Maxillofacial and Ocular Emergencies Study Guide for the CEN

General Information

This is one of the two least-assessed content areas on the CEN, but you’ll still want to know all of the important concepts regarding face and eye emergencies. About 7% of the questions assess these components of emergency nursing.

Maxillofacial

The maxillofacial region encompasses the mouth, jaw, face, and head. Injuries or infection in this region can be life-threatening if they cause airway obstruction or if the brain is affected. Prompt identification and treatment of the issue are key to preventing further complications. Here’s a quick rundown of what to look for.

Abscess

An abscess occurs when a pocket of pus from an infection collects within a contained space. Types of abscesses that affect the maxillofacial region include periapical abscesses in the pulp of the tooth, periodontal abscesses in the tissues that surround the tooth, mandibular abscesses that can affect the upper or lower jaw, a nasal or sinus abscess, and peritonsillar abscesses that affect the tonsils.

Assessment

The specific symptoms depend on the location of the abscess. In general, the patient will present with pain at the abscess, tenderness and swelling in the tissues affected by the abscess site, and redness. The patient can have a hoarse voice if they have a peritonsillar abscess. If the abscess is severe, then the patient may also have a fever, chills, and generalized weakness and fatigue.

The provider will perform a physical exam of the affected area. A CT scan may be performed for severe cases to see how big the abscess is prior to intervening. A CBC will help to determine whether the patient is experiencing a systemic infection and has the potential to develop sepsis. A culture of the abscess exudate will be performed to determine which bacteria or fungi have caused the abscess.

Treatment

The primary treatment is an incision and drainage to drain the abscess and relieve the patient’s discomfort. A root canal can be performed for patients with dental abscesses to help save the tooth. If they cannot save the tooth, then it needs to be extracted. Recurrent peritonsillar abscesses may require the patient to have a tonsillectomy. The infection can be treated with antibiotics (usually oral, sometimes IV for really severe cases) or antifungal medications, depending on what organism caused the abscess.

Epistaxis

Epistaxis is any bleeding from the nose. It can be caused by trauma, a dry nose, taking blood thinners, repeated use of medications such as intranasal steroids, picking the nose, or bleeding disorders such as hemophilia. Left untreated, severe epistaxis can be life-threatening.

Assessment

The primary symptom is bleeding. Even minor spotting on a Kleenex is technically epistaxis. The severity ranges from spotting to severe bleeding that can be life-threatening if it isn’t controlled. The patient may also have pain and swelling in their nose, especially if the epistaxis is due to nasal trauma. If the patient swallows blood, they can also experience nausea and vomiting. The emesis may appear coffee-ground-like due to the blood that the patient has swallowed. A nasal endoscopy is performed to locate the source of the bleeding.

Treatment

The treatment is to stop the bleeding. Most minor nose bleeds will resolve with pressure applied on the bridge of the nose for 10-15 minutes. The patient should tip their head forward to allow blood to drain from the nose and not tip their head back. Tipping their head back causes them to swallow the blood. Intranasal medications such as Afrin (oxymetazoline) cause vasoconstriction and help to slow/stop the bleeding. In extreme cases, the patient may need to go to the OR for nasal cautery performed by an ear, nose, and throat doctor. A patient who is on blood thinners may need to stop, switch to a new medication, or adjust their medication dose. A patient with a bleeding disorder will need order-specific treatment as well.

Facial Nerve Disorders

The two primary facial nerves are the facial nerve (cranial nerve VII) and the trigeminal nerve (cranial nerve V). One example is Bell’s palsy, which causes unilateral temporary facial paralysis that resolves in several weeks to six months, and is triggered by swelling or irritation in the facial nerve due to viral infections, autoimmune disorders, or other unknown etiologies.

Trigeminal neuralgia (trigeminal nerve) causes severe facial nerve pain attacks that last from a few seconds to a few minutes, which can be triggered by activities such as light touch and tooth brushing. Trigeminal neuralgia does not usually completely resolve, but patients can experience periods of remission between flare-ups.

