Monday, March 3, 2014
We lead with our noses. The protuberance in the front of our face falls victim to tripping on the sidewalk, bumping into walls and other assorted misadventures. And then there is the danger of sports, where an inadvertent elbow and head butt can turn a player like LeBron James into the masked avenger. We lead with other noses and they are prone to break, accounting for almost 40% of facial injuries. Most of the time a fractured nose (remember that broken, fractured and cracked all mean the same thing and one term does not imply a more or less serious injury) is an inconvenience.
For all its simplicity, the nose performs a variety of functions as air gets inhaled and exhaled. There are the olfactory, or sense of smell receptors, that are also closely associated and needed for taste and why food is less appealing when we’re stuffed up. There are the tiny nasal hairs that trap large particles before they get into our lungs. Air is also warmed and humidified by the nose and is especially important for those who live in the frozen tundra of Wisconsin. The bony spine makes up the bridge of the nose and holds the cartilage in place, but it is the cartilage that makes most of its shape and length and separates the nostrils from each other.
As with any other injury, pain and swelling are the result of a nose injury but anytime the nose bleeds, it is likely that the cartilage may be broken. There is also the potential of whether the nose has become deformed. The initial care of a broken nose has little to do with the cosmetic issue and a lot to do with looking for the complications associated with the break. This is less than satisfying for the patient, since they often leave looking the same way they arrived and have been told that time will decide what happens. Those complications include a septal hematoma, a maxillary fracture and a cribriform plate leak. And not to forget that the face provides frontal protection of the face: a concussion is always a possibility with any injury to the face.
When injured, the blood rich septum will bleed but the nosebleed will usually resolve quickly with holding direct pressure on the nose. This can be painful because you have to squeeze something that is broken. But the doctor is more interested in looking inside the nostril at the septal wall, looking for a hematoma or clot that is trapped under the cartilage lining. Left there, its pressure will increase, damaging and potentially causing a sepal perforation or a hole that would connect the two nostrils. This can lead to infection, recurrent nosebleed and permanent changes to the appearance of the nose.
The cribriform plate is part of the ethmoid bone located at the base of the nose where it attaches to the skull. On the brain side of this bone are the meninges or the lining of brain tissue. Damage to the cribriform area can cause CSF, cerebrospinal fluid that bathes the brain with nutrients, to leak and more importantly allow the outside world, full of infection, into the brain. CSF leak from the nose appears thin and clear, and is definitely different than snot. Cribriform plate injuries with CSF leaks become a medical priority.
While it is common to have an isolated nose injury, the maxilla or cheek bone can also be damaged. This is the bone that holds the upper teeth and is also the bone that supports the orbit and eye, and the doctor will want to check out not only the maxilla but also the mandible.
Once the complications are ruled out, there is little to be done right away. Even if the nose is obviously deformed, x-rays aren’t usually required and neither is an emergency visit to an ENT specialist or plastic surgeon. Waiting for a few days for an office allows the swelling to resolve and allow a better assessment of the way the nose looks. Ice, elevation and some pain medication is all that is usually required. After a few days, if the nose needs to be realigned, that procedure can happen using local anesthetic in the specialists’ office.
Broken noses hurt and the injury can make a dent in daily routines. Rolling over in bed and hitting the nose against a pillow is not pleasant. Habits like rubbing the nose, sniffing or blowing it will cause pain. Fortunately, the healing is relatively quick, though the badge of a broken nose may last much longer. Protective masks that form fit, like that worn by Mr. James, are not often worn by “normal” people but of course most of us also don’t have elbows flying around our heads as we rebound under the basket.This entry was tagged borken, cartilage, fracture, hematoma, LeBron James, nose, nosebleed
Monday, February 24, 2014
The list runs 10 pages and is updated every year. It is the compilation of what drugs are not allowed to be used in international sport and it is the bible of the Olympics. While athletic performance will be remembered and podium celebrations will fill the dreams of the next generation of Olympians, there are six athletes who embody the dark side of competition. The six ran afoul the World Anti-Doping Agency prohibited substance list and their Olympic aspirations were tarnished.
Sometimes the infraction seems petty, as seemed to be the case for Nicklas Backstrom, a forward for the Swedish hockey team. He was found to have pseudoephedrine in his urine, a common over the counter cold medications used as a decongestant. The team coach and doctor were aware of the medication, Zyrtec D, and Mr. Backstrom said that he had taken the medications intermittently for seven years to help with allergies. The International Ice Hockey Federation declared Mr. Backstrom “an innocent victim of circumstances” but the WADA specifically lists the drug as a prohibited stimulant if the levels in the urine are greater than 150 micrograms per milliliter. Backstrom’s level…195. Ignorance of the rule is not a defense and Mr. Backstrom was banned from the gold medal game.
Hockey is one of the marquis sports at the winter games, and the players will be in the spotlight within the week when they return to NHL action. For others who participate in less well marketed sports, the Olympics is their one time to make their national team and compete when the whole world watches, and perhaps it is a once in a lifetime opportunity. The risk reward for using performance enhancing drugs becomes more enticing. Ukrainian cross country skier, Marina Lisogor, tested positive for trimetazidine and Johannes Duerr, an Austrian cross country skier tested positive for EPO. Both drugs may aid an endurance athlete but there is significant risk.
EPO, or erythropoietin, is a hormone that helps regulate the number of red blood cells that the body produces. Red blood cells deliver oxygen form the lungs to the cells of the body; the more oxygen supplied, the longer a muscle can work aerobically, before running out of gas, turning to anaerobic metabolism (without oxygen) and forming lactic acid, the killer chemical when it comes to athletic performance. If an athlete injects EPO or its long acting cousin darbypoietin, the bone marrow can be stimulated to produce more than normal red cells. The same effect can occur by living and training at altitude or by blood doping, getting a blood transfusion. Better athletic performance is tempered by the potential of having too many red cells in the bloodstream, leading to the sludging of blood and clot formation. This complication may lead to stroke or heart attack.
Trimetazidine is a drug developed to help patient with coronary artery disease, angina and heart attack. It allowed heart muscle cells to use oxygen more efficiently and was approved as a second line heart drug, to be used only if other medications could not control angina. As well, the drug increased coronary artery blood flow to deliver more blood to the heart. It doesn’t take much of a leap to think that a drug that allowed one type of muscle cell (the heart) to use oxygen would not also be able to help other types of muscles. And perhaps for that reason, WADA lists it as prohibited. Perhaps another reason is the high potential for developing Parkinson like tremor, rigidity and gait instability.
Three Sochi athletes tested positive for methylhexanamine, a drug that looks like adrenaline to the body and was developed to help with allergies. It was withdrawn from the market because of the FDAThis entry was tagged DMAA, EPO, methylhexanamine, Nicklas Backstrom, Olympics, pseudoephedrine, The List, trimetazidine, WADA, ZYrtec-D
Dr. Wedro weighs in
“The difference between doctors who look after mere mortals and those who look after elite athletes may have to do with how many tests they can order, regardless of the cost.”