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Emergency Medicine - BT > Ch 19. HEENT > Flashcards

Ch 19. HEENT Flashcards

1
Q

Which bones border the orbit (4) and which is the most likely to break? (4+1)


A
  1. Superior – frontal sinus

  2. Medially – ethmoid sinus

  3. Inferior – maxillary sinus
    
4. Laterally – zygomatic bone
*
    The ethmoid bone (lamina papyracea) is paper thin and most likely to break in blunt eye trauma* 

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2
Q

A history of sudden painless vision loss is ________ until proven otherwise (1)


A
  1. Central retinal artery occlusion (stroke – think AFib, carotid stenosis)

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3
Q

Which cranial nerves control EOM? (3)


A
  1. Superior oblique (CN IV) – moves the eye down and in

  2. Lateral rectus (CN VI)

  3. Everything else is CN III
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4
Q

What does a Marcus-Gunn pupil mean? (1)


A
  1. A RAPD (swinging light test) tells you that light isn’t getting to the optic nerve, or the optic nerve isn’t working.
    * Think optic neuritis, central retinal artery occlusion, retinal hemorrhage or detachment *

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5
Q

Define hypopyon, hyphema, flare, seidel test (positive) (4)

A
  1. Hypopyon – a layer of WBC in the anterior chamber
  2. Hyphema – a layer of blood in the anterior chamber
    
3. Flare – cells visible in the anterior chamber (usually clear) – anterior uveitis!

  3. Seidel test – aqueous humour waterfalls down a full thickness corneal wound

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6
Q

What is normal IOP and what is associated with AACG? (2)


A
  1. Normal IOP 10-20mm Hg


2. AACG IOP >30, often >50


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7
Q

Chalazion vs hordeolum (2)

A
  1. Chalazion – acute/chronic blockage of a Meibomian oil gland. Painless lump. Refer to optho.
    
2. Hordeolum (stye) – Staph infection of an eyelash follicle. Rx warm compress, erythro ointment. 

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8
Q

Red eye DDx (10)


A
  1. Conjunctivitis (viral, allergic, bacterial)
    
2. Corneal abrasion – scratch to the cornea
    
3. Corneal ulcer – bacterial infection of the cornea

  2. Corneal foreign body – foreign body to cornea

  3. Keratitis – mild pain (unless UV keratitis)

  4. Scleritis – severe pain

  5. Subconjunctival hemorrhage – painless, normal VA

  6. Iritis/uveitis – pain, photophobia, decreased VA, watery discharge, pupil constricted, flare, 

  7. AACG – severe pain, HA, N/V, decreased VA, cloudy cornea

  8. Endopthalmitis – infection of the globe. Ocular pain, photophobia, fever, decreased VA, purulent discharge, flare.
    
11. Preseptal cellulitis – mild pain, fever, normal VA

  9. Orbital cellulitis – severe eye pain, pain with eye movement, fever, decreased VA (LATE)
    
13. Chemical burn – chemical exposure.
  10. Hordeolum/Chalazion – mild pain. Normal VA.
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9
Q

Differences between periorbital cellulitis and orbital cellulitis (2)
How do you know when an orbital cellulitis evolves to cavernous sinus thrombosis? (1)


A
  1. Periorbital cellulitis – often peds. Staph, strep. Eye not involved (full + Painless EOM). Rx clavulin
    
2. Orbital cellulitis – bacterial infection of the orbit. Pain with EOM. Decreased VA. Proptosis.
Often results from spread of paranasal sinusitis through the ethmoid sinus (thin). Polymicrobial – staph, strep, anaerobes. Admit for IV antibiotics. CT orbit. Consult optho. Ceftriaxone flagyl.
    
