HEADACHE
Tension or fatigue headache is characterized by throbbing pain in the temples, over the eyes, and in the posterior neck and shoulder muscles. It can be treated with rest, sunglasses, and moderate pain medication, such as aspirin or acetaminophen every 3 to 4 hours. Sometimes, applying warm packs or massage to tense muscles relaxes them and helps relieve the pain.
Migraine headache is generally more severe. It is defined as episodic attacks of headache lasting 4 to 72 hours and characterized by at least two of the following: moderate to severe intensity, one-sided pain, throbbing or “pulsating,” and worsening with movement. In addition, there is nausea or vomiting (which may be treated with metoclopramide [Reglan] 10 mg by mouth or with ondansetron [Zofran] 4 mg oral dissolving tablet), and aversion to light or sound. Migraine headache is currently thought to be caused by painful dilation of small arteries in the head. Migraine headaches have many variations, which may include stuffy or runny nose and weakness of an arm or a leg. Some people experience an “aura” before the “classic” migraine headache, in which they may smell strange odors or see flashing lights. Others develop tunnel vision—diminished peripheral vision. The headaches are characterized as excruciating, pounding, or explosive. Occasionally they will respond to nonsteroidal antiinflammatory medications, such as ibuprofen, but often require stronger pain medications and sometimes may need to be treated with narcotics. A person suffering from a migraine should be placed in a quiet, dark area to minimize external stimuli. He should be encouraged to drink enough liquid to treat or prevent dehydration and offered ibuprofen, acetaminophen, or aspirin. Caffeine may be helpful.
Specific antimigraine medications include the “triptans,” such as sumatriptan (Imitrex), naratriptan (Amerge), rizatriptan (Maxalt), and zolmitriptan (Zomig). These medications should be given as early as possible in the course of the headache to achieve maximal effectiveness. Other medicines that are effective include propranolol or metoprolol, amitriptyline, methysergide, flunarizine, and prochlorperazine (Compazine) given with diphenhydramine (Benadryl). Ergotamine drugs (such as dihydroergotamine mesylate [Migranal] nasal spray) directly constrict arteries; these should only be used under the direct supervision of a physician, since they may worsen the effects of certain types of migraines. If an oxygen (see page 431) tank is available, the victim may get some relief by breathing 10 liters per minute by face mask. An elderly person with a severe migraine, which may be confused with a stroke (see page 144), should seek immediate medical attention. A migraine headache may be precipitated by lack of sleep, high altitude, emotional stress, cyclical hormone changes, noxious odors, and certain ingested substances (such as caffeine and monosodium glutamate). Therefore, the migraine sufferer should seek to obtain regular sleep (go to bed and wake up at the same times every day), rest, and meals (do not skip or delay); limit caffeine consumption to the equivalent of two cups of coffee or two 12-ounce sodas per day; avoid tobacco products; avoid known personal triggers (e.g., red wine); practice relaxation techniques; and strive to maintain fitness through regular exercise and dietary discretion. For certain sufferers, a neurologist may prescribe topiramate (Topamax) to be taken between episodes of migraine to reduce the frequency of headaches.
Sinus headache is associated with sinus infection (see page 194) and is typified by fever, nasal congestion, production of a foul nasal discharge, and pain produced by tapping over the affected sinus(es). It should be treated with an oral decongestant (pseudoephedrine), nasal spray (Neo-Synephrine 0.25% or Afrin 0.05%), an antibiotic (azithromycin, amoxicillin-clavulanate, erythromycin, or ampicillin) if an infection is present, and warm packs applied over the affected sinus(es).
Subarachnoid hemorrhage is bleeding that occurs, usually suddenly, from a leaking blood vessel (commonly an aneurysm) underneath the thin tissue layer that surrounds the brain and spinal cord. The headache is usually sudden in onset, described as “the worst headache of my life,” and may be associated with a fainting spell, altered mental status, seizure, and collapse. If a person suffers a subarachnoid hemorrhage and remains awake, he may complain of a stiff or painful neck with or without back pain about 2 to 4 hours after the bleed. Anyone who complains of a severe headache after extreme physical straining (such as weight lifting or a difficult bowel movement) or who collapses suddenly after reporting a headache should be suspected to have suffered a subarachnoid hemorrhage and be brought rapidly to a hospital.
Meningitis, an infection that involves the lining of the brain and spinal cord, is a true emergency. The headache of meningitis is severe, and often accompanied by nausea, vomiting, photophobia, fever, altered mental status, and weakness. A purplish skin rash indicates infection with the bacteria Neisseria meningitidis, a particularly fulminant and contagious form (“meningococcal”) of infectious meningitis. The classic signs of meningitis are a stiff neck with a fever. The victim demonstrates extreme discomfort when the chin is flexed downward against the chest, and may complain that the pain also occurs in the back (along the course of the spinal cord). It is important to note that an infant can suffer meningitis without a stiff neck and may present only with poor feeding, fever, vomiting, seizures, and extreme lethargy (“floppy baby”). If meningitis is suspected, the victim must be evacuated rapidly. If antibiotics are available, the recommendations currently given to doctors for antibiotics are as follows: age 16 to 50 years, vancomycin plus either cefotaxime or ceftriaxone; age greater than 50 years, vancomycin plus either cefotaxime or ceftriaxone, as well as ampicillin.
Giant cell arteritis is a type of inflammation that occurs in elders that can affect the temporal artery, which travels in a path along the sides of the scalp over the ears (temples). The associated headache may be quite severe and accompanied by thickened and tender arteries that may be noticeably enlarged with or without overlying reddened skin. Pulses may or may not be appreciated in these arteries, and the victim may have pain radiating down the side of the face as low as into the jaw. Permanent partial or complete loss of vision may occur in one or both eyes, which makes this condition an emergency. This condition is frequently associated with the disorder polymyalgia rheumatica. The immediate treatment is administration of a corticosteroid, such as prednisone 40 to 60 mg by mouth each day until a physician can evaluate the patient.
A headache that is atypically severe or prolonged may represent a serious problem, such as accelerated (out of control) high blood pressure (hypertension), brain tumor, infection, glaucoma, blood clot within the brain, carbon monoxide poisoning, inflammation of the temporal artery, or hemorrhage. The victim should be evaluated by a physician at the earliest opportunity. If a person develops a severe headache associated with a fainting spell or stiff neck, or is known to suffer from high blood pressure, keep him as calm as possible and urgently seek assistance. If high blood pressure is known to be the problem, and the victim is taking antihypertensive drugs, he should be advised to avoid using medications or other substances that might counteract the effects of his antihypertensives. These include ephedra, phenylephrine, certain herbal supplements (such as ginseng and yohimbine), appetite suppressants, anabolic steroids, and certain nonsteroidal antiinflammatory drugs.
In general, particularly worrisome headaches include a single headache that is the “first” or “worst” of a person’s life; headache with a fever that is not explained by an obvious illness; headache with vomiting that is not explained by an obvious illness; headache associated with a neurologic sign, such as weakness or altered speech; headache associated with altered mental status; headache associated with neck pain when the chin is flexed to the chest; progressively worsening headache; sudden headache in an elder; headache in someone suffering from cancer; headache after a blow to the head; headache following an episode of loss of consciousness; or headache in someone suffering from immunosuppression.
BELL’S PALSY
Bell’s palsy is a form of facial paralysis caused by a problem with a specific nerve (the seventh [facial] cranial nerve) that supplies the face. It is rapid in onset, and can cause the muscles of one side of the face to be completely paralyzed less than 2 days after the first weakness is noted. There is usually no pain except perhaps a slight discomfort behind the ear on the affected side. This pain may appear a day or two before the weakness. Bell’s palsy may mimic a stroke. With Bell’s palsy, the muscles of the forehead are affected. If they are not, the victim should be immediately evacuated for a full medical evaluation. The cause of Bell’s palsy may be involvement of the nerve with the herpes virus. The current recommendation is to treat with prednisone 1 mg/kg (2.2 lb) of body weight by mouth per day for 7 to 10 days. It is somewhat more controversial to also treat with the antiviral drug acyclovir (800 mg by mouth 5 times a day for 7 days). It is also important to protect the eye if the victim cannot close his eye or blink. The eye can be patched or gently taped closed to protect the cornea.
EAR
Earache
An earache may be caused by infection, injury, or a foreign body in the ear. For a discussion of ear squeeze (barotitis) that occurs with scuba diving, see page 404.
