Facial, Dental, Ear, Nose, and Throat Emergencies

*Sinusitis

*Bell’s Palsy

*Trigeminal Neuralgia

*Facial Lacerations

*Soft Tissue Injuries

*Mandibular Fractures

*Maxillary Fractures

*Zygomatic Fractures

*Dental*Odontalgia*Tooth Eruption*Pericoronitis*Fractures Tooth*Subluxed/Avulsed Tooth*Dental Abscess*Ludwig’s Angina*Trench Mouth

*Ear*Acute OE

*Acute OM

*Ruptured Tympanic Membrane

*FB

*Meniere’s Disease

*Labyrinthitis

*Nose*Rhinitis

*Epistaxis

*Nasal Fracture

*FB

*Throat*Pharyngitis

*Tonsillitis

*Laryngitis

*Fractured Larynx

*Peritonsilar Abscess

*FB

*Nature of Injury/History

*Bleeding

*Airway Obstruction

*Loss of Consciousness

*Sensory Deficits/

Changes

*Medical /Surgical History

*Physical Assessment

*Psychosocial Responses

*Stress Factors

*Behavioral responses

*Diagnostic Procedures

*Radiological

*Facial Bones

*Water’s View

*Skull series

*C-spine

*CXR

*CT

*Diagnostic Procedures*Laboratory*Cultures

*Coags

*ABGs

*T&C

*ABC

*Control Bleeding

*Fluid and Electrolyte Balance

*Prevent Further CNS complications

*Control Pain

*Relieve Anxiety

*Education

Pediatric

*6-7 year: primary eruption of teeth

*Head is larger proportionally than adult’s

*Neck muscles are relatively weaker for large head mass

*Always explain and be honest

*Limitations in verbal expression

*Facial bones are more pliable and softer

Geriatric*Age-related changes*Decreased vital capacity

*Diminished ability to cough

*Visual acuity changes

*Diminished hearing

*Loss of short-term memory

*Muscle atrophy

*Chronic Disease

*Delayed responses

*Medications

*Inflammation of mucous membranes*Maxillary sinus most common*Frequently follows URI*Other causes: *allergies* dental *infections *trauma*polyps

Symptoms*Pain/Pressure

*Fever or not

*HA

*Decreased appetite

*Nasal congestion

*Nasal voice

*Red, swollen mucosa

*Purulent nasal drainage

*Conjunctivitis

*Tenderness to palpation

*Puffy eyes

*Bad breath (esp. children)

Treatment*Decongestants

*Antibiotics

*HOB elevated

*Apply heat

*Room vaporizer

*Severe: hospitalization

IV antibiotics Surgery

Education*Should improve 3-4 days

*Vaporizer, steam bath

*Increase fluids

*Avoid smoking

*“Rebound congestion”

*Paralysis of all facial muscles on one side of face

*Usually unilateral

*Swelling of facial nerve as a result of virus or immunodeficiency disease

*> 40 yrs

*Usually self-limiting

*Complete resolution in 80-90% of cases

Symptoms

*Rapid, acute onset

*Hx of Virus?

*Unilateral facial weakness/paralysis

*Retro auricular and/or facial discomfort

*Drooling

*Dysphagia

*Inability to close eye on affected side

*Decreased lacrimation

*Drooping of mouth

*Speech difficulty

*Positive corneal sensation /negative blink

*Inability to wrinkle forehead

*Diagnostics*Exclude other diseases

*Treatment/Education*Explain this disease

*Not a stroke

*Recovery within 3 weeks

*Artificial tears

*Eye patch

*Gentle manual closure of eye

*Not contagious

*Keep face warm, avoid drafts

*Possible analgesics and steroids

*Moist heat

*Facial muscle exercises

*Fifth cranial nerve

*Usually second and third division – maxillary and mandibular areas

*Brief, recurrent paroxysms of excruciating facial pain

*> 40 yrs and female

*Right side affected more often than left

Symptoms*Electrical shock type pain

*Unilateral

*Minimal to no sensory loss

*Painful paroxysms precipitated by touching of trigger zone

Diagnosis*History and physical exam

*Exclude other diseases

Treatment*Tegretol, Dilantin, analgesics

*Surgical interventions

Education

*Majority of patients respond to medical therapy within 48 hrs

*25-50% eventually will require surgical intervention

*Avoid cold exposure (iced drinks, winds, swimming)

