10 Treatment: head and neck

The head can be thought of in terms of the neurocranium—the brain box—and the face (viscerocranium). The face acts as a protection to the brain in large impacts—rather like an air bag in a car. The two structures are intimately related to each other and to the neck, which is forcibly extended following a frontal blow to the face. In major facial trauma it is essential to look for signs of cervical spine injury (10% of mid face fractures will have a concomitant c-spine fracture) and start head injury observations.

Areas of the head are described according to their underlying bony parts (Fig. 10.1). The eyes lie protected within the orbit, while the prominent nose is susceptible to injury.

The breathing and digestive passages cross in the oropharynx, requiring complex mechanisms to ensure correct routing (Fig. 10.2). The nose and upper airway form a humidification and filtering mechanism. The opening to the lower airway is the larynx, a complex cartilaginous structure hung from the hyoid bone, which in turn is slung from the base of the skull. When foods or fluids are swallowed, the epiglottis, a roof-like flap, closes over the glottis and protects the trachea. Inside the lower end of the larynx are the vocal cords, used both to provide a watertight seal to the airways and to phonate. The two prominent thyroid cartilages form the anterior border, the ‘Adam’s apple’ of the larynx. Just below these cartilages is an obvious groove, the cricothyroid membrane—the safest location for emergency surgical access to the airway.

The swallowing mechanism primarily involves the tongue and oropharynx. Movement of a food or fluid bolus to the back of the mouth causes reflex closure of the larynx and a peristaltic wave to pass down the oesophagus. Tongue swelling or a sore throat will disrupt swallowing.

Whatever the outdoor pursuit, the face is an easy target for injuries as it is left uncovered by most protective helmets so that we can see, breathe, and talk. Facial injuries may affect bones, soft tissues and teeth (see Chapter 11).

Consider the face as divided into equal thirds, plus the inside of the mouth:

In each area check the bony tissues for tenderness, mobility, or unexpected steps, the soft tissues for lacerations and bruising, and nerve function. Sensation is conveniently conveyed by a branch of the trigeminal nerve for each of the thirds of the face. Motor function is via the five branches of the facial nerve. Any lacerations which cross the path of these nerves may cause a nerve injury. Finally each area has unique features summarized in Table 10.1 and which you should note have been checked.

Head injuries such as bruises, black eyes, or lacerations are relatively common; more serious head injuries are fortunately rare, but are an ever- present risk during outdoor activities.

(See Wound types and management, p. 272.)

Scalp lacerations tend to bleed a lot initially and can look a lot worse than they really are. Apply firm pressure until the bleeding stops. Small wounds can be closed using cyanoacrylate tissue glue. Conventional superglue has been used for this purpose, but can provoke tissue reactions and is not recommended.¹ Shaving the hair around large lacerations may make wound closure easier.

Simple facial lacerations usually heal well, but it is important to minimize scarring. Clean the wounds carefully and, where possible, use glue or skin fixers (Steri-Strips™, etc.) to bring the edges together. If wounds are deep, try to remove tension from the surface by placing resorbable subcutaneous sutures (e.g.4/0 Vicryl^® Rapide) to approximate the edges and then suture the skin itself using a fine suture material (e.g. 5/0 Novafil^® on face; 6/0 for lips and eyelids) to finish the job. Ensure that tension is even throughout the wound and that the edges are aligned. When a lip has been cut, make every effort to realign the vermilion edges as even small deviations are very obvious and may require subsequent corrective surgery. Remove sutures after 5 days. Most facial lacerations do not require antibiotics.

Complex or heavily contaminated lacerations will require specialist surgical management. Cover exposed bone with saline-soaked dressing, begin an IV antibiotic such as co-amoxiclav 1.2 g IV three times daily (if no penicillin allergy), and evacuate the casualty urgently for specialist surgical treatment.