Assessment

Symptoms of Bell’s palsy include facial drooping, most noticeable at the eyelid and mouth, difficulty smiling, drooling, eye dryness and irritation on the affected side, facial paralysis, pain behind the ear before or during the onset of paralysis, loss of taste, and sensitivity to sound. Diagnostic tests for Bell’s palsy include a physical assessment of the patient’s facial function, EMG testing to assess the severity of facial paralysis, head CT or MRI to rule out other underlying causes of the paralysis, blood work to check for Lyme disease or sarcoidosis, and a Schirmer’s test to measure the patient’s tear production, which can decrease in Bell’s palsy.

The primary symptom of trigeminal neuralgia is severe stabbing pain that lasts for a time frame ranging from a few seconds to a few minutes. The pain is most commonly located around the jaw, cheek, or eye. Triggers for the attacks include teeth brushing, chewing, talking, and even a light breeze in severe cases. The pain is usually unilateral but can be bilateral in rare cases. Some patients experience an aching or throbbing sensation. There is no specific diagnostic test for trigeminal neuralgia, but the provider will perform a detailed physical exam, take a comprehensive medical history, and order diagnostic imaging like a head CT or MRI to rule out other underlying causes of the pain.

Treatment

Treatment for Bell’s palsy includes corticosteroids to reduce inflammation of the facial nerve and, if the inflammation is due to a viral infection, antiviral medications like acyclovir or valacyclovir. Moisturizing eye drops and ointments are used to prevent damage to the eye. Physical therapy can help to strengthen and retrain the paralyzed muscles. Rarely, surgery is needed to decompress the nerve and restore facial function.

Treatment for trigeminal neuralgia includes anticonvulsant medication such as carbamazepine, topiramate, lamictal, gabapentin, and pregabalin that help to block transmission of pain signals from the nerve. There are several procedures that can help reduce the pain associated with trigeminal neuralgia. Microvascular decompression separates the trigeminal nerve from any blood vessels that are compressing it, Botox injections to block the transmission of pain signals, rhizotomy to destroy the trigeminal nerve, and stereotactic radiosurgery, which is focused radiation that targets the trigeminal nerve.

Maxillofacial Infections

A maxillofacial infection is any infection that affects the patient’s jaw, face, or surrounding areas. These infections are usually bacterial, but can also be fungal. Ludwig’s angina is a severe cellulitis affecting the patient’s tongue, floor of the mouth, and neck that usually originates from a dental infection. Otitis media is an ear infection. Sinusitis is a sinus infection. Mastoiditis is an infection of the mastoid bone behind the ear that usually results from an ear infection that spreads to the bone.

Assessment

The symptoms vary depending on the specific area of the maxillofacial region that is infected. In Ludwig’s angina, the patient may experience a toothache, redness and swelling in the floor of their mouth, drooling, difficulty swallowing, slurred speech, neck stiffness and swelling, and stridor if the swelling progresses to the point that the patient’s airway is affected. The airway swelling can be life-threatening if left untreated.

Otitis media symptoms include ear pain and pressure, fever, loss of appetite, and fussiness in young children. Symptoms of sinusitis include sinus pressure, headache, nasal congestion, and post-nasal drip. Symptoms of mastoiditis include severe ear pain, redness and swelling behind the ear, high fever, hearing loss, and vertigo.

Most minor cases of maxillofacial infections are diagnosed through a physical exam and the patient’s symptom presentation. More severe or recurrent cases will need to have diagnostic imaging such as a head CT to reveal the extent of the infection and any associated tissue damage. A CBC will be drawn to rule out systemic infection in severe cases.

Treatment

The immediate concern in Ludwig’s angina is to ensure that the patient’s airway remains patent. Emergency intubation or even a tracheostomy can be needed in severe cases. Intravenous steroids such as dexamethasone or inhaled racemic epinephrine both help to reduce airway swelling. To treat the underlying infection, the patient will initially receive broad-spectrum IV antibiotics and then transition to oral antibiotics for several weeks after their infection is controlled. An incision and drainage or tooth extraction may be needed to clear out the source of the infection.

