CURRENT Diagnosis & Treatment Emergency Medicine, 7e > Chapter 32. Emergency Disorders of the Ear, Nose, Sinuses, Oropharynx, & Mouth >

Immediate Management of Potentially Harmful Disorders

Ear Pain

The complaint of ear pain is more common among children than adults and usually relates to an infectious process. Though some conditions are serious, patients with most ear pain conditions can receive treatment and be discharged by the emergency physician without consultation (Table 32–1).

Clinical Findings

History

Ask patients about history of trauma, surgery, or recurrent infections involving the ear. Also ask about specific symptoms (eg, recent fever, upper respiratory infection, or canal discharge) and pain quality (eg, pain, pressure, itching, or "buzzing" sounds). Have the patient identify the exact location of the pain. A narrow differential diagnosis can be explored based on these historical characteristics.

Physical Examination

Visually inspect the external ear, external canal orifice, and surrounding structures. Palpate the area surrounding the ear to identify lymph nodes or a bony prominence. Tender nodes are common in infections of the middle and external ear. Pain, swelling, and erythema at the mastoid process should prompt the clinician to consider mastoiditis. Next, view the canal and tympanic membrane. Make careful note of the appearance of the tympanic membrane regarding color, reflectivity, visibility of landmarks, and presence of fluid, air bubbles behind the membrane, or perforations. Check tympanic membrane motility by insufflation. Compare to the normal ear. If the ear examination is normal, look to the upper teeth and temporomandibular joint as possible causes.

Other Studies

If history and physical examination suggest mastoiditis, computed tomography (CT) scan should be obtained.

Treatment

Each condition requires a specific treatment (see Table 32–1).

Hearing Loss

Sudden hearing loss is a deficit of less than 3 days duration and may be partial or complete. Diagnoses can be categorized as conductive (mechanical cause) or sensorineural (inner ear or cochlear nerve-central nervous system cause). Medication-related hearing loss is usually dose and duration related. Many potential causes must be considered (Table 32–2).

Clinical Findings

History

The patient's account of precipitating events (trauma or recent activities) and the duration of symptom onset (seconds, hours, days) should help narrow the focus on possible causes. Unilateral deafness should increase the suspicion for a structural process (conductive or acoustic neuroma), whereas bilateral symptoms would suggest a systemic (metabolic or drug related) problem. Take a careful medication history. Severity (partial vs complete loss of hearing) also should be assessed. Finally, the presence of tinnitus, vertigo, or other neurologic symptoms should alert the clinician to the likelihood of a sensorineural cause.

Physical Examination

Look at the canals and tympanic membranes to rule out foreign body obstruction, infection, or injury. The cranial nerves should be examined. Weber and Rinne tests are useful for differentiating between conductive and sensorineural causes only in cases with unilateral hearing loss. The Webber test is performed by placing a vibrating 512-Hz tuning fork on the midparietal head (Figure 32–1). Sound should be heard equally on both sides. The Rinne test is performed by placing the base of a vibrating fork on the mastoid process. When the patient can no longer hear the sound, it is quickly moved off the bone and the tines placed at the ear canal (Figure 32–2). Repeat on each side. The patient should be able to hear the vibration in the air after the fork is removed from the bone. In sensorineural hearing loss, the Rinne test will be normal bilaterally and the Webber test will lateralize to the unaffected side. In conductive hearing loss, the Webber test will lateralize to the affected side and the Rinne test will also be abnormal on that side.

Other Studies

Bloodwork is helpful if infectious or metabolic causes are being considered. CT or magnetic resonance imaging (MRI) scan is appropriate for a suspected acoustic neuroma.

Treatment

Treatment should be directed toward the underlying disorder. Rapid follow-up by the appropriate provider (ie, otolaryngologist and neurologist) is recommended.

Vertigo

True vertigo is a sense of motion when one is stationary. It is typically described as feeling the world spin. It can be quite disconcerting to patients, some of whom present in dramatic discomfort.

Clinical Findings

History

The most important determination is between central (central nervous system) and peripheral (relating to the eighth cranial nerve or the inner ear apparatus) causes. This classification usually can be resolved on the basis of history alone (Table 32–3). Symptoms that are severe, of sudden onset, and related to head movement are typically caused by a peripheral disorder. Ask about recent use of potentially vestibulotoxic drugs such as aminoglycosides, vancomycin, phenytoin, quinidine, and minocycline. Caffeine, nicotine, and alcohol are known to exacerbate symptoms. Head trauma can occasionally lead to semichronic symptoms (lasting months to years). Specific causes of peripheral vertigo are described in Table 32–4.

Physical Examination

Examine the ear canal, tympanic membrane, cranial nerves, and cerebellar function. All patients with vertigo may have difficulty with the tandem walk exercise, but the presence of focal cerebellar examination findings (rapid alternating movements, heel-shin slide, or finger-to-nose pointing tests) should raise suspicion for a central cause. Identifying nystagmus, especially with head movement can help narrow the differential diagnosis. The Dix-Hallpike test can help elicit the vertigo symptoms and nystagmus if they are not present at rest. In this test, the examiner places a hand on the patient's occiput, and the patient is rapidly reclined from an upright position onto a flat surface. The head should extend off the back edge so that the neck can be somewhat hyperextended. The test can be repeated with the head rotated to each side. A positive result occurs with acute worsening of the vertigo or production of nystagmus. Nystagmus relating to a peripheral cause typically starts in 1–3 seconds and diminishes over 5–30 seconds after head movement. Nystagmus from a central cause does not typically extinguish.

