Facial, Dental, Ear, Nose, and Throat Emergencies.

Facial, Dental, Ear, Nose, Facial, Dental, Ear, Nose, and Throat Emergenciesand Throat Emergencies

FACIAL EMERGENCIESFACIAL EMERGENCIES

SinusitisSinusitis Bell’s PalsyBell’s Palsy Trigeminal NeuralgiaTrigeminal Neuralgia

Facial LacerationsFacial Lacerations Soft Tissue InjuriesSoft Tissue Injuries Mandibular FracturesMandibular Fractures Maxillary FracturesMaxillary Fractures Zygomatic FracturesZygomatic Fractures

DENTAL AND ENT DENTAL AND ENT EMERGENCIESEMERGENCIES

DentalDental• OdontalgiaOdontalgia• Tooth EruptionTooth Eruption• PericoronitisPericoronitis• Fractures ToothFractures Tooth• Subluxed/Avulsed Subluxed/Avulsed

ToothTooth• Dental AbscessDental Abscess• Ludwig’s AnginaLudwig’s Angina• Trench MouthTrench Mouth

EarEar• Acute OEAcute OE• Acute OMAcute OM• Ruptured Tympanic Ruptured Tympanic

MembraneMembrane• FBFB• Meniere’s DiseaseMeniere’s Disease• LabyrinthitisLabyrinthitis


NoseNose• RhinitisRhinitis• EpistaxisEpistaxis• Nasal FractureNasal Fracture• FBFB

ThroatThroat• PharyngitisPharyngitis• TonsillitisTonsillitis• LaryngitisLaryngitis• Fractured LarynxFractured Larynx• Peritonsilar Peritonsilar

AbscessAbscess• FBFB

FACIALFACIAL

AssessmentAssessment Nature of Injury/HistoryNature of Injury/History BleedingBleeding Airway ObstructionAirway Obstruction Loss of ConsciousnessLoss of Consciousness Sensory Deficits/Sensory Deficits/

ChangesChanges Medical /Surgical HistoryMedical /Surgical History Physical AssessmentPhysical Assessment

AssessmentAssessment

Psychosocial ResponsesPsychosocial Responses• Stress FactorsStress Factors• Behavioral responsesBehavioral responses


Diagnostic ProceduresDiagnostic Procedures• RadiologicalRadiological

Facial BonesFacial Bones Water’s ViewWater’s View Skull seriesSkull series C-spineC-spine CXRCXR CTCT


Diagnostic ProceduresDiagnostic Procedures• LaboratoryLaboratory

CulturesCultures CoagsCoags ABGsABGs T&CT&C

PrioritiesPriorities

ABCABC Control BleedingControl Bleeding Fluid and Electrolyte BalanceFluid and Electrolyte Balance Prevent Further CNS complicationsPrevent Further CNS complications Control PainControl Pain Relieve AnxietyRelieve Anxiety EducationEducation

Age-related PearlsAge-related Pearls

PediatricPediatric• 6-7 year: primary eruption of teeth6-7 year: primary eruption of teeth• Head is larger proportionally than adult’sHead is larger proportionally than adult’s• Neck muscles are relatively weaker for large Neck muscles are relatively weaker for large

head masshead mass• Always explain and be honestAlways explain and be honest• Limitations in verbal expressionLimitations in verbal expression• Facial bones are more pliable and softerFacial bones are more pliable and softer

Age-related PearlsAge-related PearlsGeriatricGeriatric

• Age-related changesAge-related changes Decreased vital Decreased vital

capacitycapacity Diminished ability to Diminished ability to

coughcough Visual acuity changesVisual acuity changes Diminished hearingDiminished hearing Loss of short-term Loss of short-term

memorymemory Muscle atrophyMuscle atrophy

Chronic DiseaseChronic Disease Delayed responsesDelayed responses MedicationsMedications

SinusitisSinusitis

Inflammation of mucous membranesInflammation of mucous membranes Maxillary sinus most commonMaxillary sinus most common Frequently follows URIFrequently follows URI Other causes: Other causes:

• allergiesallergies• dental dental • infections infections • traumatrauma• polypspolyps

SinusitisSinusitis

SymptomsSymptoms• Pain/PressurePain/Pressure• Fever or notFever or not• HAHA• Decreased appetiteDecreased appetite• Nasal congestionNasal congestion• Nasal voiceNasal voice

• Red, swollen mucosaRed, swollen mucosa• Purulent nasal drainagePurulent nasal drainage• ConjunctivitisConjunctivitis• Tenderness to palpationTenderness to palpation• Puffy eyesPuffy eyes• Bad breath (esp. Bad breath (esp.

children)children)

SinusitisSinusitis

TreatmentTreatment• DecongestantsDecongestants• AntibioticsAntibiotics• HOB elevatedHOB elevated• Apply heatApply heat• Room vaporizerRoom vaporizer• Severe:Severe: hospitalization hospitalization

IV IV antibioticsantibiotics

SurgerySurgery

EducationEducation• Should improve 3-4 Should improve 3-4

daysdays• Vaporizer, steam bathVaporizer, steam bath• Increase fluidsIncrease fluids• Avoid smokingAvoid smoking• ““Rebound Rebound

congestion”congestion”

Bell’s PalsyBell’s Palsy

Paralysis of all facial muscles on one side Paralysis of all facial muscles on one side of faceof face

Usually unilateralUsually unilateral Swelling of facial nerve as a result of virus Swelling of facial nerve as a result of virus

or immunodeficiency diseaseor immunodeficiency disease > 40 yrs> 40 yrs Usually self-limitingUsually self-limiting Complete resolution in 80-90% of casesComplete resolution in 80-90% of cases

