Facial Pathologies and
Related Special Tests
Orthopedic Assessment III – Head,
Spine, and Trunk with Lab
PET 5609C
Ear Pathologies

Auricular Hematoma:
“Cauliflower Ear”

MOI: Repeated blunt trauma
or shearing forces to external
ear

Pooling of blood between the
skin and cartilage (cartilage
deprived of nutrition)

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Over time, hematoma can scar deformity
Inspection:
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Red appearance
Swelling of auricle
Ecchymosis
Ear Pathologies

Auricular Hematoma:
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Palpation:
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Functional/Neurological
Tests:
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Acute Injury: pain, confirm
presence of hematoma
Chronic Injury: hardened
feeling
Otoscope → check inner
ear
Hearing and Balance
Note: Rule out brain
trauma (blow to head)
Ear Pathologies

Tympanic Membrane Rupture:

History:

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Onset of Symptoms → Acute
Pain → Severe pain in middle ear;
radiating inward and outward
MOI:

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Sudden change in air pressure →
blunt trauma (slap to ear),
blocked sneeze, mechanical
intrusion (i.e. cleaning ear with
pen)
 Tympanic membrane bursts
Predisposing Conditions → URI,
otitis media
Ear Pathologies

Tympanic Membrane Rupture:

Inspection:

Blood, fluid leaking from ear (fluid should not be
present in canal → immediate referral)
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Inspection with Otoscope:
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Can signify skull fracture
Cerumen – reddish-brown wax formed in auditory meatus
Functional Testing:
Hearing Loss
 Valsalva maneuver may result in audible escape of air
from within inner ear

Ear Pathologies

Tympanic Membrane Rupture:

Complications:

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Permanent hearing loss
Ear infection (otitis media)
Treatment:

Ruptured or perforated eardrum usually
heals by itself within 2 months

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Treatment: relieve pain, prevent infection
(Antibiotics)
Surgical repair of the ear drum may be
needed
Prevention:
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Keep ear dry and clean while it heals
Prevent water entering the ear
Ear plugs while swimming.
Do not insert objects into the ear canal
Ear Pathologies

Otitis Externa: “Swimmer’s Ear”


Infection of external auditory meatus
History:

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Pain: constant, pressure, itching
MOI: Inadequate drying of ear canal (water sports)
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Inspection:
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Excessive water exposure
 Water collects in the ear canal (trapped by wax)
Resultant bacteria (streptococcus, staphylococcus) /fungus growth
Predisposing Conditions: Psoriasis, eczema, oily skin, open wounds
within ear; Overcleaning of external auditory canal
Redness, possible presence of clear discharge from middle ear
Palpation: ↑ pain with tugging on earlobe
Treatment:

Prescription drops (acid-based) mixed with antibiotics or
corticosteroids
Ear Pathologies

Otitis Externa:

Prevention:

Decrease exposure to water


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Ear plugs (if prone to
infection)
Swimmer's ear drops or
alcohol drops (SwimEAR®) used in the ear after
water exposure followed by
drying the ear with a hair
dryer held at arms length
Do not insert instruments,
scratch, or use cotton swabs
in the ears.
Ear Pathologies

Otitis Media:

Infection or inflammation of
the middle ear

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Often begins when infections
(viral or bacterial) that causes
URI spread to the middle ear
History:

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Pain/pressure within ear
Irritability, difficulty sleeping,
fever
Fluid draining from the ear
Loss of balance
Hearing difficulty
Ear Pathologies

Otitis Media:

Inspection:
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Functional Testing:
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Otoscope → fluid build-up /
reddened, bulging tympanic
membrane
Hearing
Weber Test
Treatment:

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Oral antibiotics
Decongestants and
antihistamine medications
Nasal Pathologies
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Nasal Fractures:

History:
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Onset: Acute (most commonly
fractured facial/skull bone)
Pain: Bridge of nose and
cartilage, frontal and zygomatic
bones
MOI: Direct blows
Inspection:
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Possible deformity
Bleeding
Ecchymosis (raccoon eyes)
Nasal Pathologies