Other Studies

Imaging (by CT scan or MRI) is warranted for patients with a suspected central cause or elderly patients with equivocal findings. MRI provides superior resolution of the cerebellum, though CT scan will typically rule out large lesions.

Treatment

Patients with prolonged nausea and poor fluid intake will often require intravenous hydration. Pharmacotherapy is more successful in peripheral-type vertigo. It is directed at relief of symptoms and does not affect the duration of the illness. The first-line agent is oral meclizine (25–50 mg every 8–12 hours), but patients unable to manage oral fluids are better off with intravenous normal saline and diazepam (5–10 mg intravenously, 2–4 mg intravenously for the elderly). In general, drugs with anticholinergic effects are useful. These include diphenhydramine (50 mg intramuscularly or orally every 6–8 hours), dimenhydrinate (50–100 mg intramuscularly or orally every 4 hours), cyclizine (50 mg orally every 6 hours), and promethazine (25 mg orally, rectally, or intravenously every 6–8 hours). Patients with peripheral vertigo can be discharged after moderate improvement of symptoms and ability to take oral liquids. Some patients may need to be admitted to hospital for severe symptoms or inability to maintain oral intake. Depending on the cause, symptoms are likely to last several hours to 1 week but may persist for 4–5 weeks. Many patients with central vertigo will require inpatient management targeted at the underlying cause, though those who are comfortable after treatment and have firm follow-up can be discharged.

A particle repositioning (Epley) maneuver may be attempted if positional vertigo is suspected. It is based on the belief that moving the canalith to the utricle area of the inner ear will prevent it from stimulating the sensory mechanism. All motions should be done slowly such that each full cycle of the maneuver takes 2 minutes. First, perform the Dix-Hallpike test. Then place the patient in a sitting position, turn the head 45° toward the affected side, lay the patient down, and allow the head to extend 45° beyond neutral while hanging off the top edge of the bed. Rotate the extended head to the midline and then 90° away from the affected side (as determined by the fast component of the nystagmus). Then flex the neck to neutral, sit the patient up, and rotate the head back to midline. The maneuver often must be repeated several times to be successful.

Epistaxis

Most episodes of epistaxis do not result in significant blood loss, are not life-threatening, and can be managed with minimally invasive measures. However, the clinician should begin with an assessment of hemodynamic stability and provide support (intravenous fluids or blood products) when appropriate. The typical bleeding site is the Kiesselbach area of the anteromedial nostril, an area at risk due to the anastomoses of three separate arteries (Figure 32–3). Though predominantly due to trauma or environmental exposure, epistaxis can rarely be the first symptom of a growing nasal or sinus malignancy.

Clinical Findings

History

Many patients will be predisposed to bleeding, due to warfarin, platelet-inhibiting medications, renal failure, or hemophilia. Initial history should be directed toward medications as well as easy bruising or bleeding. In cold seasons, the dry conditions created by heated indoor air can dehydrate the airways, predisposing the nasal mucosa to cracking. The repeated blowing and wiping of a nose in the setting of upper respiratory infection or allergic rhinitis can abrade and injure the mucosal surface as can blunt trauma and nose picking. The possibility of pregnancy should be assessed since the incidence of epistaxis is increased and the choice of pharmacologic agents may be changed by this knowledge.

Physical Examination

Hemodynamically stable patients are best examined sitting upright. In this position, most blood will exit the anterior nose and ingestion or aspiration will be minimized. If the bleeding is active, the patient should be told to clear each nostril of clots and then pinch the entire cartilaginous portion of the nose for 15 minutes continuously. This is sometimes all that is required to stop the bleeding (however, the nose should always be reexamined to confirm hemostasis). During this time, the clinician should don protective clothing and eyewear and set up adequate lighting, a nasal speculum, and a suction device. The predominant side of the epistaxis should be noted. Bilateral bleeding suggests a posterior source. All mucosal surfaces of the nose should be examined for bleeding and the integrity of the septum confirmed. Observe the posterior oropharynx for 10–15 seconds to confirm whether fresh blood is flowing down the back wall. Bilateral bleeding suggests a posterior source as does a large amount of fresh blood in the oropharynx and little in the anterior nose.

Treatment

Anterior Epistaxis

Epistaxis from an anterior source can usually be controlled. In general, minimally invasive and technically simple methods are preferred, but refractory bleeding requires escalation to more invasive procedures. Some patients may benefit from gentle opiate or benzodiazepine sedation. While using the suction device to keep the field clear of blood, apply 1% phenylephrine, 4% cocaine, or 2% lidocaine-epinephrine solution with a cotton swab or pledget for vasoconstriction and local anesthesia. Alternatively these solutions may be sprayed onto the mucosal surface. When the bleeding site can be visualized, simple cautery with silver nitrate is often all that is required (see Figure 32–3). Exercise care to use only unilateral, brief applications. Roll the tip a short distance from above and over the bleeding site to prevent interference from blood flowing downward.

