CEN: HEENT Emergencies

In depth

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Eye examination in the emergency department

Visual acuity is the vital sign of the eye and is recorded before anything else except chemical irrigation. Grade it from best to worst: Snellen line, counting fingers, hand motion, light perception, no light perception. Then look at pupil shape and the swinging-light response (an afferent pupillary defect points to optic nerve or widespread retinal damage), eye movements, anterior chamber depth and blood, and the red reflex. Fluorescein under cobalt blue light shows epithelial defects; fluorescein streaming away from a wound (a positive Seidel sign) means aqueous is leaking through a full-thickness wound.

• When an open globe is possible, nothing may press on the eye: retract lids gently or not at all.
• Before dilating anyone, estimate anterior chamber depth: dilation can trigger angle closure in a narrow angle.
• Patching is not used for abrasions; it does not ease pain or speed healing and may raise infection risk.

Open globe and intraocular foreign body

Suspect an open globe with a visible corneal or scleral wound, a positive Seidel sign, a very shallow chamber (or a very deep one when the rupture is behind the lens), a misshapen pupil or an absent red reflex. The aim before the ophthalmologist arrives is to keep the eye contents in: a plastic or metal shield, or the bottom of a paper cup, taped to the bony orbital rim so nothing touches the globe, and no patch or gauze under it.

• NPO and ready for general anesthesia; IV antibiotics (Merck names ceftazidime and vancomycin); tetanus prophylaxis.
• Treat nausea early: vomiting, retching, coughing and straining raise pressure in the eye and push tissue out.
• No topical antibiotics, ointment or steroids until the wound is closed.
• CT to find a foreign body and fractures; avoid MRI because an occult metal fragment may be present.
• High-speed tools, hammering metal on metal and explosions are the classic mechanisms for an intraocular foreign body, which needs immediate surgical removal.

Chemical eye burns

Chemical injury is 10 to 20% of eye trauma. Alkalis cause liquefaction necrosis and penetrate deeply; acids coagulate the surface and are usually less severe. Irrigation starts the moment the patient arrives, before history taking or acuity. One drop of a topical anesthetic such as proparacaine helps the patient open the eye, but must not delay the flush.

• Fluid: saline, sterile water or even tap water; an isotonic balanced solution is better tolerated for long irrigation.
• Amount and time: at least 30 min, 1 to 2 L, continued until the conjunctival pH is 7.0 to 7.2 on expanded-range pH paper.
• Evert the lids (double-evert the upper lid) and sweep the fornices for trapped particles.
• Afterward: antibiotic ointment, a cycloplegic for comfort, oral analgesia; no more topical anesthetic; steroids only from an ophthalmologist.
• Severely reduced vision, white avascular conjunctiva or loss of epithelium: ophthalmologist as soon as possible, within 24 h at the latest.
• Never neutralize an acid with a base or the reverse (see Burns).

Hyphema and sickle hemoglobin

Hyphema is graded by how much of the anterior chamber the blood fills: grade I under a third, II a third to a half, III over half, IV total. Higher grades raise the pressure more often. Conservative care is a shield, limited activity and the head raised so blood settles low (Merck 30 to 45 degrees, EyeWiki at least 45). Avoid aspirin and NSAIDs. Rebleeding usually comes within the first 5 days and can be more severe than the first bleed; Merck quotes up to 38%, EyeWiki a likely 5 to 10%. Admit for a large hyphema, a bleeding disorder, anticoagulants, sickle disease with raised pressure or poor follow-up.

• Screen patients at risk for sickle hemoglobin: in sickle disease or trait the pressure can rise within hours.
• Avoid acetazolamide (more acid aqueous, more sickling) and systemic hyperosmotics such as mannitol (sickle crisis in a dry patient); alpha-1 agonists such as apraclonidine are a concern too.
• With sickle hemoglobin, surgery is indicated if the pressure stays above 25 mm Hg for more than 24 h despite treatment.
• Raised pressure: timolol 0.5% twice daily (Merck), with pressure checks every 1 to 2 h until controlled.

Orbital compartment syndrome and blowout fractures

Blood, air or pus in the closed orbit can raise orbital pressure until the optic nerve is ischemic. Signs are sudden vision loss, pain, proptosis, tense lids, chemosis, restricted movement, an afferent pupillary defect and a high intraocular pressure. The diagnosis is clinical, and decompression by lateral canthotomy with inferior cantholysis is done at once, before imaging. Meanwhile: head of bed 45 degrees, reverse any coagulopathy, control pain, nausea, coughing, straining and severe hypertension, cool compresses; short-term IV mannitol is an adjunct that must not delay decompression.

