This document provides information on oral, ear, nose, and upper airway emergencies. It discusses the anatomy of teeth, trauma to teeth including the Ellis classification system, and conditions such as Ludwig's angina, peritonsillar abscess, epiglottitis, and croup. It also covers ear emergencies including otitis media, mastoiditis, otitis externa, and Ramsay Hunt syndrome. Nasal emergencies like sinusitis and trauma are described. The document concludes with some extras on chalazions and hordeolums.

1. ENT
Oral
Emergencies,
Ear, Nose, and
Upper Airways
Gabriella Minera, PGY-4

2. Oral Emergencies
•
•
•
•
Pulp: Sensory, makes Dentin
Crown: Covered with Enamel
Root: Covered with Cementum
Innervation:
•
•
Maxillary Teeth by Superior Alveolar Nerves
(branch from CN V2)
Mandibular Teeth by Inferior Alveolar Nerve
(branch from CV V3)

3. Oral Emergencies
• Nomenclature
• Clockwise from maxillary 3rd molar to
bottom mandibular molars

4. Oral Emergencies
•
Trauma
•
•
Primary Tooth: No tx required
Secondary Tooth: Reimplant within 20
minutes. Peridontal ligaments die >60
minutes. Rinse with water, milk or Hank
Solution. Do not Scrub. Grasp tooth by
crown.
•
•
Brace with zinc oxide paste (Coe-Pak)
Abx: Pcn VK or Erythromycin

5. Oral Emergencies
•
Ellis Classification
•
•
Class I: Enamel injury, Painless
Class II: Dentin and Enamel,
Hot/Cold Sensitivity, Yellow Dentin
exposed
•
•
Tx: Calcium Hydroxide, Urgent
referral
Class III: Enamel, Dentin, Pulp,
Pain/painless (NV supply dependent),
Pink tinge indicates exposed pulp
•
Tx: Emergent/Immediate OMFS,
Abx

6. Oral Emergencies
•
•
•
•
•
•
Concussions: injuries that involve tenderness to percussion
but no mobility
Subluxation: ttp, mobility, without evidence of dislogement
•
Tx: NSAIDs, soft diet, referral to dentist
Extrusive Luxation: tooth is partially avulsed from alveolar
bone
•
Tx: reposition the tooth, splint with zinc oxide
Lateral Luxation: lateral displacement with fracture of alveolar
bone
Intrusive Luxation: tooth is forced below the gingiva, poor
outcome
Avulsion: tooth has been completely removed from its socket.

7. Oral Emergencies
•
Cheek Lacerations: Check for involvement of
salivary ducts and injury to facial nerve
•
Parotid (Stensen) and Submandibular
(Wharton) MC injured
•
•
ENT consult if duct injury
Perioral Electrical Burns: Full-Thickness Burn at Lip
Commissure
•
•
•
Delayed Bleeding from Labial Artery 5-21 days
postinjury
Anticipate bleeding/Apply direct pressure
Involve plastics/ENT as outpatient

8. Oral Emergencies
•
Acute Necrotizing Ulcerative Gingivitis
(ANUG)/Vincent’s Angina/Trench Mouth:
overgrowth of normally present bacteria
which invade nonnecrotic tissue
•
•
Pseudomembrane, Metallic Taste,
Friable
Periapical Abscess: Infection of root apex,
usually confined to alveolar bone, facial
edema
•
Tx: Pcn VK, Clinda, referral, +/- I+D

9. Oral Emergencies
• Alveolar Osteitis (Dry Socket): sudden
excruciating pain 3-4 days after
extraction caused by displacement of
clot from socket and local osteomyelitis
• Tx: Pack with iodoform gauze
(Euginol)
• Abx: usually not required

10. Oral Emergencies
• Trigeminal Neuralgia
• High Rate of spontaneous remission
• Tx: Tegretol, also Dilantin, Baclofen,
Sx (relief of vascular compression)
• Often seen with Multiple Sclerosis