3. Suspect cavernous sinus thrombosis with cranial nerve involvement (3-4-6)

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10
Q

Aggressive facial infection in diabetics (1)


A
  1. Mucormycosis

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11
Q

Can’t miss eye infections of the neonate (3)


A
  1. Gonococcal conjunctivitis

  2. Chlamydial conjunctivitis

  3. HSV keratitis

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12
Q

Treatment of bacterial conjunctivitis, with and without contacts (2)


A
  1. No contacts – erythromycin ointment


2. Contacts - erythromycin ointment or moxifloxacin ointment


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13
Q

Dx and treatment of HSV keratoconjunctivitis, Herpes zoster opthalmicus (4)


A
  1. HSV keratoconjunctivitis – red eye, + dendrites with fluorescein. Rx Valacyclovir PO and topical. Consult optho and FU 24 hours. 

  2. Herpes zoster opthalmicus – shingles of V1. + Hutchinson sign (lesion on tip of nose). Rx valacyclovir. Consult optho.
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14
Q

Clinical findings in iritis/uveitis (4). DDx of iritis/uveitis (5)


A
  1. Iritis/uveitis is inflammation of the anterior eye. Sign/Sxs: painful, photophobia, perilimbal flush, +flare and cells, +consensual photophobia.
    

    DDx iritis/uveitis:
    
1. Systemic disease: JRA, Ank Spond, Ulcerative colitis, Reactive arthritis, Sarcoidosis, Behcet’s

  2. Infectious: TB, lyme, HSV, VZV, toxoplasmosis, syphilis

  3. Malignancy: leukemia, lymphoma, melanoma

  4. Trauma: blunt trauma, corneal foreign body, UV/chemical exposure

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15
Q

Q. What is the Dx?

1. Sudden painless vision loss immediate and over hours (2)

2. Sudden painless vision loss with black spots, haziness, and cobwebs

3. Trauma with decreased VA and shallow anterior chamber

4. Trauma with resulting restriction to upward or lateral gaze
5. Trauma with hyphema

6. Trauma with eye pain and elevated IOP

7. Sudden onset of eye pain, HA, V, with a fixed midposition pupil, cloudy cornea, conjunctivitis

8. Sudden painless vision loss with a blood and thunder fundus

9. Sudden onset flashers and floaters (DDx 2)

10. Transient vision loss with headache, jaw claudication, myalgia, fever


A
  1. Sudden painless vision loss = central retinal artery occlusion - immediate, or optic neuritis (hours-day). Consult neurology/optho immediately. Treatment is unclear ?maybe tPA. 

  2. Sudden painless vision loss with black spots, haziness, and cobwebs = vitreous detachment/hemorrhage
    
3. Trauma with decreased VA and shallow anterior chamber = ruptured globe (also look for abn pupil shape, RAPD, hyphema, + Seidel test. Dx. CT. Rx tetanus and ceftriaxone, consult optho. 

  3. Trauma with resulting restriction to upward or lateral gaze = blowout fracture with entrapment. Rx Keflex consult optho/plastics for repair. 

  4. Trauma with hyphema = traumatic hyphema is ruptured uvea. CT orbits. Consult optho.

  5. Trauma with eye pain and elevated IOP (and proptosis) = post-septal hemorrhage or retro-bulbar hematoma. IOP >40mm Hg = emergency lateral canthotomy. Consult optho.

  6. Sudden onset of eye pain, HA, V, with a fixed midposition pupil, cloudy cornea, conjunctivitis = AACG. Measure IOP (elevated IOP >30, especially >50 is a medical emergency)

  7. Sudden painless vision loss with a blood and thunder fundus = central retinal vein occlusion. Consult neuro/optho.
    
9. Sudden onset flashers and floaters (DDx 2)=retinal detachment or vitreous detachment. Beside US and refer to optho.

  8. Transient vision loss with headache, jaw claudication, myalgia, fever = temporal arteritis. Start steroids. The biopsy will be positive for a week after steroids.
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16
Q

Treatment of AACG (4)


