11 CEN: Maxillofacial and Ocular Emergencies

Question 1

What is a Peritonsillar abscess (PTA)?
S/S? Tx?

Answer 1

Peritonsillar abscess is an area of pus-filled tissue at the back of the mouth, next to one of the tonsils.

S/S: severe throat pain, DEVIATED UVULA, fever, halitosis (bad breath), pain that radiates to ear, erythematic tonsils.

TX: throat culture, IV fluids, analgesics, antibiotics, steroids, aspiration incision and drainage (I&D).

Question 2

What is Ludwig’s Angina?
S/S? Tx?

Answer 2

Bacterial infection submandibular after a tooth abscess.

S/S: difficulty swallowing, DROOLING, swelling and redness of neck, TONGUE SWELLING.

TX: maintain airway, antibiotics.

Question 3

What is the immediate intervention for an Avulsed tooth?

Answer 3

TX: preserve tooth by placing back IN SOCKET or between in cheek/gum or under tongue only if patient alert and ADULT.

If altered LOC, concurrent injury, or CHILD, place tooth in saline, MILK or in a CALCIUM-based solution; replant tooth within 6 hours if possible. Hold by crown, do not touch root.

Question 4

What is needed for Lip lacerations?

Answer 4

Lip laceration - consider specialty consultation to suture if laceration is through vermillion border. First stitch prior to LIDOCAINE (xylocaine) due to swelling to approximate.

The muscle layer and oral mucosa should be repaired with 3-0 or 4-0 absorbable sutures, and skin should be repaired with 6-0 or 7-0 nylon sutures.

Question 5

What are causes of anterior and posterior epistaxis?

Answer 5

Anterior is most common, bright red blood caused by picking nose.

Posterior is more serious, caused by HTN and coagulopathies - heaver bleeding, darker red, drips out of nares and down throat, leads to clots, monitor airway.

Question 6

What is treatment for epistaxis?

Answer 6

TX: elevate HOB, suction available, IV fluids, pinch nostrils firmly for 10-15 minutes for anterior, progress to cauterizing with silver nitrate or electrocutery, nasal packing soaked in TXA, phenylephrine, or lidocaine with epinephrine).

Monitoring airway is most important, so may need to admit.
BP management for posterior; avoid blowing/picking nose and cool mist humidifier for anterior bleed.

Question 7

What is Bell’s Palsy? S/S?

Answer 7

Bell’s Palsy- Unilateral facial paralysis due to cranial nerve VII (facial) inflammation.

S/S: tears, drooling, unable to blink or close affected eye, facial drooping, ipsilateral loss of taste, increased sensitivity to sound (hyperacusis).


Question 8

How is Bell’s Palsy Dx and Tx?

Answer 8

DX: Rule out stroke and meningitis.

TX: antivirals and corticosteroids to shorten progression, analgesics, and eye lubricants.

Question 9

DC teaching for Bell’s Palsy?

Answer 9

wear sunglasses/eye protection to help with eye irritation, moist heat from humidifier, ARTIFICIAL TEARS during wake hours, FACIAL MASSAGE can prevent permanent contractures/paralysis.

Most resolve in 3-6 months.

Question 10

What is Trigeminal neuralgia (tic doloureux)?

Answer 10

a type of chronic pain disorder that involves sudden, severe facial pain. It affects the trigeminal nerve, or fifth cranial nerve, which provides feeling and nerve signaling to many parts of the head and face.

Question 11

What are causes of Trigeminal neuralgia (tic doloureux)?
S/S? Tx?

Answer 11

Causes: Compression of CN V from tumor, Arteriovenous malformation, trauma, or multiple sclerosis

S/S: Sudden, unilateral, severe, stabbing pain on one or more of branches of CN V (Trigeminal); facial twitching that is provoked by brushing teeth or chewing.

TX: Tegretol (carbamazepine), phenytoin, valproic acid, gabapentin, lamotrigine, clonazepam.

Question 12

What should be monitored with a Nasal Foreign Body?

Answer 12

most common in pediatrics, monitor for aspiration.

Question 13

What are S/S of a Nasal Foreign Body?
Tx?

Answer 13

S/S: pain in nasal/sinus cavity, unilateral purulent nasal drainage, recurent epistaxis, fever.

TX: use least invasive means possible - decongestants or pressor agent prior to removal to decrease swollen tissue; occlude unaffected nostril and ask child to blow nose, or ask mother to blow in mouth or use BVM; wall suction, forceps as last resort.

Question 14

What is one of the most dangerous foreign bodies?

Answer 14

Alkaline button batteries dangerous, cause saponification of tissue quickly.

An electrical current can form in the body, and hydroxide, an alkaline chemical, can cause tissue burns that can be fatal.

Question 15

What are S/S of a Ear Foreign Body?
Tx?

