Facial Trauma

Nasal injuries are frequently encountered in sports. The higher the impact velocity, the higher is the probability of concomitant injury requiring urgent referral. Situations requiring emergency department (ED) evaluation include associated prolonged loss of consciousness, vision abnormalities suggesting orbital fracture, malocclusion of the teeth suggesting maxillary or mandibular fracture, facial paresthe-sias suggesting infraorbital nerve injury, open or significantly displaced nasal fractures, and uncontrollable epistaxis. Examination findings prompting early referral include clear rhinorrhea suggesting cribriform plate injury with cerebro-spinal fluid (CSF) leak and impaired extraocular movements, especially unilateral limited upward gaze, which suggests an orbital fracture with inferior oblique or rectus muscle entrapment, or both. Nasal septal hematoma should be referred to an otolaryngologist expeditiously for incision and drainage. If left untreated, subsequent cartilage degeneration can result in a nasal saddle deformity (Stackhouse, 1998).

If initial assessment does not mandate immediate referral, subsequent management requires assessing the extent of deformity and controlling epistaxis. In the first few days, swelling can make assessment for bony deformity difficult, but close follow-up is helpful. Any persistent obstruction of the nares or cosmetic abnormality unacceptable to the patient should be referred to an otolaryngologist within 5 days, because reduction is best performed within 10 days of injury. Epistaxis is best managed with a topical deconges-tant such as oxymetazoline nasal 0.05% (Afrin) and compression of the anterior plexus by pinching the nose for 15 minutes. A short nasal tampon soaked with oxymetazoline can be placed into the bleeding nostril to assist with hemo-stasis and return to play, but anterior packing should only be performed with appropriate visualization, to avoid further injury.

Ear trauma in sports can result in auricular hematomas or injury to the tympanic membrane. Auricular hematomas mainly occur in wrestling, rugby, and boxing and result in hemorrhage between the perichondrium and the underlying cartilage. Failure to evacuate the hematoma can lead to fibrosis, necrosis, and a chronic deformity known as cauliflower ear. An acute auricular hematoma should be drained by needle aspiration under aseptic conditions, and a pressure dressing (using cotton wool soaked in collodion or a silicone splint) carefully applied against the contours of the outer ear and reexamined daily. Occasionally, incision and drainage are required.

Blows across the side of the head can also result in tympanic membrane rupture, marked by pain, bleeding, fluid drainage, and impaired hearing. Tympanic membrane ruptures usually heal spontaneously over 4 to 6 weeks. Antibiotic prophylaxis in the first week should be considered, especially if the rupture occurred in a contaminated environment. The ear canal should be kept clean and dry, and a cotton ball coated with petroleum jelly and placed gently into the ear canal can be helpful while showering.

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