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Ovid: Oxford Handbook of Accident and Emergency Medicine

Editors: Wyatt, Jonathan P.; Illingworth, Robin N.; Clancy, Michael J.; Munro, Philip T.; Robertson, Colin E. Title: Oxford Handbook of Accident and Emergency Medicine, 2nd Edition Copyright ©2005 Oxford University Press > Table of Contents > Chapter 12 – Ear, nose and throat Chapter 12 Ear, nose and throat P.524
ENT foreign bodies Ear FBs All sorts of FBs may become lodged in the external auditory canal, including insects, vegetable matter and various inert objects. The patient may present with pain, deafness, discharge or in the case of live insects, an irritating buzzing in one ear. Diagnosis depends upon direct visualization with the auriscope. In children, remember that, as with FBs elsewhere, there may be no history of FB available. Removal:

  • many FBs can be removed under direct vision with hooks. Manipulate gently to avoid causing damage or further impaction.
  • drown live insects in 2% lidocaine first.
  • do not try to syringe out vegetable matter with water, as this may cause swelling and ↑pain.
  • if there is some difficulty (eg ball bearing or bead in an unco-operative child), refer to ENT to consider removal under GA. Sometimes, beads can be removed using an orange stick with a tiny amount of superglue on the end, but this requires complete patient co-operation.

