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CHAPTER 214 EVALUATION OF ACUTE FACIAL PAIN AND SWELLING

and hypercarbia because posterior packing can cause airway obstruction, particularly in elderly patients, due to the down ward displacement of the soft palate and subsequent palatal edema and swelling or slipped packing. Unfortunately, packs must be left in place for a minimum of 5 days to be effective. Posterior packing is associated with a great deal of discomfort. Patients generally require intravenous hydration because of poor oral intake due to painful swallowing. Additional needs include antibiotics to prevent sinusitis, pain medications, and careful observation by the nursing staff for impending airway obstruction. In all cases of nasal packing, awareness of poten tially devastating toxic shock syndrome must be maintained. Any form of nasal packing should not be taken lightly in the elderly or patients with known cardiopulmonary disease. Pack ing can often be avoided, or removed earlier, if the patient undergoes an endoscopic nasal examination and the site is visu alized and electrocauterized directly, usually in the operation room. Failing this, where available, arterial embolization of the involved internal maxillary–sphenopalatine artery system can be used in life-threatening situations. ANNOTATED BIBLIOGRAPHY (see also Chapter 179 Bibliography) 1. Hallberg OE. Severe nosebleed and its treatment. JAMA 1952;148:355. ( A classic article that is still very useful. ) 2. Kirchner JA. Epistaxis. N Engl J Med 1982;307:1126. ( A review of anatomy, etiology, and therapy. ) 3. Perry WH. Clinical spectrum of hereditary hemorrhagic telangiectasia (Osler–Weber–Rendu disease). Am J Med 1987;82:989. ( A detailed review of clinical presentation; nosebleeds are a major feature. ) 4. Schlosser RJ. Epistaxis. N Engl J Med 2009;360:784. ( Excellent summary of pathophysiology, epidemiology, and basic treatment for the generalist reader. ) 5. Her C. Nasopharyngeal cancer and the Southeast Asian patient. Am Fam Physi cian . 2001;63:9. ( Concise summary of epidemiology and etiology of nasopharyngeal cancer in this high-risk population ) 6. Benninger MS, Marple BF. Minor recurrent epistaxis: prevalence and a new method for management. Otolaryngol Head Neck Surg 2004;131:317. ( Introduces simple product effective for typical, minor epistaxis. ) 7. Dupius-Girod S, Ambrun A, Decullier E, et al. Effect of bevacizumab nasal spray on epistaxis duration in hereditary hemorrhagic telangiectasia: a ran domized clinical trial. JAMA 2016;316:934. ( No significant improvement over placebo for this anti-VEGF monoclonal antibody when applied topically. )

First Aid Few patients understand the proper treatment for the care of minor nosebleeds at home; simple telephone instruction may obviate the need for an office or emergency room visit: • • Instruct the patient to sit up and remain calm and lean forward and pinch the side of the nostril against the septum on the side that is bleeding to tamponade the flow. It is important to emphasize that the patient press on the soft portion of the nostril rather than the skin overlying the nasal bones. • • Then have the patient spray the nose with any of the over-the-counter nasal sprays that contain phenylephrine (e.g., Neo-Synephrine) or oxymetazoline (e.g., Afrin). • • Follow with the use of a small pledget of cotton lightly soaked with the spray and pressed against the bleeding portion of the septum. After 10 minutes, most nosebleeds will have stopped. • • Have the patient apply a petrolatum-based ointment , such as zinc oxide or bacitracin, to the septum to prevent further drying and abrasion of the septum. It should be left in for a few days. • • Instruct the patient to limit heavy lifting, other forms of straining or bending over, intake of spicy or hot foods, hot showers, and medications that might impair hemostasis (see Chapter 81). Consider the initiation of a stool softener . Reassure the patient when the nosebleed is purely a local phenomenon; many people attribute nosebleeds to hyperten sion and fear cerebral hemorrhage.

INDICATIONS FOR REFERRAL AND ADMISSION

Patients with active posterior bleeding should be admitted to the hospital immediately for emergency treatment to control the bleeding. All patients who undergo extensive posterior nasal packing need to be closely observed for signs of hypoxia

Chapter 214

EVALUATION OF ACUTE FACIAL PAIN AND SWELLING EDWARD T. LAHEY III

T he primary care physician often encounters patients whose presenting complaints are facial pain and/or swelling. The differential diagnoses to consider for this presentation can be broad and include infections, neuropathy, neoplasms, autoim munity, vascular malformations, trauma, and inflammation of structures such as the masticatory apparatus (teeth, gums, jaws, muscles) or salivary glands. Dental decay is the most prevalent infectious disease in the United States and a major cause of conditions leading to facial pain and swelling. Because dental symptoms may be referred to nondental structures and because an odontogenic infection may involve areas of the head and neck seemingly unrelated to the teeth, the patient may first seek the advice of a physician rather than of a dentist. Prompt recognition and effective initial treatment may well prevent the development

of a serious complication such as abscess formation and avoid delays in patients being referred to the appropriate specialist.

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PATHOPHYSIOLOGY AND CLINICAL PRESENTATION (1–5) Odontogenic Tooth Decay and Inflammation of the Pulp

Caries or dental decay is a multifactorial disease and encompasses dietary factors (most notably, refined carbohydrates), environ mental factors (such as lack of fluoride ion exposure during