WK5 - Ear, Nose, Throat and Dental Flashcards
What are the 3 main nasal injuries?
- epistaxis (nosebleed)
- nasal fractures
- septal hematoma
What is epistaxis?
Spontaneous (more common)
- From Little’s area –> Nasal septum
* Kiesselbach’s plexus
- Often recurrent
* May see surgeon if it keeps occurring
Traumatic
- Reflect area of trauma
- Potential fracture of nose
What are the 3 main arteries in the nasal region from SUP to INF? And what is the main plexus?
- ANT ethmoidal artery
- POS ethmoidal artery
- Sphenopalatine Artery
Kiesselbach’s Plexus
What is the treatment for nasal injuries?
- direct pressure 20mins
- gauze (direct pressure: socked with adrenaline (1:1000)
- cautery
- nasal packing (if it keeps bleeding)
- specialist ENT referral
What is the process of applying direct pressure?
*Holding nose (at soft part), ask athlete to hold their own nose
*Must wait for enough time to pass so blood has time to clot
*If continue bleeding, tip head forward so blood drips out instead of down their throat
What is the mechanisms for nasal fractures?
direct blunt trauma
What are the symptoms of nasal fractures?
- local pain
- epistaxis
- local swelling/bruising
- deformity
- crepitus (grating sound or sensation produced by friction between bone/cartilage/fractured bone parts
- increased mobility
Consider wearing goggles to prevent blood spray from getting into eyes
What are key considerations of nasal fractures in relation to DRSABC?
- protect yourself from blood
- control bleeding
What other injuries should be assess for?
- concussion
- neck
- facial features
- eye injury
- teeth damage, jaw, cuts in/on lips, other facial fractures // problems with vision
List bone and cartilage in nose from SUP to INF.
- paired nasal bones
- upper lateral cartilages
- lower lateral cartilages
- accessory cartilages
- fibrofatty tissue
What is the process of treatment for simple nasal fractures?
- control bleeding (local pressure 10-20mins for blood to clot + nasal packing + antiobiotics)
- lacerations (steristrip or suture)
imaging
- not warranted - clinical diagnosis
- unless suspect other facial/orbit fractures (CT or MRI)
When are fracture reductions considered?
look fine and can breathe = does NOT need reduction
indications: marked deformity // nasal obstruction
timing
- acutely - severe deformity
- ENT referral
- reduction and splint (prevent immediate refracturing)
What is septal haematoma?
area of bleeding from nasal trauma
Complication: 2% of people with nasal trauma
What is the pathology of septal haematoma?
- septal cartilage injury
- bleeding in overly mucoperichondrium (accumulates more blood = increased swelling // can damage cartilage)
Unless drained risk
- septal necrosis (saddle nose deformity)
- septal abscess
- meningitis/intracranial abscess/cavernous sinus thrombosis = due to blood draining back into brain, no protection between brain and frontal part of face
What is the history of septal haematoma?
- increasing nasal pain
- increasing nasal obstruction
- develop fever = abscess present
How to examine septal haematoma?
- septal swelling (bilateral)
- ‘boggy’ to palpation - blunt probe (drained by med professional)
- obstructing airway
What are the treatments for septal haematoma?
-ENT referral or ED
-Incision and drainage
-Packing – prevent recurrence and blood from accumulating again
If there is abscess
* Emergency referral
* Incision and drainage
* IV antibiotics
What are the 3 main ear injuries?
- ear laceration
- auricular haematoma (collection of blood over cartilaginous area of ear)
- perforated tympanic membrane (ear drum)
What is the treatment for ear lacerations?
- control bleeding by holding pressure
-Check for other injuries - Eg. head injury, look behind ear as well
-Simple = suture
-Ear torn forward = suture skin
-Chondral involvement (cartilage damage) - Suture perichondrium
- Prophylactic oral antibiotics
-Complex laceration = Refer
List the mechanisms of auricular haematoma?
- shearing forces/blows
- recurrent
- haemorrhage (bleeding) under perichondrium (cause necrosis to cartilage)
What sports have the common injury of auricular haematomas?
