Head (including eye, ear, nose, throat, and mouth)

Tension headache

Tension headaches are characterized by tightening or pressure-like (sometimes throbbing) pain in the temples, over the eyes, in jaw muscles, and in the posterior neck and shoulder muscles. They are usually bilateral. Sometimes there is aversion to bright light and/or loud sounds. They are not related to exercise. It can be treated with rest, sunglasses, and moderate pain medication, such as ibuprofen or acetaminophen every 3 to 4 hours. Adding caffeine (e.g., drinking coffee) might help, but one must be cautious to avoid caffeine withdrawal, which can also cause headaches. Sometimes, applying warm packs or massage to tense muscles relaxes them and helps relieve the pain.

Migraine headache

Migraines are 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 can be treated with promethazine (Phenergan) or metoclopramide (Reglan). Ondansetron (Zofran) might not be as effective and might worsen the headache. There might be aversion to light (photophobia) or sound (phonophobia). Migraine headaches have many variations, which might include stuffy or runny nose and weakness of an arm or a leg, difficulty with balance, speech impairment, diminished hearing, or double vision. Some people experience an “aura” before the “classic” migraine headache, in which they might smell strange odors or see flashing lights, have speech difficult, yawn, suffer neck pain, and/or have mood changes. Others develop tunnel vision (diminished peripheral vision) or hypersensitivity to being touched. The headaches are characterized as excruciating, pounding, or explosive. They commonly awaken people from sleep. Occasionally they will respond to nonsteroidal antiinflammatory drugs (NSAIDs), but often require stronger pain medications. A person suffering from a migraine should be placed in a quiet, dark area to minimize external stimuli. They should be encouraged to drink enough liquid to treat or prevent dehydration and offered an NSAID, ketorolac, acetaminophen, or aspirin. Depending on the person, caffeine may or may not 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 to achieve maximal effectiveness. Other medicines that are effective include propranolol or metoprolol, amitriptyline, methysergide, flunarizine, prochlorperazine (Compazine) given with diphenhydramine (Benadryl), and metaclopramide. 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 might worsen the effects of certain types of migraines. Erenumab-aooe (Aimovig), which is a calcitonin gene-related peptide receptor antagonist, is a new drug approved for monthly injections to prevent migraine. Similar drugs are rimegepant (also available as an orally disintegrating tablet [ODT]), galcanezumab, and fremanezumab, some also effective as well against cluster headache. If other drugs are not effective, dexamethasone in an adult dose of 8 mg by mouth might be effective. If an oxygen (see page 431) tank is available, the victim might get some relief by breathing 10 liters per minute by face mask. An elderly person with a severe migraine, which can be confused with a stroke (see page 165), should seek immediate medical attention. A migraine headache might be precipitated by lack of sleep, high altitude, emotional stress, fatigue, dehydration, bright lights, loud noises, types of weather, missing meals, excessive exercise, cyclical hormone changes, noxious odors, and certain ingested substances (such as caffeine [either by ingesting it or ingesting it irregularly] 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 and try to maintain a “caffeine pattern”; 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 might prescribe topiramate (Topamax) to be taken between episodes of migraine to reduce the frequency of headaches.

The Cerena Transcranial Magnetic Stimulator is a device for treatment of migraine headache that is preceded by an aura (see earlier). It works by releasing a pulse of magnetic energy to stimulate the occipital cortex in the brain, which might stop or lessen the pain of the headache. The Cefaly device is a small, portable, battery-powered unit that is worn like a headband across the forehead. It applies an electric current to the skin and underlying tissues to simulate branches of the trigeminal nerve.

Cluster headache

Cluster headaches (a form of trigeminal autonomic headache) are severe and on one side of the head, last from 30 to 90 minutes, and are associated with restlessness, agitation, eye redness and tearing, runny or congested nose, sometimes eyelid swelling, and sweating. These severe headaches might occur many times in a day, awaken the sufferer from sleep, and are not usually associated with nausea and vomiting. The same treatments for migraine, particularly inhalation of oxygen, are sometimes effective for cluster headaches. Prevention techniques are likewise similar.

Paroxysmal hemicrania

These are similar to cluster headache in that it is an adult headache that involves severe throbbing pain on one side of the face, in-around-and-behind the eye, and perhaps all the way to the back of the head and neck. It also has similar eye and nose symptoms. The headache comes in “attack” form, lasting 2 to 3 minutes up to 40 times per day. It is debilitating and can last for months. This type of headache shows relief after administration of the NSAID indomethacin (Indocin) 25 mg by mouth two or three times per day.