A blowout fracture (usually the orbital floor) gives diplopia, enophthalmos, cheek and upper lip numbness, nosebleed and subcutaneous emphysema. Teach no nose blowing, since air forced into the orbit can cause a compartment syndrome; a topical nasal vasoconstrictor for 2 to 3 days helps the nosebleed. Many floor fractures are managed without surgery. A child with a white, quiet eye after orbital trauma who has nausea, vomiting, bradycardia and severely restricted eye movement may have a trapped muscle (white-eyed blowout): urgent repair within 24 to 48 h, not a concussion workup alone.

Retinal artery occlusion, giant cell arteritis and detachment

Central retinal artery occlusion is an ophthalmic emergency handled like a stroke: refer to the nearest stroke center at once, because these patients often have silent brain infarcts and a high stroke risk in the following weeks. Retinal infarction begins within about 90 minutes. Workup looks for the embolic source with carotid Doppler and echocardiography. IV thrombolysis is controversial; a meta-analysis suggested possible mild benefit within 4.5 h but reported deaths. Ocular massage, anterior chamber paracentesis, pressure-lowering drops and rebreathing have no proven benefit, and the same meta-analysis linked them to worse outcomes; Merck still lists them as options.

In anyone over 50 with sudden vision loss, ask about headache, scalp tenderness, jaw pain, fever and weight loss and draw ESR, CRP and platelets. Giant cell arteritis is treated with high-dose systemic steroids started immediately; the temporal artery biopsy is done within 2 weeks of starting them, so it never delays treatment.

Rhegmatogenous retinal detachment (a tear lets fluid lift the retina) is the common type: painless flashes, a sudden shower of floaters and a curtain over part of the field. Risks are myopia, prior cataract surgery, trauma, lattice degeneration and family history. Refer urgently; repair is most urgent when an acute detachment threatens central vision. Repair may leave a gas bubble in the eye for up to 2 months, and nitrous oxide is contraindicated while any gas remains.

Acute angle-closure glaucoma

Headache, nausea and vomiting with a red eye: look at the eye, because angle closure is mistaken for a GI or neurologic illness. The iris blocks the drainage angle and the pressure climbs within hours, usually to 40 to 80 mm Hg. Triggers include dilating drops (cyclopentolate, phenylephrine) and systemic anticholinergic or alpha-agonist drugs. Merck's emergency regimen, started at once:

• Timolol 0.5%, 1 drop every 30 min for 2 doses.
• Pilocarpine 2 to 4%, 1 drop every 15 min for 2 doses (it rarely works while IOP is above 40 to 50).
• Brimonidine 0.15 or 0.2%, 1 drop every 15 min for 2 doses.
• Acetazolamide 500 mg by mouth, or IV if vomiting, then 250 mg every 6 h; consider an osmotic agent.
• Laser iridotomy once the cornea clears, in both eyes: the fellow eye has about an 80% chance of an attack.

Corneal abrasions, keratitis and topical anesthetics

Abrasions cause foreign-body sensation, tearing and redness; up to a quarter of eye complaints in the ED are abrasions. Evert both lids after a drop of anesthetic; multiple vertical streaks mean a particle under the upper lid. Steel or iron left on the cornea for more than a few hours leaves a rust ring that an ophthalmologist removes. Most abrasions get an antibiotic ointment (bacitracin-polymyxin or erythromycin); contact lens wearers get antipseudomonal coverage such as ciprofloxacin and no lens wear until healed. A single dose of a short-acting cycloplegic helps an abrasion larger than 10 mm². Most heal in 1 to 3 days, with follow-up in 1 to 2 days.

Topical anesthetics were never sent home in the past because repeated use harms the epithelium. The 2024 ACEP consensus guideline accepts a short course for simple abrasions: as needed up to every 30 min for the first 24 h, no more than 1.5 to 2 mL dispensed, the remainder discarded. Oral analgesics remain the alternative, and topical steroids are contraindicated.

Bacterial keratitis shows a focal white infiltrate, sometimes with pus in the anterior chamber (hypopyon). Contact lens wear is the leading risk factor, and virulent organisms can destroy the cornea within 24 h, so it goes to an ophthalmologist the same day for scraping, culture and frequent, often fortified, antibiotic drops. Herpes simplex keratitis produces a branching dendrite with bulb-like ends; it is treated with topical ganciclovir or trifluridine or an oral antiviral, and topical steroids are contraindicated in epithelial disease.

Orbital cellulitis and its complications

Preseptal cellulitis is far more common and leaves vision, eye movement and globe position normal. Orbital cellulitis adds proptosis, pain with eye movement, restricted movement, chemosis and reduced acuity, usually with fever; most start in the sinuses, especially the ethmoids. Contrast CT of the orbits and sinuses is the study of choice; MRI is added when cavernous sinus thrombosis is suspected. Admit, give IV antibiotics at meningitic doses, involve ophthalmology and, with sinusitis, ENT.