Intra-oral lacerations are closed with resorbable 3/0 or 4/0 sutures. Explore them well using suction. If the labial mucosa is involved ask for help from a colleague to pull the lip tightly away from the teeth to give you a flat surface to suture.

(See Nasal fracture, p. 308 and Epistaxis (nose bleed), p. 335.)

Injured noses tend to bleed a lot. Apply cool compresses. Almost all nose bleeds can be controlled by pinching the soft tissues together across the tip of the nostrils, although rarely it may be necessary to pack a nostril using either a nasal tampon or ribbon gauze lubricated with paraffin ointment or a suitable antibiotic ointment.

Bitten tongues and burnt tongues are usually made worse by attempting surgical treatment. Provide pain relief, rest, and keep the patient head-up if there is significant airway swelling. Sucking ice, if available, can relieve pain and swelling.

Neck sprains most commonly result from low-velocity, rear-end road traffic collisions, but may also occur in other circumstances such as being rolled by a wave whilst surfing. Initial assessment should attempt to eliminate the possibility of a fracture or dislocation of the neck, which can be indicated by the mechanism of injury, usually severe pain, and localized midline tenderness of the cervical spine. Assessment and exclusion without the aid of X-rays is difficult, especially for the inexperienced. If in doubt, immobilize and evacuate for specialist assessment (see Neck and other spinal injuries, p. 198).

However, if muscular pain predominates without bony tenderness or neurological symptoms, then it is probably that the neck has been sprained with damage to trapezius and sternomastoid muscles. Neck sprains are managed with analgesia and encouragement to mobilize. Immobilization with neck collars causes stiffness and should be avoided.

Detailed diagnosis of facial bone fractures is impossible and irrelevant in a remote environment. Fractures to both the mandible and maxilla will cause pain and swelling, limit diet, and may threaten the airway. The best advice is to arrange early evacuation to specialist care. However, this may take time and in the interim the following can help, assuming there are no other life-threatening injuries:

The bottom jaw is typically fractured following a fall or punch. Patients complain of sensory loss of the lower lip, pain, and teeth not meeting properly (‘deranged dental occlusion’). There may be blood and/ or gaps around individual teeth and step defects along the plane of the tops of the teeth. It may be possible to elicit movement of the mandible between teeth—passive and active on examination.

Broadly speaking we can consider the fractures as being in the tooth-bearing area (a–d in Fig. 10.3) or in the ramus and condyle of the mandible (e–h).

There are many categories—don’t worry about them. Once you have identified the presence of a fracture of the maxilla, check the airway, eyes, and cervical spine (especially in falls from height) and arrange for evacuation. The type of fracture can be determined by the receiving medical team by CT scan. Typically the window for operating is 2 weeks.

The airway is very rarely a problem. An awake patient will naturally sit forward to keep their airway patent. But in an unconscious patient with a high fracture, the facial bones may be pushed down and back along the skull base, causing the soft palate to snag on the tongue and so closing the airway. A Guedel airway, laryngeal mask, or endotracheal tube may be required, or, if there is extreme airway swelling or bleeding, a cricothyroidotomy ( Maintaining an open airway, p. 187) could be life-saving. Fortunately such situations are very unusual. Deal with epistaxis if present using pressure or nasal packs.

Cheek bone fractures can involve either the arch of the zygoma causing a dimple in the skin over the arch and possibly entrapment of the coronoid process of the mandible limiting jaw movement, or the zygomatic body. There may be bruising and swelling in the region with flattening deformity if displaced. Look for bloody injection of the white of eye lateral to pupil: subscleral haemorrhage and paraesthesia of the face below the eye (infra-orbital nerve).

Examine for signs of eye involvement (diplopia, visual acuity loss, or an injury to the globe), a blow out fracture of the orbit, or even retrobulbar haemorrhage (see Examination of the eye, p. 325; Orbital compartment syndrome, p. 331).

