CPEN Maxillofacial, Ocular, and ENT Emergencies — Questions and Answers
Question 1: A child presents after a chemical splash to the eye. The parent is unsure of the substance. What is the emergency nurse's first priority intervention?
- Identify the exact chemical before beginning treatment
- Immediately irrigate the eye with copious normal saline or water (Correct answer)
- Apply antibiotic ointment to prevent secondary infection
- Patch both eyes and arrange immediate ophthalmology consultation
Correct answer: Immediately irrigate the eye with copious normal saline or water
Immediate, copious eye irrigation is the priority for any chemical ocular injury — particularly alkaline substances, which penetrate deeply and cause progressive damage. Irrigation must begin before identifying the specific chemical, as any delay worsens outcomes. After irrigating to pH 7.0–7.4, further assessment and specialist consultation follow.
Question 2: A 4-year-old presents with ear pain after swimming. Examination reveals intense pain when the pinna is moved, an edematous external auditory canal, and purulent discharge. The tympanic membrane appears intact. What is the most likely diagnosis?
- Acute otitis media
- Otitis externa (Correct answer)
- Mastoiditis
- Cholesteatoma
Correct answer: Otitis externa
Otitis externa ('swimmer's ear') is an infection of the external auditory canal, commonly caused by Pseudomonas aeruginosa. The hallmark finding is pain exacerbated by traction on the pinna or pressing the tragus, with an intact tympanic membrane. Otitis media involves the middle ear and does not cause tragal tenderness.
Question 3: A 7-year-old presents with a 2-day history of fever, periorbital swelling, proptosis, pain with eye movement, and limited extraocular motility. What is the most serious diagnosis to suspect?
- Preseptal (periorbital) cellulitis
- Orbital cellulitis (Correct answer)
- Allergic conjunctivitis
- Hordeolum (stye)
Correct answer: Orbital cellulitis
Orbital cellulitis is a sight- and life-threatening emergency involving infection posterior to the orbital septum. Key distinguishing features from preseptal cellulitis are proptosis, pain and limitation with eye movement, and potential decreased visual acuity. Preseptal cellulitis is anterior to the septum and does not cause these findings. Orbital cellulitis requires urgent IV antibiotics and CT imaging.
Question 4: A 3-year-old is brought to the ED after a caregiver witnessed the child insert a small bead into the nostril. The child is comfortable and breathing normally. Which technique is the appropriate first-line approach for removal?
- Immediate procedural sedation and forceps removal
- Vigorous nasal irrigation with normal saline
- Occlude the unaffected nostril and have the parent deliver a short puff of air into the child's mouth ('mother's kiss') (Correct answer)
- Refer to ENT for outpatient removal in 48–72 hours
Correct answer: Occlude the unaffected nostril and have the parent deliver a short puff of air into the child's mouth ('mother's kiss')
The 'mother's kiss' technique — where positive pressure is delivered into the child's mouth while the unaffected nostril is occluded — is a safe, effective first-line method for anterior nasal foreign bodies in cooperative children. It avoids procedural sedation and has high success rates. Vigorous irrigation risks pushing the object further back and risks aspiration.
Question 5: A child struck by a ball presents with periorbital ecchymosis, numbness in the cheek and upper teeth, and diplopia on upward gaze. Which injury does this presentation most suggest?
- Zygomatic arch fracture
- Orbital floor (blowout) fracture (Correct answer)
- Mandibular fracture
- Nasal bone fracture
Correct answer: Orbital floor (blowout) fracture
An orbital floor (blowout) fracture occurs when blunt orbital trauma forces the orbital floor into the maxillary sinus. Entrapment of the inferior rectus muscle causes restricted upward gaze and diplopia. Infraorbital nerve involvement produces numbness along the cheek and upper dentition. CT of the facial bones confirms the diagnosis.
Question 6: A 9-year-old presents with epistaxis that has not resolved after 20 minutes of continuous direct anterior pressure. What is the next most appropriate intervention?
- Immediate posterior nasal packing
- Apply a topical vasoconstrictor such as oxymetazoline and reassess (Correct answer)
- Order CT of the sinuses to identify a bleeding source
- Administer IV fresh frozen plasma for presumed coagulopathy
Correct answer: Apply a topical vasoconstrictor such as oxymetazoline and reassess
After 20 minutes of direct anterior pressure fails, the next step is application of a topical vasoconstrictor (oxymetazoline or phenylephrine), which constricts the bleeding vessel. Posterior packing is reserved for refractory posterior bleeds and carries risks including hypoxia. CT and FFP are not indicated in uncomplicated epistaxis without evidence of coagulopathy.
CPEN Maxillofacial, Ocular, and ENT Emergencies
A child presents after a chemical splash to the eye.
The parent is unsure of the substance.
What is the emergency nurse's first priority intervention?