*Side effects of medications

*Lacerations

*Abrasions

*Puncture wounds

*Contusions

*Avulsions

*Range from simple isolated injury to those accompanied by airway obstruction, edema, hemorrhage, facial trauma, and multisystem injuries

Symptoms/Assessment*MOI

*Facial asymmetry/swelling

*Pain/tenderness

*Foreign bodies

*Motor and sensory deficits

Diagnosis*Rule other S/S of more extensive facial injures, CNS injury, and multisystem injury

*Radiographs

*CT

*Cultures

*Treatment*Control bleeding*Irrigate wounds copiously*Clean intact skin and wound edges*Replace tissue flaps*Td*Analgesics*Ice to area of trauma, not to avulsed part

*Suture

*Anesthetic*Lido with epi unless contrindicated

*Restraint

*Lighting

*Scissors to cut hair / never shave or cut eyebrows

Education

* Wound care

*One of the most frequently fractured facial bone

*TMJ dislocation may accompany

*Fight and crashes most common causes

Symptoms/Assessment

*MOI

*Pain/point tenderness

*Malocclusion

*Facial asymmetry

*Bleeding around mouth

*Numbness of lower lip

*Trismus

*Edema/hematoma

*Ruptured tympanic membrane

*Mobility of fracture fragments

*Ecchymosis in floor of mouth

*Sunlingual edema

Diagnostics*PA, lateral, oblique skull films

*Waters’

*CT

Treatment*Ensure patent airway

*Prevent aspiration of blood, teeth, bone fragments, etc

*Control bleeding

*Have emergency airway equipment readily available

Ice

*Analgesics

*Surgical reduction/wiring

*Antibiotics

*½ and ½ peroxide and water

*Td

Education

*S/S infection

*Mechanical soft diet

*Use a straw

*Drink plenty of liquids

*Less common than mandibular

*Usually associated with other multisystem injuries

*LeFort I, II, III

*Common causes: fight and crashes

Symptoms/Assessment

*MOI

*Pain/tenderness

*Swelling

*Asymmetry/distortion

*Infraorbital mobility/paresthesia

*Ecchymosis

*Epistaxis

*Malocclusion

*Visual disturbances

*CSF rhinorrhea

*Subconjuctival hemorrhage

*Midface maxillary mobility

*S/S of intracranial, spinal, or multisystem injuries

Diagnostics

*Waters’ view

*Individual facial films

*CT scan

Treatment/Education*Ensure airway patency

*Prevent aspiration

*Positioning – Fowler’s/Semi-Fowlers

*Emergency intubation available

*Control bleeding

*Cold packs to face

*Definitive treatment*Open reduction

*Internal wiring

*Antibiotic prophylaxis

*Hospital admission

*Td

*Support and reassurance

*Causes: Fight, Crash, and Falls

*Tripod fractures

*Frequently associated with orbital floor fractures – blow-out fractures

Symptoms/Assessment*MOI

*Pain/point tenderness

*Bleeding

*Edema

*Pain with jaw movement

*Visual disturbances/diplopia

*Facial asymmetry

*Epistaxis

*Subjunctival hemorrhage

*Paresthesia of cheek, nose, upper lip of affected side

*SQ emphysema

Diagnosis*Waters’ view

*Submentovertical view

Treatment/Education*Analgesia

*Position and elevate head

*Ice

*Definitive treatment*Open reduction

*Internal wire fixation

*Hospital admission

*Explanations and reassurance

History

*Bleeding

*Obstructed Airway

*Swelling/Edema

*Asymmetry/

Dislocation

*Fever/Chills

*Nausea/Vomiting

*Drooling

*Facial numbness

*Dysphasia/Dysphagia

*Foul odor and taste in mouth

*Loss of hearing

*Tinnitis or vertigo

*Trismus

*Discharge/Drainage

*Itching

*Neck pain

*HA

*Medical History*HTN

*CAD

*Atherosclerosis

*Neuro diseases

*Dental/ENT surgery and/or infections

*CA

*Smoking

*Diabetes

*Radiology*Chest

*Waters’

*CT scan

*Laboratory*Cultures

*CBC

*Sed rate

*Coags

*ABGs

*ABCs

*Control Bleeding

*Fluid Volume

*Pain control

*Anxiety

*Definitive Treatment

*Prevent Complications

*Education

*Pediatric

*85% of FB aspirations < 3 y/o*Boys twice as likely than girls

*Persistent cough or chronic wheezing may be indicative of aspirated FB

*In 20-38% of esophageal ingestions there are no symptoms

*Abrupt onset of respiratory and pulmonary symptoms suggest FB ingestion.