A
  1. IV mannitol 1g/kg IV
    
2. Topical beta blocker (blocks aqueous humor production)

  2. Topical alpha-2 agonist (blocks aqueous humor production)

  3. Carbonic anhydrase inhibitor, acetazolamide 500mg IV (blocks aqueous humor production)

  4. Topical pilocarpine 1% one drop q15min – facilitates outflow of aqueous humor

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17
Q

Indications for eyelid laceration referral to ophthalmology (5)


A
  1. Involve lid margin

  2. Within 8mm of the medial canthus

  3. Involve the lacrimal duct
    
4. Ptosis
    
5. Involves tarsal plate
* Have a high suspicion for underlying corneal laceration and globe rupture 

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18
Q

Chemical ocular injury management (4)


A
  1. Irrigate eye with 1-2L NS continuously (topical anaesthetic PRN)
    
2. Test the eye pH: if pH >7.4 continue irrigation until pH is less than 7.4

  2. Document VA and measure IOP

  3. Consult opthomolagy

  4. Rx tetanus IM and erythromycin ointment
* Alkali (base) injuries are worse than acid, especially lye and ammonia
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19
Q

Define amaurosis fugax (1)


A
  1. Amaurosis fugax: transient monocular blindness from transient retinal ischemia

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20
Q

What is the difference between binocular floaters and monocular floaters (1)


A
  1. Binocular = brain (ex ophthalmic migraine), monocular = eye.

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21
Q

Treatment of Bell’s Palsy (3)


A
  1. Prednisone 50mg daily for 6 days, then a 10 day taper

  2. Val-acyclovir 1000mg PO TID 10 days

  3. Eye drops, and tape eye shut during sleep
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22
Q

What is Genu VII Bell’s Palsy (1)


A
  1. Genu VII Bell’s Palsy: a stroke masquerading as a CN VII Bell’s Palsy, but the patient cannot ABDUCT the eye.

    * Do EOM testing in all Bell’s Palsy patients.

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23
Q

Dx: pupil down and out (1)


A
  1. Pupil down and out = CN III palsy (with pupil dilatation) is a posterior communicating artery aneurysm until proven otherwise. Urgent CT/CTa and neurosurgery.

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24
Q

Horner’s syndrome (3)

Acute horner’s syndrome workup (2)


A
  1. Ptosis

  2. Miosis (pupil constriction)

  3. Anhydrosis
    *From loss of sympathetic fibres *
    Horner’s workup:
    
1. CXR (?chest mass)

  4. CT-angio arch to vertex (stroke, carotid dissection, tumors, lymphoma)
25
Q

Dx: headache, nausea, blurry vision, and diplopia on lateral gaze (from CN VI palsy) (1)


A
  1. Pseudotumor cerebri (idiopathic intracranial hypertension)
- Perform LP, record opening pressure. Rx acetazolamide 500mg BID- monitor visual fields

26
Q

Weber and Rinne test (2)


A
  1. Weber – vibrating tuning fork to head. Should be equal. If it localizes there is conductive hearing loss to that ear, or sensorineural loss to the other ear. 

  2. Rinne – place a vibrating tuning fork beside the ear, and on the mastoid. It should be heard better through the air. If it is heard better through the mastoid there is conductive hearing loss on that ear. 

27
Q

Treatment of otitis externa (1)


A
  1. Ciprodex drops BID. Safe with perforation. Covers staph and pseudomonas.

28
Q

Dx and management of malignant otitis externa (2)


A
  1. Dx Otitis externa resistant to 2 weeks of conventional therapy. Severe otalgia. Edema ot the external canal. Otorrhea. Trismus. Fever. Toxic.

  2. Tm. PipTazo Vanco. CT. ENT consult. 

29
Q

Treatment of adult otitis media (1)

A
  1. No watch and wait. Just treat. Amoxil 1000mg po BID 7/7
- If they appear septic admit for CT and tympanocentesis and IV antibiotics
- These patients need close FU for possibility of occult malignancy occluding the Eustachian tube. 