Bell’s PalsyBell’s PalsySymptomsSymptoms

• Rapid, acute onsetRapid, acute onset• Hx of Virus?Hx of Virus?• Unilateral facial Unilateral facial

weakness/paralysisweakness/paralysis• Retro auricular and/or Retro auricular and/or

facial discomfortfacial discomfort• DroolingDrooling• DysphagiaDysphagia

• Inability to close eye on Inability to close eye on affected sideaffected side

• Decreased lacrimationDecreased lacrimation• Drooping of mouthDrooping of mouth• Speech difficultySpeech difficulty• Positive corneal Positive corneal

sensation /negative blinksensation /negative blink• Inability to wrinkle Inability to wrinkle

foreheadforehead

Bell’s PalsyBell’s Palsy DiagnosticsDiagnostics

• Exclude other Exclude other diseasesdiseases

Bell’s PalsyBell’s Palsy

Treatment/EducationTreatment/Education• Explain this diseaseExplain this disease• Not a strokeNot a stroke• Recovery within 3 weeksRecovery within 3 weeks• Artificial tearsArtificial tears• Eye patchEye patch• Gentle manual closure of Gentle manual closure of

eyeeye• Not contagiousNot contagious

• Keep face warm, avoid Keep face warm, avoid draftsdrafts

• Possible analgesics and Possible analgesics and steroidssteroids

• Moist heatMoist heat• Facial muscle exercisesFacial muscle exercises

Trigeminal NeuralgiaTrigeminal Neuralgia

Fifth cranial nerveFifth cranial nerve Usually second and third division – Usually second and third division –

maxillary and mandibular areasmaxillary and mandibular areas Brief, recurrent paroxysms of excruciating Brief, recurrent paroxysms of excruciating

facial painfacial pain > 40 yrs and female> 40 yrs and female Right side affected more often Right side affected more often

than left than left

Trigeminal NeuralgiaTrigeminal Neuralgia

SymptomsSymptoms• Electrical shock type Electrical shock type

painpain• UnilateralUnilateral• Minimal to no sensory Minimal to no sensory

lossloss• Painful paroxysms Painful paroxysms

precipitated by precipitated by touching of trigger zone touching of trigger zone

DiagnosisDiagnosis• History and History and

physical examphysical exam• Exclude other Exclude other

diseasesdiseases

Trigeminal NeuralgiaTrigeminal NeuralgiaTreatmentTreatment

• Tegretol, Dilantin, Tegretol, Dilantin, analgesicsanalgesics

• Surgical Surgical interventionsinterventions

EducationEducation• Majority of patients Majority of patients

respond to medical respond to medical therapy within 48 hrstherapy within 48 hrs

• 25-50% eventually will 25-50% eventually will require surgical require surgical interventionintervention

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

• Side effects of Side effects of medicationsmedications

Facial lacerations and soft Facial lacerations and soft tissue injuriestissue injuries

Lacerations Lacerations AbrasionsAbrasions Puncture woundsPuncture wounds ContusionsContusions AvulsionsAvulsions Range from simple isolated injury to those Range from simple isolated injury to those

accompanied by airway obstruction, edema, accompanied by airway obstruction, edema, hemorrhage, facial trauma, and multisystem hemorrhage, facial trauma, and multisystem injuriesinjuries


Symptoms/Symptoms/

AssessmentAssessment• MOIMOI• Facial Facial

asymmetry/swellingasymmetry/swelling• Pain/tendernessPain/tenderness• Foreign bodiesForeign bodies• Motor and sensory Motor and sensory

deficitsdeficits

DiagnosisDiagnosis• Rule other S/S of Rule other S/S of

more extensive more extensive facial injures, CNS facial injures, CNS injury, and injury, and multisystem injurymultisystem injury

• RadiographsRadiographs• CTCT• CulturesCultures


TreatmentTreatment• Control bleedingControl bleeding• Irrigate wounds copiouslyIrrigate wounds copiously• Clean intact skin and Clean intact skin and

wound edgeswound edges• Replace tissue flapsReplace tissue flaps• TdTd• AnalgesicsAnalgesics• Ice to area of trauma, not Ice to area of trauma, not

to avulsed partto avulsed part

• SutureSuture• AnestheticAnesthetic

Lido with epi unless Lido with epi unless contrindicatedcontrindicated

• RestraintRestraint• LightingLighting• Scissors to cut hair / Scissors to cut hair /

never shave or cut never shave or cut eyebrowseyebrows


EducationEducation• Wound careWound care

Mandibular FracturesMandibular Fractures One of the most frequently fractured facial One of the most frequently fractured facial

bonebone TMJ dislocation may accompanyTMJ dislocation may accompany Fight and crashes most common causesFight and crashes most common causes

Mandibular FracturesMandibular Fractures

Symptoms/AssessmentSymptoms/Assessment• MOIMOI• Pain/point tendernessPain/point tenderness• MalocclusionMalocclusion• Facial asymmetryFacial asymmetry• Bleeding around mouthBleeding around mouth• Numbness of lower lipNumbness of lower lip• TrismusTrismus• Edema/hematomaEdema/hematoma

• Ruptured tympanic Ruptured tympanic membranemembrane

• Mobility of fracture Mobility of fracture fragmentsfragments

• Ecchymosis in floor of Ecchymosis in floor of mouthmouth

• Sunlingual edemaSunlingual edema


DiagnosticsDiagnostics• PA, lateral, oblique PA, lateral, oblique

skull filmsskull films• Waters’ Waters’ • CTCT


TreatmentTreatment• Ensure patent airwayEnsure patent airway• Prevent aspiration of Prevent aspiration of

blood, teeth, bone blood, teeth, bone fragments, etcfragments, etc

• Control bleedingControl bleeding• Have emergency Have emergency

airway equipment airway equipment readily availablereadily available

IceIce AnalgesicsAnalgesics Surgical Surgical

reduction/wiringreduction/wiring AntibioticsAntibiotics ½ and ½ peroxide and ½ and ½ peroxide and

waterwater TdTd

Mandibular FracturesMandibular FracturesEducationEducation

• S/S infectionS/S infection• Mechanical soft dietMechanical soft diet• Use a strawUse a straw• Drink plenty of liquidsDrink plenty of liquids