Answer 15

S/S: pain, anxiety/fear (increased with live insects), bleeding, hearing loss on affected side, N/V, dizziness, purulent drainage from ear.

TX: flying insects may fly to the light. Suffocate live insect with viscous lidocaine or mineral oil, then irrigate and attach wall suction. Use alcohol base solution in irrigation of organic material (bread peas, beans).

Last resort - consider sedation, then use forceps to remove object, without pushing deeper in canal.

Question 16

What is otitis externa?
S/S? Tx? DC teaching?

Answer 16

Infection (typically bacterial) of external auditory canal. (Swimmer’s Ear; outside tympanic membrane)

S/S: pain with movement of tragus or auricle, possible periauricular cellulitis, hearing loss, drainage from ear, swelling, erythema.

TX: analgesics, antibiotics, warm otic drops.

DC teaching: apply warm compress, keep ear dry, no objects in ear, earplugs while swimming/bathing.

Question 17

What is otitis media?
S/S? Tx? DC teaching?

Answer 17

Infection of inner ear canal; blocked Eustachian tubes causing fluid to build up behind TM; common 6 months - 3 years old, after an URI.

S/S: sharp ear pain, pulling at ear, fever, hearing loss, sensation of fullness, bulging of TM, history of URI.

TX: analgesics, possible systemic antibiotics, antipyretics.

Question 18

What is Sinusitis?
S/S? Tx? DC teaching?

Answer 18

Sinusitis - bacterial infection of mucosa of paranasal sinuses

S/S: pain, nasal congestion, purulent drainage, malaise, fever, facial swelling, decreased transillumination of sinuses.

DX: frontal view of maxillary sinus, orbits & nasal structures (Water’s View X-ray).

TX: oral antibiotics, analgesia, antipyretics, limited use of nasal decongestants.

DC teaching: monitor BP for HTN from antihistamines, limit nasal sprays.

Question 19

What is Mastoiditis?
S/S? Tx?

Answer 19

Mastoiditis- Complication of otitis media that erodes mastoid and affects surrounding structures.

S/S: history of otitis media, pain & swelling in mastoid area, ear pain, fever, possible TM rupture, headache, hearing loss.

TX: prepare for admission, IV antibiotics, analgesics, surgical intervention.

Question 20

What is Labyrinthitis?
S/S? Tx?

Answer 20

Labyrinthitis- Inflammation of inner ear (labyrinth) from recent infective process (fluid), treatable.

S/S: nystagmus, vertigo, tinnitus (ringing in ear), pain in ear (otalgia), N/V, hearing loss.

TX: corticosteroids, meclizine for motion sickness, antihistamines, fall risk.

Question 21

What is Labyrinthitis?
S/S? Tx? D/C teaching?

Answer 21

Meniere’s Disease (acute attack)- Unknown etiology, more common in women 40-60 years old. It is a disorder caused by build of fluid in the chambers in the inner ear.

S/S: recurring episodes of nystagmus, vertigo, tinnitus, hearing loss, N/V, headache, loss of balance, and sweating.

TX: corticosteroids, meclizine (Antivert) for motion sickness, antihistamines, diuretics, anticholinergics.

DC teaching: bed rest, slow position changes to avoid falls, limit activity and sodium/sugar intake; avoid caffeine, nicotine, and alcohol.

Question 22

Where is a Le Fort I fracture? S/S?

Answer 22

Le Fort I: “A man with a MUSTACHE”

Transverse detachment of the entire maxilla above the teeth at the level of nasal floor; Free-floating maxilla.

S/S: malocclusion, lip laceration, fractured teeth, swelling to area.

Question 23

Where is a Le Fort II fracture? S/S?

Answer 23

Le Fort II: “goes to the PYRAMIDS”

Pyramidal shaped fracture with transverse detachment of maxilla (base of pyramid), fracture at bridge of nose (top of pyramid), fracture through lacrimal & ethmoid bones (sides of pyramid).

S/S: nasal fracture, epistaxis, malocclusion, lengthening of face.

Question 24

Where is a Le Fort III fracture? S/S?

Answer 24

Le Fort III: “and takes off his Halloween MASK”

Free-floating segment of mid-face; craniofacial disjunction - involves maxilla, zygomatic arch, orbits, & cranial base bones.

S/S: commonly unresponsive, malocclusion, immense swelling “beach ball”, severe hemorrhage.

Question 25

Where is a Mandibular Fracture? S/S? Tx?

Answer 25

Mandibular Fracture is a fracture of the jaw.

S/S: malocclusion, trismus (lockjaw), edema, ecchymosis, numbness (paresthesia) of lower lip, pain.

TX: secure airway (loss of tongue control), elevate HOB, suction frequently, ice, surgery, analgesics, antibiotics.

Question 26

What is the most common cause of an Orbital Wall Fracture?
S/S? Tx? Education?