Ear Infection
Ear infection can be either internal (otitis media) or external (otitis externa) to the eardrum (tympanic membrane) (Figure 107).
Figure 107 Ear infections. A, Normal ear anatomy. B, Otitis media (inner ear infection). The eardrum bulges outward as the middle ear fills with fluid. The eustachian tube narrows or closes. C, Otitis externa (external ear canal infection). The canal becomes swollen and drains pus.
Otitis media. Infection may occur that reddens and inflames the eardrum and causes blood, serum, or pus to collect behind the drum (see Figure 107, B). With otitis media (middle ear infection), there is no drainage from the external ear canal (unless the eardrum ruptures, which is unusual in an adult, although more common in a child) and the victim has a fever, often with a sore throat. In many cases, the victim has a history of prior infections. Most often, otitis media occurs in children; when it occurs in an adult, it may be associated with a sinus infection or functional obstruction of the eustachian tube (the pressure-release mechanism from the middle ear into the throat). A young child can rapidly become severely ill from otitis media; an infant may develop meningitis (see page 174) following an ear infection. It is interesting to note that children who chew sugarless gum containing xylitol (or who ingest syrup or granules containing xylitol), which is derived from birch trees, may have fewer ear infections. This is supposedly because xylitol inhibits the growth of certain bacteria that cause the infections. It is reasonable to advise children prone to ear infections to avoid sugar-containing gum or candies.
Although many cases of otitis media in children are caused by viruses, such as respiratory syncytial virus, and resolve without antibiotic treatment, if you are distant from physician care and suspect otitis media, treat the child victim with an antibiotic. Adults and children should be treated with amoxicillin (80 to 100 mg/kg [2.2 lb] of body weight per day in three divided doses), amoxicillin-clavulanate (same dose of the amoxicillin component as for amoxicillin), cefdinir (14 mg/kg once daily or in 2 divided doses), cefpodoxime (10 mg/kg once daily or in two divided doses), cefuroxime (15 mg/kg in two divided doses), or clarithromycin for 10 days, or with azithromycin for 5 days. An additional antibiotic choice for children is erythromycin-sulfisoxazole for 10 days. Other antibiotics that have been approved for treatment are cephalexin, cefprozil, loracarbef, and ceftibuten. Aspirin, ibuprofen, or acetaminophen should be used to control fever. To avoid Reye syndrome (postviral encephalopathy and liver failure), do not use aspirin to control fever in a child under age 17.
Otitis externa (swimmer’s ear). Ear infection, commonly from the bacterium Pseudomonas aeruginosa, that develops in the external ear canal (often noted in swimmers and divers who do not keep the canal completely dry) rarely involves the eardrum (see Figure 107, C). When the external canal is kept moist, it is easier for bacteria to invade the skin and cause infection. The earliest symptom may be itching. Subsequent symptoms include a white to yellow-green liquid or cheesy discharge from the ear, pain, and decreased hearing. Occasionally, the victim complains of exquisite tenderness when the earlobe is tugged or the jaw is moved and has tender, swollen lymph glands in the neck on the affected side. In a severe case, the victim may have a fever and appear toxic.
If the victim has only a discharge without fever or swollen lymph glands, he may be treated with ear drops, such as 2% nonaqueous acetic acid (VoSoL or Domeboro Otic). Household vinegar diluted 1:1 with fresh water or with rubbing (isopropyl) alcohol (approximately 70%) can be used as a substitute. These ear drops should be administered four to five times a day and may be retained with a cotton or gauze wick gently placed into the external ear canal, or by using an expanding foam ear sponge (such as a Speedi-Wick, Shippert Medical Technologies). To avoid injuring the eardrum, do not attempt to clean out the ear with a cotton swab or similar object. The solution should be retained in the ear for a minimum of 5 minutes with each application. If there is any suggestion that the eardrum may be punctured (e.g., the presence of bleeding), do not use this solution.
If the victim has a discharge with fever and/or swollen lymph glands, the ear drops should contain hydrocortisone (VoSoL HC); he should also be given oral ciprofloxacin, erythromycin, or penicillin. An ear drop that may be useful is ciprofloxacin with hydrocortisone (Cipro HC otic suspension). Another is ofloxacin otic solution (Floxin otic) 0.3%. These ear drops are used twice a day. If the discharge from the ear is gray or black, a fungal infection may also exist, in which case tolnaftate 1% solution may be added to the treatment regimen. Aspirin, ibuprofen, or acetaminophen should be used to control fever. To avoid Reye syndrome (postviral encephalopathy and liver failure), do not use aspirin to control fever in a child under age 17.
To prevent swimmer’s ear, the external ear canal should be irrigated with VoSoL, Domeboro Otic solution (2% acetic acid, aluminum acetate, sodium acetate, and boric acid) or diluted vinegar/alcohol (described above) after each scuba dive or immersion episode in the water. Keep the solution in the canal for a full 5 minutes before allowing it to drain.
The Sahara DryEar warm air ear dryer is a small, portable device to prevent and treat ear disorders by drying the ear canal. The airflow from this device runs for 80 seconds at a comfortable temperature and dries the outer ear canal. The device has a customized computer chip that directs a heater and fan to regulate the flow of warm air into the ear canal. The DryEar is equipped with a rechargeable lithium ion battery and can run 50 times before requiring a recharge. The device is not waterproof, so one must take care when carrying it near the water, and it should be stored in a safe, dry location.
Referred Pain
“Referred” pain is pain that appears in one body region but actually originates in another. This occurs because different body regions are supplied with nerves that share common central pathways. In the case of ear pain, the cause may be a sore throat, tooth infection, or arthritic jaw. The ear pain will not disappear until the underlying cause is corrected.
Injury to the Eardrum
If something is poked into the ear, a hard blow is struck to the external ear, a diver descends rapidly without equalizing the pressure in his middle ear (see page 404), or a person is subjected to a loud explosive noise, the eardrum may be ruptured. This causes immediate intense pain and possibly loss of hearing, along with occasional nausea, vomiting, and dizziness. If the eardrum is ruptured, cover the external ear to prevent the ingress of dirt, and seek the aid of a physician. If debris has entered the ear, start the victim on penicillin or erythromycin by mouth. Do not put liquid medicine into the ear if you suspect that the eardrum is ruptured. If the dizziness is disabling, administer medicine for motion sickness (see page 440). Use appropriate pain medication.
Foreign Body in the Ear
A foreign body in the ear can be incredibly painful, particularly if it is dancing on the eardrum or resting against the sensitive lining of the ear canal. An inanimate foreign body (a piece of corn, peanut, foxtail, stone, or the like) can be left in the ear until an ear specialist with special forceps can remove it. If a live creature (cockroach, bee) enters the external ear canal and causes pain that is intolerable, the ear should be filled with 2% to 4% liquid lidocaine (topical anesthetic), which will (slowly) numb the ear and drown the bug at the same time. If lidocaine is not available, mineral oil can be used, with the caution that it will frequently cause the insect to struggle, which may encourage a sting or bite and incredible temporary pain. Once the animal is dead (a few minutes), a gentle attempt should be made with small tweezers to remove it. Don’t attempt this unless you can see part of the bug, however. Don’t push the bug in farther, or you might rupture the eardrum.
Wax in the Ear
If hearing is diminished in an ear because of a wax plug, the wax must first be softened with a solution such as Cerumenex or Debrox. Another useful wax softener is docusate sodium (Colace) solution. Put a few drops in the ear (retained by a wick or cotton) four to five times a day for 1 to 3 days. This will turn hard ear wax into mush. If none of these is available, household hydrogen peroxide might work. Then use a forceful stream of lukewarm water to flush out the wax. You can fashion a flushing device by attaching a plastic 18-gauge intravenous catheter (without the needle) to an 8 to 30 mL syringe. Don’t try to clean out the ear with a cotton-tipped swab or other rigid object, because you may force the wax down deeper, perforate the eardrum, or scrape and cut the exquisitely sensitive skin that lines the external ear canal, setting up an infection.
EYE
A proper eye examination is composed of an inspection for obvious injury to the eye or soft tissues surrounding the eye, assessment of the ability to see (visual acuity), muscular motion of the eyes, pupils for size and equality, and the presence of blood or pus underneath the cornea. To check visual acuity, have the victim read something, one eye at a time, at a distance of about 16 inches. If the person uses glasses, have him wear them.