Bleeding that persists should be treated with packing. Several options are available. Cotton pledgets soaked with vasoconstrictive agents such as phenylephrine or lidocaine-epinephrine can be placed in the inferior nostril via narrow forceps and successively pushed superiorly until the nostril is packed. Commercial nasal tampons are simple to place (Figure 32–4A). They are inserted blindly along the inferior (floor) surface of the nostril and then expanded with the application of saline or 1:1 dilutions of the vasoconstricting agent. Take care not to injure the lateral turbinates. As the material expands, pressure is uniformly applied to the inner walls, tamponading bleeding. Procoagulant products (Surgicel, Gelfoam) may be used alone or in conjunction with other materials to augment the hemostatic effect.

If none of these methods is successful, a formal anterior pack with petroleum jelly gauze strip material may be necessary. It is placed in a similar fashion to the pled-gets: the end of a continuous strip is placed inferiorly and far back in the nose, then pushed up to tamponade the upper surfaces and make room for successive strips. The nostril must be fairly tightly packed, and most clinicians repeat the procedure on the other side if bleeding persists. Many authors suggest that patients with nasal packs should receive prophylaxis against bacterial sinusitis: amoxicillin–clavulanate, 875 mg twice daily for adults, 40 mg/kg/d divided two to three times daily for children. More study is needed, but some studies indicate antibiotics may not be needed in these patients. Packing material should be removed in 3–5 days. Patients with anterior packs can be discharged to home.

Posterior Epistaxis

Posterior bleeding more typically arises from an arterial source and will not respond to the methods described above. Treatment of this entity usually requires the use of a nasal balloon device (Epistat, Nasostat) (Figure 32–4B). In addition to a posterior balloon, the specialized devices have an anterior tamponade apparatus (balloon or expanding tampon) that can be inflated or expanded independently. To prevent ischemia of the anterior nasal mucosa, the anterior portion is intended to exert less pressure than the posterior balloon. Insert it into the nostril such that the balloon is in the posterior portion of the nose. Then inflate the posterior balloon with saline until the point of discomfort. Properly placed, the posterior balloon may be all that is required to stop the bleeding. Usually, though, the anterior nose should be packed as well. Most patients with posterior packs should be admitted for airway observation, prophylactic antibiotics, and ENT consultation.

Nasal Obstruction

Most patients who present to the emergency department will have an acute obstruction (foreign body, trauma). Rarely, the problem is a complication of a chronic obstructive condition, such as an infection relating to a tumor or deviated septum.

Clinical Findings

History

Ask the patient how long the symptoms have been present and whether there were any precipitating events. In children, the most common cause of obstruction is a foreign body, often a colorful bead or a piece of food, and the history and diagnosis will be straightforward. Patients should also be queried regarding presence of a discharge. Purulent or foul-smelling discharge suggests an established organic foreign body. Nearly all cases of nasal obstruction will involve one side, negating the risk of airway compromise and allowing for outpatient workup of cases that defy emergency department management.

Physical Examination

Look into each nostril with the otoscope or a nasal speculum. Most conditions can be characterized and treatment initiated based on direct inspection (Table 32–5).

Sore Throat

Many conditions lead to the common symptom of throat pain, and although most are relatively benign, several can result in airway compromise and require heroic interventions. The patient who presents with drooling, severe difficulty in swallowing, stridor, or difficulty moving air should be examined in a setting where airway equipment is close by. The evaluation of persons with obstructive airway symptoms requires balancing the need for examination and imaging studies with their safety, because certain conditions may worsen with time. In some cases, it may be prudent for a person skilled in airway management to be present while ancillary tests such as X-rays are obtained. In general, children with these symptoms should remain with the parent and any source of excessive stimulation such as lab draws or intravenous lines should be avoided.

Clinical Findings

History

In children, a careful immunization history may help identify those at risk for Haemophilus influenzae type B (Hib) infections. Although the incidence of pediatric epiglottitis has fallen dramatically as a result of the Hib vaccine, it is not zero. The rapid development of severe symptoms requires a prompt workup and treatment. The presence of associated odynophagia (pain with swallowing) or dysphagia (difficulty swallowing) should prompt the examiner to consider imaging the neck. Fever, cough, or sputum should prompt consideration of other infectious causes. Diffuse symptoms (eg, headache, body aches, chest and joint pains, diarrhea) suggest a viral source.

Physical Examination

Patients with significant airway swelling and compromise (epiglottitis, abscesses) voluntarily sit straight up with the neck slightly extended. Such a general appearance is ominous. Examine the floor of the mouth, looking for focal elevations and tongue displacement. Look at the gingiva for evidence of abscess.

Examine the uvula, tonsillar pillars, and entrance of the oropharynx for swelling, exudate, or erythema. Asymmetry should increase the suspicion for an abscess (Figure 32–5). Examine the anterior neck for lymphadenopathy, masses, or asymmetry. Palpate the larynx for tenderness, particularly if the remainder of the physical examination is unimpressive.

Other Studies

Lateral and anteroposterior soft tissue neck X-rays can be useful for identifying epiglottis or retropharyngeal abscesses (Figure 32–6), but they do not reliably rule out these processes. These tests should not be done initially in the unstable patient as described above. Stable patients will benefit from intravenous contrast CT scan to delineate the exact location and extent of any mass or abscess.