Blunt trauma to the globe of the eye (e.g. from a fall or a punch) can cause the weak bony orbital floor to fracture. This may cause prolapse of orbital fat into the maxillary sinus below. Double vision can occur from the swelling, which may be intolerable and require patching of the damaged eye (see Fig. 10.6). Surgical repair, if required, is possible for up to 2 weeks following injury.

In children, the inferior rectus muscle can become trapped and be the cause of diplopia. A simple test to check is to get them to look up and if the globe cannot move, there is entrapment. This can cause malaise, vomiting, and headache, and be confused with a head injury. These children need urgent surgical release—ideally within 24 h—to prevent permanent visual impairment.

Diagnosis is made of the basis of:

If you suspect this injury:

Injuries of this type may also lead to:

If visual acuity is reduced after a blunt trauma, evacuation is essential.

The TMJ may dislocate, typically when yawning too wide. The individual may well have a history of this. If dislocation occurs in association with trauma, be wary—fracture dislocations require specialist surgical management.

The TMJ consists of the mandibular condyle (the finer projection up from the mandible) and the glenoid fossa—the dished surface on the temporal bone skull base, in which the condyle articulates. During small movements the condyle just pivots in a fixed position, but when the jaw opens wide it slides forward, down, and out of the glenoid fossa. It soon meets a physical block—the articular eminence, which stops it moving further—but in extremely wide opening it can flip over this eminence and get stuck leaving the mouth fixed open, the lower jaw jutting forward and the chin very prominent.

A closed fixed mouth is not a dislocated jaw, by definiton.

Just pushing the mandible backwards will not reduce the dislocation—it simply pushes the condyle straight back into the articular eminence, so the mandibular condyle has to be pushed down and over the articular eminence. Attempt relocation as soon as you can before the jaw muscles go into spasm and prevent further movement. Lie the patient flat in a quiet environment. The process is not painful but it can be uncomfortable.

Stand in front of the patient. With gloved hands insert your index finger into the mouth behind the most posterior lower tooth onto the mucosa overlying the bone behind the molar teeth (Fig. 10.4). Do this on both sides if both condyles are dislocated. Make sure that your fingers lie around the cheek side of the back teeth and not over them or you will get bitten when the jaw goes back into place! Then curl the thumbs under the chin on each side. Your aim is not to push the mandible straight back as this just pushes the condyle back onto the articular eminence. Instead you have to push the condyle down and back, over the articular eminence before it returns to the glenoid fossa. Press down and back with the index fingers and push the chin up with the thumbs. This rotates the mandible making the condyle move down and back more easily. It is not a sudden relocation but instead is a slow sustained pressure for up to several minutes. Usually one condyle returns before the other. Obviously in unilateral dislocation that is enough, but most are bilateral and will require a little more effort. However, once one side is in the other usually swiftly follows. Then advise the patient to rest the jaw joint for a few weeks by stifling yawns by preventing wide mouth opening with a hand underneath the chin and having a soft diet.

Cases which cannot be relocated easily may need sedation, local anaesthetic injections to the muscles around the joint, or evacuation to be relocated under a short general anaesthetic.

For discussion of the assessment and management of suspected cervical spine trauma see Neck and other spinal injuries, p. 198.

A person should be considered to have a head injury if they have suffered any trauma to the head, apart from superficial lacerations to the face. Head injuries can be:

It is best to avoid a head injury! About 60% of adults with moderate head injuries and 85% with severe head injuries remain disabled 1 year after their accident. Even a minor head injury can ruin a trip: 3 months later, 80% have persistent headaches and 60% have memory problems. Wear a suitable helmet if at risk of head injury.

Secondary deterioration is usually due to:

Swelling inside the closed cranium interferes with blood flow into the brain. Cerebral perfusion pressure (CPP) is the balance of mean arterial pressure (MAP) less intracranial pressure (ICP):

It is therefore important to maintain BP, with fluid replacement, and minimize ICP. Factors that increase ICP that can be correctable in the wilderness include pain and hypoxia due to altitude.