Chemical Injury to the Eye
A chemical burn of the eye is a true emergency. If any acid, alkali, spitting cobra venom, skunk musk, or other chemical irritant is splashed into the eye, immediately flush the eye with cool water. Assist the victim in holding the eyelids open. Continue the irrigation for at least 30 minutes. Do not patch the eye closed, and seek immediate medical attention. If you are far from care, inspect the eye carefully for retained particles and remove them with a moistened cotton-tipped swab. Administer ofloxacin (Ocuflox) ophthalmic solution 0.3%, moxifloxacin 0.5% (Vigamox), or gatifloxacin 0.3% (Zymar) (1 to 2 drops 4 times a day) until the eye is healed.
If “superglue” comes in contact with the eyelids and they become glued shut, gently try to pull them apart. If this is not possible, apply Neosporin or bacitracin ointment to the eyelid margins and cover the eye with a patch. In 24 to 48 hours, the glue should dissolve and soften to allow the eyelids to separate. Do not use “superglue remover,” which may contain acetone and is harmful to the cornea (clear surface of the eye). If antiseptic ointment is not available, patch the eye closed overnight with the eyepads presoaked with water. This may loosen the bond and allow the eyelids to be separated.
Foreign Body under the Eyelid and Scratched Cornea; Corneal Ulcer
If a foreign body lodges on the cornea (the clear surface of the eye) without actual penetration of the eyeball, irrigate the eye copiously with an eyewash solution (use water if you do not have eyewash). If this is not successful, have the victim look downward, grasp his upper lid firmly by the eyelashes, and fold it up and inside out over a cotton swab (Figure 108). You can lightly grease the swab with antiseptic ointment to keep it from sticking to the skin. If you can see the foreign body on the undersurface of the upper eyelid, gently wipe it away with a cotton swab or piece of moistened cloth. If you do not see the object, check between the lower eyelid and the eyeball. After the inspection, pull down on the eyelashes to unfold the lid.
Figure 108 Eversion of the eyelid to locate a foreign body. A, The lid is grasped and pulled over a cotton swab or small blunt stick. B, The underside of the eyelid is inspected for a foreign body while the victim looks downward.
Once you have removed the object, if the victim still feels as if something is in his eye, he may have suffered a scratch on the cornea (corneal abrasion). In this case, it may help control the discomfort to patch the eye closed for 24 hours. However, never patch an eye closed if there is any sign of an active infection (pus or discharge). When the patch is removed, if there is residual pain, a gritty sensation, gooey discharge, or blurred vision, see a doctor as soon as possible. Tiny objects, such as the spine of a horse nettle (sand brier), can become embedded in the cornea and not be visible without the magnification available to an ophthalmologist.
To patch an eye, a ½ in (1.3 cm) thick pad of soft cloth or bandage should be shaped to fit neatly over the eye socket, and affixed snugly to the face with tape or bandages extending across the patch onto the cheek below and the forehead opposite the affected eye (Figure 109). Prepackaged sterile elliptical eye pads are available. If only tape is available, the eyelids may be taped closed with a single small piece of tape.
Figure 109 Taping a patch over the eye.
Another way to hold an eye shield, patch, or padding around the eye is with a cravat (see page 277). First, place a strip of cloth approximately 2 in (5 cm) wide and 15 in (38 cm) long over the top of the head front-to-back, so that the face-side end hangs over the uninjured eye, near the nose. Place the patch, pad, or shield over the eye and hold it in place with a cravat, which should be wrapped horizontally around the head and then tied in position on top of the hanging cloth strip. Make the first tie (single loop or half square knot) in the cravat behind the head and at the base of the skull, and keep wrapping it around, to complete the final tie (square knot) where the ends meet. If the final tie will be over an eye, shift the cravat. Pull up the ends of the hanging cloth strip and tie them at the top of the head; this should lift the cravat up off the uninjured eye (Figure 110).
Figure 110 Holding an eye patch in place with a cravat. Hang a cloth strip over the uninjured eye. Hold the patch in place with a cravat. Tie the cloth strip to lift the cravat off the uninjured eye.
If the eye cannot be patched, sunglasses should be worn. For a scratched cornea, administer an antibiotic in the affected eye until it is healed, which usually occurs in 3 to 5 days. Use ofloxacin (Ocuflox) ophthalmic solution 0.3%, moxifloxacin 0.5% (Vigamox), or gatifloxacin 0.3% (Zymar) one or two drops to the affected eye every 3 to 4 hours, or a ribbon of erythromycin ophthalmic ointment every 6 hours.
A corneal ulcer is a serious erosion, usually caused by a bacterial infection, that causes a “red eye,” pain, and sometimes decreased visual acuity. It may follow a scratched cornea. The white of the eye is very reddened and if you look closely, you may notice a small, round white or yellowish spot on the surface of the cornea. This is an emergency, because the ulcer may spread rapidly and cause permanent damage. If a corneal ulcer is suspected, immediately use ofloxacin (Ocuflox) ophthalmic solution 0.3%, gatifloxacin 0.3% (Zymar), or moxifloxacin 0.5% (Vigamox) two drops to the affected eye every 2 hours and seek immediate medical attention. Do not patch the eye if a corneal ulcer is seen or suspected.
Injured Eyeball
If the eyeball is perforated, there will be a combination of loss of vision (ranging from hazy vision to blindness), pain, excessive tearing, a dilated pupil, and visible blood in the eye. There may be gelatinous material extruding from the eye, and the pupil will be irregular or jagged in appearance. Do not attempt to rinse out the wound vigorously; remove obvious dirt and debris without placing any pressure on the eye. Close the eyelid gently and cover the eye with a protective shield. This can be fashioned by cutting gauze pads or soft cloth to the proper size, or by fashioning a doughnut-shaped shield with a cloth, cravat bandage, or shirt (Figure 111). Another good way to keep pressure off the eye is to cut an eye-sized hole in a stack of gauze pads and place the stack over the eye, taping or wrapping it in place. An eye shield can also be improvised by cutting off the bottom 2 in (5 cm) of a paper cup and taping it over the eye. Metal or plastic preshaped eye shields can be carried.
Figure 111 Bandage for the injured eye. A cravat or cloth is rolled and wrapped to make a doughnut-shaped shield, which is fixed in place over the eye.
Do not exert pressure on the eyeball, because this can increase the damage. Instruct the victim to keep both eyes closed, and start him on ciprofloxacin, penicillin, doxycycline, cephalexin, or erythromycin. Seek immediate medical attention.
Bleeding into the Eye
If the eyeball has been struck (not torn or ruptured), there may be bleeding from small blood vessels within the eye into the clear liquid that fills the space directly behind the cornea and in front of the lens. Such bleeding is called a hyphema. It first appears as diffuse bloody (red) clouding of the fluid behind the cornea, which settles over the course of 6 to 8 hours into a clearly visible layer of blood (Figure 112). If such a condition is noted, the victim should have his eye patched closed (see the previous section) or wear sunglasses; he should be transported to an eye doctor. If possible, keep his head elevated and in an upright position and apply a rigid eye shield to protect the eye from being struck. The victim should avoid straining.
Figure 112 Hyphema. Bleeding into the eye causes an accumulation of blood in the anterior chamber, where it settles into a layer behind the cornea. In severe cases, the pupil is obscured by red blood.
Removing Contact Lenses
If a victim is severely injured and he is wearing contact lenses, they should be removed. A contact lens remover may be used, or a slightly sticky surface of mini-marshmallow can be placed carefully against the lens to grasp it. Either soft or hard lenses can be removed by the following technique (Figure 113):
1. Slide the lens off the clear surface of the eye (cornea) over to the white area away from the nose.
2. Place one finger at the outside edge of the lower eyelid and pull the eyelid taut, while keeping the eye slightly open. This should lift the edge of the lens, so that you can pick it up. If you cannot remove the lens, position it so that as much as possible is over the white (and not on the cornea).
3. Place the lens in a container with contact lens solution, eyewash, or water (if possible, add 1 tsp, or 5 mL, of table salt per pint, or 473 mL, of water).
4. A soft contact lens can often be removed by simply pinching it gently between your thumb and index finger.
Figure 113 Contact lens removal. A, Push the lens gently to the lateral (away from the nose) white portion of the eye. B, A downward and outward pull on the skin at the lateral corner of the eye pops the lens free.
If you cannot remove a contact lens, it is best to close the eye gently, place a soft cloth or gauze pad patch over it, and tape it closed. Be certain that someone knows why this has been done (i.e., the lens is still in the person’s eye).