30
Q

Complications of otitis media (4)


A
  1. Rupture of the tympanic membrane

  2. Mastoiditis – spread of infection to mastoid air cells. Post-auricular erythema, swelling, pain, protrusion of the ear forward. CT scan and IV ceftriaxone. Consult ENT.
  3. Meningitis

  4. Brain abscess

  5. Lateral sinus thrombosis – headache, papilledema, CN VI palsy. Need a CT-angio venous phase. Antibiotics. Consult ENT.
31
Q

Define trigeminal neuralgia, drug therapy for management (2)


A
  1. Trigeminal neuralgia – severe intermittent, seconds of pain in the CN V distribution

  2. Rx carbamazepine

32
Q

Vascular source of bleeding in anterior and posterior epistaxis (2)


A
  1. Anterior epistaxis = Kiesselbach plexus (Little’s area)


2. Posterior epistaxis = Sphenopalatine artery

33
Q

Treatment options for anterior epistaxis (6)


A
  • Start by blowing nose to expel the clot

    1. Direct pressure 20 minutes

    2. Topical metalazone
    
3. Topical phenylephrine

    4. Topical cocaine

    5. Cautery with silver nitrate
    
6. TXA soaked pledget

    7. Gelfoam or surgical

    8. Anterior nasal packing (rhinorocket)

34
Q

Treatment of displaced nasal fractures in peds and adults (2)


A
  • CT only if concern for intracranial injury or other facial bone fractures. Radiographs don’t change management in isolated nasal fractures. Check for nasal obstruction or septal hematoma.
    
1. If the patient presents immediately, without edema and swelling, attempt reduction

    2. If the landmarks are displaced refer for ENT FU in 2-4 days (Peds – rapid healing) or 6-10 days (adults) 

35
Q

Treatment of nasal septal hematoma (3)


A
  1. Anesthetize with cotton pledgets with 4% lidocaine +/- topical vasoconstrictor

  2. Incise, drain the clot
    
3. Bilateral nasal packing with topical antibiotic ointment

  3. FU ENT 1-2 days
36
Q

Treatment of rhinosinusitis (3), and indication for antibiotics (1)


A

Rhinosinusitis: nasal congestion/discharge, facial pain, decreased smell, tooth pain, >7days


  1. Nasal saline irrigation

  2. Topical decongestant oxymetallazone (only 3 days to avoid rebound)

  3. Topical corticosteroid spray


Antibiotics are only for:

1. Purulent secretions, severe symptoms, toxic, >7days

2. Amoxil 1000mg PO TID

37
Q 
Define clinically: (6)
1. Cellulitis to the submandibular space

2. Cavernous sinus thrombosis

3. Lemierre’s syndrome

4. Peritonsillar abscess

5. Epiglottitis

6. Retropharyngeal abscess

A
  1. Cellulitis to the submandibular space = Ludwig’s angina
    
2. Cavernous sinus thrombosis = infection of infra-orbital space with meningeal signs, sepsis, coma

  2. Lemierre’s syndrome = worsening strep pharyngitis, neck swelling – suppurative 
thrombophlebitis of the internal jugular vein

  3. Peritonsillar abscess = sore throat, fever, trismus/muffled voice – deviation of the uvula ** 90% are treated effectively by needle aspiration. I + D unnecessary. Rx Pen + Flagyl

  4. Epiglottitis – sitting up, toxic, drooling, sniffing position, stridor. Clinical Dx, confirmed by Xray (thumb-print sign). Rx Ceftriax + Vanco 15mg/kg BID + Methylpred 125mg IV

  5. Retropharyngeal abscess = appear toxic, stridor, neck swelling, trismus. Rx airway control, CT, PipTazo (polymicrobial). Often arise from odontogenic dental abscess – especially the molars. 