Embedded ear-rings The ‘butterfly’ piece of an ear-ring may become embedded in the posterior part of the ear lobe, causing inflammation ± infection. The ear-rings are usually easily removed once adequate analgesia has been established: render the ear anaesthetic with a greater auricular nerve block (p292). Apply pressure in a posterior direction to effect release. Occasionally, forceps and a small posterior skin incision may be required to open up the track of the ear-ring. If there is evidence of infection, prescribe antibiotics (eg co-amoxiclav) after removal and arrange GP follow-up. Advise the patient to refrain from using ear-rings again until the inflammation has settled. Nasal FBs Mostly affect children, who present with an offensive unilateral nasal dis-charge. They are also found in adults in psychotic illness or mental retardation. Removal It may be appropriate to remove easily accessible, anteriorly placed nasal FBs in A&E. However, there is a risk of aspiration with any nasal FB, particularly in unco-operative patients. Refer such patients to an ENT surgeon for removal of FB with airway protection. Before using instruments, instruct the patient to blow his nose whilst occluding the unaffected nostril. If unsuccessful, consider attempting removal using a combination of nasal speculum, hook and forceps, as appropriate. A fine bore tracheal suction catheter attached to wall suction can also work. One technique which has been reported in co-operative children is to ask a parent to blow into the child’s mouth (‘parent’s kiss’), having first ensured a good seal and also occluded the normal nostril. Note Nasal button batteries or magnets (p205) can cause significant damage, so refer to ENT. Inhaled FBs Aspiration causing complete upper airway obstruction is an emergency, requiring immediate intervention (p316). FBs lodged in the larynx or tracheobronchial tree cause persistent coughing. Auscultation of the chest is often normal, but may reveal wheezes or localised absence of breath sounds. CXR may be normal or show a radio-opaque FB with distal consolidation or hyperinflation (FB acting as a ball valve). A CXR in expiration may show this more clearly. Refer to a cardiothoracic surgeon. P.525
Ingested FBs A variety of FBs, both radio-opaque (eg coins, rings) and non radio-opaque (eg plastic pen tops, aluminium ring pulls) are frequently swallowed by children and by adults with psychiatric disorders. Provided that the FB reaches the stomach, it is likely to pass through the remainder of the GI tract without incident. An exception is button battery ingestion (p205). For radio-opaque FBs, confirm with lateral neck X-ray and CXR that it is not impacted in the oesophagus. Refer patients who are symptomatic, have impacted FBs, or who have swallowed potentially dangerous items (button batteries, razor blades, open safety pins). Note that magnets can be dangerous if two or more are ingested, since they can attract each other through tissues and cause pressure necrosis and perforation of bowel wall. Only discharge patients who are asymptomatic (with the advice that they should return if they develop abdominal pain and/or vomiting), and arrange suitable follow-up. Unless the ingested FB is valuable or of great sentimental value, examination of the stools by the patient for the FB is unnecessary—some FBs can take 6wks to pass, and many can be very hard to find in the stools. Impacted fish bones Fish bones often become stuck in the pharynx or oesophagus. Direct visualization with a good light (a headtorch is useful) and wooden spatula acting as tongue depressor may reveal fish bones lodged in the tonsils or base of the tongue—remove these with Tilley’s forceps. If no FB is seen, search for fish bones by obtaining soft-tissue lateral neck X-rays (but bear in mind that they are not all radio-opaque), then refer to ENT for endoscopy. Depending upon local policy, the ENT team may decide to see the patient immediately, or (provided that the patient can swallow) the following day. It is worth noting that a fish bone often scratches the pharynx/oesophagus causing the sensation of a FB to persist after the bone has gone. Oesophageal food bolus obstruction Usually involves a lump of meat. Patients with complete obstruction present unable to swallow solids or liquids (including their own saliva). There may or may not be associated discomfort. If there are no associated symptoms (such as stridor—suggesting airway obstruction), try small amounts of fizzy drinks. If the patient remains symptomatic, refer for inpatient treatment. P.526
Earache Painful ears commonly present as a result of the problems described below, but many are due to referred pain from other sites, including: teeth, temporomandibular joint, tonsils, pharynx, Ramsay—Hunt syndrome, cervical spine. Otitis externa Often caused by Pseudomonas, Staph. aureus, Strep. pneumoniae, E. coli. Common in swimmers/surfers and after minor trauma. An itchy ear is accompanied by pain which gradually ↑ and is accompanied by a discharge (profuse discharge implies middle ear disease). Pain and itching typically precede hearing loss. On examination, the external canal is inflamed and oedematous, which together with debris, may obscure the tympanic membrane. Pressing on the tragus or pulling the pinna causes pain. Management Prescribe topical antibiotics ±topical steroids, advise avoidance of swimming and arrange GP follow-up. In severe cases (eg if the drum is not visible), refer to an ENT surgeon for aural toilet to remove debris from the auditory canal. Furunculosis of the external ear Hair follicle infection in the outer third of the ear causes severe pain, made worse by movement of the ear. Examination reveals a localised inflamed swelling. Treat with analgesia (eg NSAID) and antibiotics (eg flucloxacillin 500mg PO qds for 5days). Arrange GP follow-up. Acute otitis media Most common in children aged 3—6yrs and may follow an upper respiratory tract infection. Commonest pathogens are Strep. pneumoniae and H. influenzae. Presentation Earache may be accompanied by fever, deafness, irritability and lethargy. Typically, hearing loss precedes pain. Examination of the tympanic membrane shows evidence of inflammation with loss of the light reflex and bulging of the drum. Eventual perforation results in purulent discharge with some relief of pain. Look for associated swelling/tenderness over the mastoid—this implies secondary mastoiditis (see below). Treatment Prescribe oral analgesia. The use of antibiotics remains very controversial. Oral antibiotics (eg amoxicillin or erythromycin) are of questionable value, but are traditionally and commonly given. If perforation has occurred (often heralded by a sudden ↓pain), arrange ENT follow-up and advise avoidance of swimming. Otherwise, arrange GP follow-up. Acute mastoiditis This is an uncommon, but important diagnosis to make, in view of the risk of intracranial spread of infection. Mastoiditis follows an episode of acute otitis media—consider it if there is no response to therapy (eg discharging ear for >10days). Suspect it if there is pain, redness, swelling or tenderness over the mastoid process. The pinna may be pushed forwards/outwards—swelling may mean that the drum is not visible. Refer urgently to the ENT surgeon for admission and IV antibiotics. Cholesteatoma This erosive condition affects the middle ear and mastoid and may result in life-threatening intracranial infection. There may be an offensive discharge, with conductive hearing loss ± vertigo, facial nerve palsy. Tympanic membrane examination may reveal granulation tissue and/or perforation with white debris. Refer to ENT surgeon. P.527
Traumatic tympanic membrane rupture May follow direct penetrating injury, blast injury (p375) or basal skull fracture (p348). Pain is associated with ↓hearing. Perforation is visible on examination. Treatment Most heal spontaneously with conservative measures, including advice to keep out of water. Arrange ENT follow-up and give prophylactic oral antibiotics according to local policy. Barotrauma Pain and hearing loss, associated with fluid behind the tympanic membrane, results from sudden changes in atmospheric pressure in the presence of a blocked Eustachian tube. This commonly occurs in aircraft passengers and divers. The problem usually resolves spontaneously, but takes time. Give analgesia (NSAID) and arrange follow-up. Vertigo Vertigo is the term used to describe the impression or illusion of movement when there is none. Take care to distinguish vertigo from the more general term of ‘dizziness’, which is often used to describe a feeling of light-headedness. Patients may present with vertigo as a result of a number of disease processes:

  • Benign positional vertigo (esp elderly, lasts ≈2mins with position change)
  • Menière’s disease (characterized by: vertigo, tinnitus, deafness)
  • Acute labyrinthitis (follows viral infection of inner ear, often with nausea)
  • Otitis media (see below)
  • Acoustic neuroma (‘giddiness’ is more common than vertigo—see p532)
  • Cholesteatoma (see below)
  • Cerebrovascular events (see p140)
  • Trauma
  • Wax or FB in the ear

Manage patients who present with vertigo according to the underlying cause. If the cause is unclear, refer to the medical/ENT team as appropriate. Patients with cochlear implants Cochlear implants comprise an implanted radio receiver and decoder package containing a magnet secured to the skull ≈5cms above and behind the ear, together with a removable external microphone/radio transmitter. X-rays and CT do not damage this device, provided that the external microphone/transmitter is first removed and switched off. Avoid MRI as this can cause significant damage to both the device and the patient. Refer to the ENT team any concerns relating to a cochlear implant and in particular:

  • significant direct trauma, including exposure by a scalp wound
  • suspected otitis media of the implanted ear

Epistaxis Nasal bleeding may be idiopathic or follow minor trauma (eg nose picking). It also occurs in patients with hypertension and coagulation disorders—in the case of the latter, haemorrhage can be severe and has a significant mortality. Epistaxis may follow isolated nasal fracture and more major facial injury. Site of bleeding Most nasal bleeding emanates from the anterior nasal septum in or close to Little’s area. A few patients have posterior nasal bleeding, which may be brisk. Equipment Direct visualization of the anterior nasal cavity is aided by a good headlamp (eg battery-operated headtorch), fine soft suction catheter and nasal speculum. Wear goggles during examination in order to avoid blood splashes in the eyes. Initial approach Associated facial injury Assess ABC (especially pulse and BP) and resuscitate as necessary (p312). Treat hypovolaemia vigorously. No associated injury Check airway patency, pulse and BP. Treat hypo-volaemia aggressively. Check coagulation status of patients on anticoagulant therapy and treat appropriately (p164). Sit the patient up and instruct him to compress the fleshy part of his nose between finger and thumb for 10mins. If this stops the bleeding, observe for a further 15mins, then allow the patient home with strict instructions not to sniff, pick or blow the nose. Continuing bleeding after pressure Adults Apply a cotton wool pledget soaked in 4% lidocaine with 1 in 1000 epinephrine/adrenaline. Then, with a headlamp and nasal speculum, try to identify the bleeding point. Treat small anterior bleeding points with cautious cautery by applying a silver nitrate stick for 10—15secs. Avoid excessive cautery and never cauterize both sides of the septum—this may cause septal necrosis. If cautery is successful in terminating the bleeding, observe for 15mins, then discharge with GP follow-up. Advise avoidance of sniffing, picking or blowing the nose meantime. Children Application of nasal antiseptic cream (eg naseptin) is as effective as cautery in stopping bleeding. The cream is relatively easy to apply. Continuing bleeding despite cautery Insert a nasal pack. A specialized compressed surgical sponge nasal tampon (eg Merocel®) is ideal: gently insert a lubricated tampon and ‘inflate’ with a 10mL syringe of normal saline. Alternatively, pack the nose in traditional fashion with 1.25cm wide ribbon gauze soaked in oily paste (eg bismuth iodoform paraffin paste). Once packing has stopped the bleeding, refer to an ENT surgeon to consider admission: observation is advisable (especially in the elderly) in view of the risk of the pack becoming dislodged and obstructing the airway. Continuing bleeding despite packing Enlist the assistance of an ENT surgeon. The bleeding site is likely to be posterior—occasionally, this may be rapid, producing hypovolaemic shock. In this situation, insert 2 large bore IV cannulae, send blood for FBC, coagulation screen, X-matching and commence an IVI. Posterior nasal bleeding usually responds to tamponade with a Foley catheter. Remove the nasal tampon and insert a lubricated, uninflated Foley catheter through the bleeding nostril into the nasopharynx. Inflate the balloon with air and gently withdraw the catheter, thus tamponading the bleeding site. Secure the catheter to the cheek with tape, then re-insert the anterior nasal tampon. P.529
Nasal fracture The prominent exposed position of the nose, combined with the delicacy of its bones, render it relatively prone to injury. Remember that the nose is part of the head, so nose injury = head injury (and potentially cervical spine injury also). History The nose is commonly broken by a direct blow (eg from a punch) or following a fall onto the face. Nasal fracture is usually accompanied by bleeding. Search for a history of associated facial/head injury (diplopia, loss of consciousness etc). Examination The diagnosis of nasal fracture is essentially clinical, based upon a history of injury with resultant nasal swelling and tenderness. Having made the diagnosis, assess whether or not there is any nasal deviation: it is often useful to ask the patient to help by looking in a mirror. Check and record whether the patient can breathe through each nostril. Look for an associated septal haematoma—this will appear as a smooth bulging swelling which may obstruct the nasal passage. Children are at particular risk of septal haematoma. The problem of septal necrosis mostly relates to secondary infection. Assess for additional injuries to the head or face (eg tender mandible, diplopia, tender maxilla). Injury to the bridge of the nose may result in persistent epistaxis and/or CSF rhinorrhoea. Investigation Do not X-ray simply to diagnose a nasal fracure—the diagnosis is a clinical one. Obtain appropriate X-rays (eg OPG or facial views) if there is clinical suspicion of other bony injuries. Nasal fractures are often apparent on facial X-rays or CT scans. Treatment