Subconjunctival Hemorrhage
Bleeding into the white of the eye (subconjunctival hemorrhage) may occur spontaneously or after coughing, straining (vigorous exertion), vomiting, or strangulation (Figure 114). The bleeding is painless, does not interfere with vision (the cornea is not involved), and does not require any therapy. The blood will absorb over a period of a few weeks, as from any other bruise. If it does not, seek the care of an eye doctor.
Figure 114 Subconjunctival hemorrhage. The red discoloration does not involve the cornea, which remains clear.
Red Eye
A red or pink, itchy eye is usually caused by a viral infection. Other causes include bacterial infection, insect bite or sting, allergy (see page 205), overuse of contact lenses, corneal abrasion or ulcer (see page 180), foreign body (see page 180), irritation from chemicals or smoke, snow blindness (see page 187), glaucoma (see page 190), or injury (see page 182). If the infection is caused by a virus or bacteria, symptoms include itching, tearing, watery (viral) or thick (bacterial) discharge (runny yellow or greenish pus), crusted eyelashes and lids, and swollen eyelids, which are often stuck together on awakening in the morning. You may notice a swollen lymph gland in front of the ear. If fluid collects underneath the loosely attached (to the eyeball) conjunctiva (membrane-like external lining of the eyeball), it may cause it to swell up and balloon away from the eyeball.
If the cause is a known allergy or irritation from smoke, use eyedrops with 0.025% oxymetazoline (OcuClear, Visine L.R.); antazoline phosphate 0.5% and naphazoline 0.05% (Vasocon-A); or tetrahydrolozine (Visine).
If there is much yellowish discharge, suspect a bacterial infection and administer antibiotic eyedrops (moxifloxacin 0.5%, tobramycin or gentamicin 0.3%, ofloxacin 0.3%, or sodium sulamyd 10%); the dose is two drops every 2 hours for 4 to 5 days while the victim is awake. Never use steroid-containing eyedrops unless directed to do so by a physician. Antibacterial ointments are messy and may blur vision.
Viral conjunctivitis is very contagious, so the victim should be advised to avoid close contact with others, including sharing towels or swimming in shared pools, for 2 weeks after the onset of the infection.
“Pink Eye” and Contact Lenses
“Pink eye” usually refers to a viral infection that causes redness, often accompanied by itching and a thick, yellow or green discharge. Often the lids are stuck together in the morning after sleeping. This viral conjunctivitis is believed to be highly contagious, so the sufferer should take care to not share his implements of facial washing and drying. It is not uncommon to have “pink eye” develop in one eye and then rapidly be spread to the other eye, presumably because of touching the infected eye and then transferring the infection.
Serious eye infections can be caused by fungus, such as that of the genus Fusarium, which has been discovered to grow in contact lens solution. Some experts believe that multipurpose solutions in general are more prone to transmitting infection, for reasons that have yet to be clearly determined.
Regardless of whether or not multipurpose solutions are riskier than single-purpose solutions, outdoor enthusiasts should note that contact lenses may be more difficult to manage in a wilderness environment for the following reasons:
1. Should a contact lens become displaced (e.g., fall out of the eye), it may be more easily lost than eyeglasses.
2. Contact lens solution can degrade or become contaminated by exposure to extreme temperatures, dehydration, or passing over dust and dirt that can accumulate on the threads of bottle caps.
3. Handling contact lenses with dirty hands can introduce bacteria and fungi to lenses or tissues of the eyes.
4. It may not be easy to change out contact lenses quickly if needed for a different refraction or environmental (e.g., sun or wind exposure) condition.
5. Once an eye becomes infected, contact lenses must be removed. They should not be reused if removed because of infection.
For these reasons, it’s important to carry at least one, and preferably two, pairs of eyeglasses. If you need reading glasses, carry these as well. Also, be sure that you have sunglasses that block out as much ultraviolet light as possible. Include side shields if you are going to be at high altitude, on snowfields, on the water’s surface, or traversing other highly reflective terrain, such as bright sand.
Dry Eyes
Dry eyes are common in dry environments, after prolonged exposure to wind, at high altitude, and associated with certain medical conditions in which tear production is diminished. Artificial tears, such as carboxymethylcellulose sodium 0.5% (Refresh Tears), or lubricating ointment (e.g., Lacri-Lube, containing mineral oil, white petrolatum, and lanolin alcohols) or gel (e.g., Refresh Liquigel, containing carboxymethylcellulose) may be soothing. In the event that dry eyes persist despite administration of artificial tears, an ophthalmologist may prescribe cyclosporine (Restasis), an antiinflammatory medication that has been shown to increase the production of the recipient’s own tears, and to relieve symptoms within 3 to 4 weeks.
Blepharitis
Blepharitis is usually a chronic flaking and irritation of the skin at the base of the eyelashes, affecting both eyes. It may become infected, and be accompanied by fluctuating vision, itchy and burning eyes, and mucous discharge on awakening. Treatment is the application of bacitracin or erythromycin ophthalmic ointment thinly to the lid margins at bedtime for 4 weeks. Warm, moist compresses should be used a few times a day for 5 to 10 minutes at a time to loosen the debris, which is then gently wiped away. Artificial tears are useful to lessen the sensation of dry eyes.
Snow Blindness
Exposure to ultraviolet radiation (UVR) from the sun can lead to a “sunburn” of the cornea (clear surface of the eye). This occurs when proper precautions are not used at high altitudes, where a greater amount of unfiltered (by the atmosphere) ultraviolet radiation is present; the exposure may be compounded by reflection from the snow. The intensity of ultraviolet energy increases by a factor of 4% to 6% for every 1,000 ft (305 m) increase in altitude above sea level. Snow reflects 85% of ultraviolet B (UVB, the culprit wavelengths that cause snow blindness); dry sand reflects 17%, and grass or sandy turf reflects 2.5%. Water may reflect 10% to 30% of ultraviolet B, depending on the time of day and location.
The cornea absorbs ultraviolet radiation below 300 nanometers (nm), which includes a fair portion of UVB. Radiation of wavelengths longer than 300 nm is transmitted to the lens and, over time, can cause cataracts.
High exposure to UVB can cause a corneal burn within 1 hour, although symptoms may not become apparent for 6 to 12 hours. Symptoms include excessive tearing, pain, redness, swollen eyelids, pain when looking at light, headache, a gritty sensation in the eyes, and decreased (hazy) vision. Similar symptoms occur when the surface of the eye is physically scratched (corneal abrasion). Treatment consists of patching the eye closed (see page 181) after instilling a few drops of ophthalmic antibiotic solution (such as moxifloxacin 0.5%, sodium sulamyd 10%, or gentamicin), because the surface of the cornea will regenerate spontaneously in 24 to 48 hours. It is important to check the eye first for a foreign body (see page 180). After patching, the eye must be rechecked in 24 hours. If the eye appears to be infected with pus, it should be left unpatched; administer a topical antibiotic solution (see page 182) three to four times a day, and have the victim wear sunglasses. Pain medicine should be used as appropriate. If both eyes are involved, only the more severely affected eye should be patched, so that the victim can continue to make his way.
Some people recommend a topical nonsteroidal antiinflammatory or steroid solution to hasten the resolution of snow blindness. In a situation in which the diagnosis is certain and such medication is available, instillation may indeed improve things. However, if a topical steroid is applied to a misdiagnosed bacterial or viral infection—particularly herpes virus—the effect can be to worsen the situation. Since snow blindness is self-limited, the application of a topical steroid is not imperative and best left to an ophthalmologist. A useful nonsteroidal topical solution is ketorolac ophthalmic solution (Acular), one drop four times a day.
Eye Allergies
Seasonal allergies commonly involve the eyes, often causing conjunctivitis. See page 185.
Protective Eyeglasses (Sunglasses)
The wavelengths of sunlight that appear to be most damaging to the eye are blue (400 to 500 nm), ultraviolet A (320 to 400 nm), and ultraviolet B (290 to 320 nm). Ultraviolet C (200 to 290 nm) is filtered out by the ozone layer of the atmosphere. Standards for ultraviolet protection in nonprescription sunglasses are set by the American National Standards Institute (ANSI). These state that such lenses should maintain UV absorption up to 400 nm and block 99.8% of ultraviolet B light and 95% of UVA. Lenses advertised for mountaineering or specifically for ultraviolet protection should meet these standards.