Management options for a significant head injury in a remote environment are limited:

Severe head injuries have many consequences, and may require long-term rehabilitation.

An episode of transient loss of consciousness is often referred to as a ‘blackout’. Blackouts commonly result from:

It may prove difficult, if not impossible, to determine the cause of some blackouts in the wilderness. Any previous diagnosis in an expedition member should be treated with caution, particularly if there are unusual features about the new attack.

Seizures may occasionally complicate high-altitude cerebral oedema (HACE High-altitude cerebral oedema, p. 664.)

Cardiac syncope accounts for most blackouts, and of these the majority of cases are due to reflex syncope, with up to 30% of people suffering reflex syncope during their lives. In contrast, epilepsy only affects ~0.5% of the population at any one time, with a lifetime incidence of 2%, although many of these will develop at one or other extreme of age. Blackouts are also often seen in the absence of organic physical disease; such attacks may be accompanied by apparent convulsive movements, but their origin could be psychological rather than physical, particularly in very stressful circumstances.

The cause of syncope may be either cardiac or vascular:

In hot environments, consider heatstroke ( Heat-related illnesses (HRIs), p. 748).

Diagnosis is made from the history, particularly the circumstances around the blackout. Syncope results in transient self-limited loss of consciousness owing to transient reduction in blood flow to the brain, typically leading to collapse; most attacks, particularly those with vascular causes, therefore occur when patient is standing, although fainting can occur while sitting.

Epilepsy can be classified as idiopathic, a condition in isolation, or symptomatic, resulting from some underlying disease. The resulting seizures are either generalized, involving the whole brain from onset, or focal, starting in one area but then affecting all areas.

A separate classification describes the resultant seizures: these are partial or generalized.

Other types of generalized seizures include collapse with rigidity (tonic seizure) or without change in muscle tone (atonic seizures). These usually only occur in the context of a complex epilepsy associated with learning disability. Generalized seizures also include absences, with preserved posture, and daytime myoclonus, both of which may be seen in previously diagnosed idiopathic childhood and juvenile epilepsies.

These range from simple panic attacks with hyperventilation, which rarely cause blackout and are usually readily recognized, to a wide spectrum of non-epileptic seizures. Typically occurring in adolescents or young adult women, they can be frequent and without apparent cause. Assessment is very difficult, and it is essential to exclude organic disease. Such behaviour is disruptive, especially in a hazardous environment, so evacuation or repatriation may be required.

If you consider that the blackout was due to syncope, then check for any predisposing systemic illness:

Few investigations are possible in the wilderness. Check pulse and temperature to check for systemic illness, and check blood glucose if possible. Measure oxygen saturation if a pulse oximeter is available.²

Migraine is a disorder characterized by recurrent, usually unilateral, moderate to severe headaches that may be accompanied by dizziness, nausea, vomiting, or extreme sensitivity to light and sound. Migraine is common in young adults. Most migraine sufferers know they have the condition, so a first attack would be unusual but could be precipitated by, for instance, altitude. The cause of migraine is unknown.

Women may be more prone to migraine if on the combined oral contraceptive pill. Focal migraine is a contraindication to the use of the oestrogen- containing contraceptive pill—it may increase the risk of stroke. Triggering factors include:

Migraine usually develops in a predictable way:

Rest, hydration, and adequate analgesia.

If the individual is known to have migraine they may have brought their medication with them. Otherwise, give 900 mg soluble aspirin, which should be given with a glass of milk, if available, to protect the stomach, and ideally also with an anti-emetic. Metoclopramide or domperidone are particularly useful as they promote gastric emptying, but avoid metoclopramide in adolescents and young adults, as it can precipitate an extrapyramidal reaction. Prochlorperazine is a suitable alternative.

Complications are unlikely. If migraine develops for first time in women on oral contraception then this should be stopped, particularly if migraine has focal features.

