Maxillofacial Injuries in Sports
and Exercise
Kevin deWeber, MD, FAAFP
Director, Sports Medicine Fellowship
Adapted from: “Dude, he gave you a Facial!,”
by Anthony Beutler,M.D. and Gary Ho, MD
“Professional athletes don’t wear
Why aren’t
they smiling?
mouthguards.”
Objectives
Briefly discuss scope of
ENT injuries in sports
Briefly discuss on-field
assessment of ENT
injuries
Review common ENT
injuries
PREVENTION IS KEY
Epidemiology
Scope of the problem
18% of all athletic
injuries
Boys: 3 times more
facial injuries than girls
Most frequently
associated sport:
– Before 1964, Football
– Now Baseball (40%)
Epidemiology:
Oral and Facial Trauma
50 : 50
– 50% mouth & teeth
– 50% ears, nose & face
Low Speed
– elbows & fists
– soft tissue lacerations
& contusions
High Speed
– balls, pucks, sticks
– Bone / tooth fractures
On Field Assessment
ABC’s always
come FIRST
– Airway
– Breathing
– Circulation
– Don’t get
distracted!
C-spine
precautions
On Field Assessment
Mechanism of Injury
On Field Assessment
History
– How? (MOI)
– Other Injuries?
Other symptoms
Respiratory symptoms?
– Concussion?
Symptoms
– Leakage of fluid (LOF)?
– Able to move jaw?
– Teeth mesh normally?
Sideline Examination
Risk of returning to
play
Inspection
–
–
–
–
Obvious deformity
Asymmetry
Swelling
Bleeding, LOF
Otorrhea
Rhinorrhea
– Ecchymosis
Raccoon’s eyes
Battle’s sign
– Dysfunction
Neuro exam
(esp EOM)
– OP and dental exam
Sideline Examination
Palpate
–
–
–
–
–
–
–
Orbital rims
Maxilla & malar areas
Zygomatic arches
Nasal bones
Midface stability
Jaw & alveolar ridges
Temporal mandibular
joints
– Teeth for dental trauma
– Malocclusion
Special tests
– Ring test for CSF
– Septal hematoma
– Hemotympanum
Facial Fractures
Diagnostic Imaging
Plain film x-rays
– Facial series
Waters view
(Occipitomental)
Caldwell (PA) view
Lateral
Submentovertex view
– Lower face series
Panorex
Lateral oblique
Other views
CT Scan – (Hi Res)
Common Injuries
Nasal Injuries
Ear Injuries
Mouth Injuries
Teeth Injuries
Eye Injuries
Nasal Injuries
Most commonly
injured structure
of the face
– Fractures
– Septal deviation
– Epistaxis
– Septal hematoma
Saddle deformity
Nasal Fracture
Swelling
Ecchymosis
Deviated appearance
Epistaxis
Crepitus to palpation
Indentation to palpation
Nasal Fracture Management
•Exam: septal
hematoma, midfacial
injuries
•Preferable to reduce
quickly after injury
•If not, wait 5-7 days
for decision
•Local, general or
moment anesthesia
•Manipulation after 10
days is very difficult
Epistaxis
Epistaxis
Anterior
– 95%
– Kiesselbach’s
plexus
– Traumatic
– Visualizable
– Squeeze & Pack
– Profuse anterior
bleeding after
fracture
Anterior ethmoid
laceration
Needs reduction,
packing, consult
and admission
Epistaxis
Posterior
– 5%
– Larger vessels
– Atraumatic
– Nonvisualizable
– Consult & Admit
Epistaxis Management
Epistaxis
Compression,
ice, nasal spray
Locate site
Anterior (95%)
Posterior (5%)
Anterior packing Posterior packing
ENT consult
Anterior
cautery / QR
powder
Posterior
packs/surgery
Surgery
Admit
Epistaxis Management
Epistaxis Management
Epistaxis Management
Epistaxis Management
• Insert 12-16 F catheter
with 30cc balloon until
tip is visible in posterior
pharynx
• Slowly inflate with 15cc
saline and pull
anteriorly to set against
choanae.