Answer 26

Orbital Wall Fracture - fracture of orbit that holds eye in proper placement.
Assault or hard blow to the face

S/S: ecchymosis, ocular entrapment (unable to look up with affected eye CN 3), diplopia, swelling, subconjunctival petechiae, infraorbital hypesthesia (reduced sensation).

TX: elevate HOB, ice pack (not chemical) to reduce swelling.

Education: ophthalmic follow-up; ice packs to face; avoid valsalva maneuver, straining, and blowing nose.

Question 27

Where is a Zygomatic Fracture?
S/S? Tx? Education?

Answer 27

Zygomatic Fractures are typically seen with orbital wall fracture. Involve the outer part of eye to cheek bone

S/S: TIDES =
Trismus: reduced ability to open jaw related to muscle spasm;
Infraorbital hypesthesia: abnormal loss of sensation to heat, cold, touch, or pain;
Diplopia: double vision;
Epistaxis: nosebleeds;
Symmetrical abnormality (asymmetry); also, loss of cheekbone (malar) eminence.

TX: elevate HOB, ice pack (not chemical) to reduce swelling, EENT consult.

Education: ophthalmic follow-up; ice packs to face; avoid valsalva maneuver, straining, and blowing nose.

Question 28

What are Corneal Abrasions?
S/S? Dx? Tx? Education?

Answer 28

Corneal Abrasions - scratching of cornea, most common eye injury seen in ED.

S/S: ocular pain, sensation of foreign body, photophobia, tearing, blurred vision.
DX: visual acuity, topical anesthetic (Tetracaine), fluorescein staining.
TX: ophthalmic antibiotics drops, nonsteroidal agents for eye, systemic analgesics.
DC teaching: No patching required since there is consensual movement of eyes.

Question 29

How are the effects of alkali and acid Ocular Burns different?

Answer 29

Ocular Burns - true ocular emergency from chemicals, radiation, or thermal

1. Alkali (lye, cement, ammonia, drain cleaner) - will have deep penetration until neutralized (requires large amounts of irrigation), liquification or saponification;
2. Acid - limited penetration.



Question 30

Ocular Burns from chemicals, radiation, or thermal present with what S/S?
Tx? DC teaching?

Answer 30

S/S: severe pain, photophobia, decreased visual acuity, tearing, involuntary spasms/closing of eyelid (blepharospasm).

TX: Immediately irrigate (do not delay for assessment or visual acuity, Tetracaine and irrigate with NS or LR until pH is 7.0-7.4, tetanus, ophthalmology consult.

DC teaching: ophthalmic appointment within 24 hours, dark environment.

Question 31

What are examples of Ocular Foreign bodies?
S/S? Tx?

Answer 31

Ocular Foreign bodies:

Welder - metal may leave rust ring if not removed immediately.
Organic material (wood chips) can cause infection, so remove quickly.

S/S: pain, photophobia, sensation of “something in eye,” tearing, blurred vision.

TX: analgesics tetracine) before exam, remove object with cotton tipped applicator or 25-27 g needle, examine cornea for rust ring, treat as corneal abrasion after removal.

Question 32

What is Acute Angle Closure Glaucoma?

Answer 32

-Aqueous humor cannot move into anterior chamber; there is an ↑ in intra ocular pressure (IOP), compression of CN 2 Optic Nerve; blindness within hours if left untreated.

Acute angle closure glaucoma completely blocks your canals. It stops fluid from flowing through them, kind of like a piece of paper sliding over a sink drain. The pressure that builds up can damage your optic nerve. If you don’t treat the problem quickly enough, you could lose your sight completely.

Question 33

What are Acute Angle Closure Glaucoma?
S/S? Tx? DC teaching?

Answer 33

S/S: pain, decreased peripheral vision “tunnel vision”, halos around light, N/V, headache, reddened eye, dilated, fixed pupil, cloudy cornea, firm feeling globe, shallow chamber due to pressure.

TX: HOB elevated, miotic drops (pilocarpine), topical beta blockers (timolol maleate), carbonic anhydrase inhibitors (acetazolamide), antiemetics, opioids for pain.

DC teaching: ophthalmology follow-up, no lifting > 5 pounds, avoid coughing/straining, do not lower head below waist.

Treatment effective if IOP < 20 (which is normal) IOP.

Question 34

What is a Central retinal artery occlusion (CRAO)?
S/S? Tx? DC teaching?

Answer 34

Central retinal artery occlusion (CRAO) - “eye stroke”

Loss of perfusion to the retina; circulation must be restored within 60-90 minutes to prevent blindness, causes: emboli (atrial fibrillation increases risk), thrombosis, HTN, temporal arteritis.

S/S: sudden onset of painless loss of vision, “curtain or shade came down over eye”, cherry red spot, Amaurosis fugax (transient episodes of blindness), DX: increased IOP.