On an expedition many factors may disturb sleep, including time zone shifts, unfamiliar harsh living conditions, physical discomfort, environmental extremes including high altitude, sport-specific disturbances (night watches sailing, pre-dawn starts climbing), and psychological factors such as anxiety about the venture ahead or homesickness. Few things erode team morale and daytime performance as much as disturbed sleep; however, forward planning and simple measures can improve things considerably.

Many body functions are under circadian control, including hormone secretion, body temperature, cellular and enzymatic function, and sleep. The natural circadian rhythm approximates 24 h. Rapid travel across time zones is associated with desynchronization between the body’s circadian clock and the actual local time, resulting in jet lag. This is experienced as difficulty getting to sleep following an eastward flight, wakening early following a westward flight, disturbed sleep, daytime sleepiness, difficulty concentrating, irritability, depressed mood, anorexia, and nocturia. These symptoms usually only pose a minor inconvenience for travellers; however, performance, including decision-making, may be impaired in the first few days following arrival in a new time zone, and this should be allowed for in the travel schedule.

Obstructive sleep apnoea (OSA) is a condition in which repeated blockage of the upper airway fragments sleep. It presents with snoring, pauses in breathing, and daytime sleepiness. People with this pre-existing condition should consult their physician prior to travel.

OSA may be treated using nasal continuous positive airway pressure (CPAP) during sleep. If CPAP has to be discontinued briefly, there is some carry forward benefit for 1 to 2 nights before symptoms return. An alternative to CPAP for patients with milder OSA is a jaw advancement device, which has the merits of being small, readily portable, and requiring no electrical power. Interestingly mild OSA improves somewhat on ascent to high altitude, presumably as tone in the upper airway is increased by the additional respiratory effort driven by hypoxia.

Ophthalmology is viewed by the general physician with anything from mild boredom to abject fear. Unfortunately, eye problems may occur while travelling and this section is designed to help you assess and treat them. An expedition medic should have some experience of using a magnifying loupe and ophthalmoscope as well as administering eye drops and applying a double eye pad.

It is important to have a basic understanding of ocular anatomy to assess the severity of an injury. Fig. 10.5 shows an external and internal view of the eye; note that the cornea is continuous with the sclera and that the conjunctiva lines both the inside of the eyelids and covers the sclera up to the cornea.

Relevant ocular information can be obtained from the pre-departure health questionnaire (see Box 10.1 and also Box 2.3).

Travellers with chronic eye conditions may need to take other precautions and should ensure that they have ample supplies of regular medications.

In the wilderness, contact lens users are vulnerable to dry eyes and serious corneal infections, so should be advised on sensible contact lens use (no more than 8 h a day) and strict hygiene when handling lenses. Remind them to bring spectacles as well as plenty of spare contact lenses.

Any potential infection, even an apparently simple conjunctivitis, should be taken very seriously. Contact lens wear should be stopped and intensive broad-spectrum antibiotic drops should be started (e.g. ofloxacin hourly). If no improvement within 5 days, evacuate the patient.

Refractive surgery is becoming increasingly popular amongst outdoor enthusiasts to decrease dependence on spectacles or contact lenses. During this type of surgery, the refractive power of the cornea is changed either through surgical incisions or laser ablation. However, high altitude can affect the surgical results, causing blurred vision that usually resolves upon descent. Radial keratotomy (RK) has now been superseded by laser in situ keratomilieusis (LASIK), laser epithelial keratomilieusis (LASEK), and photorefractive keratectomy (PRK).

RK tends to cause long-sightedness (hypermetropia) at altitude whereas LASIK, LASEK, and PRK may cause short-sightedness (myopia) at altitude. This phenomenon is not predictable and can severely affect vision. Avoid elective refractive surgery within 3 months of an expedition as refraction can be unstable and infection a risk.

Another form of refractive surgery is to have the natural lens removed and replaced with an intraocular lens in a procedure similar to cataract surgery. There is a risk of dry eye and a small chance of intraocular infection after clear lens extraction, but vision is unlikely to change at high altitude.