Sinus headache

Sinus headaches are associated with sinus infection (see page 215) and 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), and warm packs applied over the affected sinus(es).

Occipital neuralgia

This neuralgia is pain in the back of the head, upper neck, and sometimes up over the top of the head, and less commonly behind the eyes. It is attributed to damage to the occipital nerves. The pain becomes chronic, and the sufferer describes it as sharp, shocking, or stabbing. In addition to the medications used to treat migraine headaches, there might be relief from rest and local application of heat, and in the hands of a skilled medical practitioner, nerve blocks with anesthetic drugs or even surgery to cut or decompress the nerves.

Trigeminal neuralgia, also called tic douloureux, while not a headache, is a type of nerve-caused facial pain in the distribution of one or more divisions of the trigeminal nerve. It is most commonly caused (in the “classical” and “secondary” types) by compression of the trigeminal nerve within the skull. The episodes of severe, electric shock-like pain, are triggered by activities of daily living, like a gentle touch. The trigger location might be remote from the location of the pain. The pain is sometimes accompanied by contraction of the facial muscles (the “tic’), which might be subtle or overt. If trigeminal neuralgia is suspected, the person should be referred to a doctor for diagnosis and considerations of medical or surgical therapy.

Subarachnoid hemorrhage

This sudden headache is from 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 might be associated with a fainting spell, altered mental status, seizure, and collapse. A common term for such a headache is “thunderclap.” If a person suffers a subarachnoid hemorrhage and remains awake, they might 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 lifting a heavy weight or having 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. It is probably best to consider any thunderclap headache indicative of a potentially serious problem and to promptly seek medical attention.

Meningitis

This is a severe 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, neck stiffness, fever, altered mental status, and weakness. The victim demonstrates extreme discomfort when the chin is flexed downward against the chest and might 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 might present only with poor feeding, fever, vomiting, seizures, and extreme lethargy (“floppy baby”). A purplish skin rash indicates infection with the bacteria Neisseria meningitidis, a particularly fulminant and contagious form (“meningococcal”) of infectious meningitis. If meningitis is suspected, the victim must be evacuated rapidly and started on broad-spectrum intravenous (IV) antibiotics.

Giant cell arteritis

This is a type of inflammation that occurs in elders (it is rare in persons younger than 50 years of age and is more common in women) that can affect the temporal artery, which travels in a path along the sides of the scalp over the ears (temples). The associated headache might be quite severe and accompanied by thickened and tender arteries that might be noticeably enlarged with or without overlying reddened skin. Pulses might or might not be appreciated in these arteries, and the victim might have pain radiating down the side of the face as low as into the jaw. Permanent partial or complete loss of vision might occur in one or both eyes, which makes this condition an emergency. The immediate treatment is administration of a high dose of a corticosteroid, such as prednisone 80 to 100 mg by mouth each day until a physician can evaluate the patient. Hopefully, symptoms will improve within a few days of beginning the corticosteroid medication.

Sudden hearing loss

Sudden hearing loss can occur in one or both ears. It is often accompanied by ringing in the ears and/or vertigo (see page 192). If it is due to obstruction of the external ear canal by wax, this can be treated (see page 200). Otherwise, it can be caused by an infection, eardrum rupture, fluid in the middle ear, bone conduction problems in the inner ear, or malfunction of the nerves that participate in the hearing process. This will be determined by a specialist who should be seen promptly for evaluation and possible treatment. If a specialist cannot be seen within 2 weeks of onset of sudden hearing loss, administer the adult patient 60 mg prednisone (or its equivalent) per day for 3 consecutive days, then taper the dose over the ensuing 7 days. This therapy is intended to preserve hearing in the event that the cause is inflammatory.

Earache

An earache might 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 410.

Ear infection

Ear infection can be either internal (otitis media) or external (otitis externa) to the eardrum (tympanic membrane) ( Fig. 147 ).

• Otitis media. Infection might occur that reddens and inflames the eardrum and causes blood, serum, or pus to collect behind the drum (see Fig. 147 , 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 might 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 might develop meningitis (see page 196) following an ear infection.