- rugby union
- boxing
What is the acute treatment for auricular haematoma?
-Ice and compression
-Aseptic drainage and compression
* Incise, remove blood clot, then place skin back for pressure
* Ensure blood doesn’t reaccumulate
* Tape down
-Packing
-Firmly bandaged – pressure
-Daily review to make sure blood has accumulated again
Return to contact sport
-Headgear for prevention
What is the mechanism of perforated tympanic membrane (rupture of eardrum)?
- acute blow (pressure wave - nowhere for force to go)
- barotrauma (pressure change e.g. diving/scuba)
What are the symptoms of perforated tympanic membrane?
- sudden ear pain
- bleeding from ear
- decreased hearing (can be little or substantial
- tinnitus (ringing in ear)
- may/may not have vertigo (dizziness due to inner ear imbalance - vestibular regions // cause nausea)
What can be seen in examination of perforated tympanic membranes?
tear/rupture of eardrum
smaller the perforation = more likely to heal by itself
What is the treatment for a perforated tympanic membrane?
Keep dry
*Don’t want water in middle ear
*Prevent infection and prevent inner ear structures from getting wet
Amoxycillin
*Prevents infection
Allow it to heal spontaneously
*Living tissue
What is the prognosis of a perforated tympanic membrane?
more likely to heal spontaneously
- younger
- smaller perforation
- no infection (keep dry)
- blunt trauma rather than penetrating trauma
What is the RTS process for a perforated tympanic membrane?
If contact sport, ensure no vertigo
- Avoid another blow to the ear
Swimming/water polo athletes– ear plugs (usually custom made which prevents water from entering ear)
- If recreational, just modify with land-based training
Scuba/diving – await healing
What are the characteristics of Otorrhea?
it is a skull fracture
- significant head trauma
- clear fluid from ear (cerebrospinal fluid) –> leaks out from mid-ear due to hole in membrane. Bridge from outer environmnet into brain
- base of skull fracture
- neurological referral immediately
What are common dental injuries?
- fractured tooth
- avulsed tooth
What is the treatment for a fractured tooth?
-Collect all fragments for reattachment
-Wash off
-Store in saline or milk (skim milk best)
-Ensure has not been inhaled or ingested
* Introduction of infection
-Dental referral to reattach fragments
-Ensure they don’t have any other injuries, head injury possible if they have dental injury
* Eg. head injuries – may bite your fingers off while your fingers are in their mouth
What is the treatment for an avulsed tooth?
meaning tooth out of socket
- handle by crown not root (can cause damage to root, allow reconnection back to blood supply to be renourished)
- wash off with saline
Must be reimplanted to allow tooth to grow again
- correct alignment
- correct tooth in correct socket
- do not force
- bite down on gauze
dental referral or med professional
- 1st 12-24h for highest chance of survival
How to store a tooth out of socket?
- unable ot reimplant
- handle by crown
- wash off with saline
- if storing for <10min, use saline
- if storing 2-3h. use cold skim milk
- use athletes saliva if no milk available
- dental referral ASAP
How to prevent tooth avulsions?
- education (use mouthguards!)
customised // comfy
wear every time
ensure compliance
educate risks
face guards/shield
They do not protect against concussions!
What is considered in blunt abdominal/trunk trauma?
- potentially life-threatening (vital organs - liver, spleen, kidneys, pancreas)
- determine disposition of player
- should player RTP/be removed or transported for further eval?
- mechanism of injury (acc/dec injury may have different signs (superficial))
What are the early signs of shock in trunk injuries?
BP normal
Increased Pulse rate
Normal skin colour
cool/moist skin temp
increased rate and depth of respiration
what are the late signs of shock in trunk injuries?
BP >90mmHg systolic
Increased Pulse rate / weak
pale kin colour
cold skin temp
increased rate but shallow respiration
What are symptoms of shock in trunk injuries caused from?
