Head and Facial Conditions
Chapter 10
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Anatomy of Head and Face
• Bones of skull
– Cranium
• Protects the brain
– Facial
• Provide the structure of the face
• Form the sinuses, orbits of the eyes, nasal cavity,
and the mouth
• Scalp
– Protective function
– Extensive blood supply
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Anatomy of Head and Face (cont.)
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Anatomy of Head and Face (cont.)
• Brain
– Major regions
• Cerebral hemispheres
• Diencephalon
• Brainstem
• Cerebellum
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Anatomy of Head and Face (cont.)
• Meninges
• Protective tissue that encloses brain and
spinal cord
• Dura mater; arachnoid mater; pia mater
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Anatomy of Head and Face (cont.)
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Anatomy of Head and Face (cont.)
• Eyes
– Conjunctiva
– Lacrimal glands
– Tunics: sclera; choroid; retina
– Cornea
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Anatomy of Head and Face (cont.)
• Nose
– Composed of bone and hyaline cartilage
– Nasal septum
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Anatomy of Head and Face (cont.)
• Ear
– Major areas
• Outer ear (auricle and external
auditory canal)
• Middle ear (tympanic membrane)
• Inner ear (labyrinth)
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Anatomy of Head and Face (cont.)
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Anatomy of Head and Face (cont.)
• Nerves
– Cranial nerves
• Motor functions, sensory
functions, or both
• Numbered and named in
accordance with their
functions
• Blood vessels
– Common carotid
– Vertebral
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Prevention of Head and Facial Injuries
• Protective equipment
– Helmets
– Face guards
– Mouth guards
– Eye wear
– Ear wear
– Throat protectors
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Scalp Injuries
• Highly vascularized; bleeds freely
• Laceration
– Control bleeding
– Prevent contamination
– Assess for skull fracture (fx)
– Management:
• If no fx, cleanse, cover, and refer
• Abrasions and contusions
– Cleanse; ice and pressure
– 24 hours: no improvement – refer
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Cranial Injury Mechanisms
• Injury dependent on:
– Material properties of skull
– Thickness of skull
– Magnitude and direction of force
– Size of impact area
• Bone deforms and bends inward
– Inner border – tensile strain
– Outer border – compressed
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Cranial Injury Mechanisms (cont.)
• Brain acceleration
– Shear, tensile, and
compression strains
within brain
– Contrecoup injury
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Cranial Injury Mechanisms (cont.)
• Focal injury
– Localized damage
– Epidural, subdural, or intracerebral hematomas
• Diffuse injury
– Widespread disruption
– Concussion
• Accurate assessment of head injury is essential
• Conscious, ambulatory individual should not be considered to
have only a minor injury
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Skull Fracture
• Types
– Linear
– Comminuted
– Depressed
– Basilar
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Skull Fracture (cont.)
• Potential for varying signs and symptoms (S&S)
– Visible deformity–do not be misled by a
“goose egg”; a fracture may be under the
site
– Deep laceration or severe bruise to scalp
– Palpable depression or crepitus
– Unequal pupils
– Raccoon eyes or Battle’s sign
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Skull Fracture (cont.)
– Bleeding or CSF from nose and/or ear
– Loss of smell
– Loss of sight or major vision disturbances
– Unconsciousness 2 minutes after direct trauma to
the head
• Management: activation of EMS (refer to Application
Strategy 10.1)
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Focal Cerebral Conditions
• Epidural hematoma
– Direct blow to side of head
– Meningeal artery tear
– Rapid “high-pressure” hematoma
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Focal Cerebral Conditions (cont.)
• Epidural hematoma (cont.)
– S&S
• LOC
• Lucid interval
• Gradual deterioration
 Head pain, dizziness, nausea, dilation of one
pupil, sleepiness
• Possible:
 Deteriorating consciousness, neck rigidity,
depression of pulse and respiration, convulsions
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Focal Cerebral Conditions (cont.)
• Epidural hematoma (cont.)
– Life threatening … death
– Management: activate EMS; ABCs, vitals,
shock
– Requires surgical decompression
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Focal Cerebral Conditions (cont.)
• Subdural hematoma
– Acceleration forces
– Involves bleeding of the veins
– S&S slower to develop
• Acute – 48-72 hours post-injury
• Chronic – later time frame
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Focal Cerebral Conditions (cont.)
• Subdural hematoma (cont.)
– Simple
• Blood in subdural space—no injury to cerebrum
– Complicated
• Cerebral swelling
– S&S
• Headache, nausea, dizziness, sleepiness
• simple – usually no LOC
• complicated – unconscious, pupil dilation on one side
– Management: activate EMS; ABCs, vitals, shock
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Focal Cerebral Conditions (cont.)