Sunglasses should be equipped with side protectors and, if necessary, optional nose guards. Frames should be prepared with wraparound temples and retaining straps or lanyards. Polycarbonate lenses, which are lightweight, scratch resistant, and shatterproof, can be manufactured to absorb 99% of ultraviolet light. Most recreation supply companies manufacture or carry sunglasses and wraparound goggles that meet ANSI standards.
In general, amber, yellow, orange, brown, and rose lenses filter out blue light and increase the perception of contrast. Green and gray lenses soften glare and transmit a spectrum that does not increase contrast. Glass ambermatic or photochromic lenses (darker in bright sunlight), which contain millions of silver halide crystals, darken when exposed to ultraviolet light close to the visible spectrum. Polarized lenses improve vision by decreasing glare, but this does not decrease exposure to UV light.
Improvised sunglasses can be made by cutting small slits or puncturing pinholes in cardboard or two layers of a strip of duct tape after the adhesive sides have been stuck together. Fashion a shape that will fit across the eyes like a pair of sunglasses; tie in the back with a string attachment. The opening should be just large enough to allow adequate vision. This serves two purposes: limitation of ultraviolet transmission and creation of crude refraction to improve focus in a person who is nearsighted.
Vitreous Detachment
Floaters are small spots, lines, clouds, cobwebs, or veils that move around in the field of vision, especially when the eyes move. They can be in one or both eyes, but usually show up in one eye at a time. They are easiest to see when one looks at the sky or against a plain white background. Floaters are caused by tiny opacities inside the vitreous, which is the gel that fills the inside of the eyes. In childhood and adolescence, the vitreous gel is clear, so that floaters are not seen. In adulthood, floaters can develop when the vitreous gel forms small clumps as part of the aging process. As light passes from the outside of the eye, through the cornea and lens, and then through the vitreous gel before it strikes the retina to record an image, the floaters can cast shadows on the retina. Floaters are annoying, but not dangerous, particularly if they have been present for a long time.
The sudden appearance of floaters can signify separation of the vitreous gel from the retina, which is the layer of tissue in the back of the eye on which visual images are recorded on specialized receptor cells. This occurs because the vitreous gel shrinks as it ages. If it shrinks enough, it begins to peel away from the retina, in what is called a vitreous separation or detachment. It is more common in nearsighted people and in persons who have had cataract surgery or injuries to their eyes or head. When a vitreous separation occurs, the floaters appear suddenly. As the gel peels away from the retina, it tugs on it, which can cause a person to appreciate flashes of light, usually on the outer (ear) side of the eye. These usually last no more than a second, and are caused by the nerves within the retina (which connect to the large optic nerve) being stimulated mechanically by the tug of the vitreous gel. Flashes are difficult to appreciate in daylight, but can be easily seen in the darkness. Moving the head or eyes can cause the flashes. Since flashes mean that the vitreous is pulling on the retina, this is a warning sign, because the traction can cause a retinal tear. If this happens, an ophthalmologist needs to perform laser surgery as soon as possible to prevent a full-blown retinal detachment.
The normal course for a vitreous separation is a 2- to 4-week process in which the separation is completed. This may be punctuated by intermittent addition of new floaters, but usually the burst of opacities is at the beginning of the process. Over time, most of the floaters diminish or disappear, but there may be some residual floaters. During the course of the separation, when a person first notices the floaters, and if a person suddenly develops new floaters, more frequent flashing lights, or a defect in a field of vision (often described as a “dark curtain”), an ophthalmologist should perform an examination to be certain that there is not a retinal tear or detachment. It is important to avoid sudden eye or head movements for several weeks after the onset of a vitreous separation, to decrease the likelihood of developing a retinal tear or detachment.
If a new vitreous detachment is suspected, it is wise to begin to head toward civilization to undergo a proper eye examination. However, if it is likely that a retinal detachment has occurred (e.g., there is a “field cut,” or a darkened area of vision as if a curtain was being pulled across the field of vision from any direction), it is prudent to evacuate immediately, including a more expensive mode of transportation if necessary, because treatment for retinal detachment is usually an operation by an ophthalmologist, and time is of the essence. A progressive retinal detachment can lead to permanent loss of vision in the affected eye.
In terms of exercise, it is wise to avoid sudden head or eye movements, so no jogging or swimming with rapid head movements, wrestling, significant straining, and so on. Until the vitreous separation process is complete, a person should try to turn the head to look in a direction, rather than hold the head in a fixed position and move the eyes. All of this may be difficult in a precarious situation, such as rock climbing or kayaking, but one should just do the best he can given the particular circumstances.
Injury to the Retina
The retina is the thin inner posterior-surface tissue layer of the eye, the “screen” on which images are transmitted by light. From the retina, nerves from the eye carry signals to the brain. The retina can be injured by the transmission of unrestricted infrared rays (wavelengths of light beyond the red end of the visible spectrum). Usually, this occurs when someone views the sun directly during an eclipse or when a person stares at the sun while under the influence of hallucinogenic drugs. Symptoms include pain and blindness. If such an injury is suspected, sunglasses should be worn or the eye should be patched. The victim should be transported to an eye doctor.
Occasionally, a structural abnormality, the aging process, or a blow to the eye will cause the retina to become separated from the back of the eye (retinal detachment). Early symptoms include flashes of light and persistent floating spots in the field of vision (“floaters”: see description above in section on vitreous detachment). As the retina peels off farther, a person loses vision painlessly, as if a curtain (“of darkness”) was descending. Retinal detachment is a serious condition and requires emergency repair.
Optic Neuritis
Optic neuritis is inflammation of the optic nerve, which carries signals from the eye to the brain in the process of vision. It causes blurred vision of gradual onset, pain with eye movement, and an aching sensation in the affected eye. Commonly associated with multiple sclerosis, it can also be caused by infections (e.g., Lyme disease), cancer, and autoimmune syndromes. The treatment is high-dose steroids and other agents administered under the care of an ophthalmologist. In any circumstance when vision becomes impaired without an obvious cause that can be effectively treated or temporized in the wilderness, get the victim to an eye doctor as soon as possible.
Glaucoma
Glaucoma is a condition in which the pressure of the fluid within the eye is elevated. If this happens suddenly, the pressure can injure the nerves within the eye that record vision; blindness can result. Symptoms of an acute attack of glaucoma include severe pain, blurred vision or “halos” around lights, clouding of the cornea, intense reddening of the white of the eye, a dilated pupil that doesn’t react to light, nausea, vomiting, and headache. The victim of acute glaucoma is truly miserable. If an attack occurs, the victim should be kept in a sitting or standing position and rushed to an ophthalmologist. If the victim is carrying medication(s), instill a drop of pilocarpine or carbachol and (depending on which medications are carried by the victim) a drop of timolol (or betaxolol, carteolol, levobunolol, or metipronol), latanoprost (or travoprost, unoprostone, or bimatoprost), brimonidine (or apraclonidine), and/or dorzolamide (or brinzolamide) in the affected eye. If you are distant from care, and acetazolamide (Diamox) is available and there are no contraindications to its use (see page 336), it may be administered in a dose of 125 mg, 250 mg, or 500 mg sustained release by mouth twice a day.
Injured Eyelid
If the eyelid is injured, wash the eye carefully, apply bacitracin or mupirocin ointment, and then patch the eye closed (see page 181). If the eye cannot be covered with eyelid, apply a thick layer of antiseptic ointment to the eyelid and exposed eyeball and patch the eye. Seek immediate medical attention.
Sty
A sty is a small abscess (see page 241) that develops in one of the glands at the base of an eyelash. The infection causes the eyelid to swell, redden, and become painful. The victim may notice increased tear production and the sensation of a foreign body in the eye. Usually, the sty comes to a head on the outside of the lid, but occasionally it will come to a head inside. If a sty begins to develop, the victim should hold warm, moist compresses to his eyelid for 30 minutes four times a day to soften the abscess. It will either disappear or enlarge and come to a head. Never squeeze an abscess on the face. If the sty enlarges, comes to a head, and is extremely painful or interferes with vision, but will not open spontaneously, it can be carefully lanced with a sharp blade or needle to drain the pus. A physician should perform this procedure, unless the victim is more than 48 hours from medical attention and the infection has worsened to the extent that there is progressive swelling of the eyelid that impedes vision, or of the cheek or forehead. In this event, also administer dicloxacillin, erythromycin, or cephalexin. After the sty is incised, the pus can be expressed gently by pressing on opposite lateral sides with two cotton-tipped applicators.