• Secure with umbilical
clamp
• Place anterior nasal
pack
Epistaxis Management
QR Powder
– Hydrophilic polymer
Absorbs H2O from
blood  polymer
swells
– Potassium salt
Binding agent forms
artificial scab
Septal Hematoma
Collection of blood
b/w cartilage septum
& mucoperichondrium
Most often associated
with fracture
Dx: grape-like, blue
bulge that obstructs
nares
Left untreated: can
cause “saddle nose”
deformity
Septal Hematoma
Treatment
– Prompt aspiration /
drainage to prevent
saddle nose
– Packing / splinting
– Prophylactic
anitbiotics
– Tetanus prn
Nasal Injuries
Common Injuries
Nasal Injuries
Ear Injuries
Mouth Injuries
Teeth Injuries
Eye Injuries
Ear Problems
Auricular Hematoma
(“Wrestler’s Ear”)
Auricular Hematoma
Trauma causes
bleeding between skin
and cartilage
Fluctuant bluish
swelling in auricle
Untreated 
– Pressure necrosis
– Fibroneocartilage
formation
– Unsightly scarring
Tx: prompt drainage
Auricular Hematoma
Needle Drainage
Need to be promptly
aspirated
– Have done up to 10
days out
20 gauge needle
Sterile conditions
+/- Prophylactic
antibiotics
Auricular Hematoma
Clot Evacuation
After
evacuation,
apply
compression
for 7-10 days
to prevent
hematoma
recurrence
Auricular hematoma
Unreliable
techniques for
compression:
Auricular Hematoma
•Best technique for compression:
Sutured tubular gauze
•Allows quick return to play
•Need to protect it!
Auricular Hematoma
complications
Perichondritis is bad.
Sterility is important.
Poor cosmesis is bad.
Headgear is important.
Y
O
U
M
A
K
E
T
H
E
OR
C
A
L
L
Auricular
Laceration
Key is to look for
cartilage involvement
Anesthesia: no epi
Repair cartilage first
w/ 5/6-0 suture
Then repair skin
Tetanus +/- oral abx
Thermal Injuries of Auricle
Frostbite
–
–
–
–
–
–
–
Avoid refreezing
Rewarm
Avoid rubbing
Protect
Blister management
Abx / Td prn
Nutrition & hydration
Sunburn
–
–
–
–
–
Pain relief
Moisturizers, ointments
Blister management
Abx / Td prn
Nutrition & hydration
Tympanic Membrane Rupture
Mechanism of injury
– Barotrauma
– Percussive blow or
slap to side of head
Explosions
Travel at altitude
Diving
Boxing, wrestling,
martial arts
Water skiing
Surfing
Wake Boarding
Tympanic Membrane Rupture
Symptoms
– Painful “pop”
– Minor bleeding
– Unilateral hearing
loss
– Can have vertigo
&/or nausea
Exam
– Otoscopic exam
Tympanic Membrane Rupture
Usually no treatment needed,
except re-exam
Oral abx if a/w infection
Avoid valsalva and pressure
changes (no diving)
– Swimming OK
– Protect w/ custom plugs
90% heal in 8 weeks
Refer to ENT if not healed by 3
months
Large ruptures >25%
– consider hearing screen to r/o
sensorineural hearing loss
Otitis Externa
Infection of external
auditory canal:
–
–
–
–
–
Pseudomonas
E. coli
Proteus
Staphylococcus
Fungus
Swimmers
Other water sports
Pain with auricle
movement
Red, swollen EAC
+/- exudate
Otitis Externa
Bacterial Tx: abx ear
drops
– Buffered acetic acid qid
x10d
– Cortisporin otic
– Ciprofloxacin otic
– Systemic abx?
Fungal (black dots, fuzz)
– Tx: antifungal ear drops
– 1% tolnaftate drops
Ear wicks are beautiful
things, but hard to find
Otitis Externa Prevention
?