Nasal Fractures:
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Palpation:
Pain
 Crepitus
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Note: Any patient
suffering a nasal
fracture needs to be
screened for injury to
the eyes/head
Nasal Pathologies

Repeated Nasal
Trauma:

Saddle-Nose
Deformity:
Necrosis of nasal
cartilage
 Collapsed bridge of
nose

Nasal Pathologies

Repeated Nasal Trauma:

Deviated Septum:

Nasal Septum - thin wall inside
your nose that separates right
and left nasal cavities


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Ideally, septum is situated in
the center of your nose
80 percent of people have a
septum that is displaced to
one side (one nasal passage
smaller than the other)
Septum significantly offcenter (deviated septum)
Nasal Pathologies

Deviated Septum:
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Blockage of one side of your
nose – reduced air flow
Signs and Symptoms:
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Causes:
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Difficulty breathing
Nasal congestion
Nosebleeds
Frequent sinus infections
Can be present at birth
Result of injury
Treatment:
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Medication, Surgery
Throat Pathologies
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Throat Trauma:
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History:
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Inspection:
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Bruising, swelling
Mouth/throat – possible bloody septum
Patient: coughing (attempting to clear airway) / altered voice
Palpation:
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Onset – acute
Pain: Anterior neck, increased during swallowing or taking deep
breaths
MOI: Blow to anterior neck
Point tenderness, crepitus, displacement of cartilage
Treatment:

Immediate referral / Monitor vital signs
Facial Fractures
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Mandibular Fractures:
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History:
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Inspection:
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Onset: Acute
Pain: Ramus or mental
protuberance of
mandible
MOI: Direct blow
Swelling, gross
deformity
Malocclusion of teeth
Palpation:

Tenderness, crepitus
Facial Fractures
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Mandibular Fractures:
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Functional Tests:
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Neurological Tests:
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Cranial Nerves V, VII
Special Tests:
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Pain with
opening/closing mouth
Lateral tracking of
mandible
Tongue Blade test
Treatment:

Referral
Facial Fractures
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Zygoma Fractures:
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History:
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Inspection:
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Subconjunctival hematoma
Periorbital swelling
Palpation:
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MOI: Direct blow to cheek or
inferior periorbital area
Pain: Injury site, possibly ↑ with
eye movement
Tenderness at zygomatic arch,
lateral eye socket
Treatment:
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Referral
Facial Fractures
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Maxillary Fractures:
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History:
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Inspection:
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Ecchymosis
Swelling
Palpation:
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May occur concurrently with
nasal fracture
Pain: Midpoint of face
Pain and crepitus
Treatment:
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Referral
Facial Fractures
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LeFort Fractures:
Midface fracture
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MOI: High-impact forces
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Inspection:
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Automobile accident
Unusual in athletics
Upper teeth/face can be
displaced forward
Classification:
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I – maxilla
II – maxilla and nasal
III – crosses zygomatic and
orbital bones
Dental Conditions
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Dental Injuries: Rates
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Female athletes:
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1.5% - softball
7.5% - basketball
Male athletes:
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Basketball (highest)
Ice hockey
Lacrosse
Football
Soccer
Baseball
Volleyball
ADA: Universal National
System (1-32)
Dental Conditions

Tooth Fracture:
Classifications (Ellis
System)
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Class I – enamel only
Class II - enamel and dentin

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pain to touch and sensitivity to
air.
Class III – enamel, dentin,
pulp

Pain with manipulation, air, and
temperature.
Dental Conditions

Tooth Luxation:

Extrusive luxation: partially displaced from the
socket

Greatly increased mobility and radiographs show
displacement
Lateral luxation: tooth displaced laterally
 Intrusive luxation: teeth forced into their
sockets in an axial direction

Can be buried (no visibility)
 Decreased mobility

Dental Conditions
Intrusive Luxation
Lateral and extrusive
luxation
Avulsion and luxation
Dental Conditions