Maxillary FracturesMaxillary Fractures

Less common than mandibularLess common than mandibular Usually associated with other multisystem Usually associated with other multisystem

injuriesinjuries LeFort I, II, IIILeFort I, II, III Common causes: fight and crashesCommon causes: fight and crashes


Symptoms/AssessmentSymptoms/Assessment• MOIMOI• Pain/tendernessPain/tenderness• SwellingSwelling• Asymmetry/distortionAsymmetry/distortion• Infraorbital Infraorbital

mobility/paresthesiamobility/paresthesia• EcchymosisEcchymosis• EpistaxisEpistaxis

• MalocclusionMalocclusion• Visual disturbancesVisual disturbances• CSF rhinorrheaCSF rhinorrhea• Subconjuctival Subconjuctival

hemorrhagehemorrhage• Midface maxillary Midface maxillary

mobilitymobility• S/S of intracranial, S/S of intracranial,

spinal, or multisystem spinal, or multisystem injuriesinjuries


DiagnosticsDiagnostics• Waters’ viewWaters’ view• Individual facial filmsIndividual facial films• CT scanCT scan


Treatment/EducationTreatment/Education• Ensure airway patencyEnsure airway patency• Prevent aspirationPrevent aspiration• Positioning – Positioning –

Fowler’s/Semi-FowlersFowler’s/Semi-Fowlers• Emergency intubation Emergency intubation

availableavailable• Control bleedingControl bleeding• Cold packs to faceCold packs to face

• Definitive treatmentDefinitive treatment Open reductionOpen reduction Internal wiringInternal wiring

• Antibiotic prophylaxisAntibiotic prophylaxis• Hospital admissionHospital admission• TdTd• Support and Support and

reassurancereassurance

Zygomatic FracturesZygomatic Fractures

Causes: Fight, Crash, and FallsCauses: Fight, Crash, and Falls Tripod fracturesTripod fractures Frequently associated with orbital floor Frequently associated with orbital floor

fractures – blow-out fracturesfractures – blow-out fractures


Symptoms/AssessmentSymptoms/Assessment• MOIMOI• Pain/point tendernessPain/point tenderness• BleedingBleeding• EdemaEdema• Pain with jaw movementPain with jaw movement• Visual Visual

disturbances/diplopiadisturbances/diplopia• Facial asymmetryFacial asymmetry

• EpistaxisEpistaxis• Subjunctival Subjunctival

hemorrhagehemorrhage• Paresthesia of Paresthesia of

cheek, nose, upper cheek, nose, upper lip of affected sidelip of affected side

• SQ emphysemaSQ emphysema


DiagnosisDiagnosis• Waters’ viewWaters’ view• Submentovertical Submentovertical

viewview


Treatment/EducationTreatment/Education• AnalgesiaAnalgesia• Position and elevate Position and elevate

headhead• IceIce

• Definitive treatmentDefinitive treatment Open reductionOpen reduction Internal wire fixationInternal wire fixation

• Hospital admissionHospital admission• Explanations and Explanations and

reassurancereassurance

ASSESSMENTASSESSMENT

HistoryHistory BleedingBleeding Obstructed AirwayObstructed Airway Swelling/EdemaSwelling/Edema Asymmetry/Asymmetry/

DislocationDislocation Fever/ChillsFever/Chills Nausea/VomitingNausea/Vomiting DroolingDrooling

Facial numbnessFacial numbness Dysphasia/DysphagiaDysphasia/Dysphagia Foul odor and taste in Foul odor and taste in

mouthmouth Loss of hearingLoss of hearing Tinnitis or vertigoTinnitis or vertigo TrismusTrismus Discharge/DrainageDischarge/Drainage

ASSESSMENTASSESSMENT

ItchingItching Neck painNeck pain HAHA

Medical HistoryMedical History• HTNHTN• CADCAD• AtherosclerosisAtherosclerosis• Neuro diseasesNeuro diseases• Dental/ENT surgery Dental/ENT surgery

and/or infectionsand/or infections• CACA• SmokingSmoking• DiabetesDiabetes

DIAGNOSTICSDIAGNOSTICS

• RadiologyRadiology ChestChest Waters’Waters’ CT scanCT scan

• LaboratoryLaboratory CulturesCultures CBCCBC Sed rateSed rate CoagsCoags ABGsABGs

PRIORITIESPRIORITIES

ABCsABCs Control BleedingControl Bleeding Fluid VolumeFluid Volume Pain controlPain control AnxietyAnxiety Definitive TreatmentDefinitive Treatment Prevent ComplicationsPrevent Complications EducationEducation

Age-Related PearlsAge-Related Pearls PediatricPediatric

• 85% of FB aspirations < 3 y/o85% of FB aspirations < 3 y/o Boys twice as likely than girlsBoys twice as likely than girls

• Persistent cough or chronic wheezing may be indicative of Persistent cough or chronic wheezing may be indicative of aspirated FBaspirated FB

• In 20-38% of esophageal ingestions there are no symptomsIn 20-38% of esophageal ingestions there are no symptoms• Abrupt onset of respiratory and pulmonary symptoms Abrupt onset of respiratory and pulmonary symptoms

suggest FB ingestion.suggest FB ingestion.

