EENT emergencies Flashcards

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1
Q

Diff areas of epistaxis?

A
  • Keisselbach’s plexus: anterior

- sphenopalatine plexus: posterior

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2
Q

How should pt be sitting w/ epistaxis? Why?

A
  • should be sitting straight up - 90 degrees:
  • this decreases nasal arterial pressures
  • prevents aspiration
  • may have to modify if pt appears shocky
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3
Q

Sig of posterior bleed as opposed to anterior bleed?

A
  • distinguish b/t the 2: posterior won’t stop bleeding, anterior should be able to visualize
  • if packing and cauterization isn’t working: most likely a posterior bleed
  • posterior is more serious
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4
Q

Hx questions to ask pt w/ epistaxis?

A
  • one nare or both
  • sensation of blood in back of throat
  • hx of epistaxis, trauma, head/neck tumor, radiation or head/neck surgery
  • family hx of bleeding disorders
  • anticoag, NSAIDs, ASA?
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5
Q

Underlying causes of epistaxis?

A
  • nose picking
  • dryness
  • trauma
  • anticoag or ASA therapy
  • bleeding diathesis: heme (polycythemia, TTP, VW dz, hemophilia, aplastic anemia)
  • FB
  • allergies: nasal steroid use
  • ASA? and HTN?
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6
Q

Tx of epistaxis - step 1?

A

step 1: start w/ direct pressure:

  • compress nares b/t thumb and index finger or 2 tongue depressors taped together - for 20 minutes, have pt lead forward or sit upright
  • *this will have to effect on posterior bleeds
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7
Q

Step 2 tx of epistaxis?

A

if still bleeding after direct pressure:

  • apply a topical anesthetic+vasoconstrictor
  • commercial prep like Afrin and cotton balls soaked in lidocaine 2%
  • or make own by mixing 2% lidocaine and 1:1000 epi and soaking cotton balls in mixture
  • place impregnated cotton balls in nare x 10 min
  • remove cotton ball and evacuate clot (blowing or suction)
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8
Q

Step 3 tx of epistaxis?

A

determine site of bleeding:

  • you need good light, nasal speculum, suction, ENT chair and patience
  • many times site is determined by age:
  • kids - kiesselbach’s area - anterior
  • adults - generally posterior to kiesselbachs area
  • older adults - most difficult and often posterior
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9
Q

Step 4 tx of epistaxis?

A

cautery w/ silver nitrate stick:

  • if still bleeding and can visualize the bleeding area
  • apply pressure w/ silver nitrate for 5-10 sec
  • cauterize small area around bleeder as well
  • apply abx oitment to area
  • if this resolves the bleed then abx ointment for 7 days
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10
Q

Step 5 tx for epistaxis?

A

anterior packing:
- indicated if all measures up to this pt have failed
- can use nasal tampons or nasal balloon catheters
- apply topical anesthetic to nare
- apply surgical lubricant to packing
- insert along horizontal plane to max depth
- foam polymers may need water to expand, some devices may reqr inflation
- after care:
remove packing in 48-72 hrs, oral abx reqd, pt to remain upright (even sleeping) for 48 hrs, no lifting and avoid laughing for 24 hrs

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11
Q

if bleeding still exists after packing and cauterization what should you suspect?

A
  • posterior bleed

- consult ENT emergently

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12
Q

Tx of posterior epistaxis?

A
  • direct pressure is ineffective, nasal packs are uncomfortable to place, posterior packed pts are often admitted for observation
  • ENT consult is warranted
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13
Q

Complications of posterior epistaxis?

A
  • difficulty swallowing
  • otitis media
  • necrosis of nasal mucosa, TSS
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14
Q

Nasal fx: how is dx made? Management?

A
  • MC fx bone in face
  • dx based on Physical :
    nose usually edematous and tender, look for displacement, crepitus, epistaxis
  • inspection w/ nasal speculum mandatory to r/o septal hematoma
  • mangagement: closed reduction - 2-10 days post injury to allow for reduction of swelling
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15
Q

Complications secondary to nasal fx?