Eyelid Infection and Periorbital Cellulitis
If there is a discharge and pain, with or without redness, from an eyelid on the side nearest the nose, this may be an infection in the tear duct. Apply warm compresses and administer amoxicillin-clavulanate, moxifloxacin, levofloxacin, ciprofloxacin, or cephalexin.
Redness and swelling of the eyelid and “soft” tissues around the eye (eyebrow, upper cheek) caused by infection is known as periorbital (around the orbit, or eye) cellulitis. This is extremely serious and must be treated aggressively, because the infection can spread to create an abscess in the brain. Treatment consists of administration of an antibiotic (moxifloxacin, levofloxacin, ciprofloxacin, cephalexin, clindamycin, amoxicillin-clavulanate, dicloxacillin, or erythromycin) and immediate evacuation to a hospital. To differentiate periorbital cellulitis from the swollen eyelids associated with an allergic reaction, note that with cellulitis, the onset will have been more gradual (typically associated with a less severe eye infection, such as conjunctivitis, or a local infection such as a sty or pimple), the affliction is only on one side, there are fever and chills, the soft tissues are painful, there is headache, and there is often a purulent (with pus) discharge from the eye. With an allergy, the eye is more “puffy,” the onset is sudden, the eye is itchy and watering, there is no purulent discharge, and there are associated signs and symptoms of allergy (skin rash, generalized itching, swollen lips, etc.) (see page 66).
Orbital cellulitis involves a deep infection around the eye, and presents as a swollen, red eye with significant pain on eye motion, decreased vision, and bulging of the eyeball in its socket. Victims of periorbital cellulitis have normal vision and painless motion of the eye. Orbital cellulitis is an emergency, so the victim should be started on the antibiotics listed previously and immediately evacuated to hospital medical care.
Pterygium
A pterygium is a noncancerous degeneration of the conjunctiva that occurs in persons who spend large amounts of time outdoors, particularly with exposure to ultraviolet light. It appears as a yellow, raised, “fleshy” knob of tissue that appears to begin in the nasal corner of the eye, and extends from there over the white part. It occasionally encroaches on the nasal margin of the cornea. It rarely grows further or requires treatment, because vision is usually not affected.
NOSE
Nosebleed
Nosebleed is classified as anterior or posterior, depending on where it originates within the nose. Generally, anterior nosebleed is less serious, because the victim will usually drain blood outward through the nostrils. Posterior nosebleed is more difficult to control, and the victim often drains blood back into the throat, with coughing and potential choking. Anterior nosebleed is more common and can usually be managed outside of the hospital. If you suspect a posterior nosebleed (bleeding from the nose accompanied by brisk bleeding into the throat, so that a lot of blood is continually swallowed, particularly after the anterior bleeding has been controlled), immediately evacuate the victim to a hospital.
The most frequent cause of a nosebleed is a small bleeding blood vessel or cut on the inner mucosal surface of a nostril. This is more common at high altitudes and in cold weather, because the drying effect causes the skin to become irritated and crack. One way to prevent nosebleeds is to keep the inside of the nose lubricated with an ointment such as mupirocin or bacitracin, or to spray regularly with saline solution (such as Ocean saline mist or drops with 0.65% sodium chloride). It is possible that nosebleeds are more common in persons whose blood pressure has risen out of control. People on prescription anticoagulant drugs are prone to nosebleeds.
To control an anterior nosebleed, attempt simple maneuvers first. Have the victim blow his nose to remove all clots. Keep him upright (sitting leaning forward) and calm, and firmly press both nostrils closed against the nasal septum (middle cartilage). Hold this position for 15 minutes without release; letting go before this time will only restart the bleeding, because it takes the small blood vessels and scratched surface a while to stop oozing. After 15 minutes, let go and see if the bleeding has stopped. If not, gently but firmly pack both nostrils with a gauze or cotton roll moistened with phenylephrine 0.25% (Neo-Synephrine ¼%) and repeat the pinching maneuver for 20 minutes. Generally, this does the trick; if it doesn’t, repeat the packing without the phenylephrine. After the bleeding has stopped, leave the packing in place for 2 hours and then gently remove it. Cold compresses applied to the bridge of the nose or a roll of gauze or cotton placed beneath the upper lip are of limited help when dealing with a brisk nosebleed. Packing with absorbable gelatin foam (Gelfoam) or oxidized cellulose (Surgicel) may be helpful. Another hemostatic packing gauze is QuikClot NoseBleed gauze (Z-Medica Corporation). A useful device for packing the nose to stop a nosebleed is the Rhino Rocket (Shippert Medical Technologies), which is a compressed medical-grade foam sponge with applicator. The foam is guided into place, where it swells on contact with moisture (blood) to 8 to 10 times its compressed size. A string is attached to the sponge so that it can be easily removed. Weimert Epistaxis (nosebleed) Packing uses a similar approach. The rapid RHINO nasal pack with Gel Knit (ArthroCare Corporation) uses a hemostatic (stops bleeding) carboxymethylcellulose fabric over an inflatable balloon to apply compression within the nose. In one study, this device was felt to be less painful to insert and easier to remove than the Rhino Rocket. Merocel is a polyvinyl alcohol nasal tampon that is inserted into the nose, whereupon exposure to a topical vasoconstrictor (e.g., phenylephrine 0.25%) and saline causes it to expand and create pressure over the bleeding point. NasalCease (Catalina Healthcare) is a bundle of fine fibers made from brown seaweed (active ingredient calcium alginate) extract that can be inserted into the nose to aid clotting.
If the nose is packed, administer an antistaphylococcal antiseptic (such as dicloxacillin or trimethoprim-sulfamethoxazole) for the duration of the packing. The nasal packing should be kept moist with sterile saline or oxymetazoline (Afrin) spray.
Broken Nose
A fractured nose may or may not be deformed. If the nose is obviously depressed or pushed to one side, and the victim is having difficulty breathing through his mouth, the nose can be relocated, but this is usually quite painful. Grasp the bridge of the nose firmly and crunch it upward and back over to the midline. In the wilderness, it can be difficult to improvise an external splint. A malleable soft-aluminum nasal splint with adhesive ventilating foam is available as The Denver Splint (Shippert Medical Technologies). Treat any nosebleed as previously discussed. The only reason to relocate the injury is to improve breathing if mouth breathing is inadequate. The nasal bones won’t begin to set solidly for 5 to 7 days; cosmetic manipulation can easily be performed after such a delay. If the skin is cut deeply over a broken nose, start the victim on an antibiotic (penicillin, cephalexin, or erythromycin).
Another risk from a broken nose is the formation of a blood clot under the skin that lies over the nasal septum (cartilage) between the nostrils. If such a clot is not promptly drained, its resolution can cause collapse of the cartilage, infection, or erosion through the septum, leaving a hole through the septum. Anyone who has suffered a broken nose needs to be examined by a physician within 3 to 5 days of the injury, to avoid erosion of the nasal septum by a blood clot.
Foreign Body in the Nose
A small child will occasionally stuff a foreign object, such as a pebble or bead, into a nostril, where it will become stuck. Signs and symptoms include pain, a foul-smelling drainage, and sometimes fever. This can be a tough problem away from the hospital, because once the sensitive skin inside the nostril becomes irritated, it swells and traps the foreign object within a matrix of mucus, and sometimes blood or pus. If the object can’t be easily seen and extracted without forcing it farther into the nostril or torturing the child, seek a physician’s assistance. If you are carrying a flashlight and a small nasal speculum (a device for gently widening the nostril to facilitate access to the inside of the nose—Disposable Nasal Speculum, Bionix), you can attempt to look up the nose, but most small children will be extremely uncooperative, because this is pretty uncomfortable for them. One way to remove a nasal foreign body is to put a small dab of cyanoacrylate glue on the tip of a small stick (such as the rod portion of a cotton-tipped swab), and then hold the stick against the object until it is stuck, so that the stick can be used to pull out the object. If the object is metallic, try using a magnet. If fever is present, start the child on dicloxacillin or erythromycin.