11. Oral Emergencies
•
Oral Manifestations of Systemic Disease:
•
•
•
•
•
Heavy Metal: Lead (Gingival “lead line”)
Dilantin: Gingival Hyperplasia in 40%
Coxsackie (Hand-foot-mouth syndrome): Vesicles
spare buccal mucosa, gingiva, and tongue.
Hairy Leukoplakia: EBV, white patches on side of
tongue that cannot be removed with tongue blade.
Tx: Acyclovir
Kaposi Sarcoma: malignant cancer of lymphatic
endothelium, HHV8, AIDS defining, MC on hard
palate

12. Ear Emergencies

13. Ear Emergencies
•
Acute Otitis Media:
•
•
•
Viral > Bacterial
S. pneumo > H. Flu > M. Cat
Most Sensitive Test is mobility of TM with
pneumatic ototscopy
•
Treatment:
•
•
•
•
•
<6 months: tx even if uncertain
6 months- 2 years: observe if unsure
> 2years: tx only if certain and illness
severe
Abx: Amoxicillin (80 mg/kg/day x 10 days),
if fails, give second course with Augmentin
x 3 days
Complications: Hearing Loss, Cholesteotoma
(accumulation of keratin-producing squamous
epithelium in middle ear, destructive epidermoid
cyst)

14. Ear Emergencies
• Mastoiditis: complication of AOM
when infection spreads to adjacent
mastoid air cells via the aditus ad
antrum
• MCC: S. pneumo
• High risk of meningitis, need
admission for IV abx and possible
surgical drainage

15. Ear Emergencies
•
Otitis Externa (Swimmer’s Ear)
•
•
•
•
Pseudomonas (MC etiology)
Aspergillus and Candida are MC fungal pathogens.
Pain with movement of pinna or tragus
Tx:
•
•
Keep Canal Dry
Abx: FQs
•
•
•
•
Cipro Otic: Children > 6 months of age
Use suspension if TM perforated: Cortisporin Otic suspension (Neomycin,
Polymyxin B, hydrocortisone). Aminoglycosides avoided because of
ototoxicity***
Steroids: topical hydrocortisone reduces symptoms but not time to clinical
resolution
Necrotizing (Malignant) Otitis Externa: through the periauricular tissue and into the
temporal bone. Tx with systemic abx.

16. Ear Emergencies
•
•
Herpes Zoster Oticus (Ramsey-Hunt Syndrome)
•
•
•
Triad: vesicles in the auricle/canal, ipsilateral facial
paralysis, ear pain
CN V, VII, IX, and X
Tx: Acyclovir, referral
Bullous Myringitis
•
•
•
Viral: Mycoplasma
Hemorrhagic or clear blisters on TM
Tx: Macrolide

17. Ear Emergencies
•
Trauma
•
Ear Laceration
•
•
•
Skin is vascular but cartilage is avascular and
relies on overlying tissue
All exposed cartilage must be completely covered suture through skin and perichondrium with 6-0
nylon
Subperichondral Hematoma
•
Aspiration vs. I +D, pressure x 48-72 hrs.
Complications - Cauliflower Ear

18. Nasal Emergencies

19. Nasal Emergencies
•
Sinusitis
•
•
•
Imaging: CT preferred to plain films (air fluid levels, 4
mm of sinus wall thickening)
For purulant discharge, symptoms > 1week:
Augmentin x 10 days, another option: Azithromycin or
Levaquin x 3 days
Complications:
•
•
Frontal Bone Osteomyelitis (Pott puffy tumor)
Acute Sphenoid Sinusitis (Most posterior of
sinuses). Cavernous Sinuses located laterally
(Internal carotids, CN II, III, IV, V3, VI). Sx drainage
if no improve x 24 hrs.