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

Age-Related PearlsAge-Related Pearls

GeriatricGeriatric• Difficulty in masticationDifficulty in mastication• Loss of sensationLoss of sensation• Progressive hearing lossProgressive hearing loss• Most dental and ENT emergencies in the Most dental and ENT emergencies in the

elderly is related to falls, visual changes, elderly is related to falls, visual changes, MVCs, and assaultsMVCs, and assaults

DentalDental

OdontalgiaOdontalgia

Toothache / Dental cariesToothache / Dental caries Sharp to throbbingSharp to throbbing If left untreated, will eventually lead to If left untreated, will eventually lead to

necrosisnecrosis Prevention is best treatmentPrevention is best treatment

OdontalgiaOdontalgiaSymptomsSymptoms

• Pain in diseased toothPain in diseased tooth• May be referred to gum line, jaw, temple, ear, neckMay be referred to gum line, jaw, temple, ear, neck• More intense nocturnal painMore intense nocturnal pain• Heat or cold stimulusHeat or cold stimulus• Tooth discolorationTooth discoloration• Foul breathFoul breath

DiagnosticsDiagnostics• Rule out abscessRule out abscess

OdontalgiaOdontalgia

TreatmentTreatment• Topical Topical

anestheticanesthetic

• AntibioticsAntibiotics

• AnalgesicAnalgesic

EducationEducation• Preventative Preventative

hygienehygiene

• Follow-up with Follow-up with dentistdentist

Tooth EruptionTooth Eruption

Primary teeth in infants and childrenPrimary teeth in infants and children Wisdom teethWisdom teeth


SymptomsSymptoms• Pressure/Pressure/

TendernessTenderness• Irritability/AgitationIrritability/Agitation• Low-grade tempLow-grade temp• DiarrheaDiarrhea• Refusal to eat or Refusal to eat or

drinkdrink

• Nasal dischargeNasal discharge• CryingCrying• DroolingDrooling• Reddened, Reddened,

edematous tissue edematous tissue over erupting toothover erupting tooth

• Rash around mouthRash around mouth


TreatmentTreatment• Gentle massageGentle massage• Teething ringTeething ring• OrajelOrajel• Tylenol/IbuprofenTylenol/Ibuprofen• Warm saline mouth Warm saline mouth

rinsesrinses• Soft solid dietSoft solid diet

PericoronitisPericoronitis

Erupting or impacted molarsErupting or impacted molars Acute inflammation surrounds the gingival Acute inflammation surrounds the gingival

tissue or crown of erupting toothtissue or crown of erupting tooth Commonly seen in the 30 y/o adultCommonly seen in the 30 y/o adult Complications: cellulitis, Ludwig’s angina, Complications: cellulitis, Ludwig’s angina,

and peritonsillar abscessand peritonsillar abscess

PericoronitisPericoronitisSymptomsSymptoms

• Nonspecific diffuse Nonspecific diffuse extraoral pain or pain extraoral pain or pain upon opening mouthupon opening mouth

• Earache on affected sideEarache on affected side• Sore throat, jaw painSore throat, jaw pain• Unerupted third molarUnerupted third molar• Red, inflamed soft Red, inflamed soft

tissues around crowntissues around crown

• Lymphadenopathy, Lymphadenopathy, trismus and fever if trismus and fever if has progressed to has progressed to systemicsystemic

PericoronitisPericoronitis

Treatment/EducationTreatment/Education• Irrigate pericoronal flap Irrigate pericoronal flap

with warm NS to with warm NS to remove debrisremove debris

• Refer to dentist for Refer to dentist for debridement or tooth debridement or tooth extractionextraction

• If infection:If infection: AntipyreticsAntipyretics AntibioticAntibiotic Assist with Assist with

drainage of drainage of abscessabscess

Fractured ToothFractured Tooth Common causes: Falls, MVCs, Physical Common causes: Falls, MVCs, Physical

abuse, Sport-related injuries, Seizuresabuse, Sport-related injuries, Seizures Ellis Class I – Ellis Class I –

• involve only the enamel, minor, rough appearanceinvolve only the enamel, minor, rough appearance

Ellis Class II Ellis Class II • Enamel portion and the dentinEnamel portion and the dentin

• Pain sensitivitiesPain sensitivities

• Should be seen by dentist in 24hrShould be seen by dentist in 24hr

Fractured ToothFractured Tooth

Ellis Class III –Ellis Class III –• Enamel portion, dentin, and pulpEnamel portion, dentin, and pulp• Dental EmergencyDental Emergency


Symptoms/AssessmentSymptoms/Assessment• MOIMOI• Disfigurement of Disfigurement of

tooth/change in colortooth/change in color• Pain/tendernessPain/tenderness

SpontaneousSpontaneous Hot or coldHot or cold InspirationInspiration

• HAHA• N/V Involvement of N/V Involvement of

enamel, dentin, pulpenamel, dentin, pulp• MalocclusionMalocclusion• BleedingBleeding• Intraoral or extraoral Intraoral or extraoral

woundswounds


TreatmentTreatment• Suspect and rule out Suspect and rule out

other injuriesother injuries• Fracture involving Fracture involving

enamel and dentinenamel and dentin Apply Calcium Hydroxide Apply Calcium Hydroxide

to protectto protect Mild oral analgesicMild oral analgesic Dental referral within 24 Dental referral within 24

hrshrs AntibioticsAntibiotics

Fracture involving pulpFracture involving pulp• High risk of infectionHigh risk of infection• Apply Calcium Apply Calcium

Hydroxide to exposed Hydroxide to exposed crown surfacecrown surface

• Oral analgesicOral analgesic• Dental referral for Dental referral for

pulpectomypulpectomy

Subluxed/Avulsed ToothSubluxed/Avulsed Tooth

Symptoms/AssessmentSymptoms/Assessment• Pain at site Pain at site • BleedingBleeding• Neck painNeck pain• Respiratory statusRespiratory status• Other woundsOther wounds• Other injuriesOther injuries• Prevalent in ages 7-10Prevalent in ages 7-10

TreatmentTreatment• Local anestheticLocal anesthetic• Subluxed or partially avulsed Subluxed or partially avulsed

should be repositioned for should be repositioned for stabilitystability

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

• Clean mouth and socket with Clean mouth and socket with NS or cold waterNS or cold water

• Tooth should be transported in Tooth should be transported in moist saline gauze or milkmoist saline gauze or milk

Subluxed/Avulsed ToothSubluxed/Avulsed Tooth

EducationEducation• Minimal mobility will Minimal mobility will

usually heal within 2 usually heal within 2 weeksweeks

• Soft dietSoft diet• Avoid biting into Avoid biting into

anything with affected anything with affected toothtooth

• Avoid hot and cold Avoid hot and cold substancessubstances

• Refer to dentist or oral Refer to dentist or oral surgeonsurgeon

Dental AbscessDental Abscess

Localized accumulation of pus in a cavity of a Localized accumulation of pus in a cavity of a toothtooth