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Focal Cerebral Conditions (cont.)
• Cerebral contusion
– Focal injury, without mass-occupying
lesion
– Acceleration-deceleration
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Focal Cerebral Conditions (cont.)
• Cerebral contusion (cont.)
– S&S (can vary greatly)
• Develop over hours and days
• Normal function or neurologic deterioration
• Danger sign:
 Neurological exam—normal
 But presence of headaches, dizziness, and
nausea
– Management: activate EMS; ABCs, vitals, shock
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Diffuse Cerebral Conditions
• Concussion
– common features incorporate clinical, pathological, &
biomechanical injury constructs
• caused by direct blow to head, face, neck, or elsewhere with
an impulsive force transmitted to head; typically result in rapid
onset of short-lived impairment of neurologic function that
resolves spontaneously.
• neuropathologic changes may occur, but acute clinical
symptoms typically reflect a functional disturbance rather than
a structural injury.
• may or may not involve an LOC …may lead to a gradient of
clinical symptoms associated with grossly normal structural
neuroimaging studies.
• resolution of the clinical and cognitive symptoms usually
follows a sequential course
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Diffuse Cerebral Conditions (cont.)
• Classification of concussion
– Numerous!!! …potentially problematic!
– Zurich panel 2008
• diagnosis of a concussion will involve the assessment of
a range of clinical signs and symptoms in four
categories: physical, emotional, cognitive, and sleep
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Cognitive
Physical
Emotional
Sleep
Feeling like in a “fog”
Headache
Irritability
Drowsiness
Feeling slowed down
Nausea or vomiting
Sadness
Sleeping more
than usual
Difficulty
concentrating
Balance problems
More emotional
Sleep less than
usual
Difficulty
remembering
Visual problems
Nervousness
Trouble falling
asleep
Forgetful of recent
information
Fatigued
Confused about
recent events
Photophobia
Answers questions
slowly
Sensitivity to noise
Repeats questions
Dazed or stunned
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Diffuse Cerebral Conditions (cont.)
– On-field management
• Remove from activity; examine immediately –
standard emergency assessment &
management
• Detailed clinical assessment of signs and
symptoms using SCAT 2 or similar tool
• Presence of any signs/ symptoms – initiate
appropriate management
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Diffuse Cerebral Conditions (cont.)
Return to activity after a concussion follows a sequential
process:
1. No activity, complete rest; once asymptomatic, proceed
to step 2
2. Light aerobic exercise such as walking or stationary
cycling; no resistance training
3. Sport-specific exercise (e.g., skating in hockey, running
in soccer);
4. Noncontact training drills; Progression to more complex
training drills; may start progressive resistance training
5. Full-contact practice -- after medical clearance
6. RTP – normal game play
(Refer to Table 10.4)
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Diffuse Cerebral Conditions (cont.)
• Posttraumatic headache
– Result of vasospasm; doesn’t usually occur
with impact, but develops shortly afterward
– S&S
• Localized area of blindness that may follow
the appearance of brilliantly colored
shimmering lights
• Posttraumatic migraines
– Management
• Immediate referral to a physician
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Diffuse Cerebral Conditions (cont.)
• Postconcussion syndrome
– Can occur following a mild or serious concussion
– S&S
• Decreased attention span
• Persistent headaches
• Blurred vision
• Vertigo
• Memory loss
• Irritability
• Inability to concentrate on even simplest task
• Exercise may lead to headache, dizziness, and
premature fatigue
– Management
• No definitive treatment other than treat headache
symptoms
• No activity
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Diffuse Cerebral Conditions (cont.)
• Second impact syndrome
– A second head injury before the symptoms
associated with a previous one have totally
resolved
– Does not necessarily require a blow to the
head
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Diffuse Cerebral Conditions (cont.)
• Second impact syndrome (cont.)
– S&S
• May not lose consciousness; stunned look; may leave
field under own power
• Rapid deterioration of condition
 LOC, dilated pupils, loss of eye movement,
respiratory failure
– Brainstem failure in 2-5 minutes
– Management
• Activate EMS
– Prevent it from happening!!!
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Assessment of Cranial Conditions
• ALWAYS ASSUME A CERVICAL INJURY
IS PRESENT!!!!!!!!!!!!!
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Assessment of Cranial Conditions (cont.)
• Vitals
– Pulse
• Small weak pulse
• Short, rapid weak pulse
• Slow bounding pulse
• Accelerated pulse
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Assessment of Cranial Conditions (cont.)