*Irritability and lack of feeding in infants may be potential S/S of ENT/Dental emergencies

*Geriatric

*Difficulty in mastication

*Loss of sensation

*Progressive hearing loss

*Most dental and ENT emergencies in the elderly is related to falls, visual changes, MVCs, and assaults

*Toothache / Dental caries

*Sharp to throbbing

*If left untreated, will eventually lead to necrosis

*Prevention is best treatment

Symptoms*Pain in diseased tooth

*May be referred to gum line, jaw, temple, ear, neck

*More intense nocturnal pain

*Heat or cold stimulus

*Tooth discoloration

*Foul breath

Diagnostics*Rule out abscess

Treatment*Topical anesthetic

*Antibiotics

*Analgesic

Education*Preventative hygiene

*Follow-up with dentist

*Primary teeth in infants and children

*Wisdom teeth

Symptoms*Pressure/Tenderness

*Irritability/Agitation

*Low-grade temp

*Diarrhea

*Refusal to eat or drink

*Nasal discharge

*Crying

*Drooling

*Reddened, edematous tissue over erupting tooth

*Rash around mouth

Treatment*Gentle massage

*Teething ring

*Orajel

*Tylenol/Ibuprofen

*Warm saline mouth rinses

*Soft solid diet

*Erupting or impacted molars

*Acute inflammation surrounds the gingival tissue or crown of erupting tooth

*Commonly seen in the 30 y/o adult

*Complications: cellulitis, Ludwig’s angina, and peritonsillar abscess

Symptoms*Nonspecific diffuse extraoral pain or pain upon opening mouth

*Earache on affected side

*Sore throat, jaw pain

*Unerupted third molar

*Red, inflamed soft tissues around crown

*Lymphadenopathy, trismus and fever if has progressed to systemic

Treatment/Education*Irrigate pericoronal flap with warm NS to remove debris

*Refer to dentist for debridement or tooth extraction

*If infection:*Antipyretics

*Antibiotic

*Assist with drainage of abscess

*Common causes: Falls, MVCs, Physical abuse, Sport-related injuries, Seizures

*Ellis Class I –

*involve only the enamel, minor, rough appearance

*Ellis Class II

*Enamel portion and the dentin

*Pain sensitivities

*Should be seen by dentist in 24hr

*Ellis Class III –

*Enamel portion, dentin, and pulp

*Dental Emergency

Symptoms/Assessment*MOI

*Disfigurement of tooth/change in color

*Pain/tenderness*Spontaneous

*Hot or cold

*Inspiration

*HA

*N/V Involvement of enamel, dentin, pulp

*Malocclusion

*Bleeding

*Intraoral or extraoral wounds

Treatment*Suspect and rule out other injuries*Fracture involving enamel and dentin*Apply Calcium Hydroxide to protect*Mild oral analgesic*Dental referral within 24 hrs*Antibiotics

*Fracture involving pulp

*High risk of infection

*Apply Calcium Hydroxide to exposed crown surface

*Oral analgesic

*Dental referral for pulpectomy

Symptoms/Assessment

*Pain at site

*Bleeding

*Neck pain

*Respiratory status

*Other wounds

*Other injuries

*Prevalent in ages 7-10

Treatment

*Local anesthetic

*Subluxed or partially avulsed should be repositioned for stability

*Avulsed must be replanted with 30 minutes (no longer than 6 hrs)

*Clean mouth and socket with NS or cold water

*Tooth should be transported in moist saline gauze or milk

Education*Minimal mobility will

usually heal within 2 weeks

*Soft diet

*Avoid biting into anything with affected tooth

*Avoid hot and cold substances

*Refer to dentist or oral surgeon

*Localized accumulation of pus in a cavity of a tooth

*Gingival swelling results from plaque and debris collecting between tooth and gingiva

*Peridontal disease results when infections spreads into surrounding tissues and bone