  • Resuscitate and treat for associated head injury.
  • Continuing nasal haemorrhage is uncommon—refer to an ENT surgeon to consider urgent MUA to stop the bleeding: meanwhile, insert a compressed surgical sponge nasal tampon (see below).
  • Refer urgently to an ENT surgeon if there is a septal haematoma—this will require incision and drainage in order to prevent septal necrosis.
  • Clean and close overlying skin wounds: steristrips often allow good skin apposition. If there is significant contamination of the wound, start a course of prophylactic oral antibiotics (eg co-amoxiclav: one tablet PO tds for 5days).
  • Provide oral analgesia (eg ibuprofen 400mg PO tds).
  • If the nose is deviated/distorted, or if there is too much swelling to allow a judgement to be made about this, arrange for ENT follow-up at 5—7days, so that MUA may be performed within 10days. Due to growth potential, it is particularly important to ensure accurate reduction of fractures in children.
  • Discharge with head injury instructions to a relative or friend.

Sore throat Tonsillitis Causes Acute pharyngo-tonsillitis may result from infection with a variety of viruses or bacteria:

  • viral EB virus, herpes simplex virus, adenoviruses.
  • bacterial group A ß-haemolytic streptococcus (most common bacterial cause), mycoplasma, Corynebacterium diphtheriae.

Features Sore throat is frequently accompanied by fever, headache and mild dysphagia. Inspection of the tonsils reveals inflammation—the presence of pus on the tonsils suggests bacterial infection. Enlarged cervical lymph nodes are found in a variety of infections, but generalized lymphadenopathy (sometimes also with splenomegaly) is indicative of glandular fever (infectious mononucleosis—see p231). Diagnosis Despite the clinical pointers described above, it is usually impossible to distinguish clinically bacterial from viral causes. Investigation Consider throat swabs and anti-streptolysin titre in severe cases. If glandular fever is suspected, send blood for FBC and Paul—Bunnell test. Treatment Unless contraindicated, give paracetamol (1g PO qds PRN) or aspirin (300mg PO qds PRN—avoid in children) and discharge to GP. Although frequently prescribed, oral antibiotics are rarely of benefit: a sensible approach is to limit their use for patients with any of the following: a history of valvular heart disease, immunosupression, DM, marked systemic upset, peritonsillar cellulitis. In this case, prescribe penicillin 500mg PO qds for 5days (or erythromycin 500mg PO qds for 5days if allergic). Avoid ampicillin, amoxicillin and co-amoxiclav, which cause a rash in patients infected with EB virus. Occasionally, patients with acute tonsillitis may be completely unable to swallow fluids (this is more commonly a feature of peritonsillar or retropharyngeal abscess—see below). In this case, refer for IV antibiotics and IV fluids. Complications Otitis media, sinusitis, retropharyngeal abscess, peritonsillar abscess. Peritonsillar abscess (quinsy) Typically preceded by a sore throat for several days, the development of a peritonsillar abscess is heralded by high fever, pain becoming localized to one side of the throat, and pain on swallowing. Difficulty swallowing can result in drooling. Trismus may make inspection difficult, but if visualized there is tense bulging tonsil, pushing the uvula away from the affected side. Group A ß-haemolytic streptococci are frequently implicated. Treatment Insert an IV cannula and give IV benzyl penicillin 600mg, and refer immediately to an ENT surgeon for aspiration or formal drainage. Retropharyngeal abscess Spread of infection from adjacent lymph nodes may occasionally cause a retropharyngeal abscess, particularly in children aged < 3yrs. It is characterized by a sore throat, difficulty swallowing, fever and dehydration. Lateral X-rays of the neck show soft tissue swelling. Treatment Insert an IV cannula and give IV fluids. Refer immediately to an ENT surgeon. The differential diagnosis includes acute epiglottitis (p640). Pharyngeal burns after cocaine use Smoking cocaine can result in dangerous burns of the throat, since the drug acts as a local anaesthetic. Swelling of the epiglottis may result in airway obstruction. P.531
Paranasal sinusitis Bacterial infection may result from direct spread from infected tooth roots or (more usually) be secondary to viral URTI. Clinical features