20. Nasal
Emergencies
• Trauma
• Septal Hematoma: Drainage followed
by anterior packing
• Saddle Nose Deformity

21. Oral and Upper Airway
Emergencies
•
•
Ludwig’s Angina
•
•
Polymicrobial cellulitis of oral floor
Consider prophylactic intubation as airway
compromise occurs quickly. May not be
able to cric.
Sialadenitis and Sialolithiasis
•
•
•
•
Sialadenitis: inflammation of salivary glands
(parotid, submandibular, sublingual)
Sialolithiasis (stone formation in salivary
gland)
Submandibular form of both MC
Etiology: Viral (Mumps/HIV) and Bacterial
(S.aureus). Pus from Wharton’s duct
(submandibular) or Stenson’s duct (parotid)

22. Oral and Upper Airway
Emergencies
•
•
Peritonsillar Abscess
•
•
•
Hot Potato voice
The abscess is PERItonsillar so the needle is not placed into
the tonsil
Carotid Artery is located 2.5 cm inferior lateral to tonsil
Retropharyngeal and prevertebral space abscesses
•
•
•
•
•
MC in children < 6 years (lymph nodes regress in adulthood)
Posterior to pharynx/Anterior to vertebral bodies/Carotid
sheaths laterally/Inferiorly by mediastinum
Duck “quack” (cri du canard)
Holds neck extended/ Trismus/Stridor
X-ray: Obtain in full extension, inspiration, tissue space should
be no wider than vertebral body

23. Oral and Upper Airway
Emergencies
•
Pharyngitis
•
Bacterial: Group A Strep
•
•
•
•
•
Rapid Strep Test: variable sensitivity and specificity
Culture: 95% sensitive
Centor Criteria: All four 55% probability of Strep etiology
•
•
•
•
1. Tonsillar exudate
2. Fever
3. Tender cervical LAD
4. Absence of cough
Treatment: tx within 9 days to prevent rheumatic fever
(Glomerulonephritis not prevented by abx administration).
PCN VK (erythro if PCN allergic)
Viral (60%):
•
Enterovirus MC from spring through fall, Adenovirus
associated with unilateral conjunctivitis in 50%

24. Oral and Upper Airway
Emergencies
• Epiglottis
•
•
•
•
•
More in Adults now since the H. Flu
vaccine. Vaccination efficacy
decreases with age.
Diagnosis initially missed in 33% of
cases
Etiology: H Flu, S. pneumo, S.aureus
Patient sitting in sniffing position,
“tripod”
Tx: Manage in OR for kids, airway
compromise less common in adults
(increased ratio of trachea diameter to

25. Oral and Upper
Airway Emergencies
•
Croup (Laryngotracheobronchitis)
•
•
•
•
•
•
•
MCC of upper respiratory obstruction in kids
Peak Incidence: 2 years old
50% by Parinfluenza virus
Tx: Cool mist, racemic epi (observe for 4-6 hours for
rebound), Steroids (controversial)
Admission Criteria: Hypoxia, respiratory distress/stridor
persists, <6 months of age
Wesley Croup Score
•
Mild Croup < 2points, Moderate Croup 2-7 points,
Severe Croup >8 points
Bacterial Tracheitis
•
•
•
•
•
•
Laryngeal/Tracheal/Bronchial inflammation
Etiology: Staph
Peaks in ages 3-4 y/o
Barky cough, inspiratory/expiratory stridor - difficult to
differentiate from croup or epiglottis but in BT patients
have mucopurulant cough and are toxic appearing
X-rays show subglottic narrowing as in croup
Tx: OR for intubation, Bronchoscopy may be diagnostic

26. Some Extras...
•
•
Chalazion
•
•
•
Chronic Stye, Not infected
Point inside to the lid
Meibomian gland
Hordeolum
•
•
•
Hordeolum is a painful nodule from
blocked Zeiss + Moll gland (abscess on lid
margin)
Points externally
Hordeolum is a stye because horders live
in a pig stye.

