17.5 Ophthalmologic, ENT & Dental Emergencies: Eye Injuries, Angle Closure, Angioedema, Epistaxis, Ear & Throat Infections and Dental Pain

17.5 Ophthalmologic, ENT & Dental Emergencies: Eye Injuries, Angle Closure, Angioedema, Epistaxis, Ear & Throat Infections and Dental Pain

Ophthalmologic Emergencies

Chemical Eye Injury

Irrigate first, examine later. Alkali burns (lye, lime, ammonia, airbag dust) penetrate deeper than acid burns and are more dangerous.

1. Instill a topical anesthetic (proparacaine or tetracaine) to allow the patient to open the eye.
2. Irrigate with at least 1 to 2 L of normal saline or lactated Ringer's, using a Morgan lens if available. Tap water is acceptable if it is the only option.
3. Wait 5 to 10 minutes, then check the pH. Continue until it is neutral (about 7.0 to 7.5), and sweep the fornices for retained particles.
4. Arrange urgent ophthalmology follow-up.

Acute Angle-Closure Glaucoma

Patients have a painful red eye, halos, blurred vision, headache and vomiting, with a mid-dilated, poorly reactive pupil and very high intraocular pressure.

Laser peripheral iridotomy is the definitive treatment.

Drugs that can trigger angle closure in susceptible eyes:

• Anticholinergics: nebulized ipratropium, scopolamine, diphenhydramine
• Sympathomimetics
• Topiramate, which causes bilateral angle closure through ciliary body swelling. Stop the topiramate; pilocarpine does not help this type and cycloplegics are used instead.

Corneal Abrasion

• Topical antibiotic: erythromycin ointment or polymyxin-trimethoprim. Contact lens wearers need antipseudomonal coverage, such as ciprofloxacin, ofloxacin or moxifloxacin drops, and no lens use until healed.
• Analgesia: topical NSAID drops or oral analgesics. Patching does not improve healing.
• Topical anesthetics at home have traditionally been avoided because of concern for keratitis. Small randomized trials of short, supervised courses found no harm, but practice varies; never send patients home with unlimited anesthetic drops.

Serious Eye Infections and Trauma

• Gonococcal conjunctivitis (hyperacute, copious discharge): ceftriaxone 1 g IM once (CDC 2021) and urgent ophthalmology.
• Herpes zoster ophthalmicus: valacyclovir 1 g three times daily for 7 days, started within 72 hours, with ophthalmology follow-up. Nasal-tip lesions (Hutchinson sign) predict eye involvement.
• Orbital cellulitis: IV vancomycin plus ceftriaxone (or ampicillin-sulbactam), imaging and ophthalmology review.
• Open globe injury: place a rigid shield, give no topical drugs, update tetanus, give antiemetics and analgesia to prevent straining, and start IV antibiotics as directed by ophthalmology.
• Avoid steroid eye drops without ophthalmology input, because they worsen herpes simplex keratitis and fungal infections.

Central Retinal Artery Occlusion

Sudden, painless, monocular vision loss is treated like a stroke. Send the patient to a stroke center urgently for vascular workup. IV thrombolysis within 4.5 hours is being studied and is considered case by case. Ocular massage and anterior chamber paracentesis have no proven benefit.

ENT Emergencies

Epistaxis

• Have the patient lean forward and apply firm pressure for 10 to 15 minutes, then use a topical vasoconstrictor (oxymetazoline 0.05%) and cauterize a visible vessel with silver nitrate.
• Topical tranexamic acid (for example 500 mg on a pledget) has mixed evidence. A 2013 trial showed better control than anterior packing, but the NoPAC trial (2021) found no reduction in the need for packing compared with placebo.
• Packing or balloon devices follow. A posterior bleed needs admission and specialist care.
• Lowering blood pressure has not been shown to stop epistaxis. Routine antibiotics for anterior packing are not supported by evidence.
• Patients on anticoagulants: decide on reversal based on severity (Section 10.1). Most can continue anticoagulation after local control.

