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• Temporomandibul

ar 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