– Respiration
• Slow breathing (bradypnea)
• Cheyne-Stokes breathing
• Ataxic (Biot’s) breathing
• Apneustic breathing
– Blood pressure
• Increase in the systolic blood pressure or a decrease in
the diastolic blood pressure indicates rising intracranial
pressure
– Pulse pressure
• >50 mm Hg indicates increased intracranial bleeding
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Assessment of Cranial Conditions (cont.)
pulse
respiration
blood pressure
pulse pressure
slow bounding pulse
 intracranial pressure
accelerated pulse
pressure on base of brain
bradypnea
 intracranial pressure
Cheyne-Stokes breathing
brain damage
Ataxic (Biot’s) breathing
brain damage, typically at the medullary level
apneustic breathing
indicates trauma to the pons
 systolic BP or  diastolic BP
 intracranial pressure
 BP (rare in head injury)
possible cervical injury or serious blood loss
from an injury elsewhere in the body
pulse pressure 50 mm Hg
 intracranial bleeding
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Assessment of Cranial Conditions (cont.)
• History and mental status testing
– Orientation
– Concentration
– Memory
– Behavior
– Symptoms
– Loss of consciousness
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Assessment of Cranial Conditions (cont.)
• Observation and inspection
– Leakage of cerebrospinal fluid
– Signs of trauma (deformity, body posturing, raccoon
eyes, and Battle’s sign)
– Skin color
– Loss of emotional control (irritability, aggressiveness,
or uncontrolled crying)
– Graded symptom checklist
• Palpation
– Bony and soft tissue structures for point tenderness,
crepitus, depressions, elevations, swelling, blood, or
changes in skin temperature
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Assessment of Cranial Conditions (cont.)
• Neurologic examination
– Cranial nerve assessment
– Pupil abnormalities
• Pupil size
• Response to light
• Eye movement
• Nystagmus
• Blurred or double vision
– Babinski’s reflex
– Strength
– Neuropsychological assessments
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Assessment of Cranial Conditions (cont.)
– Coordination and balance
• Finger to nose test
• Gait
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Assessment of Cranial Conditions (cont.)
• Romberg test
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Assessment of Cranial Conditions (cont.)
• One-legged stork stand
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Assessment of Cranial Conditions (cont.)
• Balance error scoring system (BESS)
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Assessment of Cranial Conditions (cont.)
• External provocative test
– 40-yard sprint
– 5 sit-ups
– 5 push-ups
– 5 knee bends
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Assessment of Cranial Conditions (cont.)
• Determination of findings
– Re-assess every 5-7 minutes
– Immediate management and follow-up care
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Facial Conditions
• Facial soft tissue conditions
– Contusions, abrasions, and lacerations are
managed the same as elsewhere on the body
– Complicated injuries—immediate physician
referral
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Facial Conditions (cont.)
• Temporomandibular joint conditions
– S&S
• Inability to open and/or close mouth (dislocation and
meniscus displacement)
• Malocclusion
• Joint crepitus with opening and closing
• Pain with opening and biting
• Deviation of the mandible on opening (toward side of
injury)
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Facial Conditions (cont.)
• Fractures
– Zygomatic
• S&S: cheek appears flat or depressed, double
vision, numbness in affected cheek
• Management: ice, immediate referral
–
Mandibular
• Common: mandibular angle and condyles
• S&S: malocclusion, changes in speech, oral
bleeding, + tongue blade
• Management: ice, immediate referral
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Facial Conditions (cont.)
• Fractures
– Maxillary
• LeFort fx (upper jaw)
• S&S: appearance of longer face, nasal bleeding,
malocclusion, nasal deformity, ecchymosis
• Management: ice, immediate referral
• Facial “red flags” (refer to Box 10.2)
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Nasal Conditions
• Epistaxis
– Anterior – bleeding from anterior septum
Posterior – bleeding from lateral wall
– Management: ice, mild pressure, slight forward head tilt;
nasal plug; 5 minutes – physician referral
• Deviated septum
– S&S
• Consistent difference in airflow between the 2 sides of
the nose when one nostril is blocked
• Confirm using otoscope
– Management: physician referral
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Nasal Conditions (cont.)
• Fractures
– Most common: lateral displacement
– Range of severity varies
– S&S
• Asymmetry – especially with lateral force
• Epistaxis
• Crepitus
– Management: control bleeding; refer
• Nasal “red flags” (refer to Box 10.3)
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Oral and Dental Conditions
• Periodontal disease
– S&S of gingivitis
• Tender, swollen, or bleeding gums
• Change in the gums' color from pink to dusky
red
• Plaque and bacteria that cover the teeth not
readily visible
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Oral and Dental Conditions (cont.)