Treatment

Each condition requires specific treatment (Table 32–6). Simple pharyngitis is by far the most common cause of sore throat among children and adults, and viral infections predominate (90%). Recent investigations suggest that differentiating bacterial from viral causes is difficult to accomplish by appearance alone. Untreated group A streptococcal infections have been associated with acute rheumatic fever and valvular heart disease.

The broad application of antibiotics will inevitably lead to emergence of resistant strains. The combination of throat pain, fever, tender anterior cervical lymph nodes, and the absence of a cough suggest streptococcal infection and might reasonably be treated immediately. Otherwise, many clinicians rely on rapid streptococcal tests or culture to determine which patients need antibiotics. This approach requires a reliable follow-up mechanism to be successful. Anxious parents can usually be convinced of the wisdom of this strategy because it avoids unnecessary antibiotics and the occasional allergic reaction.

Consideration should be given to the use of steroids in patients with significant odynophagia or dysphagia. Among sicker children and adults, the need for admission will depend on serial assessment of breathing comfort and ability to take oral liquids and maintain hydration.

Tooth Fracture

Tooth fractures are graded by the Ellis classification system (Figure 32–7). Fractures of the enamel alone (Ellis class I) require no urgent treatment (save gentle smoothing of any rough edges with sandpaper). An office dentist can fill in the defect later to satisfy cosmetic needs, but there is no risk of long-term damage to the tooth. Class II fractures are deeper and expose the dentin. A patch of yellow in the middle of the tooth defect characterizes such injuries. The dentin is vulnerable to bacteria, and prompt covering is essential for long-term preservation of the tooth. The wound should be irrigated with sterile saline, dried, and covered with calcium hydroxide paste, foil, or equivalent dressing. Because the permanent teeth in children have relatively thin dentin layers, bacterial penetration to the pulp is a greater risk in Ellis II fractures and dental consultation is appropriate if readily available.

Identification of blood or a pink spot in the defect indicates exposure of the pulp and an Ellis class III injury. Typically, this portion of the tooth is quite sensitive, making most class III fractures quite painful. Treatment is the same as an Ellis class II injury with dental consultation within 24 hours. Consider applying a local anesthetic block for management of pain.

Tooth Subluxation or Avulsion

Subluxation is a traumatic injury and results in a tooth that is, to varying degrees, loose in the socket. The subluxed or avulsed tooth should be identified as primary (deciduous) or secondary. Primary teeth require no treatment other than removal if significantly subluxed to prevent ankylosis to the alveolar bone or aspiration. Gentle pressure by grasping the tooth with a sterile gauze dressing will demonstrate the degree of subluxation. Patients with minimal laxity (up to 2 mm at tip) can be discharged with advice to eat only liquid or soft foods and follow-up with a dentist. Moderate mobility (more than 2 mm) or teeth that appear partly extruded from the socket depth will require socket reseating and a splint to prevent further injury to the vascular supply and fibrous cementum connections with the underlying alveolar bone. Immobilizing the tooth will maximize its long-term viability. Various materials are available for this purpose. If the emergency physician has access to these materials, he or she may apply the splint and discharge the patient with dental follow-up. At the very least, a foil-like material can be pressed over the loose tooth and its neighbors to anchor it.

Total avulsion is a somewhat more urgent matter, because the chance for tooth survival falls with every minute it is out of the socket. If the tooth cannot be found, the possibility of tracheal aspiration should be investigated. Hanks Balanced Salt Solution (HBSS) is the perfect storage and transportation medium. Milk, saliva, and normal saline are less ideal options. Plain water or dry surfaces are to be avoided. Dry teeth will benefit from a brief soak in HBSS or normal saline, but there should be little delay before replanting them directly into the socket. This procedure cannot wait for the dental consultant and can be done by the first clinician to make contact with the patient.

When handling the tooth, touch only the crown (enamel) surface of the tooth. Do not scrub or manually clean the root as this may cause damage to the cementum, which is very fragile. After irrigation with HBSS or saline, place the tooth firmly into the socket. Compare the shape of mirror-image teeth on the other side of the mouth to clarify proper orientation if multiple teeth are out. Splinting (see above) will ensure that the tooth remains securely in place. This may require consulting the dentist. A short course (5 days) of prophylactic antibiotics should be given and dental follow-up arranged.

Post-Extraction Tooth Hemorrhage

Bleeding from the site of a recently extracted tooth may result from the simple dislodgment of clot from the base of the socket or may be a sign of an underlying coagulopathy. Patients should be asked about a history of hemophilia or use of antiplatelet or anticoagulant drugs. Laboratory testing may be necessary to evaluate the coagulation status. Initial management should entail placing rolled cotton gauze in the socket and asking the patient to bite down for 20 minutes. As an adjunct, lidocaine–epinephrine can be injected into the gingiva at the bleeding site prior to gauze pressure. Bleeding that does not respond to these measures will require dental consultation for revision of the socket.


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Management of Specific Disorders

Disorders of the Ear

Please refer to the Immediate Management section and Table 32–1 for discussion of the following conditions: otitis externa, malignant otitis externa, foreign body or insect in canal, infected sebaceous cyst, chondritis, perichondritis, suppurative and serous otitis media, bullous myringitis, and acute mastoiditis.