A
  • septal hematoma - complications -cause necrosis, perf septum - untx can lead to saddle nose
  • infection
  • obstructed airway from septal deviation
  • tx: drain hematoma
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16
Q

When you see septal hematoma what should you suspect as etiology? tx? Tip off that it is a cartilage fx?

A
  • adults: sig trauma and nasal fx
  • kids: can occur w/ simple falls or minor altercations
  • tx:
    drain and pack, abx (augmentin) if abscess suspected - IV clinda and admission
  • cartilage fx: tip off - formation of bilateral hematoma - ENT referral
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17
Q

Complications that occur from untx septal hematoma?

A
  • saddle nose deformity
  • septal abscess
  • septal perf
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18
Q

Presentation of external otitis?

A
  • aka swimmers ear: pseudomonas
  • edema, erythema of EAC w/ +/- exudate
  • must see TM (if not make sure you clean out ear so TM is visible - make sure not perf)
  • positive pinna tug
  • tx is generally application of wick and cortisporin otic, local heat, analgesia
  • have to r/o malignant otitis externa (goes intracranially - osteomyelitis) - need systemic tx: really painful, cellulitis
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19
Q

CNS origin of vertigo?

A
  • nystagmus: usually absent
  • hearing loss: rare
  • other neuro sxs: present
  • other sxs: rare
  • DDx:
    drug toxicity
    cerebellar stroke
    brain stem stroke
  • do neuro exam to diff from ear origin
20
Q

Ear origin - vertigo?

A
  • nystagmus: horizontal
  • hearing loss: usually present
  • other neuro sxs: absent
  • other sxs: N/V, sweating
  • DDx:
    menieres
    labrynthitis
    acoustic neuroma
    infectious
21
Q

What is meniere’s disease?

A
  • fluctuating, progressive, sensorineural deafness
  • episodic, characteristic definitive spells of vertigo lasting 20 min to 24 hrs w/ no unconscious, vestibular nystagmus always present
  • usually tinnitus
  • **tinnitus and hearing problems, episodic nystagmus
    tx: diuretics, low Na diet
22
Q

What is acute labyrinthitis? Recovery time?

A
  • infection in labyrinth (usually viral, may follow URI)
  • recovery generally takes 1-6 wks
  • an acute period, which may include severe vertigo and vomiting
  • approx 2 wks of sub acute sxs and rapid recovery
  • chronic compensation: may last for months - yrs
23
Q

What is BPV?

A
  • otoliths out of place
  • perform epley maneuver to move them back
  • also give antiemetics (zofran, anticholinergics - meclizine)
24
Q

Characteristics of acute tonsilitis? Tx?

A
  • signs and sxs: fever, beefy red tonsils w/ exudate, adenopathy common
  • r/o peritonsilar abscess (uvula deviation)
  • difficult to diff viral vs strep
  • bacterial is usually caused by strep
  • rapid strep helpful for cases that you suspect may be viral otherwise just tx
  • watch for atypical resistant infection: GC pharyngitis
  • sx tx, fluids, rest, ibuprofen for pain and swelling, steroid burst pack - if pts can’t swallow
  • for strep - PCN, amoxicillin, cephalexin, azithro
25
Q

Centor criteria - more likely to be bacterial?

A
  • need abx if 3 or more +:
  • tonsillar exudates
  • tender cervical LA
  • fever or hx of
  • no cough
26
Q

What is epiglottitis? presentation?

A
  • infection/inflammation of epiglottitis and surrounding soft tissue
  • present w/: hot potato voice, stridor, tripod or sniffing position, drooling
  • x ray: thumb print sign
  • pathogens: H flu, strep pneumo, staph, M cat
  • usually seen in kids
  • if you suspect - stop and don’t examine - obtain soft tissue lateral neck xray and call ENT/peds
  • tx w/ rocephin, if concern for MRSA add vanco or clindamycin, MRSA - will look more toxic, more systemic sxs
27
Q

Presentation of peritonsillar abscess? Dx, tx?