27. Questions
• Ludwig’s Angina is an infection that
most typically originated from which
previous location?
• Mandibular odontogenic infection
• Maxillary odontogenic infection
• Peritonsilar abscess
• Retropharyngeal abscess

28. Questions
•
A 48 year-old man with no previous medical history
presents with dizziness and hearing loss. He reports
recurrent episodes of dizziness with ringing in one
ear, severe nausea and vomiting, and feels that his
hearing has decreased over time. Which of the
following statements is TRUE regarding his condition?
•
•
•
•
High-frequency hearing loss is commonly observed
HCTZ is treatment of choice
Perilymphatic fistula is the underlying etiology
Vertical nystagmus is observed during an episode

29. •
Meniere’s Disease:
•
•
•
•
•
Recurrent but also progressive hearing loss, tinnitus
and vertigo.
Etiology thought to be due to excessive
endolymphatic fluid and endolymphatic distension.
The diagnosis if often made clinically, with horizontal
nystagmus seen.
Low-frequency sensorineural hearing loss is also
seen on audiometry.
The treatment is salt restriction and diuretics.

30. Questions
•
A 22-month-old girl is brought in parents for concern of an ear infection.
She was recently seen for an ear infection 10 days ago and was
prescribed high-dose amoxicillin, but continues to have ear pain. On
exam, the child appears listless and limp. Vital signs are BP 85/55, P
135, RR 35, T104F (40C), O2Sat 99% room air. ENT exam shows a red
and bulging right tympanic membrane with an air-fluid level, and
fluctuance and erythema behind the auricle. The remainder of the
physical exam is unremarkable, including a grossly intact neurologic
exam. Broad-spectrum antibiotics and IV crystalloid fluid bolus
resuscitation are initiated. Which of the following is the next best step in
managing this patient?
•
•
•
•
Admit to pediatrics ICU pending culture results
Consult ENT for drainage
CT head and temporal bones with contrast
Lumbar puncture to rule out meningitis

31. Questions
•
•
•
While imaging of the temporal bone is indicated in this
patient, this patient is not stable for radiographic studies
and ENT should be emergently consulted for drainage,
based on high clinical suspicion (given postauricular
fluctuance in the setting of an obvious acute otitis media
failing outpatient antibiotics).
The choice of antimicrobial therapy should be directed
to the most common microorganisms involved, which
are S. pneumoniae, S. aureus.
Antibiotics against pseudomonal species should be
considered when there is a history of recurrent otitis
media or recent antibiotics use.

32. Questions
•
A homeless patient presents complaining of a white film to
the surface of his tongue and burning pain. What findings
are suggestive of oral candidiasis versus oral hairy
leukoplakia?
•
•
•
•
HIV Positive
White plaques can be scraped off with red friable tissue
underneath
Immunocomprimised
Previous viral pharyngitis in an immunocompetent
individual

33. Questions
•
•
Oral candidiasis and oral hairy leukoplakia both occur in
HIV positive and immunocompromised patients.
Oral candidiasis can be diagnosed as a white film that
can be easily scraped off to reveal red friable tissue
underneath on the tongue
.

34. Questions
•
A 5-year-old previously healthy boy is brought in by mom for
fever and decreased appetite for 2 days. Mom has not noticed
any runny nose or cough, but patient has been complaining of
mouth pain. Oropharyngeal exam is shown, with exquisitely
painful lesions. Which of the following most accurately
describes this condition?
•
•
•
•
Adenopathy and fever typically precede the appearance of
ulcers
Antiviral can shorten duration of symptoms and reduce
recurrence
Coxackievirus is likely the causative agent
Throat culture is the gold standard for diagnosis

35. Questions
•
•
Herpes gingivostomatitis is the likely causative agent in
this case scenario.
While both herpes gingivostomatitis and herpangina can
lead to painful vesicles and ulcers in the oropharynx,
herpangina generally spares the buccal mucosa,
gingivae and the tongue (unlike herpes
gingivostomatitis).

36. ENT
• The END
• Questions?