  • clear nasal discharge becoming purulent
  • pain in (and often also tenderness over) the affected sinus
  • fever
  • headache and/or toothache

Management Provide analgesia. Despite a lack of convincing evidence, oral antibiotics (eg amoxicillin or erythromycin) ±nasal decongestant (eg 1% ephedrine) are commonly given. Advise GP follow-up. In severe cases, refer to ENT. P.532
Facial nerve palsy The facial (VII) nerve supplies the muscles of facial expression. Clinical examination will reveal whether facial nerve palsy is of upper motor neurone or lower motor neurone type. Upper motor neurone paralysis is usually due to a stroke (p142), resulting in weakness of the facial muscles, but with sparing of the muscles of the forehead. If stroke is the cause, there will usually be additional evidence elsewhere (eg hemiparesis affecting the limbs). Lower motor neurone paralysis of the facial nerve results in weakness of the muscles of the entire one half of the face. The presence or absence of additional clinical features, combined with an application of basic anatomical knowledge, allows an estimation of the site of the lesion. The facial nerve arises from its nucleus in the pons, emerges from the pons to travel past the cerebello-pontine angle, through the petrous part of the temporal bone, to emerge from the stylomastoid foramen and thence into the parotid gland, where it divides into branches. During its passage through the petrous temporal bone, the facial nerve is accompanied by the chorda tympani (carrying taste fibres from the anterior 2/3 of one half of the tongue) and gives off the nerve to stapedius. Lesions of the facial nerve in the temporal bone therefore produce loss of taste and hyperacusis (noise is distorted and sounds loud) on the affected side. Causes of lower motor neurone facial palsy

  • Bell’s palsy—the commonest cause (see below)
  • pontine tumours and vascular events—usually associated with other signs
  • acoustic neuroma—usually with evidence of other nerve involvement (V, VI, VIII nerves) at the cerebello-pontine angle
  • Ramsay—Hunt syndrome (herpes zoster infection—see below)
  • trauma
  • middle ear infection and cholesteatoma (see p526)
  • sarcoidosis
  • parotid gland tumours, trauma and infection
  • HIV

