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Raja Abou Elella

on 11 May 2015

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Transcript of Hospital

Uncommon Sports Injuries“ENT Prospective”
design by Dóri Sirály for Prezi
Temporal bone trauma is extremely varied, ranging from minor concussion without functional deficits to severe blunt or penetrating trauma with multifunctional deficits that involve the auditory and vestibular nerves, the facial nerve, and the intracranial contents.
HOB elevation > 30 deg
Lumbar drain
Stool softeners
No nose-blowing, coughing

Brodie and Thompson et al.
820 T-bone fractures/122 CSF leaks
Spontaneous resolution with conservative measures
95/122 (78%): within 7 days
21/122(17%): between 7-14 days
5/122(4%): Persisted beyond 2 weeks

Temporal Bone Fractures
Take Home Message
Conservative Treatment
Indications for Surgical Intervention

“Donkey face” (lengthening)
“Pumpkin face” (edema)
Nasal flattening
Often associated with orbital fractures

Mid Face Fractures
By: Dr. Ahmed M. Habib
ENT Specialist & Cl. Audiologist

I have no disclosure of any financial or commercial interests, nor any conflict of interest relevant to this presentation
Points of Discussion
Temporal bone fractures
Ear injuries
Facial bone fractures
Airway Maintenance Techniques
Literature updates
Take Home Message

Hearing loss: conductive or sensorineural
Facial weakness or paralysis (7% overall)
More rare: facial numbness and diplopia

Physical Examination
Ear & Eye examination
Facial nerve exam
Nasal exam for rhinorrhea
Tuning fork exam
Audiometric testing
Battle’s sign: postauricular ecchymosis
Raccoon sign: periorbital ecchymosis

High resolution CT is the gold standard
MRI for cranial nerve injury
MRA or angiogram for vascular injury

Types of Temporal Bone Fractures
Transverse Fractures
Mixed Fractures
Role of
following temporal bone fracture and facial palsy

Immediate exercising is not recommended.
Forcing movement before seeing signs that the nerve is starting to transmit signals again may create long-term problems.
When you try to force movement under these circumstances, you can inadvertently signal the wrong muscles to jump in and help.
They can result in asymmetrical and synkinetic types of motion.

How Can a Physical Therapist Help?
Physiotherapist will design exercises to:
Improve the coordination of facial muscles
Refine facial movements for specific functions, such as speaking or closing eye
Refine movements for facial expressions, such as smiling
Correct abnormal patterns of facial movement that can occur during recovery

Types of exercises
"Initiation" exercises. 
("assisted range of motion")
"Facilitation" exercises. 
("facilitate" muscle activity).
Movement control exercises. 

Ear injury
Facial bone anatomy
Facial trauma
Facial nerve injury

7% of temporal bone fractures, 25% of these permanent
Delayed onset: complete recovery in 94%
Immediate onset: complete recovery in 50-75%
Hearing loss
80% of conductive hearing loss resolves spontaneously
SNHL worse prognosis of recovery
CSF Leak
Mid Facial Injuries
Posteriorly displaced, middle third fractures may be reduced manually to improve the airway.
Additional benefit: controlling hemorrhage

“Head to Head”: pneumocephalus as a complication of soccer
All trauma patients should receive oxygen.
Several techniques exist for maintaining an airway:
Jaw thrust
Chin lift
Oro- or/ naso-pharyngeal airways
Tongue suture
Laryngeal mask
Airway Maintenance Techniques
Traumatic laryngeal fracture in a collegiate basketball player
Where are we now?
Stabilize head & neck before assessment
Do primary assessment without moving pt.
Teams dealing with these injuries should be BLS, ACLS & ATLS certified
Anticipate continued team dialogu

Signs and symptoms
Pain, swelling, deep lacerations, limited ocular movement, facial asymmetry, crepitus, deviated nasal septum, bleeding, depression on palpation, malocclusion, blurred vision, diplopia, broken or missing teeth
Soft tissue Lacerations, abrasions, avulsions

And finally...How can we do better?

Int J Emerg Med. 2013; 6: 46

Otorrhea: bloody or clear and pulsatile (send for 2 transferrin)
Pneumatic otoscopy: vertigo or flaccid TM
Laceration of canal wall

External injuries
Lacerations, avulsions, amputations
Control bleeding with direct pressure
Internal injuries
Spontaneous rupture of eardrum will usually heal spontaneously
Penetrating objects should be stabilized, not removed!

Management of Ear injury

Separation of ear cartilage
Treat as an avulsion
Dress and bandage

Bleeding from ear canal
Cover with loose dressing only

Zygoma / zygomatic arch

Variety of mechanisms
Swelling, deformity, crepitance
Anterior bleeding from septum
Usually venous
Posterior bleeding
Often drains to airway
May be associated with Sphenoid and/or ethmoid fractures, Basilar skull fracture

Nasal Injuries
Pneumocephalus is uncommon in craniofacial trauma and a rare occurrence in non-contact sports
Clinical presentations typically include headaches, nausea, vomiting, seizures, dizziness, and a depressed neurological status
Pneumocephalus may be asymptomatic or present as a space-occupying lesion. It requires prompt recognition and MANAGEMENT  (Antibiotic prophylaxis, surgical repair of the injury) to prevent unwanted morbidity and mortality such as meningitis or a cerebrospinal fluid fistula.

Laryngotracheal trauma is a rare condition that accounts for less than 1% of blunt trauma
It is rare even in settings where athletes are more vulnerable, including football, basketball, and hockey
If a laryngeal injury is suspected, immediate evaluation is required to avoid a delay in the diagnosis of a potentially life-threatening injury
Signs include edema, hematoma, subcutaneous emphysema, ecchymosis, laryngeal tenderness, loss of thyroid cartilage prominence or anatomical landmarks, open neck wound, vocal cord immobility, and bony crepitus
Surgical MANAGEMENT should be considered if there is any concern for an unstable airway

Sports Health. 2013 May;5(3):273-5
Prospective study of 'otological injury secondary to head trauma’
This was prospective study involving 50 cases of head injury
Road traffic injuries were the most frequent 64% while sports injuries (6%)
Patients with longitudinal fracture showed conductive and mixed loss and patients with transverse fracture showed sensorineural hearing loss.
Incidence of facial nerve paralysis was more with transverse fracture cases than with longitudinal fracture cases.

Indian J Otolaryngol Head Neck Surg. 2013 Dec;65

Battle's Sign
Raccon Sign
Longitudinal Fractures
The Good News
For vast majority of temporal bone fractures, we do nothing!
Full transcript