*Periapical abscess results when infections has spread beyond the bone and the virus, bacteria has colonized

Symptoms*Pain

*May radiate to ear, jaw, and neck

*Not relieved by analgesics

*Swelling of face, neck, pharynx

*Fever

*Bad breath

*Malaise

*Chills

*Sore gums

Diagnosis*Soft tissue X-ray

*WBC

*Culture

Treatment*Systemic analgesic

*Antipyretic

*Assist with I&D (may leave drain in place)

*Educate warm NS rinses every 1-2 hrs

*Refer to dentist

*Results from a secondary dental infection involving the lower second and third molars

*Bilateral diffuse swelling and extending cellulitis involving the submandibular, submental, and sublingual areas occurs

*Difficulty talking and swallowing and breathing ensues as the neck and face become swollen and causes elevation of the tongue

Symptoms*Pain and swelling of jaw and neck

*Fever/Chills

*Malaise

*Dysphagia

*Dysphasia

*Elevation of tongue and floor of mouth toward palate

*Dyspnea

*Pallor or cyanosis

*Tachycardia

*Agitation

Diagnosis*CBC

*Sed rate

*Soft tissue films

*Cultures of exudate

Treatment*Maintain airway

(emergency cric)

*Fowler’s position

*Oxygen

*I&D (with culture)

*Antibiotic

Education*Rinse mouth with warm NS 2-3 times every hour

*Hot, moist compress to jaw and neck every hour

*a.k.a Dry Socket

*Pain post extraction more than 2-3 days

*Best treated with irrigation of the clot and topical oral analgesia/anesthetic

*Monitor for development of osteomyelitis

*Small vessels that continue to bleed

*Have patient bite on gauze over extraction site for 30 minutes

*May be anesthetized with lido with epi and sutured

*Avoid hard or hot foods

*Trench Mouth

*Non-contagious

*May follow a URI

*Also associated with debilitating illnesses, emotional stressors, nutritional deficiencies, and

smoking

Symptoms/Assessment*Pain

*Fever/Chills/Malaise

*Bleeding gums

*Poor oral hygiene

*Fetid breath

*Lymphadenopathy

*Gray ulcers on pharyngeal structures

Treatment*Topical or local anesthetic

*Antibiotics

*Antipyretic

*Refer to dentist

*Teach proper oral hygiene

*Swimmer’s Ear

*Inflammation of external auditory canal and auricle of the ear

Symptoms*Pain/Tenderness

*Diminished hearing

*Swelling/Redness/ Discharge

*Pruritis

*Low-grade fever

*Fullness in ear

*Cellulitis

Treatment*Topical antibiotic for one week

*Cleaning debris out of ear with cotton tip applicator, suction

*Ear wick saturated with antibiotic and/or steroids when ear canal is acutely swollen

*Hot, moist compress

*Keep ear canal dry

*Bacterial infection of middle ear

*Causes: barotrauma, Eustachian tube dysfunction, and URI

*Swelling prevents effective drainage and allows bacteria to proliferate

*Commonly seen in infants and children

Symptoms/Assessment*Earache that increases with prone position

*Pulling at the ear

*Sensation of fullness in ear

*Decreased hearing

*URI

*Fever/Chills

*Anorexia

*Vertigo/dizziness

*Purulent nasal drainage

*Erythema of pharynx

*Erythema of TM

*Retracted or bulging TM

Treatment/Education*Antibiotic

*Antipyretic

*Analgesic

*Follow-up within 2 weeks

*Primarily caused by infection

*May be caused from impact injury and explosive acoustic trauma

*Healing is usually spontaneous

Symptoms/Assessment*Pain

*Bloody or purulent discharge

*Vertigo

*Tinnitus

*Fever/Chills

*Barotrauma

*Previous infection/illness

*Slit-shaped or irregular TM

*Decreased hearing in ear

*Disequilibrium

Treatment/Education*Antibiotic

*Analgesic

*Antipyretic

*May need to assist in removing blood and debris from ear canal

*Avoid getting ear wet

*Hydration

*Follow-up

*Commonly seen in adults

*Avoid irrigating vegetable FBs

*Mineral oil or 2% Lidocaine for insects

Symptoms/Assessment*Discomfort or pain

*Decreased hearing

*Swelling of external ear

*Insect buzzing in ear

*Agitation

Treatment/Education*Assist with removal*Irrigation*NS*Alcohol*Mineral oil*Lidocaine