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

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

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

Dental AbscessDental AbscessSymptomsSymptoms

• PainPain

• May radiate to ear, May radiate to ear, jaw, and neckjaw, and neck

• Not relieved by Not relieved by analgesicsanalgesics

• Swelling of face, Swelling of face, neck, pharynxneck, pharynx

• FeverFever

• Bad breathBad breath

• MalaiseMalaise

• ChillsChills

• Sore gumsSore gums

Dental AbscessDental AbscessDiagnosisDiagnosis

• Soft tissue X-raySoft tissue X-ray

• WBCWBC

• CultureCulture

TreatmentTreatment• Systemic analgesicSystemic analgesic• AntipyreticAntipyretic• Assist with I&D (may Assist with I&D (may

leave drain in place)leave drain in place)• Educate warm NS Educate warm NS

rinses every 1-2 hrsrinses every 1-2 hrs• Refer to dentistRefer to dentist

Ludwig’s AnginaLudwig’s Angina Results from a secondary dental infection Results from a secondary dental infection

involving the lower second and third molarsinvolving the lower second and third molars Bilateral diffuse swelling and extending Bilateral diffuse swelling and extending

cellulitis involving the submandibular, cellulitis involving the submandibular, submental, and sublingual areas occurssubmental, and sublingual areas occurs

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

Ludwig’s AnginaLudwig’s Angina

SymptomsSymptoms• Pain and swelling of jaw Pain and swelling of jaw

and neck and neck• Fever/ChillsFever/Chills• MalaiseMalaise• DysphagiaDysphagia• DysphasiaDysphasia• Elevation of tongue and floor of Elevation of tongue and floor of

mouth toward palatemouth toward palate

• DyspneaDyspnea• Pallor or cyanosisPallor or cyanosis• TachycardiaTachycardia• AgitationAgitation


DiagnosisDiagnosis• CBCCBC

• Sed rateSed rate

• Soft tissue filmsSoft tissue films

• Cultures of Cultures of exudateexudate


TreatmentTreatment• Maintain airwayMaintain airway

(emergency cric)(emergency cric)• Fowler’s positionFowler’s position• OxygenOxygen• I&D (with culture)I&D (with culture)• AntibioticAntibiotic

EducationEducation• Rinse mouth with Rinse mouth with

warm NS 2-3 times warm NS 2-3 times every hourevery hour

• Hot, moist Hot, moist compress to jaw compress to jaw and neck every and neck every hourhour

AlveolitisAlveolitis

a.k.a Dry Socketa.k.a Dry Socket Pain post extraction more than 2-3 daysPain post extraction more than 2-3 days Best treated with irrigation of the clot and Best treated with irrigation of the clot and

topical oral analgesia/anesthetictopical oral analgesia/anesthetic Monitor for development of osteomyelitisMonitor for development of osteomyelitis

Post-extraction BleedingPost-extraction Bleeding

Small vessels that continue to bleedSmall vessels that continue to bleed Have patient bite on gauze over extraction Have patient bite on gauze over extraction

site for 30 minutessite for 30 minutes May be anesthetized with lido with epi and May be anesthetized with lido with epi and

suturedsutured Avoid hard or hot foodsAvoid hard or hot foods

Acute Necrotizing Ulcerative Acute Necrotizing Ulcerative GingivitisGingivitis

Trench MouthTrench Mouth Non-contagiousNon-contagious May follow a URIMay follow a URI Also associated with debilitating illnesses, Also associated with debilitating illnesses,

emotional stressors, nutritional emotional stressors, nutritional deficiencies, and deficiencies, and

smokingsmoking

Acute Necrotizing Ulcerative Acute Necrotizing Ulcerative GingivitisGingivitis

Symptoms/AssessmentSymptoms/Assessment• PainPain• Fever/Chills/MalaiseFever/Chills/Malaise• Bleeding gumsBleeding gums• Poor oral hygienePoor oral hygiene• Fetid breathFetid breath• LymphadenopathyLymphadenopathy• Gray ulcers on Gray ulcers on

pharyngeal structurespharyngeal structures

TreatmentTreatment• Topical or local Topical or local

anestheticanesthetic• AntibioticsAntibiotics• AntipyreticAntipyretic• Refer to dentistRefer to dentist• Teach proper oral Teach proper oral

hygienehygiene

EAREAR

Acute Otitis ExternaAcute Otitis Externa

Swimmer’s EarSwimmer’s Ear Inflammation of external auditory canal Inflammation of external auditory canal

and auricle of the earand auricle of the ear


SymptomsSymptoms• Pain/TendernessPain/Tenderness• Diminished hearingDiminished hearing• Swelling/Redness/ Swelling/Redness/

DischargeDischarge• PruritisPruritis• Low-grade feverLow-grade fever• Fullness in earFullness in ear• CellulitisCellulitis


TreatmentTreatment• Topical antibiotic Topical antibiotic

for one weekfor one week• Cleaning debris out Cleaning debris out

of ear with cotton of ear with cotton tip applicator, tip applicator, suction suction

• Ear wick saturated Ear wick saturated with antibiotic and/or with antibiotic and/or steroids when ear steroids when ear canal is acutely canal is acutely swollenswollen

• Hot, moist compressHot, moist compress• Keep ear canal dryKeep ear canal dry

Acute Otitis MediaAcute Otitis Media

Bacterial infection of middle earBacterial infection of middle ear Causes: barotrauma, Eustachian tube Causes: barotrauma, Eustachian tube

dysfunction, and URIdysfunction, and URI Swelling prevents effective drainage and Swelling prevents effective drainage and

allows bacteria to proliferateallows bacteria to proliferate Commonly seen in infants and childrenCommonly seen in infants and children