Bell’s palsy Bell’s palsy is the commonest cause of sudden onset isolated lower motor neurone facial nerve palsy. It is believed to result from viral infection, producing swelling of the facial nerve within the temporal bone: there may be associated hyperacusis and loss of taste of the anterior 2/3 of one half of the tongue. The absence of involvement of other cranial nerves is a reassuring feature, helping to secure this clinical diagnosis. Treatment Most patients make a full and spontaneous recovery over several months—a small percentage will be left with permanent weakness. Latest evidence suggests that facial palsy improves after treatment with combined oral aciclovir and prednisolone—follow local protocols. Advise the use of artificial tears and an eye patch at night, to prevent corneal drying. Ramsay—Hunt syndrome This is due to herpes zoster infection of the geniculate ganglion. Clinical features of Bell’s palsy are present, together with herpetic vesicles present in the external auditory meatus and occasionally also, the soft palate. Refer to an ENT specialist for aciclovir and follow-up. P.533
Salivary gland problems Saliva is a mixture containing water, various ions, mucin and amylase, produced by the parotid, submandibular and sublingual salivary glands. The parotid glands are serous, the sublingual mucous, the submandibular mixed in type. The problems most commonly affecting the salivary glands are infection and calculous disease. Acute bilateral parotitis Painful swelling of both parotid glands is most frequently seen in the young, when it is a characteristic feature of mumps infection (p212). It is also sometimes seen in lymphoma. Acute unilateral parotitis This may occur as part of mumps infection, but also in other circumstances (eg poor oral hygiene, post-operatively). Refer to an ENT surgeon for admission and IV antibiotics. Calculous disease Mechanical obstruction of the flow of saliva is most commonly due to salivary gland stones, affecting the submandibular gland. Obstruction may also occur, however, from neoplasms or strictures. Features Blockage of a salivary duct causes pain and swelling of the affected gland on eating. Bimanual palpation of the floor of the mouth may reveal a stone—occasionally this may be visible intraorally at the duct orifice. If there is superimposed infection, it may be possible to express pus from the duct. Investigation Obtain X-rays of the floor of the mouth. If the patient presses down with the tongue when the X-ray is taken the stone may be seen more easily below the mandible on a lateral view or OPG. Treatment Refer to an oral or ENT surgeon. If an immediate consultation is not available, prescribe antibiotics (eg co-amoxiclav) in the meantime. P.534
Dental emergencies Dental anatomy The two complete sets of teeth are the primary (deciduous) dentition (the ‘milk teeth’) and the permanent dentition. The primary teeth erupt between 6months and 2yrs—they are replaced by permanent teeth which first start to appear at ≈6yrs. There are 20 primary and 32 permanent teeth. The permanent teeth are made up of 4 quadrants of 8 teeth: right upper, left upper, right lower, left lower. Each quadrant comprises (from medial to lateral): central incisor, lateral incisor, canine, first premolar, second premolar, first molar, second molar, third molar (‘wisdom tooth’). Damaged teeth Chipped teeth and crowns which have become dislodged do not require immediate attention: redirect the patient instead to his/her dentist. Specialist ‘sensitive teeth’ toothpaste rubbed over the broken area of tooth may ↓pain. Tooth fractures which involve the pulp present with a small area of bleeding and are exquisitely tender to the touch. Refer to the on-call dentist. Mobile teeth after trauma need to be stabilized as soon as possible—advise the patient to avoid manipulating the tooth and to refer to the dentist. Avulsed teeth Missing teeth need to be accounted for (especially in the unconscious patient) in order to exclude the possibility of aspiration. Obtain a PA and lateral CXR to search for both the tooth and secondary problems, such as pulmonary collapse and air trapping distal to the obstruction. Ensure that there is adequate tetanus prophylaxis. Avulsed permanent teeth brought to A&E may be suitable for reimplantation Avulsed primary teeth are usually not suitable. A history of rheumatic fever, valvular heart disease or immunosuppressive treatment are contraindications to re-implantation. Milk is the best easily available transport medium to advise a patient to bring a tooth in. The best chance of success lies with early reimplantation (within the first few hours). Handle the tooth as little as possible. Hold it by the crown to clean it gently with 0.9% saline. Orientate the tooth, then replace it within the socket using firm pressure (this may be easiest after LA—see p294). Secure it with a temporary splint (eg milk bottle top). Refer immediately to the on-call dentist for stabilization and prophylactic antibiotics (eg erythromycin). Ensure tetanus prophylaxis. Post-extraction problems Haemorrhage after tooth extraction may respond to simple measures. Ask the patient to bite on a rolled up piece of gauze placed over the socket for 10mins. If this is unsuccessful, bleeding may be stopped by the insertion of a horizontal mattress suture (eg using ‘vicryl’), placed under LA using lidocaine with epinephrine. If bleeding continues despite these measures, apply direct pressure, send a coagulation screen and refer to the on-call dentist. Dry socket pain may follow tooth extraction (typically 3—8days later) when bone is exposed in the empty socket. Gently irrigate the socket with warm saline. Prescribe oral antibiotics (eg penicillin or erythromycin) and analgesia and refer to the dentist. P.535
Dental infection Toothache without associated local or systemic symptoms/signs usually responds to analgesia (eg ibuprofen 400mg PO tds with food). Add antibiotics (eg penicillin or erythromycin) if there is a suspicion of local infection. Advise follow-up with a dentist. Toothache with associated swelling, trismus, dysphagia or systemic evidence of infection requires immediate referral to a maxillofacial surgeon for IV antibiotics ±surgical drainage.

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