• Serial checks: acuity, color vision, pupils, motility, proptosis and pressure.
• Suspect an abscess when orbital signs progress after 24 to 48 h of IV antibiotics.
• Surgery is almost always needed for optic nerve compromise, intracranial extension or deterioration after 48 h of antibiotics.
• Cavernous sinus thrombosis comes from sphenoid or ethmoid sinusitis, nasal furuncles or dental infection, most often with Staphylococcus aureus. It shows bilateral signs, CN VI palsy first, then III, IV and V, mental status change. MRI or CT venography, high-dose IV antibiotics, heparin if no contraindication. Mortality 10 to 15%, and a third of survivors have serious sequelae.

Epistaxis

Most nosebleeds are anterior, from Kiesselbach's area on the front of the septum, and stop with firm pressure on the soft part of the nose with the patient sitting up and leaning forward so blood is not swallowed. Posterior bleeds come from the back of the septum or the turbinates, are more common in older patients with atherosclerosis or bleeding disorders, and are harder to control. Red flags are signs of hypovolemia, anticoagulant use, signs of a bleeding disorder, bleeding not stopped by pressure or soaked pledgets, and repeated recurrences. Routine labs are not needed; draw CBC, PT and PTT for severe or recurrent bleeding or suspected bleeding disorders.

• AAO-HNS 2020: firm sustained pressure on the lower third of the nose for at least 5 min; packing if no site is found; resorbable packing for patients on anticoagulants or antiplatelets.
• Without life-threatening bleeding, use first-line care before transfusion, reversal or stopping anticoagulant or antiplatelet drugs.
• Posterior balloon: admit to a monitored bed for rhythm and airway watch; give oxygen because packing lowers PaO₂; deflate if the soft palate is pushed down; remove after 48 to 72 h (gauze pack 4 to 5 days); amoxicillin-clavulanate for 7 to 10 days.
• Packing risks: migration with aspiration or airway obstruction, pressure necrosis, sinusitis, otitis media, rarely toxic shock syndrome.
• Home teaching: sit and lean forward, pinch the soft nose, no nose blowing for several hours; come back if bleeding lasts 20 min (MedlinePlus).

Nose and ear foreign bodies

Children place beads, toys, food, paper and batteries in the nose and ears; a nasal object often shows up days later as one-sided foul discharge. In young children a parent can blow a short puff into the child's mouth while closing the clear nostril. Button batteries in the nose or ear are removed immediately because current and alkaline leakage cause liquefaction necrosis; ear batteries are never irrigated. Check every other orifice, since more than one object is common. A nasal object is also a clue in a toddler with one-sided foul discharge.

In the ear, kill a live insect first with lidocaine, mineral oil or alcohol, only when the eardrum is intact, then remove it with forceps. Forceps push round smooth objects deeper; a right-angle hook behind the object rolls it out. Irrigation is for nonabsorbent objects only, never beans or seeds, perforations or suspected infection. The first attempt is the best chance, and success falls sharply after a failure, so do not keep trying on an uncooperative child. Success falls sharply after a failed first attempt, so refer to ENT for sedation, wedged or sharp objects, canal bleeding or failed removal.

Dental injuries

Fractures are graded by depth: enamel only (rough edge, elective repair), dentin exposed (cold sensitivity, analgesia and dental referral), pulp exposed (bleeding from the tooth, urgent referral, usually a root canal). Loose teeth may mean a hidden root or alveolar fracture that needs urgent splinting. A missing tooth or fragment that cannot be found may have been aspirated; a chest film may be needed.

• Permanent tooth knocked out: hold the crown, rinse under cold water for no more than 10 s if dirty, replant at once.
• If it cannot go back in: saline or milk (Hanks' solution in the ED), then a wet paper towel, or the alert patient's mouth if there is no aspiration risk.
• Replanted within 30 to 60 min: often retained. After 60 min dry: ligament cells are dead and root resorption follows; the dentist decides.
• Primary teeth are not replanted: the tooth becomes necrotic and can block the permanent tooth.
• Check tetanus status if the tooth touched soil. Antibiotics after replantation: Merck says not routine in healthy patients; the dentist decides.

Jaw dislocation and facial fractures

The jaw dislocates forward after wide opening: a yawn, laughing, a big bite or a long dental procedure; neuroleptic dystonia can also do it. The mouth is locked open and closing hurts. Spontaneous dislocations are more often bilateral; a bilateral one gives a protruding lower jaw and open bite; a unilateral one shifts the midline toward the unaffected side. After trauma, get CT before any reduction, because a fracture is an absolute contraindication. Reduce promptly, since the longer it stays out the harder it is to reduce and the more likely it recurs: thumbs on the external oblique ridges (gauze-wrapped if on the molars, which can clamp down), press down, then guide back. Sedation is usually not needed. Afterward: soft diet, small bites, fist under the chin when yawning, no wide opening for 4 to 6 weeks, a Barton bandage for 2 to 3 days, and oral surgery or ENT follow-up within 1 to 2 days.