*Initial drop in BP recognized by sensors in carotid arteries and aorta, triggering release of adrenaline
*Increase HR and vasoconstricts
–> Allows body to maintain BP, and vital organ perfusion
*Diaphoresis first seen on forehead and upper lip (sweat)
What is the treatment for shock?
- trendelenburg position (elevated feet)
- call 000
What to consider with pain from trunk injuries?
*Distribution of pain
*Location of pain
*Immediate vs worsening
*Local vs diffuse
*Stationary vs radiating
^ make notes, record their pain patterns and location
*Kehr’s Sign Pain worse when patient lowers head
-Increased contact of free blood clots with left diaphragm and phrenic nerve (c3, 4, 5)
-Onset can be delayed up to 4 hours
Provide an example of Kehr’s sign.
Clot collected under L diaphragm irritates it + phrenic nerve (C3,C4) causing referred pain in L shoulder 15min after foot end elevation
referred shoulder pain = something happening in intra-abdominal space
discolouration suggest hemoperitoneum
Grey Turner’s sign take 24-48h to develop
What type of injuries are caused from blunt force trauma to abdomen?
- diaphragmatic spasm
- abdominal wall contusion –> rectus abdominis hematoma
What is diaphragmatic spasm?
e.g. getting wind knocked out
- blow to stomach / hit in solar plexus
- athlete can RTP after breathing is normalised (if no normal breathing = usually just spasm)
- unlikely bad damage due to placement of spot (well hidden behind stomach, protected by L1)
What is abdominal wall contusion (rectus abdominis hematoma)?
-Can mimic acute abdomen
* Trauma, hematoma forms and causes pain
-Relief with abdomen in supported, flexed position BUT worsening pain with active flexion
-Cullen’s sign after some hours (maybe 72h)
-Blood supply more posterior, behind muscle belly
* Consider where blood vessels are
What is the importance of the arcuate line?
Above
- epigastric arteries are well encased, wont really get a hematoma
BELOW
- a lot more potential for hematoma development as only the peritoneum nad transversalis fascia are encasing it (less support)
* lower quadrant and R side (whichever is more dominant side)
MRI does not reveals high signal intensity esp. in early stages and is not useful in diagnosis of internal trunk injuries (CT might be better). True or false?
TRUE
In acute rectus sheath hematoma of less than 48h duration, MRI of rectus sheath hematoma does not reveal high signal intensity and not useful in diagnosis
What are the characteristics of hip pointers?
At ASIS or iliac crest
*Subperiosteal edema or bleeding from nutrient vessels of underlying bone/hematoma formation within surrounding muscle
*Not necessarily due to contact
*Could be from compression of ABD muscles against ilium/iliac crest
ASIS
- due to TFL (tensor fascia latae) and sartorius
- most prominent area
iliac crest
- due to contusion
- apophysis
Is there a possibility of traction apophysitis in hip pointers?
Yes.
- ASIS only fuses around 19-20y
- injury to cartilage/bony attachment of tendons in children and adolescent
How is the liver most commonly injured?
blunt abdominal trauma
Liver injuries are quite common in sports. True or false?
FALSE
rare in sports
- high intensity acc/dec forces can cause lacerations to liver at points of attachment to peritoneum/stretch injuries to intima and media of nearby arteries
True or false? Forces exerted against ANT abdominal wall can cause compression of underlying viscera against POS thoracic wall/vertebral column
TRUE
Why is the accuracy of liver injury in physical examinations as low as 55%?
- dependent on athlete history
- responsibility lies on sports trainer to watch game and determine mechanism of injury through observations
What are the symptoms of liver injuries?
- pain/discomfort with laughing, coughing or jumping = can indicate peritoneal irritation
- location of pain (R upper quadrant, R chest wall, R flank (back)
- nausea
- vomiting
- altered sensorium
The Spleen is also at risk of damage in sports. Why is it important to consider Infectious Mononucleosis (Mono), if athlete sustains a blunt force injury to abdomen?
