Emergency Medicine Hub / Ambulatory & Fast Track • 3 min read • 4 sections

Fast-Track HEENT Infections & Foreign Bodies

Comprehensive ambulatory emergency reference for common head, ear, eye, nose, throat, and dental emergencies. Details acute vs. malignant otitis externa (temporal bone osteomyelitis), pediatric acute otitis media amoxicillin dosing, the surgical emergency of button battery nasal/ear impaction, peritonsillar abscess needle aspiration guard technique, Centor/McIsaac pharyngitis scoring, and Ellis dental fracture classification and tooth avulsion reimplantation protocols.

Resuscitation Quick Actions • First 2 Minutes

High-Acuity

Button Battery in Nose/Ear

Immediate extraction; NEVER instill saline or liquid drops (saline conducts current, accelerating liquefactive chemical burn).

Live Insect in Ear Canal

Instill 2% viscous lidocaine or mineral oil immediately to suffocate insect before attempting forceps extraction.

Malignant Otitis Externa

Elderly diabetic + severe nocturnal ear pain + granulation tissue on canal floor + CN VII palsy -> CT temporal bones + IV Cefepime/Ciprofloxacin.

Peritonsillar Abscess

Unilateral tonsillar fullness + uvular deviation + trismus + hot potato voice; needle aspirate with 1 cm cut-down plastic needle guard to avoid the internal carotid artery.

Acute Otitis Media

High-dose Amoxicillin 80-90 mg/kg/day PO divided BID x 10 days; second-line is Augmentin (14:1 ratio).

Avulsed Permanent Tooth

Handle crown only (never touch root); rinse with cold milk or saline; reimplant into socket within 60 minutes and splint.

Bottom-Line Clinical Pearl

A button battery lodged in the nasal septum or external ear canal is an absolute surgical emergency: local electrical current and hydroxide ion generation produce caustic liquefactive necrosis and permanent septal or tympanic membrane perforation within 2 hours. NEVER instill saline or ear drops prior to removal. In peritonsillar abscess aspiration, cut the needle guard to 1 cm to protect the internal carotid artery.

1. Ambulatory Otology & The Button Battery Emergency

Ear pain and foreign bodies in the external auditory canal require prompt differentiation between benign canal inflammation and destructive surgical emergencies:

Condition	Etiology & Hallmark Signs	Key Physical Exam Finding	Emergency Pharmacotherapy & Interventions
Acute Otitis Externa ('Swimmer's Ear')	Pseudomonas aeruginosa (60%), Staphylococcus aureus. Moisture and maceration breakdown cerumen barrier	Exquisite tenderness upon tragal manipulation or pinna traction; canal erythema and edema	Ciprofloxacin-dexamethasone otic suspension (4 drops BID x 7 days) OR Ofloxacin drops. Non-ototoxic (safe if TM perforated). Insert a compressed sponge Pope Ear Wick if canal is severely occluded.
Malignant/Necrotizing Otitis Externa	Invasive Pseudomonas osteomyelitis of the temporal bone and skull base in elderly diabetics or immunocompromised	Deep, boring nocturnal ear pain out of proportion to exam; GRANULATION TISSUE at the bone-cartilage junction of the external canal floor; Facial nerve (CN VII) palsy	SURGICAL EMERGENCY: Stat CT of temporal bones with IV contrast; IV Cefepime (2 g IV q8h) or IV Ciprofloxacin (400 mg q8h); urgent ENT admission for surgical debridement.
Button Battery Impaction	Direct contact with moist mucosal surface produces electrical circuit, generating hydroxide ions and alkaline pH > 12	Rapid liquefactive necrosis, tissue saponification, chondronecrosis, and septal/TM perforation in < 2 hours	IMMEDIATE ATRAUMATIC EXTRACTION: Use Katz extractor, right-angle wire hook, or magnetic probe. DO NOT IRRIGATE WITH SALINE.
Live Insect in Ear Canal	Cockroach, moth, or fly trapped against tympanic membrane causing excruciating noise and pain	Direct visualization of live, moving insect on otoscopy	Instill 2% viscous lidocaine, 2% lidocaine solution, or mineral oil into canal to paralyze and suffocate the insect within 1-2 minutes; then irrigate or extract dead insect with alligator forceps.

Board Warning: Button Battery vs. Coin Radiographic Distinction

On plain radiographs, a button battery lodged in the nose or esophagus mimics a benign ingested coin. Distinguish them by two pathognomonic signs: (1) On AP/frontal views, a button battery displays a 'DOUBLE-RING' or 'HALO SIGN' created by the outer casing and inner battery seal; (2) On lateral views, a button battery displays a distinct 'STEP-OFF' contour. A button battery must be removed emergently within 2 hours to prevent fatal aortoesophageal fistula or septal perforation.