Cerumen Impaction

Essentials of Diagnosis

Clinical Findings

The walls of the ear canal possess a secretory mechanism that results in a coating of the familiar waxy substance—cerumen. Over months, this material can collect and result in canal obstruction. Rarely does the material need to be removed on an emergency basis, but its presence can lead to mild pressure, vertigo, or hearing loss symptoms, and it may obscure inspection of the tympanic membrane.

Treatment

Two methods are available for evacuation: blunt removal and irrigation. Blunt removal entails use of a plastic curette, and care must be taken not to puncture the tympanic membrane or injure the walls of the canal. Large, hard impactions may defy easy removal by this method and are better suited to removal by irrigation. Blunt removal should be discontinued if it becomes clear that the drum is perforated. For irrigation, a warm solution of equal parts 3% hydrogen peroxide and water is directed at the mass with a flexible catheter. Cut the catheter of a butterfly needle and attach the remaining tubing to a 30-cc syringe. The flexible tubing can be inserted directly into the canal by the patient or clinician with little risk of injuring the walls or tympanic membrane. Repeated emergency department irrigation at 15-minute intervals will remove all but the hardest masses. If this method does not work, continued home treatments will soften and clear the remaining obstruction within a few days. Care should be taken with either method in elderly or diabetic patients because canal trauma may predispose the patient to malignant otitis externa.

Frostbite

Essentials of Diagnosis

Clinical Findings

The nose and auricle are particularly vulnerable to injury from cold exposure. Superficial skin injuries are red and tender in the emergency department, but moderate and severe cases will appear pale and lack sensation prior to warming. Pain may not develop until later. After warming, the skin appearance will provide clues to the severity and extent of the damage. Inspect the lips, nose, and auricle regarding shape and contours, sensation, edema, skin color, and lesions. It may be helpful to draw a diagram showing the borders of injury. The distal edges of the auricle and tip of the nose are typically the first to be affected by cold exposure, with injury progressing proximally after prolonged exposure.

Grading the Injury

Accurate grading of cold exposure injuries can be attempted 1–2 hours after rewarming, but serious cases may require 1–2 days of observation for full assessment. Frostnip is a mild form of injury, characterized by pain, pallor, and numbness and resolves with no permanent injury after rewarming. Frostbite is graded in four levels of severity:

Treatment

Patients should be assessed for systemic cold injury and receive treatment for core hypothermia if necessary. The injured areas should not be rewarmed until there is no chance of refreezing. Structures of the face may be gently rewarmed using warm saline soaked gauze. The ear should be covered (usually with a head wrap) with care taken to preserve the inherent shape and projection of the pinna. Gauze padding may be loosely placed in and behind the ear to preserve its shape until it has healed. The full extent of injury may take days to become apparent, and hospitalization for wound care is appropriate for severe (third or fourth-degree) injuries. No attempt should be made to excise injured tissue in the first 2 days since some tissues that initially seem nonviable will survive with time. Update the tetanus toxoid. Recovered areas will remain abnormally cold sensitive and prone to injury, because the tissues rarely heal completely. Encourage patients to avoid future cold exposure.

Chronic (Suppurative) Otitis Media

Essentials of Diagnosis

Chronic otitis media refers to persistent infection of fluid behind the tympanic membrane of several weeks or more. There may be varying degrees of discharge. Ordinary ruptures of the tympanic membrane heal in 1–2 weeks, and persistent defects should prompt close scrutiny. Accumulations of keratin result in formation of a cholesteatoma, which can contribute to injury to the bony structures of the middle ear. Persistent infections of the middle ear have an infrequent association with meningitis as well as mastoiditis. CT scan will reveal the latter condition, and clinical judgment should be used to determine which patients need a lumbar puncture. Management of mastoiditis is usually surgical. Infections limited to the middle ear should be treated with antibiotics (see Table 32–1) and prompt outpatient ENT evaluation.

Disorders of the Sinuses (Sinusitis)

Essentials of Diagnosis

General Considerations

The paranasal sinuses (maxillary, frontal, ethmoid, and sphenoid) are ordinarily air filled and communicate with the nasal passages through small ostia. Most cases of sinusitis occur in the setting of functional or anatomic obstruction, inflammation, and impaired drainage. While most are viral, some will have an element of bacterial overgrowth. Chronic sinusitis occurs with infections that persist for more than 3 months—often in a setting of irreversible obstruction or resistant bacteria and may require surgical drainage.

Clinical Findings

History

Sinusitis universally causes pain and pressure to the upper face, which may be perceived as a frontal headache. Fever, chills, and nasal discharge are common. Maxillary sinusitis commonly causes pain in the upper teeth. Symptoms typically worsen over 1–3 days and may follow an upper respiratory infection. Some patients with structural anomalies are predisposed to these infections and may give a history of similar previous episodes.

Physical Examination

Fever may be present. Examine the patient for signs and type of nasal discharge. Classically, pressure or gentle tapping over the affected sinus will reveal tenderness on one side. The maxillary sinus is most often affected and can be examined by applying bilateral thumb pressure to the inferior aspect of the zygotic prominence above the corners of the mouth. Transillumination of the maxillary sinus can be accomplished in a darkened room by placing the otoscope light source directly against the zygoma and observing transmission of light through the anterior hard palate. The presence of purulent fluid in the maxillary sinus will decrease the transmission of light on one side.