Suspect a mandible fracture when the bite no longer meets, one segment is swollen and tender, the teeth show a step, the alveolar ridge is broken or the lip or chin is numb; a condylar fracture causes preauricular pain and the jaw deviates toward the injured side on opening. A fracture through a tooth socket is open and gets antibiotics covering oral flora, such as clindamycin or ampicillin-sulbactam. Midface fractures are described by Le Fort level: I the lower maxilla, II through the infraorbital rim, III the whole midface separated from the skull. Fine-cut CT is the imaging of choice. Hemorrhage and swelling can compromise the airway, and severe facial trauma brings brain and cervical spine injury. Patients in maxillomandibular fixation may be told to carry wire cutters in case of vomiting.

Nasal fractures: look inside for a septal hematoma, a purplish bulge that must be drained immediately to prevent cartilage necrosis and a saddle nose. Reduction waits 3 to 5 days for swelling to settle and is done within 2 weeks. Clear drainage may be CSF: test for beta-2 transferrin, because glucose strips are unreliable.

Deep neck infections and epiglottitis

Ludwig angina is a fast-moving soft-tissue infection under the jaw on both sides, most often seeded by a diseased lower back molar; poor dental hygiene, extraction and jaw trauma add risk. The floor of the mouth turns board-hard, the tongue is pushed up against the palate, and drooling, trismus, dysphagia and stridor follow, with obstruction possible within hours. Airway comes first: awake fiberoptic nasotracheal intubation under topical anesthesia in the OR or ICU, or tracheostomy; patients not yet intubated need close observation. Antibiotics cover oral aerobes and anaerobes (clindamycin, ampicillin-sulbactam or high-dose penicillin), and the space is drained surgically.

Peritonsillar abscess (young adults) brings a one-sided sore throat, trismus, a hot potato voice, a deviated uvula and drooling; it is drained in the ED by needle or incision and treated with antibiotics such as high-dose penicillin, and most patients go home. Retropharyngeal abscess is mostly a disease of children under 5 (about 75%) after a cold: fever, neck stiffness, stridor and noisy breathing, a widened prevertebral shadow on a lateral film, CT to define it, airway first, IV antibiotics, and drainage for airway compromise, failure of antibiotics or an abscess over 3 cm.

Epiglottitis has become mainly an adult disease since the Hib vaccine. The clues are drooling with no barking cough, and severe throat pain although the pharynx looks normal; a child sits in the tripod position, and giving it up can signal respiratory failure. Do not examine the throat or send an unstable child to radiology. Children are intubated in the OR by experienced staff until stable, typically 24 to 48 h; adults with severe obstruction are intubated fiberoptically and the rest are watched in the ICU with intubation and cricothyrotomy equipment at the bedside. Ceftriaxone 50 to 75 mg/kg IV daily (maximum 2 g), humidified oxygen, upright and calm. See Pediatric Assessment and Emergencies for croup versus epiglottitis.

Ear infections and the facial nerve

Mastoiditis follows acute otitis media by days to weeks: fever, throbbing ear pain, a red, swollen, tender mastoid and an ear pushed out and down. CT confirms it and looks for intracranial spread (meningitis, abscess, sinus thrombosis). Treatment is IV antibiotics in hospital (ceftriaxone 50 to 75 mg/kg in children, maximum 2 g a day, for at least 2 weeks), myringotomy with a tube, and mastoidectomy for an abscess or failure to respond.

A peripheral facial nerve palsy weakens the whole half of the face, forehead included; a central lesion such as a stroke mainly weakens the lower face and spares the forehead, so the patient can still wrinkle the brow and close the eye tightly. Bell palsy gets steroids, ideally within 3 days of onset, and eye protection with lubricating drops and taping at night; antivirals add no benefit.

Exam pearls

• Chemical splash: the first action is irrigation, even before visual acuity.
• Suspected open globe: shield, NPO, antiemetic; never patch it or press on it.
• Proptosis with falling vision after trauma on an anticoagulant: canthotomy now, CT later.
• Sudden painless monocular blindness is a stroke; over 50, think giant cell arteritis and start steroids.
• Hyphema with sickle trait: question acetazolamide.
• Contact lens wearer: antipseudomonal antibiotic, no patch; a white spot means same-day ophthalmology.
• Live insect in the ear: kill it first. Bean in the ear: no irrigation. Button battery anywhere: out now.
• Primary teeth are never replanted; permanent teeth go back in or into milk, held by the crown.
• Unilateral jaw dislocation: the chin points away from the dislocated side. After a punch: image before reducing.
• Posterior nasal pack plus falling SpO₂ or a balloon seen behind the soft palate: airway emergency.
• Anticoagulated with a stable nosebleed: local measures before reversal.