Mono = Glandular Fever
- abdominal pain and enlargement of spleen
- lower chance of splenic rupture
- low chance of death from splenic rupture from glandular fever
Enlarged spleen = thinning of capsule = fragile = easy to rupture (splenomegaly - may not present pain)
other infectious diseases can also cause spleen to enlarge
Why should collisions/contact sports + Valsalva efforts be avoided with glandular fever?
forced/tense Valsalva manoeuvre while suffering from glandular fever = cause spleen rupture without blunt trauma
majority of splenic injuries occur within 1st 21 days of illness. Exceedingly rare at >28days
What to do if we suspect a splenic injury?
- immediate transport should be arranged as hemodynamic status can change quickly
What is the main spleen ligament called?
splenocolic ligament - It attaches the base of the splenic hilum to the left transverse mesocolon and splenic flexure
Why are kidneys more at risk of injury in children?
Kidneys are bigger compared to their overall proportions
What % of kidney injury is caused by blunt abdominal or flank injury (back)?
90%
- rapid acc/dec
- high-velocity impacts
avoid high contact sports, esp. if only have 1 kidney
Where are great forces transmitted in the kidney?
L kidney, at Renal hilum
What are the different types of kidney damage?
From Grade I - Grade V
grade 3 onwards: blood in urine as there’s damage to collecting system of kidney
> 4-5 = more trauma around hilum
Where is the bladder located?
above symphysis of pubic
Injuries associated with fractures to pelvis/surrounding structures
What % of bladder injury occurs in all blunt abdominal trauma cases (usually pelvic fractures)?
1.6%
What considerations are made for children’s bladders?
- bladder still quite abdominal, sits higher before descending nearer to adulthood
- not well protected by pubic symphysis
- lower abdominal trauma could cause irritation to bladder (macrotrauma –> compression/blood in urine from direct trauma)
What causes microtrauma of the bladder?
- long-distance running
- bladder moving forwards and back, slowly getting irritated
- not due to direct force
Where do common injuries occur in the testicle region?
- cremaster muscle
- testes
What causes injury to the testicular region?
direct trauma
What is tunica albuginea/tunica vaginalis (seal)?
- broach supporting structure = testicular rupture
- blood
- requires ultrasound
What is testicular torsion?
- 8% due to trauma
- delayed presentation of pain after scrotal trauma
- loss of cremasteric reflex, lies horizontally
- presents with diffuse, unilateral pain and tenderness (nausea/vomiting, 25% with fever // urinary/discharge not commonly reported)
- requires immediate urologic consultation
What happens when urethra is damaged?
POS most likely to sustain crush injury due to immobility nad proximity to penis) may be damaged as well (penis itself may not be damaged)
Causes:
- pelvic trauma
- blood at meautus
What causes first rib injuries?
Indirect force
e.g. trunk ROT, shoulder ADD = compression
Direct force - strong muscular force
e.g. differential pulls across ribs
Scalenes?
How to diagnose and treat first rib injuries?
Dx: more widespread // hard to see on x-rays
Tx: usually heal without long-term consequences
- no reported serious acute complications
What is the clinical presentation of first rib injuries?
-Nonspecific symptoms of shoulder girdle pain, maybe neck pain
-Most had pain in POS aspect of shoulder/scapula
-Not uncommon for athletes to have full shoulder ROM and preserved strength
-shoulder ABD >90 degrees seems to be especially painful
Are first rib injuries a common diagnosis?
Not a common diagnosis but also no uncommon
- no reported serious acute or long-term complications
- asymptomatic RTP
Ribs are not just bone, a lot of cartilage as well. True or False?
TRUE
- cartilaginous injuries don’t show on x-rays
- cartilage fractures likely lower down
“false” ribs = more vulnerable
- Ribs 6, 7, 8 involved in chondral rib fractures due to anatomical position = more exposure to blunt injury
Blunt trauma = more likely to injure lower ribs. True or false?
TRUE
What are the signs of rib cartilage injury?
- swelling at rectus abdominus and costal margin, specific for chondral fractures in contact sport
- click is often recognised by patient with Valsalva manoeuvre and twisting motions
What is rib/cartilage fixation?