Other Studies

Plain sinus X-rays may reveal the presence of large sinus fluid collections (Figure 32–8A and B), but CT scan is the most sensitive test and will reveal anatomic anomalies such as small tumors or a deviated septum (Figure 32–8C). Radiographic studies are not necessary unless the diagnosis is in doubt.

Treatment

Culturing the sinus fluid directly is not practical in the emergency department. If bacterial infection is strongly suspected by the presence of prolonged fever, empiric antimicrobial therapy should cover H. influenzae, Moraxella catarrhalis, and gram-positive bacteria. Amoxicillin–clavulanate, 875 mg twice daily, covers -lactamase-resistant strains and the mixed flora typical of these infections. Trimethoprim/sulfamethoxazole and cefuroxime are alternatives for penicillin-allergic patients. Short course therapy has been shown to be as effective as long term therapy for these patients.

Nasal decongestant pills and sprays can sometimes reduce swelling around the sinus ostia and promote drainage. Steroids should be considered to relieve inflammation in these patients as well. Often the infection in the sinus is related to a mass (tumor, polyp, deviated septum, turbinate anomaly) or inadequate drainage. Patients should be referred to an otolaryngologist for persistent or recurrent episodes.

Chronic sinusitis has been associated with Staphylococcus aureus infections, but lasting resolution will often follow only surgical drainage and correction of the anatomic obstruction. Immunocompromised persons are at risk for Pseudomonas aeruginosa and fungal infections.

Complications

Several conditions related to sinus infection have been described. Direct extension of the infection to surrounding tissues can lead to frontal osteomyelitis, facial cellulitis, periorbital cellulitis, or periorbital abscess. For this reason, high fever, ocular movement problems, exophthalmos, diplopia, facial skin swelling, erythema, or extreme tenderness should be studied by CT scan. Intracranial extension can lead to meningitis, cavernous sinus thrombosis, brain abscess, or subdural empyema. Therefore, prominence of a headache or neurologic findings should prompt examination with CT scan or lumbar puncture.

Disorders of the Oropharynx

Please refer to the Immediate Management section and Table 32–6 for discussion of epiglottitis, Ludwig's angina, and other causes of throat pain. What follows is a more detailed discussion regarding the pathophysiology and treatment of airway deep space infections.

Peritonsillitis (Peritonsillar Cellulitis and Abscess)

Essentials of Diagnosis

General Considerations

Peritonsillitis, peritonsillar cellulitis, and abscess (also known collectively as quinsy) are extensions of mixed-flora bacterial infections of the tonsils. The differentiation between cellulitis and abscess is difficult to make on clinical grounds and is determined by identification of an abscess by intravenous contrast CT scan or more commonly by drainage of pus after aspirating or incising the mass. Some have utilized bedside ultrasound to confirm the presence of abscess. See Table 32–6 for a review of typical symptoms and a differential diagnosis. These patients will all commonly have some level of trismus or difficulty opening the mouth. Once the diagnosis is made, most peritonsillar masses should be treated with intravenous antibiotics and a drainage procedure in the emergency department.

Drainage Procedure

Preparation

First, make certain that the patient does not have obstructive airway issues. Patients with impending airway collapse should receive an emergency artificial airway prior to decompression of the mass. The patient should be placed sitting upright with support for the occiput. The upright position makes handling of oral secretions easier, and the occipital support helps the patient relax and restricts movement during the procedure. The tonsillar mass should be palpated gently with a cotton swab to confirm fluctuance. Bedside ultrasound using a high frequency transducer may be used at this time as well. A pulsatile mass should prompt the clinician to order an intravenous contrast enhanced CT scan to confirm the diagnosis and rule out the possibility of carotid artery aneurysm. For the drainage procedure to be successful, patients must not have extreme trismus and they should be cooperative and well anesthetized. Patients will generally be more cooperative when premedicated with a moderate dose of an opiate analgesic. Next, use a topical anesthetic spray such as benzocaine–tetracaine, followed by an injection of 1–2 mL of 2% lidocaine–epinephrine into the mucosal layer over the abscess. Frazier suction should be made ready for control of secretions and any pus or blood that results from the procedure.

Needle Drainage

Place an 18-gauge needle on a 10-mL syringe. The tip of the plastic needle cap should be cut off such that when placed back on the needle, 0.5 cm of the needle protrudes beyond the end. This will prevent accidental deep penetration of the mass. Insert the needle on an axis level with the tongue into the superior pole of the peritonsillar mass (the most common site for fluid) and aspirate (Figure 32–9). Remove and culture as much fluid as possible. Next, aspirate from the middle pole, and then the inferior pole. Take care to avoid directing the needle in a lateral direction so as to avoid puncturing the carotid artery. Because the needle may have missed the pocket of fluid, or the fluid may have been too thick to flow through the needle, a negative aspirate procedure does not rule out an abscess.