– S&S of periodontitis
• Swollen or recessed gums
• Unpleasant taste in the mouth
• Bad breath
• Tooth pain
• Drainage or pus around one or more teeth
– Management: referral to dentist
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Oral and Dental Conditions (cont.)
• Dental caries (tooth decay)
– Primarily caused by plaque...dissolves the tooth
enamel…allows bacteria to infect the center of the tooth
– S&S
• Pain during chewing
• Sensitivity to hot/cold foods and beverages
• If tooth abscess is present:
 Throbbing pain
 Sharp or shooting pain
– Management: refer to dentist
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Oral and Dental Conditions (cont.)
• Mouth lacerations
– Minor lacerations are the same as in other lacerations
– Lip and tongue lacerations: require special suturing
• Loose teeth
– Displaced outward or lateral: attempt to place back in
normal position
– Intruded: immediate referral to dentist
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Oral and Dental Conditions (cont.)
• Fractured tooth
– Enamel: no symptoms
– Dentin: pain and increased sensitivity to heat
and cold
– Pulp or root: severe pain and sensitivity
– Management: refer to dentist
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Oral and Dental Conditions (cont.)
• Dislocated tooth
– Time is of the essence; refer
– Hold tooth by crown
– Do not rub the tooth or remove any dirt; milk or
saline
• Oral and dental “red flags” (refer to Box 10.4)
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Ear Conditions
• Cauliflower ear (auricular hematoma)
– Repeated trauma pulls cartilage away from
perichondrium – hematoma forms
– Untreated – forms a fibrosis
– Management: ice; possible aspiration by physician
– Key is prevention!
• Impacted cerumen (wax)
– Possible hearing loss or muffled hearing
– Management: irrigate canal with warm water
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Ear Conditions (cont.)
• Otitis externa (swimmer’s ear)
– Bacterial infection to lining of external auditory canal
– S&S: pain, itching
– Management: ear drops, custom ear plugs
• Otitis media
– Middle ear infection due to bacteria or virus
– S&S: earache, hearing difficulty, possible serous otitis
– Management: physician referral
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Ear Conditions (cont.)
• Tympanic membrane rupture
– Caused by:
• Infection
• Direct trauma
• Changes in pressure
• Loud, sudden noises
• Foreign objects in the ear
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Ear Conditions (cont.)
– S&S
• Very painful
• Tinnitus
• Pus-filled or bloody drainage from the ear
• Sudden decrease in ear pain followed by
drainage
• Hearing loss
– Management: physician referral
• Ear “red flags” (refer to Box 10.5)
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Eye Conditions
• Preorbital ecchymosis (black eye)
– Assessment
– Management: ice, referral to ophthalmologist
• Foreign bodies
– S&S: intense pain, tearing
– Management
• Not embedded: removal, inspection
• Embedded: do not touch, activate EMS
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Eye Conditions (cont.)
• Sty
– Infection of sebaceous gland of eyelash
– Starts as a red nodule; progresses into a painful
pustule
– Management: moist heat compress
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Eye Conditions (cont.)
• Conjunctivitis (pink eye)
– S&S: itching, burning, watering, red
appearance
– Management: infectious; refer to physician
• Corneal abrasion
– S&S: pain, tearing, photophobia, irritated
with blinking and eye movement, feeling of
“something in the eye”
– Management: drops and eye patch
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Eye Conditions (cont.)
• Corneal laceration
– S&S: severe pain, decreased visual acuity
– Management: cover with no pressure, activate
EMS, transport supine or upright
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Eye Conditions (cont.)
• Subconjunctival hemorrhage
– Rupture of small capillaries;
sclera appears red, blotchy,
inflamed
– Requires no treatment
• Hyphema
– Caused by blunt trauma
– Hemorrhage into anterior
chamber
– Management: activation of EMS
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Eye Conditions (cont.)
• Detached retina
– Can occur with or without trauma
– S&S: floaters and light flashes
– Management: patch both eyes; refer to
ophthalmologist
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Eye Conditions (cont.)
• Orbital “blowout” fracture
– Impact from a blunt object, usually larger than the eye
orbit
– S&S:
• Diplopia
• Numbness below eye
• Lack of eye movement
• Recessed downward displacement of globe
– Management: ice; immediate referral to physician
• Eye “red flags” (refer to Box 10.6)
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