*Suction*Use Flashlight for insect

*Disorder of the vestibular system in the inner ear

*Abnormal accumulation of fluid in the cochlea and labyrinth causing severe rotary vertigo, N/V, and tinnitus

*Commonly seen 40-60 y/o

*Causes: blow to the head, infection, allergies, or degeneration of the inner ear

*Attack may last several hours

Symptoms/Assessment*Rotational vertigo

*Falls toward affected ear

*N/V

*Diaphoresis

*Tinnitus

*Hearing loss

*Heightened sensitivity to sounds

*HA

*Blurred vision

*Moist, pale skin

*Nystagmus

*Rule out intracranial lesion

*Hx of otitis media

Treatment*Medications*Diuretics*Anti-emetic*Antihistamines*Vasodilator

*Bed Rest*Quiet environment*Surgery if severe and refractory to medical tx

Education* Safety R/T

vertigo, falling, meds

* Make position changes slowly

* Follow-up

* Avoid alcohol and caffeine

* Hydration

*Inflammatory response of the inner ear; may involve nerves connecting the inner ear to the brain

*Bacterial or Viral

Symptoms/Assessment*Patient feels they are moving

*Unsteadiness

*N/V

*Hearing abnormalities

*Ear pressure

*HA

*Disequilibrium

*Normal neuro exams

*Orthostasis

*Recent hx of ear infection, URI, viral illness

Treatment*Antihistamines

*Antiemetics

*Sedatives

*IVF

*Antibiotics

*Inflammatory condition of the nasal mucosa

*Viral or bacterial URI

*Spread by droplet contact

Symptoms/Assessment

*Sneezing

*Postnasal drip/Copious nasal discharge

*Nasal obstruction

*Muscle aches

*Malaise

*HA

*Water or itchy eyes

*Sore throat

*Mild fever/chills

*Inflammation of throat and sinuses

*Nasal mucosa erythematous, edematous, and congested

Treatment/Education

*Antipyretics

*Decongestants

*Antihistamines

*Nasal corticosteroid

*Hydration

*Teach to use nasal decongestants for only a few days

*Symptoms usual resolve in 7 days

*Usually results from the erosion of superficial blood vessels from the anterior and inferior nasal septum

*Causes: Nose-picking, FB, Nasal trauma, Rhinitis, Forceful nose blowing

*Anterior epistaxis usually treated with frim pressure (pinching)

*Posterior epistaxis requires nasal packing

Symptoms/Assessments*Bleeding

*History of epistaxis

*Recent trauma or surgery

*N/V

*Hx of aspirin and/or antiplatelets meds

*Hx of HTN/atherosclerosis

*Erythema and swelling of nasal mucosa

*Blood in auditory canal

*Anxiety

*Tachycardia

*Sense of impending doom

Treatment/Education*ABCs*Control bleeding*Direct pressure*Nasal packing*Suctioning*Cauterization*Hemostatic material

*Establish IV

*Medications*Anesthetic

*Topical vasoconstrictors

*Decongestant

*Antihypertensives

*Avoid blowing nose forcibly

*Most frequently fractured bone

Symptoms/Assessment*MOI

*Visual deformity

*Swelling

*Nasal bleeding

*Nasal obstruction

*Crepitus

*Pain/Tenderness

*Rule out septum injury

Diagnosis*Nasal/facial films

Treatment/Education

*Assess for other injuries

*Control hemorrhage*Direct pressure

*IV

*Packing

*Ice pack

*Medications*Anesthetic

*Decongestant

*Vasoconstrictor

*Analgesic

*Antibiotics

*Commonly seen in children

Symptoms/Assessment*Nose pain/swelling

*Nasal discharge

*Foul smell from nose

*Unilateral bleeding

*Agitation

Treatment/Education*Blow nose to dislodge or remove

*Topical vasoconstrictive

*Assist in removal*Suction

*Forceps

*Foley catheter

*Sore Throat

*Usually associated with viral URI

*Most cases resolve with symptom management

*Spread by droplet transmission

*Common during late fall, winter, early spring

*Strep

Symptoms/Assessment*Sore throat*Difficulty swallowing*Pain referred to ears, neck, jaw*Fever/Chills*Harsh cough*Anorexia*Fatigue*Body aches