Plating rib fractures
- screwing titanium plates into broken ribs to stabilise fractures
Wrap around ribs
surgery
Signs and symptoms of rib fractures due to twisting.
costochondral separation (between costal cartilage and bone)
- hard to take breaths
- hard to twist/turn UB
- sports involving twisting manoeuvres may predispose athletes to these injuries
What % of elite rowers are affected by rib stress injuries?
8-16.4%
What anatomical feature provides buffering to rib stress injuries?
Serratus ANT
- when fatigued = decreased buffering
- torsional forces cause RSI
What are the signs/symptoms of rib stress injuries?
Can be POS (scapular movement on ribs)
- tenderness common on mid-axillary line of chest wall
- somewhere along ribs 5-8 (6th rib most frequent)
- pain with press up or resisted SA testing
What have studies found with rib stress injuries?
ultrasound doesn’t significantly increase detection rate of rib fractures (may be uncomfortable as rubbing of probe back and forth)
- too time consuming
ANOTHER STUDY
- ultrasound discloses more fractures than radiography in those with suspected rib fractures + require less time than radiography
Contrast findings –> up to clinician to decide x-ray or ultrasound
Define mediastinum.
air in places not meant to be
- potential for respiratory issues
What are the potential causes of sharp chest pain?
- sternal and rib contusions
- rib fractures
- heartburn
- acute asthma exacerbation
- pneumothorax
- traumatic tracheal rupture
- myocardial infarction
- costochondritis
- pneumomediastinum (air present in mediastinum)
- pneumopericardium
Why is alertness required in chest injuries presenting 1-2h later?
- could be consequence of inappropriate presence of gas in mediastinal and pericardial spaces
esp. if they’re saying they have trouble breathing and want to sit up instead of lie down
Air collection increases, important structures are compression = rupture of alveolar walls. True or False?
TRUE
What complications arise when air is in mediastinum?
- mediastinal emphysema
- subcutaneous emphysema
What complications arise when air is in pleural cavity?
pneumothorax (lung collapse)
What complications arise when air is in pulmonary veins?
gas embolism
What is primary spontaneous pneumothoraxi (PSP)?
When air enters pleural space and disrupts -ve pressure, causing lung collapse
What happens when pneumothorax is small (15% of hemithorax) and other secondary aetiologies are ruled out?
1st episode can be managed more conservatively with observation alone
- may require chest tub in more serious case
There is a 54% (???) within the 1st 4y and there is a 30% chance for recurrence in pneumothorax. True or False
TRUE
Characteristics of closed pneumothorax?
- torn but then resealed itself
- pleural cavity pressure is less than atmospheric pressure
- resolves itself
Characteristics of open pneumothorax?
- tear is open
- pleural cavity pressure is = to atmospheric pressure
Characteristics of tension pneumothorax?
- fractured rib, pierced through pleura
- pleural tears acts as a ball nad valve mechanism
Air can’t get back in to lung, pleural cavity keeps expanding
Pleural cavity pressure > atmospheric pressure
What is the potential mechanism without fracture of ribs?
- Valsalva and grunting
- pleural porosity (more porotic) –> more potential for leakage when there is raised intrathoracic pressure –> predisposition for pneumothorax
- Blebs/bullae (small sacs of air in lungs that rupture, causing air to leak into pleural space –> puts pressure on lungs = may collapse
What are the risks of scuba diving on lung pressure?
- Chest trauma due to compressed air
- Pressure pushing on chest > ground level
- If ascend rapidly = pressure in alveoli increases (gas leakage/pneumothorax/or leak into vessels - gas emoblism)
- Exhale as you go up, don’t take breath until breaking surface of water (gets rid of pressurized gas)
List some facts about scuba diving.
- when underwater, chest pressure is 2x than at seas level
- gas mask regulator tells tank to equate pressure to undersea pressure
- something goes wrong and you ascend very quickly
- pressure in alveoli is now back to 1x, causing expansion and leakage