Symptoms/AssessmentSymptoms/Assessment• Earache that increases Earache that increases

with prone positionwith prone position• Pulling at the earPulling at the ear• Sensation of fullness in Sensation of fullness in

earear• Decreased hearingDecreased hearing• URIURI• Fever/ChillsFever/Chills

• AnorexiaAnorexia• Vertigo/dizzinessVertigo/dizziness• Purulent nasal Purulent nasal

drainagedrainage• Erythema of pharynxErythema of pharynx• Erythema of TMErythema of TM• Retracted or bulging Retracted or bulging

TMTM


Treatment/EducationTreatment/Education• AntibioticAntibiotic• AntipyreticAntipyretic• AnalgesicAnalgesic• Follow-up within 2 Follow-up within 2

weeksweeks

Ruptured Tympanic MembraneRuptured Tympanic Membrane

Primarily caused by infectionPrimarily caused by infection May be caused from impact injury and May be caused from impact injury and

explosive acoustic traumaexplosive acoustic trauma Healing is usually spontaneousHealing is usually spontaneous

Ruptured Tympanic Ruptured Tympanic MembraneMembrane

Symptoms/AssessmentSymptoms/Assessment• PainPain• Bloody or purulent Bloody or purulent

dischargedischarge• VertigoVertigo• TinnitusTinnitus• Fever/ChillsFever/Chills• BarotraumaBarotrauma

• Previous Previous infection/illnessinfection/illness

• Slit-shaped or Slit-shaped or irregular TMirregular TM

• Decreased hearing Decreased hearing in earin ear

• DisequilibriumDisequilibrium

Ruptured Tympanic MembraneRuptured Tympanic Membrane

Treatment/EducationTreatment/Education• AntibioticAntibiotic

• AnalgesicAnalgesic

• AntipyreticAntipyretic

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

• Avoid getting ear Avoid getting ear wetwet

• HydrationHydration

• Follow-upFollow-up

Foreign Body In EarForeign Body In Ear

Commonly seen in Commonly seen in adultsadults

Avoid irrigating Avoid irrigating vegetable FBsvegetable FBs

Mineral oil or 2% Mineral oil or 2% Lidocaine for insectsLidocaine for insects

Foreign Body In EarForeign Body In Ear

Symptoms/AssessmentSymptoms/Assessment• Discomfort or painDiscomfort or pain

• Decreased hearingDecreased hearing

• Swelling of external earSwelling of external ear

• Insect buzzing in earInsect buzzing in ear

• AgitationAgitation

Foreign Body in EarForeign Body in Ear

Treatment/EducationTreatment/Education• Assist with removalAssist with removal

IrrigationIrrigation• NSNS• AlcoholAlcohol• Mineral oilMineral oil• LidocaineLidocaine

• SuctionSuction• Use Flashlight for insectUse Flashlight for insect

Meniere’s DiseaseMeniere’s Disease Disorder of the vestibular system in the inner earDisorder of the vestibular system in the inner ear Abnormal accumulation of fluid in the cochlea Abnormal accumulation of fluid in the cochlea

and labyrinth causing severe rotary vertigo, N/V, and labyrinth causing severe rotary vertigo, N/V, and tinnitusand tinnitus

Commonly seen 40-60 y/oCommonly seen 40-60 y/o Causes: blow to the head, infection, allergies, or Causes: blow to the head, infection, allergies, or

degeneration of the inner eardegeneration of the inner ear Attack may last several hoursAttack may last several hours

Meniere’s DiseaseMeniere’s Disease

Symptoms/AssessmentSymptoms/Assessment• Rotational vertigoRotational vertigo• Falls toward affected earFalls toward affected ear• N/VN/V• DiaphoresisDiaphoresis• TinnitusTinnitus• Hearing lossHearing loss• Heightened sensitivity to Heightened sensitivity to

soundssounds

• HAHA• Blurred visionBlurred vision• Moist, pale skinMoist, pale skin• NystagmusNystagmus• Rule out intracranial Rule out intracranial

lesionlesion• Hx of otitis mediaHx of otitis media

Meniere’s DiseaseMeniere’s DiseaseTreatmentTreatment

• MedicationsMedications DiureticsDiuretics Anti-emeticAnti-emetic AntihistaminesAntihistamines VasodilatorVasodilator

• Bed RestBed Rest• Quiet environmentQuiet environment• Surgery if severe and Surgery if severe and

refractory to medical txrefractory to medical tx

EducationEducation• Safety R/T vertigo, Safety R/T vertigo,

falling, medsfalling, meds• Make position Make position

changes slowlychanges slowly• Follow-upFollow-up• Avoid alcohol and Avoid alcohol and

caffeine caffeine • HydrationHydration

Labyrinthitis Labyrinthitis

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

Bacterial or ViralBacterial or Viral

LabyrinthitisLabyrinthitis

Symptoms/AssessmentSymptoms/Assessment• Patient feels they are Patient feels they are

movingmoving• UnsteadinessUnsteadiness• N/VN/V• Hearing abnormalitiesHearing abnormalities• Ear pressureEar pressure

• HAHA• DisequilibriumDisequilibrium• Normal neuro examsNormal neuro exams• OrthostasisOrthostasis• Recent hx of ear Recent hx of ear

infection, URI, viral infection, URI, viral illnessillness

LabyrinthitisLabyrinthitis

TreatmentTreatment• AntihistaminesAntihistamines• AntiemeticsAntiemetics• SedativesSedatives• IVFIVF• AntibioticsAntibiotics

NOSENOSE

RhinitisRhinitis

Inflammatory condition of the nasal Inflammatory condition of the nasal mucosamucosa

Viral or bacterial URIViral or bacterial URI Spread by droplet contactSpread by droplet contact

RhinitisRhinitis

Symptoms/AssessmentSymptoms/Assessment• SneezingSneezing• Postnasal Postnasal

drip/Copious nasal drip/Copious nasal dischargedischarge

• Nasal obstructionNasal obstruction• Muscle achesMuscle aches• MalaiseMalaise• HAHA• Water or itchy eyesWater or itchy eyes