*Enlarged tonsils

*Cervical lymphadenopathy

*Exudate on pharynx and/or tonsils

*Foul breath

*Nasal speech

*Flushed face

Treatment/Education

*Antipyretic

*Analgesic

*Steroids

*Antibiotics

*Warm saline irrigation

*Rest

*Hydration

*Follow-up

*Tonsils act as filters for lymphatic circulation

*Similar to pharyngitis

Symptoms/Assessment

*Throat Pain

*Recent URI

*Pain/Difficulty swallowing

*Referred pain

*Fever/Chills

*Fatigue

*Fetid breath

*Tachycardia

*Red and swollen tonsils

*Purulent exudate on tonsils

*Enlarged cervical and submandibular lymph nodes

*Flushed face

*Culture (strep)

Treatment/Education

*ABC

*Warm saline irrigation

*Hydration (cool liquids)

*Rest

*Antibiotic

*Antitussive

*Steroids

*Follow-up

*For chronic tonsilitis: tonsillectomy

*Hoarseness

*Voice harsh and raspy

*Commonly a viral infection

*Constant urge to clear the throat or tickling sensation

Symptoms/Assessment

*Dry, tickling sensation in throat

*Partial to complete loss of voice

*Hoarseness

*Fever/Chills

*Sore throat

*Dyspnea

*Difficulty swallowing

*Dry cough

*Anorexia

*Reddened larynx and vocal cords

*Swelling of larynx and epiglottis

*Rhinorrhea

*Throat cultures

Treatment/Education

*Warm room that humidified

*Rest voice

*Antibiotic

*Inhaled steroid

*Antitussive

*Antipyretic

*Zinc

*Ice to anterior throat

*Humidifier

*Results from direct trauma (blunt or penetrating) to neck

*Common causes: MVC, strangulation, sports injuries

Symptoms/Assessment

*MOI

*Hoarseness

*Change in voice

*Pain on swallowing

*Cough

*Dyspnea

*Hemoptysis

*Ecchymosis

*Abrasions

*SQ emphysema

*Loss of normal prominence of thyroid cartilage

*Inspiratory stridor

*Substernal or Intercostal retractions

Diagnosis*CT scan

*Rule out other injuries

*Soft tissue films are not sensitive to laryngeal injury

Treatment*ABC / C-spine

*Cric or trach

*High humidity oxygen

*ABGs

*Treat concomitant injuries

*Surgery

*Infection penetrating the tonsillar capsule and superior constrictor muscle into the surrounding areolar tissue

*Streptococci bacteria are usually the pathogen

*Drainage of pus by an ENT

or oral surgeon provides immediate relief

Symptoms/Assessment

*Sore throat

*Pain on swallowing

*Ear fullness

*Fever/Chills

*Pus / exudate on tonsils

*Difficulty opening mouth

*Drooling

*Muffled voice

*Difficulty breathing

*Enlarged affected tonsil

*Displacement of uvula

*Edema and erythema of soft palate

*Profuse salivation

*Torticollis

*Increases respiratory rate

*Recent tonsilitis

Diagnosis*Culture and sensitivity

Treatment*ABC

*Pulse OX

*Oxygen

*HOB 60 to 90°

*IV hydration and medication

*Warm saline irrigation

*Antibiotics Topical anesthetic

*Analgesic

*Antipyretic

*Ice collar to throat

*I&D

*Common cause of accidental death in US Children < 6 y/o

*Can lead to obstruction of mainstem bronchus or distal trachea

*Airway management is priority

*Heimlich maneuver and/or abdominal thrusts

Symptoms/Assessment

*Sore throat

*Vocal changes

*Drooling

*Coughing

*Difficulty swallowing and/or breathing

*Difficulty talking

*Known ingestion

*FB visible in pharynx or larynx

*Stridor

*Tachycardia

*Excessive salivation

*Skin cool and moist

*Hemoptysis

*Hematemesis

*Agitation

Diagnosis*PA and lateral CXR

*Soft tissue of neck

Treatment/Education*ABC

*Finger sweep

*Heimlich

*Oxygen

*IV

*HOB 60 to 90°

*Prepare for potential emergency intubation

*Minimize environmental stimuli

*Removal procedures*Balloon-tipped Foley

*IVCS