Open Drainage

Though many clinicians advocate needle aspiration (with antibiotics) as a safer and more comfortable method, incision and drainage with a scalpel blade appear to minimize recurrence risk. After anesthetizing the upper pole of the mass (see Figure 32–9), tape should be wrapped around the proximal aspect of the blade to prevent it from being inserted deeper than 0.5 cm. A single stab of depth 0.5 cm is made into the superior pole and extended no more than 0.5 cm in an inferolateral direction, being careful to avoid the carotid artery. Place the suction device tip into the incised area to remove any pus. Any bleeding that develops will usually resolve after the patient gargles with diluted hydrogen peroxide or salt water.

Patients should be observed for at least 1 hour following the procedure. Most are dehydrated and will benefit from intravenous fluids. Those able to take oral fluids and medications can be discharged with oral antibiotics. The preferred regimen is penicillin, 2–4 million units intravenously followed by 500 mg orally four times daily, or cephalosporins (eg, cefazolin 1 g intravenously, followed by cephalexin 500 mg four times daily for 10 days). Most patients will need oral nonsteroidal antiinflammatory agents and opiate analgesics for pain control. ENT follow-up in 2–3 days should be arranged. Patients with high fever, those unable to take oral fluids, and immunocompromised patients should be admitted for intravenous fluids and antibiotics. Some authors have advocated admitting patients with negative aspirates as well, for intravenous antibiotics and close observation.

Epiglottitis

Essentials of Diagnosis

Due to widespread use of the Hib vaccine, epiglottitis is now more common among adults than children. Children with epiglottitis have high fever and varying levels of toxicity by appearance (see Table 32–6). In children suspected of having epiglottitis, every attempt should be made to keep the child calm. No intravenous sticks should be attempted and the child should remain with the parent. A skilled pediatric airway specialist must be called (this may be the emergency physician, otolaryngologist, or anesthesiologist) and should remain with the patient. If patient stability permits, this clinician can accompany the child and parent while a lateral soft tissue neck X-ray is obtained. This may demonstrate the enlarged epiglottis (see Figure 32–6C), but a normal X-ray does not rule out the diagnosis. If the patient is toxic appearing or the diagnosis uncertain, the patient should be accompanied to the operating room where laryngoscopy and endotracheal intubation can be accomplished in a setting where a surgical airway can be easily done if needed. All pediatric patients found to have epiglottitis should ultimately be intubated for airway protection.

Adults with epiglottitis usually present with 2–3 days of steadily worsening throat pain, difficulty swallowing, and fever. The potential for rapid loss of airway patency is lower among adults than children, and most patients can have X-ray and emergency department flexible fiberoptic laryngoscopy without concern for rapid airway collapse. Those with epiglottitis should be admitted and receive intravenous antibiotics and fluids.

Croup

Essentials of Diagnosis

General Considerations

Croup (laryngotracheobronchitis) is exclusively a disease of children, affecting mainly those aged from 6 months to 3 years. It is the most common cause of stridor among young children presenting to the emergency department. Unlike the supraglottic swelling of epiglottitis, croup leads to obstruction of the subglottic trachea (below the cords, mainly at the level of the cricoid cartilage).

Clinical Findings

History

The predominant cause is parainfluenza virus, and its peak incidence is in fall and winter. The children are typically brought in at night, having recently developed a barking cough preceded by 2–3 days of a viral-type respiratory infection. The stridorous breathing is noisy and high pitched, a result of air traveling through a severely narrowed upper airway. Frequently, the symptoms will have improved by the time of arrival at the emergency department—possibly related to cool humid night air. Because an aspirated airway foreign body could mimic the symptoms of croup, parents should be questioned regarding this possibility.

Physical Examination

Children with croup usually appear nontoxic. When present, fever is usually low grade, reflecting an underlying viral infection. With exertion or crying, rapid air movement through the small subglottic aperture becomes difficult and respiratory distress worsens. Because the lungs are not affected, the oxygen saturation is typically normal except in extreme case when the narrowing becomes severe. Older children may have a barking cough or hoarseness. Oropharyngeal examination is normal or may reveal the bilateral nonspecific erythema and swelling associated with a viral upper respiratory infection. Any unilateral swelling or tonsillar exudates should prompt consideration of bacterial surface or closed-space infections. Transmitted airway noise may obscure auscultation of lung sounds, which are normal in croup. The patient should be examined for mental state, oxygenation, and use of accessory muscles.

Other Studies

An anteroposterior soft tissue neck X-ray will demonstrate the steeple sign of upper tracheal narrowing (Figure 32–10A and B). The serum white blood count may be elevated, but this is not specific for croup and has little value for differentiating croup from other processes.

Treatment

Consideration should be given to the stability of the patient's airway. Croup rarely leads to complete airway obstruction except in the very young (<6 months), and mild epiglottitis can present with symptoms similar to croup (see Epiglottitis section above). The initial therapy is nebulized saline, which can be delivered by face mask or by having the parent direct the mist at the child's mouth. Nebulized racemic epinephrine should be used for patients who exhibit resting stridor: place 10 drops of 2.25% solution and 2–3 mL of saline in a nebulizer. The treatment may be repeated every 20–30 minutes. The child should be observed for 2–3 hours after the last treatment to assure that a rebound in symptoms does not occur. Dexamethasone, 0.6 mg/kg intramuscularly or orally, is a useful adjunct for croup. Serial clinical evaluations of patient comfort will help identify the small percentage of children who will require admission for observation and further therapy. The majority of patients may be discharged with steroids for several days and outpatient follow-up.