Ear Infections

Acute otitis media (AAP 2013):

• High-dose amoxicillin 80 to 90 mg/kg/day in two divided doses.
• Amoxicillin-clavulanate if amoxicillin was taken in the past 30 days or the child has otitis-conjunctivitis.
• Penicillin allergy: cefdinir, cefuroxime, cefpodoxime, or ceftriaxone 50 mg/kg IM.
• Duration: 10 days under 2 years, 7 days for ages 2 to 5, and 5 to 7 days at 6 years and older.
• Observation without antibiotics is an option for selected children with nonsevere illness.

Otitis externa: topical drops (for example ofloxacin or ciprofloxacin with or without a steroid). With a perforated eardrum or tympanostomy tubes, use only non-ototoxic fluoroquinolone drops and avoid aminoglycoside-containing drops such as neomycin. Necrotizing (malignant) otitis externa in older adults with diabetes needs IV antipseudomonal therapy and imaging.

Throat and Deep Neck Infections

Streptococcal pharyngitis:

A single dose of dexamethasone (about 10 mg) speeds pain relief.

Peritonsillar abscess needs drainage and ampicillin-sulbactam or clindamycin. Ludwig angina and deep neck infections need the airway secured first, IV ampicillin-sulbactam (adding vancomycin if MRSA is a risk) and surgical drainage.

Angioedema: Histamine vs. Bradykinin

ACE inhibitor angioedema can occur after years of uneventful use. Management focuses on the airway, often fiberoptic intubation by an expert. A randomized trial of icatibant for ACE inhibitor angioedema was negative, so its use is limited. Fresh frozen plasma has been used in case reports. Stop the ACE inhibitor permanently and record the reaction as an allergy. Angiotensin receptor blockers carry a small cross-risk and are used only with caution.

Vertigo and Sudden Hearing Loss

• Benign paroxysmal positional vertigo is treated with a repositioning maneuver (Epley). AAO-HNS (2017) advises against routine meclizine or other vestibular suppressants for it.
• Vestibular neuritis can be treated with vestibular suppressants for no more than a few days. Screen every patient with acute continuous vertigo for a posterior circulation stroke.
• Sudden sensorineural hearing loss: AAO-HNS (2019) allows oral corticosteroids (for example prednisone 1 mg/kg/day, maximum 60 mg, for 7 to 14 days) within 2 weeks of onset, plus prompt audiology.

Dental Emergencies

Dental Pain

The ADA guideline on acute dental pain recommends NSAIDs, alone or combined with acetaminophen, as first-line therapy, for example ibuprofen 400 mg with acetaminophen 1,000 mg. Opioids are reserved for patients who cannot take these drugs or do not respond, in small quantities.

Antibiotics for Dental Pain and Swelling (ADA 2019, endorsed by ACEP)

• No antibiotics for pulpitis, apical periodontitis or a localized abscess without systemic involvement. Definitive dental care (drainage, root canal or extraction) is the treatment.
• Antibiotics are indicated when there are systemic signs (fever, malaise, lymph node swelling, trismus or spreading swelling) or when definitive care is not immediately available:
  • Amoxicillin 500 mg three times daily (or penicillin VK 500 mg four times daily) for 3 to 7 days.
  • Penicillin allergy without anaphylaxis, angioedema or hives: cephalexin 500 mg four times daily.
  • Penicillin allergy with anaphylaxis, angioedema or hives: azithromycin (500 mg, then 250 mg daily for 4 days) or clindamycin 300 mg four times daily.
  • If there is no improvement, add metronidazole to amoxicillin or switch to amoxicillin-clavulanate.
• Spreading facial or neck swelling, difficulty swallowing or breathing, or trismus is a deep space infection that needs IV therapy and surgery.

Dental Trauma and Bleeding

• Avulsed permanent tooth: replant immediately if possible, or store it in milk, saline or a balanced salt solution. Update tetanus. After replantation, the International Association of Dental Traumatology (2020) suggests systemic antibiotics (doxycycline for patients over 12, or penicillin V). Never replant a primary tooth.
• Bleeding after extraction: apply firm gauze pressure. In anticoagulated patients, use local measures such as a tranexamic acid mouthwash or soaked gauze before considering reversal.