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Kin 191 B – Face And Eye Anatomy, Evaluation And Injuries
 

Kin 191 B – Face And Eye Anatomy, Evaluation And Injuries

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    Kin 191 B – Face And Eye Anatomy, Evaluation And Injuries Kin 191 B – Face And Eye Anatomy, Evaluation And Injuries Presentation Transcript

    • 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
      • 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
    • 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
    • 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
    • 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 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)
    • Facial Muscles
    • Eye Anatomy
    • Eye 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
    • 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
    • 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
    • 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
    • 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
    • Snellen Eye Chart
    • Evaluation of Facial Injuries
    • Facial Evaluation
      • 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
    • 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
    • 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
    • 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
    • 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)
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • Facial Pathologies
    • Facial Injuries
      • Ear
      • Nose
      • Throat
      • Facial fractures
      • Dental injuries
      • Temporomandibular joint injuries
      • Lacerations
    • Ear Injuries
      • 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
    • 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
    • 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
    • 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
    • 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/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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • Evaluation of Eye Injuries
    • Eye 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
    • Inspection
      • 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
    • 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)
    • 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
    • Eye Movements
    • Eye Pathologies
    • Eye Injuries and Conditions
      • 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
    • 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
    • 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
    • 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
    • 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
    • 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