Sinusitis
The sinuses are spaces filled with air and lined with mucus-producing tissues found in the front of the skull and in the bones of the face (Figure 115). Sinusitis is a blockage and infection/inflammation of the lining of the sinuses, usually caused by bacteria, and characterized by nasal congestion, headache, fever, decreased ability to smell, and tenderness in and over the involved sinus, with or without foul yellow or green discharge from the nose. Occasionally, the pain radiates to the eyes, bridge of the nose, and upper teeth. It is often made worse by bending forward. A person with sinusitis can become quite ill and suffer from excruciating headache, nausea, vomiting, and chills. Treatment involves the administration of an antibiotic (first choice is amoxicillin-clavulanate, amoxicillin, azithromycin, or telithromycin; other choices include moxifloxacin, levofloxacin, clarithromycin, doxycline, ciprofloxacin, trovafloxacin, levofloxacin, moxifloxacin, cefuroxime axetil, cefpodoxime, cefproxil, cefdinir, loracarbef, or erythromycin) and decongestants (oral pseudoephedrine and a nasal spray: phenylephrine 0.25% [Neo-Synephrine ¼%] or oxymetazoline 0.05% [Afrin]), as well as warm packs over the affected area(s). Don’t use a topical decongestant for more than 3 or 4 consecutive days, to avoid “rebound” swelling of the inside of the nasal passages from chemical irritation and sensitization to the drug. Antihistamine drugs should not be routinely used, because they may dry out nasal and sinus secretions. A person suffering from sinusitis should avoid rapid changes in ambient external pressure (such as scuba diving or air travel in unpressurized aircraft).
Figure 115 Location of the sinuses.
THROAT
Sore Throat and Tonsillitis
Sore throat (pharyngitis) is a common complication of viral infections (the common cold, infectious mononucleosis), breathing dry air (“altitude throat”), or primary bacterial throat infection (“strep throat”). Symptoms of an infection include pain with swallowing, fever, swollen lymph nodes (“swollen glands”) in the anterior neck, red throat, swollen tonsils, pus over the tonsils and throat (Figure 116), headache, fever, abdominal pain, and nausea and vomiting.
Figure 116 Inflamed tonsils.
Because the symptoms of a viral throat and tonsil infection and a bacterial strep (group A beta-hemolytic streptococcus [GABHS]) throat are frequently identical, it is hard to make the differentiation without a throat-swab “rapid strep test” or bacterial culture. Below age 3 years, a child rarely has a strep throat; in young adults, the presence of strep throat in the presence of classic symptoms (fever, pus, and swollen tonsils and lymph glands in the neck) is roughly 50%. However, because the potential complications (kidney or heart disease) of an untreated strep throat in a young person outweigh the complications of antibiotic use, it is advisable to treat with penicillin (or amoxicillin), cefadroxil, or erythromycin for a full 10-day course, or with azithromycin or clarithromycin for 5 days. If none of these drugs is available, clindamycin or cephalexin can be used. Even if the victim improves after 2 to 3 days, the antibiotic should be taken for the full course.
Adjuncts to care include saltwater gargles (½ tsp, or 2.5 mL, of table salt in 1 cup, or 237 mL, of warm water), throat lozenges, warm fluids (to moisten and soothe the throat), and aspirin or acetaminophen to control fever. To avoid Reye syndrome (postviral encephalopathy and liver failure), do not use aspirin to control fever in a child under age 17.
If a person develops an acute sore throat that rapidly becomes extremely uncomfortable (severe pain, difficulty swallowing), a single dose of dexamethasone or its equivalent (see page 340) may be given along with an antibiotic, assuming the victim can swallow the medications. This may help decrease inflammation, but should not be given routinely for a “nontoxic,” or run-of-the-mill, sore throat. If someone with a sore throat has a high fever associated with difficult or noisy breathing, altered (e.g. hoarse) or muffled voice (“like talking with a potato in his mouth”), drooling, stiff neck, or any visible swelling (bulging) in the back of the throat, he should be made as comfortable as possible and transported immediately to a hospital. Such a condition may indicate an abscess (see page 241) in the back of the throat or next to a tonsil, infection and inflammation of the epiglottis (epiglottitis), or massively swollen tonsils. Any of these may rapidly obstruct the airway.
If a person develops tender swelling under the tongue and/or under the chin, particularly associated with swollen lymph glands in the neck, fever, difficulty swallowing, and foul breath, this may indicate an infection in the floor of the mouth. Treat the victim with an antibiotic as for a strep throat and seek immediate physician consultation.
A sore throat can be caused by overgrowth of the fungus Candida albicans, which leads to a condition known as “thrush.” This occurs most commonly in persons who are immunosuppressed, have recently taken broad-spectrum antibiotics, use inhaled or oral steroids, wear dentures or orthodontic appliances, have diabetes, or are elders. Symptoms include burning in the mouth and throat, white patches on the palate and in the mouth and throat, painful swallowing, heartburn, drooling, and loss of appetite. If thrush is suspected, it can be treated with nystatin (Mycostatin) oral suspension, swished and swallowed four times a day for 2 weeks, or with nystatin oral lozenges 4 to 5 times daily for 2 weeks.
Infectious Mononucleosis
Mononucleosis (“mono”) is a viral disease characterized by low-grade (less than 101°F, or 38.3°C) fever, sore throat, swollen lymph glands (mostly in the neck, but occasionally in the armpits or in the groin), headache, fatigue, and, occasionally, skin rash, dark urine, muscle aching, and an enlarged spleen. Treatment consists of increased rest (it sometimes requires weeks for a normal energy level to return) and elimination of any physical activity that requires heavy exertion or risks abdominal injury (and thus rupture of the spleen). The diagnosis is confirmed by a blood test; until that can be performed, the victim should be treated for a possible strep throat (see page 195). Because infectious mononucleosis can be spread via saliva, infected people should avoid sharing eating utensils and towels.
Common Cold
See page 202.
MOUTH
Fever Blisters (Cold Sores)
Crops of blisters on the face, mouth, and lips that break out in times of stress (viral illness, emotional crisis, intense sun exposure) are often caused by reactivated herpes simplex virus (usually HSV-1). The blisters often weep and may become infected. Unfortunately, there is little to do for these when they first appear except keep them clean and dry. If the skin cracks and becomes painful, the blisters may be lubricated with bacitracin or mupirocin ointment. Anesthetic ointment can be used if it is helpful. Further sun exposure should be prevented with an adequate lip sunscreen (see page 228) of sun protection factor (SPF) 20 or greater.
Untreated, the lesions will disappear spontaneously in 10 to 15 days. Penciclovir 1% cream applied to the skin or lips every 2 hours while awake for 4 days may be prescribed to hasten resolution. Alternatively, acyclovir (Zovirax) ointment applied thinly five times a day for a week can hasten resolution of the blisters. Another treatment is acyclovir 200 mg by mouth five times a day, or 400 mg three times a day, for 5 days.
All herpes viruses are contagious. During times of visible blisters, eating and drinking utensils should not be shared. To maximize prevention, use a high-SPF sunscreen and consider taking acyclovir (Zovirax) (400 mg twice daily by mouth) the day before and during intense ultraviolet light exposure.
Canker (Mouth) Sores (Aphthous Ulcers or Stomatitis)
These painful white patches with reddened (inflamed) edges form inside the mouth and may be associated with viral infections or an immune response to an infection or disease. Usually they are a chronic problem. Untreated, they last for 10 to 14 days. They may be treated with a topical application of anesthetic lidocaine ointment 2.5% for a minute or two before eating, to kill the pain temporarily. An alternative is to swish and spit the antacid Maalox. Another useful topical anesthetic is 20% benzocaine (Hurricaine, Beutlich Pharmaceuticals), which can be conveniently applied from a prepackaged dry handle swab. Lidocaine viscous gel 5% may be applied to ulcers 4 times daily for 2 weeks or until ulcers heal. One recommendation is to apply a pinch of powdered alum (as in a styptic pencil) to initiate healing. Another is to apply the topical bioadhesive carmellose (Orabase) 4 times daily for 2 weeks or until ulcers heal. To hasten resolution, a physician might prescribe a mixture of fluocinonide 0.05% cream (Metosyn) and Orabase to be laid over the ulcer four times per day, or triamcinolone dental paste 1% (Adcortyl, or Kenalog in Orabase) to be administered similarly. Five percent amlexanox paste (Aphthasol) is an antiinflammatory treatment that is applied to ulcers 4 times a day for 2 weeks or until ulcers heal. The inside of the mouth should be rinsed thoroughly after eating to prevent food from becoming trapped in the sores. Antimicrobial mouthwashes, such as those containing chlorhexidine gluconate (0.12% or 0.2%), used three times daily may help prevent the onset of new sores. Any new sore in the mouth of an elderly person or frequent user of tobacco should be seen by a physician, who must consider a precancerous lesion or oral cancer.