• Sore throatSore throat• Mild fever/chillsMild fever/chills• Inflammation of throat Inflammation of throat

and sinusesand sinuses• Nasal mucosa Nasal mucosa

erythematous, erythematous, edematous, and edematous, and congestedcongested

RhinitisRhinitis

Treatment/EducationTreatment/Education• AntipyreticsAntipyretics• DecongestantsDecongestants• AntihistaminesAntihistamines• Nasal corticosteroidNasal corticosteroid• HydrationHydration

• Teach to use nasal Teach to use nasal decongestants for only decongestants for only a few daysa few days

• Symptoms usual Symptoms usual resolve in 7 daysresolve in 7 days

EpistaxisEpistaxis

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

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

Anterior epistaxis usually treated with frim Anterior epistaxis usually treated with frim pressure (pinching)pressure (pinching)

Posterior epistaxis requires nasal packingPosterior epistaxis requires nasal packing

EpistaxisEpistaxisSymptoms/AssessmentsSymptoms/Assessments

• BleedingBleeding• History of epistaxisHistory of epistaxis• Recent trauma or Recent trauma or

surgerysurgery• N/VN/V• Hx of aspirin and/or Hx of aspirin and/or

antiplatelets medsantiplatelets meds• Hx of Hx of

HTN/atherosclerosisHTN/atherosclerosis

• Erythema and Erythema and swelling of nasal swelling of nasal mucosamucosa

• Blood in auditory Blood in auditory canalcanal

• AnxietyAnxiety• TachycardiaTachycardia• Sense of impending Sense of impending

doomdoom

EpistaxisEpistaxis

Treatment/EducationTreatment/Education• ABCsABCs

• Control bleedingControl bleeding Direct pressureDirect pressure Nasal packingNasal packing SuctioningSuctioning CauterizationCauterization Hemostatic materialHemostatic material

• Establish IVEstablish IV

• MedicationsMedications AnestheticAnesthetic Topical Topical

vasoconstrictorsvasoconstrictors DecongestantDecongestant AntihypertensivesAntihypertensives

• Avoid blowing Avoid blowing nose forciblynose forcibly

Nasal FractureNasal Fracture

Most frequently fractured boneMost frequently fractured bone


Symptoms/AssessmentSymptoms/Assessment• MOIMOI• Visual deformityVisual deformity• SwellingSwelling• Nasal bleedingNasal bleeding• Nasal obstructionNasal obstruction• CrepitusCrepitus• Pain/TendernessPain/Tenderness• Rule out septum injuryRule out septum injury

DiagnosisDiagnosis• Nasal/facial filmsNasal/facial films


Treatment/EducationTreatment/Education• Assess for other Assess for other

injuriesinjuries

• Control hemorrhageControl hemorrhage Direct pressureDirect pressure IVIV PackingPacking

• Ice packIce pack

• MedicationsMedications AnestheticAnesthetic DecongestantDecongestant VasoconstrictorVasoconstrictor AnalgesicAnalgesic AntibioticsAntibiotics

Foreign Body In NoseForeign Body In Nose

Commonly seen in Commonly seen in childrenchildren

Foreign Body In NoseForeign Body In Nose

Symptoms/AssessmentSymptoms/Assessment• Nose pain/swellingNose pain/swelling• Nasal dischargeNasal discharge• Foul smell from noseFoul smell from nose• Unilateral bleedingUnilateral bleeding• AgitationAgitation

Treatment/EducationTreatment/Education• Blow nose to dislodge Blow nose to dislodge

or removeor remove• Topical Topical

vasoconstrictivevasoconstrictive• Assist in removalAssist in removal

SuctionSuction ForcepsForceps Foley catheterFoley catheter

ThroatThroat

PharyngitisPharyngitis

Sore ThroatSore Throat Usually associated with viral URIUsually associated with viral URI Most cases resolve with symptom Most cases resolve with symptom

managementmanagement Spread by droplet transmissionSpread by droplet transmission Common during late fall, winter, early Common during late fall, winter, early

springspring StrepStrep


Symptoms/AssessmentSymptoms/Assessment• Sore throatSore throat• Difficulty swallowingDifficulty swallowing• Pain referred to ears, Pain referred to ears,

neck, jawneck, jaw• Fever/ChillsFever/Chills• Harsh coughHarsh cough• AnorexiaAnorexia• FatigueFatigue• Body achesBody aches

• Enlarged tonsilsEnlarged tonsils• Cervical Cervical

lymphadenopathylymphadenopathy• Exudate on pharynx Exudate on pharynx

and/or tonsilsand/or tonsils• Foul breathFoul breath• Nasal speechNasal speech• Flushed faceFlushed face


Treatment/EducationTreatment/Education• AntipyreticAntipyretic• AnalgesicAnalgesic• SteroidsSteroids• AntibioticsAntibiotics• Warm saline irrigationWarm saline irrigation• RestRest• HydrationHydration• Follow-upFollow-up

TonsilitisTonsilitis

Tonsils act as filters for lymphatic Tonsils act as filters for lymphatic circulationcirculation

Similar to pharyngitisSimilar to pharyngitis


Symptoms/AssessmentSymptoms/Assessment• Throat PainThroat Pain• Recent URIRecent URI• Pain/Difficulty Pain/Difficulty

swallowingswallowing• Referred painReferred pain• Fever/ChillsFever/Chills• FatigueFatigue• Fetid breathFetid breath

• TachycardiaTachycardia• Red and swollen tonsilsRed and swollen tonsils• Purulent exudate on Purulent exudate on

tonsilstonsils• Enlarged cervical and Enlarged cervical and

submandibular lymph submandibular lymph nodesnodes

• Flushed faceFlushed face• Culture (strep)Culture (strep)


Treatment/EducationTreatment/Education• ABCABC• Warm saline irrigationWarm saline irrigation• Hydration (cool liquids)Hydration (cool liquids)• RestRest• AntibioticAntibiotic• AntitussiveAntitussive• SteroidsSteroids• Follow-upFollow-up