  • 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 of body weight per day in two divided doses), amoxicillin–clavulanate (same dose of the amoxicillin component as for amoxicillin), cefdinir (14 mg/kg once daily or in two 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 adults is moxifloxacin 400 mg once a day 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). 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 Fig. 147 , C). When the external canal is kept moist, it is easier for bacteria to invade the skin and cause infection. The earliest symptom might be itching and a sensation of fullness. Subsequent symptoms include a white to yellow-green liquid or cheesy discharge from the ear, pain inside the ear, and decreased hearing. Not infrequently, the victim complains of exquisite tenderness when the external portions of the ear are tugged or with jaw motion and has tender, swollen lymph glands in the neck on the affected side. In a severe case, the victim might have a fever and appear toxic, and there might be cellulitis (see page 261) of the external ear and adjacent skin.

  • If the victim has only a discharge without fever, swollen lymph glands, or cellulitis, they may be treated with ear drops, such as acetic acid 2% solution (acetic acid otic); ascetic acid 2% with hydrocortisone 1% (Acetasol HC); or 2% nonaqueous acetic acid (VōSoL or Domeboro Otic). Household vinegar (approximately 5% acetic acid) diluted 1:1 with fresh water or with rubbing (isopropyl) alcohol (approximately 40%) can be used as a substitute. These ear drops should be administered four to five times a day for 7 days and can 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 might be punctured (e.g., the presence of bleeding), do not use this solution. After beginning to use the ear drops, most persons begin to feel significantly better within 48 to 72 hours and have few or no symptoms within 7 days. If symptoms persist beyond a week, then continue therapy for up to 7 more days and see a doctor.

  • If the victim has a discharge with fever and/or swollen lymph glands, the ear drops should at a minimum contain hydrocortisone (VōSoL HC Otic); they should also be given oral amoxicillin/clavulanate, trimethoprim-sulfamethoxazole, ciprofloxacin, levofloxacin, erythromycin, or penicillin. Antibiotic-containing ear drops that can be useful are ciprofloxacin 0.2% with hydrocortisone 1% (Cipro HC otic suspension); ciprofloxacin 0.3% with dexamethasone 0.1% (Ciprodex); neomycin-polymyxin B-hydrocortisone (Cortisporin Otic); ofloxacin 0.3% otic solution (Floxin otic) 0.3%; and finafloxacin otic suspension (Xtoro). Ear drops are used three to four times a day for 7 days. If the discharge from the ear is gray or black, a fungal infection can also exist, in which case tolnaftate 1% solution can 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 VōSoL, Domeboro Otic solution (2% acetic acid, aluminum acetate, sodium acetate, and boric acid), diluted vinegar/alcohol (described earlier) or a 50:50 mixture, or an over-the-counter drying aid like Swim-EAR after each scuba dive or immersion episode in the water. Keep the solution in the canal for a full minute before allowing it to drain. Earplugs that absorb moisture and are discarded after no more than a few uses, such as ClearEars, may be helpful. Similarly, devices that dry the ear canal, such as the small, portable Mack’s DryEar dryer, may help prevent and treat ear disorders. Avoid using petroleum jelly or other substances that can form a watertight seal because they might trap water and moist debris.

Referred pain

“Referred” pain is pain that appears in one body region but 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 might 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 their middle ear (see page 410), or a person is subjected to a loud explosive noise, the eardrum might 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 437). 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 or irrigation equipment can remove it. If a live creature (cockroach, bee, tick) 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 perhaps 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 might encourage a sting or bite and incredible temporary pain. Rubbing alcohol will work but might also cause pain. Once the animal is dead (a few minutes for most bugs, but less likely successful for ticks), a gentle attempt should be made with small tweezers to remove it. Do not attempt this unless you can see part of the bug, however. Do not push the bug in farther, or you might rupture the eardrum. If a dry bean or seed has become tightly trapped in the ear, do not use water to try to remove it, because the object will swell and become more impacted.

Wax in the ear

If hearing is diminished in an ear because of a wax (cerumen) 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 IV catheter (without the needle) to an 8 to 30 mL syringe. Do not try to clean out the ear with a cotton-tipped swab or other rigid object, because you might 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. After the wax is removed, gently instill a few drops of vinegar or isopropyl (rubbing) alcohol in order to remove residual water and prevent external otitis (swimmer’s ear) (see page 199).

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 for exposure to acid and 60 minutes for alkali. Try to use at least 2 liters of liquid to irrigate the eye. It might take many more liters to remove acid or alkali, but these first 2 liters are a good start. Do not patch the eye closed. 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 four 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 might 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 eye pads presoaked with water. This might loosen the bond and allow the eyelids to be separated.