38
Q

Ellis classification of dental fractures (3)


A
  1. Ellis I – just enamel (white) – refer to dentistry

  2. Ellis II – enamel and dentin (yellow) – cover with glue/cement and refer to dentistry

  3. Ellis III - down to the pulp (red) – cover with glue/cement and refer to dentistry, Rx penicillin

39
Q

Treatment of tooth avulsion (1)


A
  1. Reimplantation at the scene (not in a child or altered LOC with aspiration risk)

  2. Option 2 – wrap in saline moistened gauze, keep cool. Replant when possible.
*If the tooth is not recovered do radiographs to check for aspiration
40
Q

Branches of the trigeminal nerve, sensory innervation, and how to block them (3)


A
  1. Opthalmic – supraorbital nerve block above the eye
    
2. Maxillary – infraorbital nerve blocki below the eye through the gingiva

  2. Mandibular – inferior alveolar nerve block by jaw
* A supraperiosteal block works as well – the cortical bone near teeth allows anaesthetic to diffuse to the tooth. 

41
Q

Centor criteria for strep pharyngitis (5)
Treatment of strep pharyngitis (1)
Why do we treat Strep pharyngitis (1)?

A
  1. Age 3-14
  2. Tonsillar exudates

  3. Cervical adenopathy

  4. Fever

  5. No cough

    * If 2 or more, send for culture. 
1.
  6. Treatment of strep pharyngitis: penicillin VK 600mg po BID 10/7
2. Dexamethasone 10mg PO x1 improves symptoms


1. Why do we treat Strep: improves resolution by 1 day, prevents rheumatic fever, but not glomerulonephritis
 or local complications

42
Q

DDx adult neck mass (5)


A
  1. Cervical lymph node

  2. Cancer (majority of masses present >6weeks are malignant – often SCC)

  3. TB
4. Hematoma
    
5. Lymphoma
    
6. Thyroid mass

43
Q

When does post-tonsillectomy bleed occur (1)


A
  1. Most occur at day 5-10 when the clot dislodges


Rx. Apply direct pressure. Airway control. Blood transfusion. Consult ENT.

44
Q

What are the bad tracheostomy bleeds (2) and treatment of tracheostomy site bleeding (3)


A
  1. Tracheoinnominate artery fistula

  2. Tracheal-thyroid vessel erosion


Treatment of tracheostomy site bleeding:

1. Hyper-inflate the cuff

2. Use an endotracheal tube inflated BELOW the level of the bleeding (you need a bronchoscope inside the tube)

3. Utley maneuvre: apply direct pressure to the site

45
Q

When should you avoid changing a tracheostomy tube? (1)


A
  1. Avoid changing the tube <7days, because the tract is not mature, and you can create a false passage
46
Q

Signs/Sx of acute angle closure glaucoma (5)


A
  1. Headache or eye pain

  2. N+V

  3. Blurry vision (halos seen around lights)

  4. Photophobia
    
5. Visual loss

  5. Pupil fixed and mid-dilated

  6. Elevated IOP (>21, in reality >40)
    
Risk factors=elderly, far-sighted, anti-cholinergics, anti-depressants/psychotics

    Pathophysiology: the aqueous fluid in the anterior humour cannot exit, because the angle closes too acutely, and the pressure builds up.

47
Q

Treatment of acute angle closure glaucoma (3)


A
  1. Beta blocker (Timolol) – decrease production of aqueous humour
    
2. Acetazolamide 500mg IV (Diamox)
    
3. Topical cholinergic (Pilocarpine) 1-2drops
    
4. Mannitol only if the above do not work

  2. Laser iridotomy as surgical rescue
    *Check IOP qHourly
48
Q

Anterior uveitis / iritis signs and symptoms (5)


A
  1. Deep aching pain, and no relief with topical anaesthetic 

  2. Pain with eye movements

  3. PHOTOPHOBIA

  4. Consensual photophobia
  5. Slit lamp cells and flare, or hypopyon
    * Uveal tract= iris, ciliary body, choroid
Treatment=cyclopegic drops to dialate the pupil
49
Q

Significance of a hypopyon after cataract surgery (1)


A
  1. A layer of inflammatory cells. Usually means endopthalmitis. BAD. 

