Otorhinolaryngology
Charles W. Webb
C. Thayer White
INTRODUCTION
Facial injuries are among the most common injuries in athletics. They comprise 4%-19% of all sports-related injuries depending on age and gender. Of all facial injuries, 3%-29% are sports related, with the majority (60%-90%) occurring in males ages 10-29 (8,9). The gender difference increases with age from 1.5:1 male to females during the ages of 1-10 years to 12:1 during the ages of 16-18 (10,13). With the addition of facemasks and mouth guards in football and hockey (1950s and 1970s, respectively), the number of severe facial injuries has declined dramatically (3).
ASSESSMENT OF FACIAL INJURIES ON THE SIDELINE
Sideline management of the athlete with a facial injury begins with the ABCs (airway, breathing, circulation). Blood, avulsed teeth, mouth guards, or other objects are airway hazards. Cervical spine precautions must be observed in all head injuries, especially when the player is unconscious.
The history should include the mechanism of injury and assess for related injuries and the presence of any other injuries past or present (9).
Most facial injuries are the result of direct trauma. Assess the nature of the impact and the presence or absence of protective equipment.
Ask about alertness, orientation, headaches, vision symptoms, and neurologic deficits to assess for concussion or intracranial injury.
Ask about neck pain and take appropriate cervical spine precautions.
Other questions to ask include the following: Can you breathe through both sides of your nose? Are you having any trouble speaking? Is your hearing normal? Have you had any previous facial injuries or surgeries, including procedures to correct vision (e.g., laser-assisted in situ keratomileusis [LASIK])?
Physical examination includes observation, palpation, and imaging (if there is any question about the diagnosis).
Observation includes evaluation of facial symmetry, bruising, lacerations, and swelling. Asymmetry is especially important to assess on the sideline because it may be a clue to facial fracture and can become obscured by swelling and hematoma (9).
Bruising around the mastoid process is called Battle’s sign and is suggestive of a basilar skull fracture.
Observation of the nares includes the septum, which can be seen with an otoscope. A bluish-tinted bulge represents a septal hematoma.
Palpation includes the orbital rim, nasal bones, maxillary bones, mandible, temporomandibular joint, mastoid process, and the upper and lower jaws
The nares should be inspected for any type of fluid drainage. This may be blood or cerebrospinal fluid (CSF). The “ring test” is a method of detecting CSF on the sideline. It is done by placing a drop of blood from the nares on a piece of paper or gauze; CSF will form a halo (clear fluid ring) around the drop of blood. This represents a severe facial fracture and requires immediate transport.
Imaging is usually of limited value. X-rays may be helpful in determining the presence of a facial fracture; however, computed tomography (CT) is the gold standard.
Return-to-play guidance is based on the history and physical examination. Suspected fractures (except some nasal fractures), airway obstruction or impending obstruction, uncontrolled bleeding, loss of consciousness, and changes in vision are contraindications for return to play.
EAR INJURIES
Ear Laceration
The more common ear injuries encountered in sports include lacerations, hematomas, otitis externa and exostosis of the outer ear, and tympanic membrane (TM) rupture (traumatic and barometric) of the inner ear.
The auricle consists of avascular cartilage, which derives its nutrition from the tightly adhered perichondrium. Overlying that is closely adhered skin with little subcutaneous tissue (1).
Signs and symptoms: Pain and bleeding around the ear with history of trauma.
Examination: Must evaluate for cartilage involvement and for radial extension to the scalp.
Treatment
Cartilage tear must be repaired unless it is very small and can be readily approximated. Absorbable 5-0 suture is preferred.
Local anesthesia is best achieved with nerve blocks of the great auricular nerve (along the superficial body of the sternocleidomastoid muscle 6.5 cm inferior to the auditory canal) and V3 nerve (2.5 cm anterior to the tragus in the notch between the condyle and coronoid process of the mandible) to avoid local tissue swelling (15).
Laceration should be irrigated thoroughly prior to suturing, being careful to avoid removing the perichondrium.
Debridement of cartilage should be kept to a minimum to maintain cosmetic appearance and minimize risk of chondritis.
All exposed cartilage must be covered after the repair.
After the repair, apply a pressure dressing to prevent formation of auricular hematoma.
Prophylactic antibiotics may be used to prevent chondritis.
Auricular Hematoma
“Wrestler’s ear” or “cauliflower ear” is caused by bleeding between the skin (perichondrium) and the auricular cartilage. This occurs secondary to repetitive contusions to the auricle. This can evolve into a permanent cosmetic deformity with chronic hematomas, secondary to an increased pressure and eventual necrosis of the cartilage.
Signs and symptoms: Acute throbbing pain, tenderness, and edema.
Examination: Soft hematoma within the auricle.
Treatment
Definitive treatment is incision and complete evacuation of hematoma as soon as possible, followed by compression (2).
Compression may be achieved by mattress sutures through the ear with or without cotton bolstering. A circumferential pressure dressing is also acceptable but less desirable.
The athlete should not return to play until after the removal of the compression device in 7-10 days and should always wear proper ear protection (head gear).
An alternative treatment method is repeated aspiration of the hematoma. This allows the athlete to return to play quickly (same day with head gear); however, this treatment method usually leads to a permanent cauliflower ear. Both the athlete and the parents should be informed of the risk and the permanence of this defect (11).
Otitis Externa (OE)
Infection of the external auditory canal is most commonly caused by bacteria (90%), primarily Pseudomonas aeruginosa, Staphylococcus aureus, or occasionally other aerobic and anaerobic species. Fungal infections cause 10% of cases (7).
Acute OE is unilateral in 90% of patients.
OE is most common in children 7-12 years old and rare after age 50.
Risk factors include high humidity, warm water, ear trauma, and compromised immune system. It is most common in water sports and has an increased incidence in poorly chlorinated pools and fresh water.
Evaluation
Mild: erythema of the canal with mild discomfort and pruritus and a watery discharge.
Moderate: developing edema and mucopurulent discharge.
Severe: obstruction of the lumen with surrounding cellulitis, parotitis, or adenopathy.
Debris may be seen in the lumen, which should be removed to visualize the TM and facilitate effective treatment.
Always ensure TM integrity before irrigation or using ototoxic topical medications.
Differential diagnosis
Other dermatologic conditions may manifest in the ear, such as contact dermatitis, eczema, or psoriasis.
Contact dermatitis from ototopicals is not uncommon, occurring in 5%-18% of patients using neomycin.
Consider fungal causes if not responding to antibacterial treatment.
Treatment
Mild cases, including most fungal causes, may be treated with astringents, such as 2% acetic acid, 2.75% boric acid, or rubbing alcohol.
Moderate to severe cases should be treated with a topical antibiotic with or without topical corticosteroid. Commonly used medications include aminoglycosides, Cortisporin Otic (neomycin/polymyxin B/hydrocortisone), and fluoroquinolones.
Fluoroquinolones are the only topical antibiotic approved for ruptured TM.
Tolnaftate or clotrimazole can be used for fungal infections.Related posts:
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