Otitis media is treated with oral antibiotics, over-the-counter pain management like acetaminophen or ibuprofen, and ear tubes for persistent cases to drain fluid and improve hearing. Sinusitis is treated with oral antibiotics for bacterial infections, nasal steroids to reduce swelling, and oral or nasal decongestants to relieve sinus pressure and congestion. Mastoiditis is treated initially with IV antibiotics and then with oral antibiotics. Surgical intervention via a mastoidectomy may be needed if medication management is ineffective.

Acute Vestibular Dysfunction

Acute vestibular dysfunction is sudden onset, continuous vertigo that affects the patient’s hearing and balance. It can cause extreme discomfort, trigger nausea/vomiting, and make it impossible for them to safely stand, walk, drive a car, or perform activities of daily living in severe cases. Acute vestibular dysfunction can be caused by most commonly by vestibular neuritis/labyrinthitis (inflammation of the vestibular nerve usually triggered by a viral infection), as well as Meniere’s disease (fluid in the inner ear that causes vertigo and intermittent hearing problems), or a posterior stroke affecting the cerebellum or brainstem. The stroke can be life-threatening, and the symptoms should be taken very seriously.

Assessment

Symptoms of acute vestibular dysfunction include a sensation of the room spinning (vertigo) that lasts for at least 24 hours, nausea/vomiting, nystagmus, gait instability, and head motion intolerance. If the cause is Meniere’s disease, the patient may also have difficulty hearing and ear pain. The patient should be evaluated for the signs of a stroke, and a head CT or MRI can be used to rule out a stroke. Electronystagmography and videonystagmography will record eye movement, which is affected by inner ear function. Rotary chair testing measures how well the eyes and inner ear work together during position changes. Video head impulse testing evaluates the effect that rapid head movements have on the inner ear. An audiogram will evaluate the patient’s hearing abilities. A vestibular evoked myogenic potential test measures the function of the vestibular nerve.

Treatment

Treating acute vestibular dysfunction is primarily symptom management until the underlying vestibular neuritis resolves and symptoms disappear. Corticosteroids, like methylprednisolone, will be used to reduce swelling in the vestibular nerve in the acute phase of symptoms during the first few days. Medications such as meclizine, diphenhydramine, and lorazepam are used to treat the spinning sensation and nausea. Antiemetics like ondansetron and prochlorperazine help to manage severe nausea and vomiting. Vestibular rehabilitation teaches the patient about exercises that can be used to retrain the inner ear and reduce symptoms. Lifestyle changes such as staying hydrated, getting plenty of rest, and avoiding bright lights and loud noises also help to relieve symptoms.

Maxillofacial Trauma

Maxillofacial trauma is any traumatic injury that affects the head and facial region. Common causes of maxillofacial trauma include motor vehicle accidents, sports injuries, motorcycle accidents, and bicycle accidents.

Assessment

The specific symptoms depend on the area of injury. The patient is likely to have pain and bleeding. They may have difficulty communicating or seeing, and reassurance should be provided. Assess the patient’s airway and ensure that it remains patent. Perform complete neurological assessments every 15 minutes for the first hour and then hourly until intracranial trauma is ruled out. Diagnostic imaging, such as an X-ray or CT scan, should be used to determine the extent of the maxillofacial trauma and any other intracranial or cervical injuries. A hemoglobin and hematocrit will be drawn to check the patient’s levels, as well as a type and screen in case a blood transfusion is needed if the trauma is severe or the patient is a polytrauma.

Treatment

The biggest concern is maintaining the patient’s airway. For patients with extremely severe maxillofacial trauma that prevents endotracheal intubation, a tracheostomy may be inserted emergently to ensure that the patient’s airway remains patent. Any bleeding should be controlled with direct pressure. Surgical repair may be needed immediately. Depending on the extent of the trauma, multiple reconstructive surgeries or skin grafting procedures may be performed by a plastic surgeon. An oral surgeon may need to address any dental damage that has occurred. The patient will likely receive IV antibiotics to prevent infection and may need blood transfusions, especially if other trauma has occurred.