50
Q

DDx Painless loss of vision (4)


A
  1. Central retinal artery occlusion – sudden painless visual loss. RAPD. Blanched, non-perfused retina. Cherry red spot. Rx. ASA, discuss with stroke/optho. Think temporal arteritis. 

  2. Central retinal vein occlusion – “DVT of the eye”. More gradual VA loss. Blood and thunder fundus. 

  3. Migraine

  4. Retinal detachment/hemorrhage

  5. Optic neuritis (usually painful)

51
Q

DDx Painful loss of vision (4)


A
  1. Acute angle closure glaucoma – check the pressure
    
2. Endopthalmitis (recent FB or surgery?)
    
3. Anterior uveitis

  2. Optic neuritis

52
Q

DDx flashers and floaters (4)


A 
1. Posterior vitreous detachment

2. Retinal detachment

3. Vitreous hemorrhage

4. Macular degeneration

5. Ocular migraine

53
Q

Symptoms of temporal arteritis (5)


A
  1. Age over 50

  2. New headache
    
3. Tenderness to temporal artery (best)

  3. ESR>50, CRP positive

  4. Positive US or Bx

  5. Jaw claudication (very specific)

  6. Diplopia (very specific)

  7. B symptoms: low grade fever, anorexia, fatigue, myalgia, night sweat, weight loss)

    Rx. IV steroids if ocular Sx. PO steroids for everyone else. Get steroids in early – before Bx! 

    Dx. US. (Studies show it is better than Bx!!)

54
Q

Triad of optic neuritis (3)


A
  1. Decreased VA (20/200)

  2. Eye pain (worse with EOM)

  3. Washed out colors “Dyschromotropsia” 

    “The patient sees nothing, and you see nothing on exam”, but + RAPD

    Rx. IV methylpred 250mg QID x3days, then taper over 1week. Consult optho.
55
Q

DDx RAPD (5)


A
  • Anything that stops light from getting to the nerve, or stops the nerve from sensing

    1. Vitreous hemorrhage

    2. Retinal detachment
    
3. Lens dislocation

    4. Optic neuritis
    
5. Retrobulbar hemorrhage
    
6. CRAO
56
Q

Treatment of conjunctivitis (1) and with contact lens use (1)


A
  1. Conjunctivitis = erythromycin ointment, or ciprofloxacin drops
    
2. Conjunctivitis + contact lens use = moxifloxacin

    AND: 
Ciloxin ointment QHS

    Over-the-counter lubricating eye drops

    Use ointment in kids and elderly because it lasts longer

57
Q

Treatment of hordeolum, chalazion (2)


A
  1. Hordeolum (stye) = infection at the eyelid margin (internal or external).
    Rx. Tobradex ointment. +/- Keflex if severe. 

  2. Chalazion = chronic, sterile, non-tender inflammation of Meibomian gland.
    Rx Warm compresses
-Refer if these are chronic (optho can excise them)

58
Q

Blunt ocular trauma: you must rule out four bad diagnoses (4)


A
  1. Retrobulbar hematoma with compartment syndrome

  2. Hyphema

  3. Retinal detachment

  4. Globe rupture

    Every ocular patient needs a VA, IOP (not if suspect globe rupture), test EOM, ?RAPD,
    
    Orbital compartment syndrome (elevated IOP) is a clinical Dx. Requires lateral canthotomy.

59
Q

Management of traumatic hyphema (3)


A
  1. Measure IOP. The RBC can block the trabecular meshwork, leading to traumatic acute glaucoma

  2. Reverse coagulopathy. Consider TXA 1g PO TID

  3. Check for cells and flare (these are RBC)

  4. Acute glaucoma needs to be managed with timolol, acetazolamide, pilocarpine, +/- mannitol


Emergency Medicine - BT (16 decks)

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