10.3 Scenario Practice for Head, Eye, Ear, Nose, and Throat Disorders
Key Takeaways
- Le Fort I is a horizontal maxillary fracture (mobile palate); Le Fort II is pyramidal involving the nose and inferomedial orbit; Le Fort III is craniofacial disjunction separating the whole midface from the skull base.
- Peritonsillar abscess shows unilateral 'hot-potato' voice, trismus, and uvular deviation away from the abscess; treatment is needle aspiration or incision and drainage plus antibiotics.
- Posterior epistaxis bleeds into the throat, is hard to tamponade, and threatens the airway; it requires posterior balloon packing and admission.
- Use the HINTS exam for continuous vertigo: a NORMAL head impulse, direction-changing nystagmus, or skew deviation points to a central (stroke) cause.
- Sudden sensorineural hearing loss is an emergency—treat with high-dose steroids within about 2 weeks and arrange urgent ENT follow-up.
Scenario 1 — Classifying Facial Fractures
A 28-year-old is brought in after a high-speed crash with massive midface swelling. When you gently grasp the upper teeth and hard palate, the entire dental arch moves but the nasal bridge and orbits stay fixed. This mobile palate with a stable upper face is the classic sign of a Le Fort I fracture — a horizontal fracture separating the maxillary alveolus from the rest of the midface.
Know the three Le Fort patterns; all of them cross the pterygoid plates:
| Le Fort type | Fracture plane | Bedside clue |
|---|---|---|
| I | Horizontal across the maxilla above the teeth | Mobile hard palate / upper teeth only |
| II | Pyramidal — nasal bridge through inferomedial orbit | Mid-face + nose move together; orbital rim involved |
| III | Craniofacial disjunction — across orbits/zygoma | Entire face moves with the skull base ('dish-face') |
The nursing priority across all facial fractures is airway first — blood, broken teeth, and swelling threaten it — followed by cervical-spine precautions (high-energy facial trauma carries a real C-spine risk) and watching for an associated basilar skull fracture (raccoon eyes, Battle's sign, CSF rhinorrhea). Do not blindly place a nasogastric or nasal airway in suspected Le Fort II/III or basilar fractures because of the cribriform-plate risk.
Scenario 2 — Sore Throat Triage
A 19-year-old has three days of worsening unilateral throat pain, a muffled 'hot-potato' voice, drooling, and can barely open the mouth. The trismus, uvula deviated to the opposite side, and a bulging soft palate point to a peritonsillar abscess (quinsy) — the most common deep-neck infection in young adults. Management is needle aspiration or incision and drainage, antibiotics covering strep and anaerobes, analgesia, and hydration.
Contrast that with the can't-miss airway diagnoses:
- Epiglottitis — rapid high fever, severe odynophagia, drooling, tripod position, stridor; the lateral neck film shows a 'thumbprint' sign. Keep upright, do not examine the throat with a tongue blade, prepare a surgical airway.
- Ludwig's angina — a rapidly spreading bilateral submandibular cellulitis, woody/brawny floor of mouth, and a tongue pushed up and back; the killer is airway obstruction from posterior tongue displacement.
The decision rule: a unilateral bulge with uvular deviation is usually a peritonsillar abscess (drainable), while bilateral floor-of-mouth swelling or a toxic patient with drooling and stridor is an airway emergency that gets no throat instrumentation.
Scenario 3 — Nosebleed and Dizziness
An anticoagulated 70-year-old has heavy bleeding that you cannot see a source for anteriorly, and blood is running down the back of the throat even after 15 minutes of firm nasal pressure and an anterior pack. Bleeding into the posterior pharynx that resists anterior tamponade signals a posterior epistaxis (typically the sphenopalatine artery). These threaten the airway and cause aspiration; treat with a posterior balloon/double-balloon pack, admit and monitor, and correct coagulopathy. Most simple anterior bleeds arise from Kiesselbach's plexus in Little's area and stop with pressure or silver-nitrate cautery.
- Use the HINTS exam (Head Impulse, Nystagmus, Test of Skew). Counterintuitively, the reassuring peripheral pattern is an abnormal head impulse (a corrective saccade), unidirectional horizontal nystagmus, and no skew. The dangerous central pattern — remembered as INFARCT (Impulse Normal, Fast-phase Alternating, Refixation on Cover Test) — is a normal head impulse, direction-changing nystagmus, or skew deviation, which suggests a posterior-circulation stroke and mandates imaging.
Brief, positional, fatigable vertigo instead suggests BPPV (diagnosed with Dix-Hallpike, treated with the Epley maneuver).
Scenario 4 — Orbital Trauma and the Painless Eye
A softball strikes a 24-year-old's eye; he now has double vision when looking up, numbness of the cheek, and the eye appears slightly sunken. This pattern — diplopia on upgaze, infraorbital-nerve numbness, and enophthalmos — is an orbital floor 'blowout' fracture with possible inferior rectus entrapment. Entrapment is an emergency in children (the 'white-eyed blowout' can cause bradycardia and vomiting via the oculocardiac reflex) and needs prompt ophthalmology/maxillofacial referral. Advise the patient not to blow the nose (orbital emphysema risk).
Contrast that with the painless sudden vision change. A patient describing flashes of light, a shower of new floaters, and a 'curtain' descending over part of the field has a retinal detachment — urgent but not chemically time-zero like CRAO. The discriminator that the CEN hides in the stem is the quality of onset: a curtain/floaters story points to detachment, while abrupt, complete, painless blackout with a cherry-red spot points to CRAO.
Scenario 5 — The Vertigo Decision Tree
When a stem gives you dizziness, first separate continuous acute vestibular syndrome (use HINTS) from episodic/positional symptoms. Then match the pattern:
| Vertigo type | Trigger / duration | Hallmark | Treatment |
|---|---|---|---|
| BPPV | Brief (<1 min), positional | +Dix-Hallpike, fatigable nystagmus | Epley repositioning |
| Vestibular neuritis | Continuous, days | Peripheral HINTS, recent viral illness | Supportive, steroids, antiemetics |
| Meniere disease | Episodic, minutes-hours | Vertigo + low-tone hearing loss + tinnitus + aural fullness | Low-salt diet, diuretic |
| Posterior-fossa stroke | Continuous | Central HINTS (INFARCT), other neuro signs | Stroke pathway, imaging |
The single most dangerous error is calling a central pattern 'just an inner-ear problem' and discharging a stroke.
On exam, grasping a trauma patient's upper teeth moves the entire hard palate while the nasal bridge and orbits remain stable. Which fracture pattern does this indicate?
A continuous-vertigo patient has a NORMAL head impulse test, direction-changing nystagmus, and a positive test of skew. How should you interpret this HINTS exam?
A young adult has unilateral sore throat, trismus, a muffled 'hot-potato' voice, and the uvula deviated to the opposite side. What is the most likely diagnosis and treatment?