• For chronic tonsilitis: For chronic tonsilitis: tonsillectomytonsillectomy

LaryngitisLaryngitis

HoarsenessHoarseness Voice harsh and raspyVoice harsh and raspy Commonly a viral infectionCommonly a viral infection Constant urge to clear the throat or tickling Constant urge to clear the throat or tickling

sensationsensation


Symptoms/AssessmentSymptoms/Assessment• Dry, tickling sensation Dry, tickling sensation

in throatin throat• Partial to complete Partial to complete

loss of voiceloss of voice• HoarsenessHoarseness• Fever/ChillsFever/Chills• Sore throatSore throat• DyspneaDyspnea

• Difficulty swallowingDifficulty swallowing• Dry coughDry cough• AnorexiaAnorexia• Reddened larynx and Reddened larynx and

vocal cordsvocal cords• Swelling of larynx and Swelling of larynx and

epiglottisepiglottis• RhinorrheaRhinorrhea• Throat culturesThroat cultures


Treatment/EducationTreatment/Education• Warm room that Warm room that

humidifiedhumidified• Rest voiceRest voice• AntibioticAntibiotic• Inhaled steroidInhaled steroid• AntitussiveAntitussive

• AntipyreticAntipyretic• ZincZinc• Ice to anterior throatIce to anterior throat• HumidifierHumidifier

Fractured LarynxFractured Larynx

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

Common causes: MVC, Common causes: MVC, strangulation, sports injuriesstrangulation, sports injuries


Symptoms/AssessmentSymptoms/Assessment• MOIMOI• HoarsenessHoarseness• Change in voiceChange in voice• Pain on swallowingPain on swallowing• CoughCough• DyspneaDyspnea• HemoptysisHemoptysis

• EcchymosisEcchymosis• AbrasionsAbrasions• SQ emphysemaSQ emphysema• Loss of normal Loss of normal

prominence of thyroid prominence of thyroid cartilagecartilage

• Inspiratory stridorInspiratory stridor• Substernal or Intercostal Substernal or Intercostal

retractionsretractions


DiagnosisDiagnosis• CT scanCT scan• Rule out other injuriesRule out other injuries• Soft tissue films are Soft tissue films are

not sensitive to not sensitive to laryngeal injury laryngeal injury

TreatmentTreatment• ABC / C-spineABC / C-spine• Cric or trachCric or trach• High humidity High humidity

oxygenoxygen• ABGsABGs• Treat concomitant Treat concomitant

injuriesinjuries• SurgerySurgery

Peritonsillar abscessPeritonsillar abscess Infection penetrating the Infection penetrating the

tonsillar capsule and superior tonsillar capsule and superior constrictor muscle into the constrictor muscle into the surrounding areolar tissuesurrounding areolar tissue

Streptococci bacteria are Streptococci bacteria are usually the pathogenusually the pathogen

Drainage of pus by an ENT Drainage of pus by an ENT

or oral surgeon provides or oral surgeon provides immediate reliefimmediate relief

Peritonsilar abscessPeritonsilar abscess

Symptoms/AssessmentSymptoms/Assessment• Sore throatSore throat• Pain on swallowingPain on swallowing• Ear fullnessEar fullness• Fever/ChillsFever/Chills• Pus / exudate on Pus / exudate on

tonsilstonsils• Difficulty opening Difficulty opening

mouthmouth• DroolingDrooling• Muffled voiceMuffled voice

• Difficulty breathingDifficulty breathing• Enlarged affected Enlarged affected

tonsiltonsil• Displacement of uvulaDisplacement of uvula• Edema and erythema Edema and erythema

of soft palateof soft palate• Profuse salivationProfuse salivation• TorticollisTorticollis• Increases respiratory Increases respiratory

raterate• Recent tonsilitisRecent tonsilitis

Peritonsillar abscessPeritonsillar abscess

DiagnosisDiagnosis• Culture and Culture and

sensitivitysensitivity

Peritonsillar abscessPeritonsillar abscess

TreatmentTreatment• ABCABC• Pulse OXPulse OX• OxygenOxygen• HOB 60 to 90HOB 60 to 90°°• IV hydration and IV hydration and

medicationmedication

• Warm saline Warm saline irrigationirrigation

• AntibioticsAntibiotics Topical Topical anestheticanesthetic

• AnalgesicAnalgesic• AntipyreticAntipyretic• Ice collar to throatIce collar to throat• I&DI&D

Foreign Body In ThroatForeign Body In Throat

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

Can lead to obstruction of mainstem Can lead to obstruction of mainstem bronchus or distal tracheabronchus or distal trachea

Airway management is priorityAirway management is priority Heimlich maneuver and/or Heimlich maneuver and/or

abdominal thrustsabdominal thrusts


Symptoms/AssessmentSymptoms/Assessment• Sore throatSore throat• Vocal changesVocal changes• DroolingDrooling• CoughingCoughing• Difficulty swallowing Difficulty swallowing

and/or breathingand/or breathing• Difficulty talkingDifficulty talking• Known ingestionKnown ingestion

• FB visible in pharynx or FB visible in pharynx or larynxlarynx

• StridorStridor• TachycardiaTachycardia• Excessive salivationExcessive salivation• Skin cool and moistSkin cool and moist• HemoptysisHemoptysis• HematemesisHematemesis• AgitationAgitation


DiagnosisDiagnosis• PA and lateral CXRPA and lateral CXR• Soft tissue of neckSoft tissue of neck


Treatment/EducationTreatment/Education• ABCABC• Finger sweepFinger sweep• HeimlichHeimlich• OxygenOxygen• IVIV• HOB 60 to 90HOB 60 to 90°°

• Prepare for potential Prepare for potential emergency intubationemergency intubation

• Minimize Minimize environmental stimulienvironmental stimuli

• Removal proceduresRemoval procedures Balloon-tipped FoleyBalloon-tipped Foley IVCSIVCS

Questions???Questions???

Facial, Dental, Ear, Nose, and Throat Emergencies.

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