Any decreased vision, redness, or pain in the eyes of someone who has had refractive surgery should be taken seriously, as they are more vulnerable to infection. If necessary, consider descent and evacuation.

Drops are easy to administer but are short lived. Ointments sooth and lubricate, but blur the vision. It is therefore worth having antibiotics in both preparations depending on the patient’s needs.

Loss of vision, even if it is transient, whether or not associated with pain, should be of great concern to the expedition medic especially if no obvious cause such as snow blindness can be found. Always consider evacuating the patient for specialist evaluation.

Conjunctivitis is the most common eye problem likely to be encountered in the wilderness setting.

One or both eyes are red and painful with pus (bacterial), profuse watering (viral), or itch (allergic) depending on aetiology. Visual acuity is usually unaffected, the conjunctiva red and inflamed, and the cornea clear.

Bacterial conjunctivitis should respond rapidly to topical antibiotics, whereas viral conjunctivitis can persist for many days but is eventually self-limiting. If the patient is a contact lens wearer then follow the specific advice earlier in the chapter (see Contact lenses, p. 325). Allergic conjunctivitis may respond to sodium cromoglicate. Bacterial and especially viral conjunctivitis are extremely contagious so enforce strict hygiene measures.

Dry eyes can be exacerbated by the dry, windy, bright conditions found at high altitude or in polar regions. Contact lens wearers are particularly vulnerable. The eyes are red, painful, and gritty.

A tear in the corneal epithelium, usually through mild trauma such as removing a contact lens or perhaps even while asleep.

An acute and exquisitely painful eye. Topical anaesthetic will provide immediate relief, but should not be used as a treatment. Fluorescein will confirm the diagnosis.

Prescribe an antibiotic ointment. An eye pad is not usually necessary and can encourage infection.

Snow blindness is caused by unprotected exposure of the cornea and conjunctiva to ultraviolet light (UVB). Like sunburn, by the time you realize there is a problem, it is too late, and it can be extremely painful. Prevention and treatment are discussed in Snow blindness (photokeratitis), p. 634.

Occasionally the protective blink reflex fails and allows a foreign body to embed itself into the cornea. This can be metallic or organic; a metallic foreign body will often leave a rust ring.

Red, painful, gritty eye, and foreign body sensation. The foreign body is usually very small, but fluorescein and a magnifying loupe can assist identification and removal. Always evert the eyelid to exclude a subtarsal foreign body.

Immediately irrigate a chemical injury before any further assessment. A chemical splash can be sight-threatening. It is important to identify the chemical because alkali penetrates the ocular tissues much faster than acid and therefore has a worse prognosis.

The eyelids play an important role in protecting the eye and preventing corneal desiccation. If they are damaged, the eye can be rendered vulnerable.

A penetrating eye injury involves disruption of the globe integrity and is a serious, sight-threatening problem. The mechanism of injury is important in determining whether there could be an intraocular foreign body or a perforating injury (entry and exit).

Orbital cellulitis is a sight-threatening condition that can also be life- threatening if it spreads to form a brain abscess. The infection may originate from an adjacent ethmoid sinus or from mild trauma to the orbital region.

Preseptal cellulitis involves only the eyelid tissue. There is periorbital inflammation and swelling but none of the other features mentioned in Orbital cellulitis, p. 330. However, preseptal cellulitis can progress to orbital cellulitis so should be treated with broad-spectrum oral antibiotics and closely watched.

The orbit is a relatively closed compartment with limited ability to expand, so orbital pressure can rise rapidly when an acute rise in orbital volume occurs. This is an emergency where prompt simple treatment can prevent blindness.

The most common cause of orbital compartment syndrome, especially in the wilderness, is retro-bulbar haemorrhage from trauma, but spontaneous retro-bulbar haemorrhage can also occur due to venous anomalies, intra-orbital aneurysms or malignant hypertension. Severe orbital cellulitis with an abscess can also cause an orbital compartment syndrome. Patients with increased orbital pressure present with pain causing vomiting, proptosis, red and swollen conjunctiva, limited eye movements, and decreased optic nerve function (decreased vision and an afferent pupillary defect).