Black Tongue
Black “hairy” discoloration of the tongue may be caused by excessive growth of the papillae of the tongue. It may be associated with topical or systemic antibiotics, poor mouth and dental hygiene, smoking, drinking alcohol, or even certain mouthwashes. Usually, the only symptom is the discoloration, but some patients suffer nausea, bad breath, or altered taste of food. Treatment consists of brushing the tongue with a soft brush. Black hairy tongue may be due to the presence of a yeast (e.g., Candida albicans) infection and/or the use of certain medications, such as bismuth (found in Pepto-Bismol) or doxycycline. If the discoloration does not resolve spontaneously, it may be treated with clotrimazole (10 mg troche dissolved in the mouth 5 times a day for 14 days) or with a 3-day treatment of fluconazole (150 mg by mouth once a day).
Toothaches and Tooth Infections
Toothaches occur in teeth that are decayed or have lost fillings. In this manner, the central pulp, which carries nerves and blood vessels, becomes inflamed (pulpitis). Symptoms of tooth inflammation include pain in the tooth and jaw that occasionally travels into the neck and ear, pain on contact with cold or hot liquids, and headache. Sometimes it is difficult to localize the problem to a specific tooth, since it may not be sensitive when it is tapped. To identify the culprit tooth, apply an ice cube sequentially to each tooth until you elicit a painful reaction. Pain medication appropriate for the degree of suffering should be administered. Have the victim keep his head elevated.
If it hurts to bite down on a tooth, but nothing is obvious on inspection of it, there may be inflammation of the supporting structures. In this case, the victim can point to the affected tooth, or feel pain when you tap on a particular tooth. Treatment is a soft diet, pain medication, and something like a strip of leather to bite down on positioned on the nonpainful (opposite) side, to create a space and prevent pressure on the affected tooth.
If an abscess (infection) (see page 241) develops in the root of the tooth or in the gum, there may be associated fever; swelling of the gum, jaw, or palate; and swollen lymph glands under the jaw and in the neck. If the abscess extends, the cheek and side of the face may swell. The victim should be started on penicillin, metronidazole, cephalexin, or erythromycin, and given appropriate pain medication. If there is a soft, pointing abscess in the gum adjacent to a tooth and the victim is suffering, the abscess can be punctured with a scalpel or knife and drained (Figure 117). Hold snow or ice against the gum to provide some anesthesia before the incision. A gauze or cotton wick should be placed into the abscess cavity for a day or two (see page 243). After this procedure, the area should be rinsed with salt water after each meal, at least four times a day.
Figure 117 Incision and drainage of a gum abscess.
To temporarily treat a cavity (decay) or site of a lost filling, dry the affected tooth carefully with cotton. Next, apply a cotton pad moistened with oil of cloves (eugenol) to the tooth cavity. In a pinch, you can use vanilla extract. Take care to keep eugenol off the gums, lips, and inside surfaces of the cheeks. Alternatively, topical benzocaine (Anbesol) can be applied to the gums. The patient needs to be taken to a dentist to have the tooth repaired or removed.
Another remedy for a cavity caused by decay or a lost filling is to fill the cavity with temporary filling material from a dental kit. Such materials include Cavit, which requires no mixing. It is applied directly to the tooth, using a wetted toothpick or cotton-tipped applicator as a packing and shaping instrument. Intermediate Restorative Material (IRM) is prepared by adding a few drops of clove oil to powdered zinc oxide to make as dry a “dough” as possible. Zinc oxide–eugenol combination cements are advantageous in that they have an anesthetic effect and can be mixed to different consistencies, depending on whether they are to be used as filling material or adhesives. However, the liquid can leak from its container, and the cement is sticky and more difficult to work with than Cavit.
Such fillings set after exposure to saliva and usually have to be replaced every few days. Another improvised filling is softened candle wax mixed with a few strands of cotton fiber, applied over a drop or two of eugenol.
If the gum line is inflamed or appears to be infected adjacent to a tooth, you can try to “break up” the infection by flossing vigorously or running a toothpick (probe) down into the space between the tooth and gum line. Administer an antibiotic, such as penicillin or metronidazole.
Pericoronitis is an infection of the gum flap that overlies a tooth that has only partially advanced (“erupted”) into the mouth. This is most common with a lower third molar and usually indicates an infection with Streptococcusbacteria. The treatment is to scrape and clean underneath and around the flap, initiate warm saltwater rinses every 2 hours, and begin the victim on dicloxacillin, cephalexin, or erythromycin.
Broken, Displaced, or Lost Tooth
If a tooth is cracked (with the root still present and in place), there is little for the victim to do other than keep his mouth clean and avoid contact with extremes of temperature. If air, saliva, the tongue, or temperature change coming into contact with an exposed nerve causes intolerable pain, a temporary cap (shield) can be created by mixing melted paraffin (candle wax) with a few strands of cotton. When the mixture begins to harden but can still be easily molded, press a wad onto the tooth, using the teeth on either side as anchors. A cap can also be fashioned from Cavit or IRM (see the discussion above).
If a tooth is broken or a crown falls off, apply a little eugenol to the tooth for immediate pain control. For a displaced crown, press it back onto the tooth and see if the crown will hold without cement. If not, apply a dab of Cavit and use it as a fastener, scraping away the excess. If all else fails, cover the tooth with paraffin or dental wax.
If a tooth is shifted out of its normal position, but is still embedded in the gum, it may need to be repositioned. If the tooth appears to be longer or off to one side, use a gloved hand, firmly grasp the tooth, and move it into proper alignment. If the tooth has been pushed into the gum and appears to be too short, do not move the tooth.
If a tooth is knocked cleanly out of the socket, it can sometimes be replaced successfully if the victim can reach a dentist within the first hour. After 2 hours, there is little hope for salvage of that particular tooth. The best treatment for a tooth that has been out of the socket for 15 minutes or less is to gently rinse it clean (do not scrub the root of the tooth) and reinsert it with firm pressure into the socket to the level of the adjacent tooth. Try to splint the tooth in place with a paraffin bridge or a cap to the adjacent tooth. A better material for this purpose is Express Putty, which hardens within 4 minutes after equal amounts of the putty base and catalyst are mixed.
The best storage solution for a tooth that will be carried to a dentist is pH (acid-base) balanced (Hank’s balanced salt solution) and accompanied by a cushion to prevent injury to the microscopic ligament cells that hold the tooth in place and must reattach for the tooth to “take.” The Save-A-Tooth or EMT Toothsaver storage device is recommended.
Alternatively, the tooth can be placed in a container and covered with a small amount of cool, pasteurized whole milk (not yogurt, low-fat milk, or powdered milk) for transport. Do not carry the tooth on a dry cloth or paper. Do not soak the tooth in tap water. A tooth can also be rinsed and carried by the victim in the space between his lower lip and lower gum (taking care not to swallow the tooth), although saliva is not particularly good for the periodontal ligament. Do not place a tooth back into the socket unless an antibiotic (penicillin 500 mg four times a day for 2 weeks) can be administered to avoid an infection, and tetanus toxoid given if necessary.
If the socket of a broken or lost tooth continues to bleed, apply direct pressure by having the victim bite on a gauze pack for 30 minutes. If there is a large blood clot, remove it, and then apply pressure. Keep the head elevated. Avoid rinsing, spitting, tooth brushing, and tobacco use for 24 hours. Gentle rinses with warm saltwater can be started after that time period. If the bleeding does not stop after several hours, biting on a dry tea bag (tannic acid) may help. “Dry socket” may occur 2 to 4 days after a tooth is lost. This is characterized by pain, foul odor, and a bad taste. Inspection of the tooth socket may show exposed bone. Treatment is gentle saltwater rinses followed by packing with a strip of eugenol-soaked gauze. The pack should be changed every 1 to 2 days until the symptoms are relieved, which may take up to 10 days. During this period, do not ingest alcohol or carbonated beverages.
Temporomandibular Joint (TMJ) Syndrome
The temporomandibular joint—where the jaw hinges into the face—can become tender if the jaw is struck, from forceful chewing or yawning, or from grinding the teeth at night. If this joint becomes irritated, the pain can be extremely distracting. Therapy consists of a nonsteroidal antiinflammatory drug such as ibuprofen, warm packs, and avoiding foods (such as beef jerky) that are difficult to chew. Don’t chew gum or open the mouth excessively wide.
Mouth Ulcer (Canker Sore)
See page 198.