Cotton w/ petroleum jelly during
swimming
Nasal Injuries
Ear Injuries
Mouth Injuries
Teeth Injuries
Eye Injuries
Lip Lacerations
Compression of lip
on teeth
Look for associated
dental and other
bony injury
Lip Lacerations
Mucosa-only lacs heal
well w/o sutures
Deep or thru & thru
lacerations require
layered repair
Vermilion border:
approximate border
FIRST, then repair
remainder (consider
referral)
Prophylactic abx or
chlorhexidine rinse bid
Tongue lacerations
Irrigate, remove
foreign bodies
Repair muscle with
3-0 absorbable if
deeper than 5mm
Repair mucosa if
still necessary,
absorbable is fine
TMJ Dislocation
Cause: jaw suddenly depressed
Condyle dislocates anteriorly
– Spasm pulls it superiorly
Signs
– Chin deviated to side OPPOSITE d-l
– Unable to close mouth
Treatment: reduction ASAP
– Hook thumbs on third molars bilat
– Apply postero-inferior pressure
– Analgesics, soft diet, avoid opening
wide for 1 week or more after
dislocation
Common Injuries
Nasal Injuries
Ear Injuries
Mouth Injuries
Teeth Injuries
Eye Injuries
Tooth Fracture
Enamel Fracture
– Small chips in
enamel
– Uniform color at
fracture site
– Dentist referral to
smooth rough
enamel edges prn
– Continue playing!
Tooth Fracture
Dentin Fracture
– Sensitivity to inhaled
air
– Yellow dentin at
fracture site
– Relieve pain:
Apply clove oil
Super-glue piece on
Tooth kit cement
Splint w/ mouthguard
– Dental attention
within 24 hours
Tooth Fracture
Pulp Fracture
– Use finger pressure
to expose larger
fractures
– Pink or red pulp at
fracture site
– Relive pain (cover)
– Immediate dental
referral for root
canal and cap
Tooth Luxation
Incomplete displacement
Reduce tooth
– Do NOT pull impacted
teeth back out
Provide splint if possible
– Mouthguard, towel bite
To dentist <24 hrs
–
–
–
–
Repositioning
Custom splinting
+/- root canal therapy
Long-term follow up
Tooth Avulsion (“knocked out”)
Pick up tooth by
ENAMEL only, not roots
Re-implant w/in 30 min
= 90% success
After 6 hrs, <5%
If can’t replace,
transport in Save-ATooth solution > milk >
saline buccal pouch
Prophylactic antibiotics
& Tetanus booster
Dentist referral ASAP
Aspirated teeth need to
be removed by
bronchoscopy
Teeth Injuries
Mouthguards
– effectively prevent
most sports related
dental injuries
– Encourage athletes to
wear mouthpieces!
Common Injuries
Nasal Injuries
Ear Injuries
Mouth Injuries
Teeth Injuries
Eye Injuries
Lid laceration repair
Sequence of
layered repair
Orbicularis
– Tarsus 6-0 Vicryl
– Orbicularis muscle
6-0 Vicryl
– Lid margin 6/7-0
non-abs
– Remainder of skin
Eye blunt trauma
Globe rupture
Blowout fracture
– diplopia
– dysconjugate
gaze
Eye Injury Gallery
Eye Injury Gallery
Corneal Abrasion
- Topical or oral analgesics
- Exam every 24 hours until healed
-refer if taking >72 hrs
- NOT RECOMMENDED: patch, midriatics
-Unknown effectiveness: abx
Eye Injury Gallery
Retinal Detachment
- Optho referral
Eye Injury Gallery
Superficial
– Apply topical
analgesic
– Remove object w/
needle tip
Deeper: REFER
Eye Injury Gallery
Subconjunctival Hemorrhage
- Most resolve in 2-3 wks
- More extensive ( ~ 360°) 
optho referral
Hyphema
- Optho referral
-Bedrest
Eye Injury Gallery
Eyelid Laceration
“Run, Luke. Run!”
Eyelid Laceration
After Appropriate
Referral
Eye Injury Prevention
Questions?