Treatment is with a surgical lateral canthotomy and cantholysis to release the pressure. This is a relatively straightforward procedure that can be performed as an emergency procedure under local anesthesia if evacuation is not possible (see Fig. 10.7).

Following infiltration with local anaesthesia (e.g. lignocaine with adrenaline) the lower eyelid is completely detached from the lateral orbital rim using sharp sterile scissors, first horizontally to cut through the lateral canthal angle (canthotomy) and then vertically to cut the lateral canthal tendon (cantholysis). This may be followed by a gush of blood from behind the eye as pressure is relieved. If the lid is held with forceps it is possible to feel when the tendon has been severed. The patient should then be evacuated for specialist evaluation and treatment.

(See also High-altitude retinal haemorrrhages, p. 667; Plate 24.)

HAR is defined as ‘one or more haemorrhages in either eye of a person ascending above 2500 m’. It is normally asymptomatic but affects around 30% of lowlanders ascending to 5000 m.

Retinal vascular tortuosity and engorgement are part of the normal physiological retinal response to the hypoxia of high altitude. However, a combination of factors, including exertion and speed of ascent, cause HAR. It is confusing to include papilloedema in the definition of HAR as this implies raised intracranial pressure; the relationship between HAR and the potentially fatal HACE is not yet known.

Any visual disturbance at altitude is an indication for descent.

Ear problems are relatively common, particularly on diving expeditions ( Barotrauma, p. 740; Otitis externa, p. 742), owing to pressure changes and prolonged exposure to salt water.

An infection of the outer ear often associated with constant moisture due to diving, or living in tropical environments. The ear canal itches, hurts, and may discharge; moving the pinna causes pain. The external canal looks swollen and red debris is usually obvious. In severe cases, hearing loss develops if the external canal becomes blocked by debris and swelling. Systemic upset with lymphadenopathy can occur.

Treat by gently cleaning the external canal with saline or clean water. Use a combination preparation of antibiotic and steroid such as Gentisone HC™ four times a day and in severe cases prescribe an oral antibiotic such as co-amoxiclav. Avoid further exposure to water until the condition resolves.

A viral or bacterial infection of the middle ear, often associated with an upper respiratory tract infection. It presents as pain and decreased hearing. The pain is made worse by changes in pressure.

Through an otoscope, the eardrum will usually appear red, but if pus collects behind the drum it can look yellow. Sometimes the drum perforates and pus discharges, with loss of hearing but relief of pain.

Prescribe painkillers and a basic antibiotic such as amoxicillin or erythromycin. A decongestant such as oral pseudoephedrine or nasal drops may help to relieve Eustachian tube obstruction.

Very occasionally, severe cases of otitis media can be complicated by mastoiditis, which causes pain, tenderness, and inflammation over the mastoid process, the bony prominence immediately behind and below the pinna. High-dose oral or, ideally, IV antibiotics should be commenced and the patient evacuated for specialist care because there is a small risk that meningitis or cerebral abscess could develop.

Tympanic membrane rupture may be caused by direct trauma or associated with a base of skull fracture. Leakage of blood or clear fluid from the ear may indicate a serious injury ( Facial injuries, p. 302). The eardrum may also rupture as a result of barotrauma—especially during diving (see Barotrauma, p. 740). Most eardrum perforations heal spontaneously and do not require specific management. Avoid swimming until the hole has healed.

Inner ear barotrauma is unpleasant. It results from inner ear haemorrhage or a rupture of the oval window. Patients experience vertigo, hearing loss, and tinnitus. Evacuate for examination by an ENT surgeon.

