swelling of conjunctiva Highly contagious – avoid touching eye Generally treated with antibiotics prophylactically

Viral or bacterial infection

Often presents with discharge, eyelids stuck together in AM, itching and redness/swelling of conjunctiva

Highly contagious – avoid touching eye

Generally treated with antibiotics prophylactically