2. Peritonsillar Abscess (Quinsy) Diagnosis & Aspiration Technique

Peritonsillar abscess (PTA) is a purulent collection between the tonsillar capsule and the superior pharyngeal constrictor muscle:

Clinical Feature	Hallmark Examination Finding	Procedural/Medical Protocol
Clinical Presentation	Severe unilateral sore throat, fever, muffled 'hot potato' voice, drooling, fetid breath, and TRISMUS (spasm of internal pterygoid muscle)	Inspect oropharynx: Marked unilateral fullness of the superior tonsillar pillar; UVULA IS DEVIATED TO THE CONTRALATERAL SIDE.
Needle Aspiration Technique	Topical lidocaine spray + 1% lidocaine with epinephrine injected into mucosa	THE NEEDLE GUARD SAFETY RULE: Cut the plastic needle guard of an 18G spinal or intramuscular needle, leaving ONLY 1.0 CM OF NEEDLE TIP EXPOSED. This physical stop prevents the needle from penetrating deeper than 1 cm, eliminating accidental puncture of the INTERNAL CAROTID ARTERY, which courses 1.5 to 2.5 cm posterolateral to the tonsil.
Medical Pharmacotherapy	Mixed polymicrobial: Group A Strep, oral anaerobes (Fusobacterium, Prevotella), S. aureus	Ampicillin-Sulbactam 3 g IV OR Clindamycin 600-900 mg IV PLUS Dexamethasone 10 mg IV (reduces trismus and edema, allowing oral discharge).

3. Pharyngitis: Centor/McIsaac Clinical Scoring

Centor/McIsaac Criteria	Points	Clinical Management Strategy
C: Absence of Cough E: Tonsillar Exudates or swelling N: Tender anterior cervical Nodes T: Temperature/Fever > 38.0°C (100.4°F) Age Adjustment (McIsaac): - Age 3 to 14 years: +1 point - Age 15 to 44 years: 0 points - Age >= 45 years: -1 point	Score 0–1 Point: Risk of GAS < 5-10% Score 2–3 Points: Risk of GAS 15-30% Score 4–5 Points: Risk of GAS > 50%	Score 0–1: No testing, no antibiotics; symptomatic treatment only. Score 2–3: Perform Rapid Antigen Detection Test (RADT); treat with antibiotics only if test is positive. Score 4–5: Perform RADT or initiate empiric oral Penicillin V (500 mg PO BID x 10d) or Amoxicillin (500 mg PO BID or 1000 mg daily x 10d). Pen-allergic: Cephalexin or Azithromycin.

4. Dental Trauma: Ellis Fractures & Tooth Avulsion Protocol

Dental Injury	Anatomic Layer Exposed	Clinical Appearance & Sensitivity	Emergency Action & Timing
Ellis Class I Fracture	ENAMEL ONLY	Chipped white tooth edge; painless; not sensitive to air or temperature	Non-urgent. Smooth rough edge with emery board or cover with dental wax; follow up with dentist for cosmetic composite bonding.
Ellis Class II Fracture	ENAMEL + DENTIN	Visible yellow-tan dentin exposed beneath white enamel; very sensitive to cold air and liquids	Urgent. Clean and dry tooth; cover exposed dentin with calcium hydroxide paste (Dycal) or glass ionomer cement to prevent bacterial micro-invasion into pulp; dental referral in 24 hours.
Ellis Class III Fracture	ENAMEL + DENTIN + DENTAL PULP	Visible RED/PINK DOT or active blood drop in the center of the fracture surface; excruciating pain	TRUE DENTAL EMERGENCY: Cover exposed pulp immediately with sterile calcium hydroxide paste and dry foil/glass ionomer; emergent dental consultation within 24 hours for pulpotomy or root canal.
Permanent Tooth Avulsion	Complete displacement of permanent tooth from socket	Empty alveolar socket; tooth intact	TIME IS PERIODONTAL CRITICAL (< 60 minutes): 1. Handle tooth by CROWN ONLY; never touch or scrape the root (destroys periodontal ligament cells). 2. Gently rinse in cold milk or saline (do NOT scrub). 3. Reimplant immediately into socket and splint to adjacent teeth with Coe-Pak or foil. 4. If cannot reimplant: transport in Hank's Balanced Salt Solution (HBSS), cold whole milk, or patient's buccal vestibule.

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