Disorders of the Mouth

Though myriad disorders involve the teeth and periodontal tissues, patients typically present to the emergency department with acute processes in the mouth such as pain. Careful examination of the mouth is the key to correct diagnosis.

Tooth Anatomy

Teeth consist of a central pulp tissue, which is innervated by pain fibers and produces dentin (Figure 32–11). The dentin surrounds the pulp, makes up the bulk of the tooth mass, and is coated with enamel—a hard material that forms the outer surface of the tooth. The tooth surface of the root portion comprises cementum, which is less dense than enamel and not designed to withstand exposure to mouth flora and acids. Each tooth is embedded in periodontium, which consists of a bony support (alveolar bone) that is contiguous with underlying mandible and maxilla. The gingiva is the highly vascular mucosal tissue (gums) that covers the alveolar bone.

Tooth Pain

See Table 32–7.

Essentials of Diagnosis

Clinical Findings

History

Duration and rate of pain onset may be useful clues to a subacute process, whereas recent trauma or dental instrumentation would suggest a noninfectious problem. The location and distribution of the pain should be ascertained. Pain that worsens with chewing implicates a local tooth problem.

Physical Examination

The focus of the examination should be the area said to be painful. Tap on suspect teeth with a tongue blade—this will elicit tenderness from infections inside the tooth (pulpitis) and at the tooth root (periapical abscesses). A high degree of tenderness suggests the latter. A thorough viewing of the tooth and surrounding periodontium from all sides (use a warmed mirror to look at the lingual aspect) may demonstrate the cavity or any swelling. Focal erythema, swelling, and fluctuance would suggest a periodontal abscess. Examine the gingiva for ulcerations and pseudomembranes (acute necrotizing ulcerative gingivitis). The presence of blood can indicate poor periodontal health or may have resulted from recent trauma or instrumentation. Examine the tongue and floor of the mouth. Extension of dental infections into the soft tissues of the mandible can lead to Ludwig's angina, characterized by a firm, boardlike mouth floor and tongue elevation (see Table 32–6).

Other Studies

CT of the head and neck may be used to define the extent of the infection and rule out other severe diseases.

Treatment

Because most conditions are best treated definitively in a fully equipped dental office, oral analgesics and discharge with dental follow-up are usually indicated. Most patients benefit from antiinflammatory agents such as ibuprofen or naproxen, or oral opiate analgesics such as codeine or hydrocodone as an adjunct. Care should be taken not to promote narcotic drug abuse, since dental pain is a favored complaint of drug seekers.

Application of a tooth block with a long-acting local anesthetic can provide hours of relief for those with severe pain and can reduce the reliance on oral analgesics.

Most painful tooth conditions also require therapy with an antibiotic. Oral penicillin, 500 mg four times daily, is the treatment of choice for typical tooth and periodontal infections, but immunocompromised patients and those with high fever or severe illness should have parenteral penicillin, 15–20 million units/d, or a cephalosporin as well as clindamycin for anaerobic (mainly Bacteroides fragilis ) coverage. Amoxicillin–clavulanate is a single oral agent that covers these organisms.

TMJ Pain

TMJ pain (also broadly labeled temporomandibular disorder) is an inflammatory process of the temporomandibular joint, which often relates to overuse, trauma, or various arthritides.

Clinical Findings

The joint area is tender to pressure on one or both sides, and pain is elicited with biting down on a tongue blade and mandible manipulation. The examiner can grip the chin and lower incisors and gently rock the mandible from side to side to elicit TMJ tenderness. Except in cases of recent trauma, X-ray images are rarely indicated in the acute setting.

Treatment and Disposition

The usual therapy is for the patient to reduce the forceful use of the joint by avoiding hard foods and to use antiinflammatory medications for 1–2 weeks. Follow-up with a dental professional for persistent pain is recommended, at which point chewing and biting habits can be explored. Occasionally, corrective appliances are used to promote correct positioning and use of the jaw.

TMJ Dislocation

Essentials of Diagnosis

Typically the patient gives a history of wide mouth opening (typically a yawn or laughter) followed by an inability to close the mouth after feeling a click. They present with mouth open, are unable to speak clearly, and are sometimes distressed due to masseter spasm and pain. If the examination reveals deviation of the mandible to one side, the dislocation may be unilateral.

Reduction of the dislocation is relatively easy. Premedication with benzodiazepines for relaxation of masseter spasm and sedation is very helpful. The patient sits on a stretcher with the back up to support the head. Several advise a trial at extraoral reduction before the intraoral approach. To accomplish this, the clinician grasps the coronoid process and the anterior surface of the angle of the mandible through the cheek and applies steady downward and backward pressure. If not successful, the intraoral approach can be tried. The clinician faces the patient, and after padding the thumbs with layers of gauze to prevent injury, places them on the posterior lower molars and grips the underside of the mandible angle with the fingers. Steady, firm downward pressure is applied onto the rear molars. Successful reduction is characterized by a sudden snapping of the mandible back into place, which can put the examiner's digits at risk of a bite injury if he or she is not prepared. The patient will have immediate relief. Patients who sustain this injury are at increased risk for developing it again and should be warned to avoid wide mouth openings in the future.


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