On expeditions, these are most commonly insects that have crawled into the external canal. Insects should be drowned in oil and will usually float out. Other foreign bodies may require removal with suitable hooks. If difficulty is experienced in foreign body removal, do not persist at the expense of damage to the tympanic membrane or external canal.

Nose bleeds are quite common in expedition situations, and may be precipitated by the low humidity found at altitude, in cold climates, or aircraft cabin atmospheres. Other associations include direct trauma to the nose and upper respiratory tract infections. Ninety per cent are anterior and 10% are posterior.

First-aid measures are usually effective in controlling haemorrhage. Press on the soft part of the nose with a finger for 15 min. If simple pressure is unsuccessful, try cauterizing off any identified anterior bleeding points with a silver nitrate stick. Before cauterizing the vessel you should apply a topical local anaesthetic such as lidocaine and adrenaline. Look up the nose using a head torch and apply the cauterization stick to the bleeding point for no longer than 5s.

If cautery is not possible or is unsuccessful, then insert a commercially available nasal tampon. Such tampons should be lubricated before insertion. Once correctly positioned, expand the device by dropping saline from a syringe. Often both nostrils have to be packed. They are uncomfortable so prescribe painkillers. If nasal tampons are unavailable, then the nose can be packed with lubricated gauze or a small vaginal tampon.

Nasal packs can precipitate sinusitis and in the expedition setting amoxicillin should be prescribed. Leave the packs in place for 48 h and then remove them.

If bleeding continues despite insertion of a nasal tampon, it is probable that the bleeding point is in the posterior part of the nose. Remove the tampon and insert a deflated urinary catheter along the floor of the nose. Gently inflate the balloon with air and pull the catheter forward until resistance is felt. The pack or tampon should then be re-inserted.

A patient with a persistent nose bleed that does not respond to the measures described will have to be evacuated for further treatment and investigation which must include a blood count and clotting studies. Rarely, transfusion is required.

See Nasal fracture, p. 308.

Foreign bodies in the nose need to be removed as they may lead to infection or aspiration. Anterior foreign bodies can be removed with hooked implements or forceps using a head torch to look up the nose.

URTIs are very common and often originate before departure. The condition is usually self-limiting and requires only symptomatic treatment. Catarrh may block sinus openings and Eustachian tubes. Pressure differences during flight or ascent may cause ear or sinus pain, which may be severe. Nasal decongestants such as phenylephrine can help. Antibiotics may help if persistent sinus pain and tenderness suggests secondary bacterial infection.

Sore throats with painful swallowing are common in travellers, especially following air travel. The throat infection may be associated with fever and systemic upset. Most are viral in origin. Pus around the tonsils suggests bacterial infection but it is not usually possible to differentiate the two clinically.

Most cases of tonsillitis settle with time and analgesia. In the remote setting, if symptoms fail to improve after a few days then antibiotics should be prescribed. A suitable antibiotic for the most common bacterial pathogen, beta haemolytic Streptococcus, is co-amoxiclav 250/125mg three times a day for 7 days. This dose can be doubled if infection severe. Clarithromycin is an alternative in penicillin-allergic patients.

Quinsy causes severe unilateral throat pain and dysphagia, with associated pyrexia and systemic upset. Trismus (an inability to open the mouth due to pain) and drooling occur. The tonsil is swollen, inflamed, and deviated medially; the uvula is usually displaced away from the affected side. IV antibiotics are required. In the remote setting the abscess should be drained by needle aspiration rather than incision and drainage.

These are most commonly fish or chicken bones. The patient complains of pain, especially on swallowing. Foreign bodies stuck in the tonsil or base of the tongue can usually be seen and removed with forceps. If no foreign body is visible it is possible that it may simply have scratched the pharyngeal mucosa on passing. A foreign body stuck out-of-sight in the pharynx may become infected and abscesses can develop, so if symptoms persist the patient must be evacuated.

A list of additional drugs and equipment that may assist with ENT problems is given in Useful equipment and drugs for ENT problems, p. 810.