TX: high triage priority, digital massage by MD, topical beta blocker, acetazolamide, sublingual nitroglycerin to dilate vessel, fibrinolytic therapy, hyperbaric (HBO).

Question 35

What is Conjunctivitis (Pink eye)? Causes?
S/S? Tx? D/C teaching?

Answer 35

Conjunctivitis (Pink eye)- Inflammation of membrane that lines the eyelid and sclera (conjunctiva).

Causes: bacterial, viral, or fungal infection, allergic reaction, chemical irritation.

S/S: crusty eyelids, sensation of foreign body, conjunctival erythema, discharge (**bacterial = purulent, **allergic/viral = serous), pruritus with allergic reaction.

TX: antibiotics (systemic if gonococcal), antivirals, compresses and decongestants for allergic reaction.

DC teaching: avoid contact lenses and eye make-up, compresses. Avoid spread - no swimming pools and hot tubs, do not share linens, hand washing.

Question 36

What is Iritis (Uveitis)?
S/S? Tx?

Answer 36

Iritis (Uveitis)

Inflammation of iris, ciliary body, and choroid (middle portion of eye), from infection, trauma, rheumatic dx, syphilis, lupus.

Iritis (i-RYE-tis) is swelling and irritation (inflammation) in the colored ring around your eye’s pupil (iris). Another name for iritis is anterior uveitis. The uvea is the middle layer of the eye between the retina and the white part of the eye. The iris is located in the front portion (anterior) of the uvea

S/S: pain, redness around the outer ring of iris, blurry vision, photophobia, tearing, decreased visual acuity, irregular shaped pupil.

TX: cycloplegics, warm compresses, ophthalmology consult.
-Cycloplegics are drugs that paralyze the ciliary muscles and cause relaxation of accommodation.

Question 37

Why is retinal detachment a TRUE OCULAR EMERGENCY?
S/s? Tx?

Answer 37

Retinal detachment- Tear in retina allowing vitreous humor to leak and reducing blood flow to retina so true ocular emergency, sudden from trauma.

S/S: sudden decrease or loss of vision, veil or curtain effect, flashes of light (photopsia), floaters or specks in vision.

TX: ophthalmic referral, prepare for surgical intervention.

Question 38

What is Hyphema? Tx? DC teaching?

Answer 38

Hyphema- Blood in anterior chamber from trauma increases intracular pressure (IOP); S/S: pain, reddish hue to vision.

TX: analgesia, steroids, maintain HOB elevated 30-45 degrees.

DC teaching: avoid NSAIDs and aspirin, protect eye with rigid shield, keep HOB elevated 30 degrees, minimize activities to increase intracular pressure, follow up to monitor for rebleed (most common 3-5 days post event).

Question 39

What is a Globe rupture? S/S? Tx?

Answer 39

Globe rupture (ruptured globe)
Loss of integrity of the globe related to trauma; penetrating - knife, scissors, nail; blunt - ruptures related to increased IOP (burst).

S/S: TEAR-DROPPED shaped pupil, visual disturbances, evisceration of aqueous or vitreous humor, decreased intracular pressure.

TX: secure protruding objects, DO NOT instill topical meds, protect with rigid shield, ophthalmology consult.

Question 40

What is a Corneal Ulceration? S/S? Tx?

Answer 40

Corneal Ulcerations - Inflammation of epithelium of cornea; caused by trauma, bacterial, fungal, parasitic or viral infection; contacts, trauma, immunosuppression increases risk for infection.

S/S: pain, photophobia, sensation of FB, tearing, blurred vision, eyelid swelling, will see “white spots, “ purulent drainage.

TX: antibiotics, antifungals, antivirals, cycloplegics.

Question 41

What is keratitis? S/s? Tx?
Education?

Answer 41

Inflammation of cornea caused by exposure to UV light - ssnow blindness, glare off water, welding.

S/S: pain, photophobia, red sclera, decreased vision, purulent drainage.
TX: antibiotics, antifungals, antivirals, cycloplegics, systemic analgesics.
DC teaching: dark environment, warm compresses.

Question 42

What is a complication of orbital cellulitis?

Answer 42

Orbital cellulitis - inflammation of eye, eyelid redness and swelling, painful and limited eye movement.

Complication: Meningitis or cavernous sinus thrombosis.

Question 43

what is a Retrobulbar hematoma?
S/S? Tx?

Answer 43

Retrobulbar hematoma- collection of blood causes increased pressure in orbit from blunt trauma or valsalva maneuver.

S/S: Proptoss from increased IOP (ocular compartment syndrome). Bulging eyes, also called exophthalmos or proptosis, is when one or both of your eyes protrude from their natural position

TX: lateral canthotomy or Mannitol to decrease pressure STAT or may have permanent vision loss.