Dental Caries: Cavities

Cause:
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Plaque – food, mucus, and
bacteria that collect and
harden on the exposed
tooth (can harden into
tartar)
Sugars, starches, acid-rich
food, poor oral hygiene
Signs/Symptoms:

As decay enlarges →
heat/cold sensitivity,
visible defect
Dental Conditions

Gingivitis: Inflammation of the gums

Cause:
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Accumulation of plaque → bacteria released into gums
Overbrushing can lead to inflammation
Increased risk:
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Signs/Symptoms:
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Poor oral hygiene
Diabetes
Pregnancy, Birth control pills
Soreness, bleeding gums
Red and swollen gums
Treatment:
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Plaque, tartar removal (dental care)
TMJ Pathology

TMJ Dysfunction:

History:
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Inspection:
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Onset: Acute, chronic
Pain: Area of TMJ;
clicking/locking of joint
MOI: Blunt trauma to the
mandible or progressive joint
degeneration (i.e. punch –
forces mandible laterally)
Swelling, Malocclusion of the
jaw
Palpation:


Point tenderness
Clicking when mouth
open/closed
TMJ Pathology

TMJ Dysfunction:

Functional Tests:
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Observation of jaw
during opening/closing
of mouth

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Any deviation?
Treatment:
Referral to physician
 Instruct athlete not to
eat hard foods (↑ pain)
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Dental Conditions
Special Tests

Otoscope:

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Allows health care providers to
see the outer and middle ear
Steps:
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Choose a speculum size
appropriate for the patient’s
canals
Hold the otoscope in the hand of
the same side as the ear you are
examining
Special Tests

Otoscope Use: (Steps
continued)

Examine the good ear first:
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Prevents spread of infection
into unaffected ear
You can see normal anatomy
(for comparison)
Inspect the Eardrum:

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Tympanic membrane should
appear shiny, translucent, and
smooth (without perforations)
Any suspected disruption,
fluid, pus, debris seen →
Medical referral
Special Tests

TMJ Palpation Test:
(External)

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Procedure: TMJ is
palpated while mouth is
opened and closed
Positive Sign:
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Asymmetry of movement
Clicking / Locking of joint
Special Tests
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TMJ Palpation Test: (Internal)
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Positioning: Examiner places his
fingers in the outermost portion of
auditory canal (with rubber gloves
on)
Procedure: Subject repeatedly
opens/closes the mouth while
examiner applies gentle pressure in
an anterior direction
Positive Findings:

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Pain, discomfort during
opening/closing of mouth
Asymmetry of movement
Special Tests

TMJ Range of Motion:
Patient Position: Seated or standing (examiner
is positioned in front of subject)
 Procedure: Patient attempts to place as many
flexed knuckles as possible between upper and
lower teeth
 Positive Test: Patient unable to place a
minimum of 2 knuckles within the mouth

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Decreased TMJ ROM
Special Tests

Weber Test:

Tests for hearing loss


Otitis Media
Procedure: Strike a tuning
fork softly and place the
vibrating fork on the middle of
the patient’s forehead

Ask patient if the sound is heard
better in one ear or the same in
both ears
Special Tests

Weber Test: (continued)

Positive Test: Athlete hears
the vibration louder in the
affected ear

Reasoning: Conduction
problem in affected ear masks
the ambient noise of the room,
while the well-functioning
inner ear picks the sound up
via the bones of the skull
causing it to be perceived as a
quieter sound in the
unaffected ear
Special Tests

Tongue Blade Test:
Possible mandibular fracture
 Position:

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Patient seated with examiner standing in front
Procedure:
Tongue depressor is placed in patient’s mouth
 Patient attempts to hold the depressor in place, the
examiner twists the tongue depressor

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Positive Test:

Patient unable to maintain a firm bite / Pain
Special Tests

Chvostek Test: Facial Nerve
Pathology

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Positioning: Patient seated or
standing
Procedure: Examiner taps over
the masseter muscle and parotid
gland
Positive Finding: Twitching of
the facial muscles (masseter)
Special Consideration: Twitching
of facial muscles may also be
result of low calcium levels in the
blood