A
  • severe pain, hoarseness, hot potato voice, drooling, dysphagia, cervical lymphadenopathy, fever, sfot palate bulging and uvula deviating away
  • CT of neck is dx Test of choice
  • call ENT to eval and take to OR for I and D, usually strep- start IV abx
  • drain abscess is tx
  • after drainage: high dose PCN, augmentin, or clindamycin for PCN allergic pts
28
Q

Characteristics of croup?

A
  • airway infection caused by virus (parainfluenza, RSV, influenza A, B)
  • MC in kids 3 m- 3 years
  • hoarse, barking cough
  • tx: racemic epi and call pediatrician
  • dexamethasone is usually effective for decreasing swelling of airway
    warning: they usually have other viral sxs: so be careful to not miss inhaled FOB
29
Q

What is ludwig’s angina?

A
  • cellulitis of sublingual and submandibular areas that is usually caused by normal mouth flora
  • most often in pts w/ poor dental hygiene or after dental procedures
  • can be life threatenign: airway obstruction, sepsis, or extension of infection into mediastinum
  • submandibular pain, swelling, trismus, and dysphagia
  • sublingual and submandibular tissues markedly swollen w/ woody appearance (tense)
  • tongue is pushed superiorly and posteriorly
  • ant/lat neck swollen and indurated: bull’s neck
  • tx: refer - surgery: drain and abx
30
Q

Dental emergencies - management?

A
  • pts will present w/ acute dental pain
  • only ED tx really available is analgesia, and abx
  • can do apical dental blocks
  • know who to refer to
31
Q

Ocular conditions that reqr immediate rx?

A
  • acute angle closure glaucoma
  • occlusion of central retinal artery (CRAO)
  • orbital cellulitis
  • retinal detachment
  • always test visual acuity first and document this!
32
Q

Presentation of acute angle closure glaucoma?

A
  • sudden increase in IOP due to blockage of outflow channels by iris root
  • increase in IOP leads to intraocular venous insufficiency w/ ischemia to retina/optic nerve
  • severe pain, halos around lights, blurred vision, photophobia, and N/V
  • affected eye is red, nonreactive midrange (often irregular) pupil, hazy cornea, shallow anterior chamber angle
  • ophtho Emergency!!! call ASAP
33
Q

Presentation of CRAO?

A
  • MC embolic in origin (carotid artery plaque or endocardial vegetation)
  • retina is completely w/o blood and will die in 30-60 min
  • sudden, painless, unilateral vision loss usually in older pt
  • pallor of optic disc, edema of retina, cherry red fovea, boxcar segmentation of retinal veins
  • ophtho emergency: call ASAP
34
Q

Cause of orbital cellulitis? Spread? Hx? Presentation? Tx?

A
  • acute infections of orbital tissues: usually Strep pneumo, staph, or H flu
  • starts in ethmoid sinus and infection spreads into subperiosteal lining of orbit through ehtmoid bone
  • usually hx of sinusitis or trauma to orbital area
  • periorbital edema, some degree of exophthalmos, limitation in cardinal fields of gaze
  • EOMs will be painful, red flag: can’t open eye lid
  • disk margins may be blurred, WBC is elevated and fever is probably present
  • CT scan will confrim
  • Ophtho urgency!
35
Q

Characteristics of retinal detachment? Fundoscopic findings?

A
  • actual separation of neurosensory layer from retinal pigment epithelium
  • may become bilateral in 25%, more common in older pts and those who are myopic
  • painless decrease in vision w/ flashes of light and sparks, may be described as curtain dropping
  • may have floaters or flashing lights that precede vision loss
  • IOP is normal or low
  • detached retina appears gray w/ white folds
  • admit, bilateral patch, and ophtho consult urgently
36
Q

Presentation of viral conjunctivitis?

A
  • itching: minimal
  • hyperemia: generalized
  • tearing: profuse
  • exudation: minimal
  • preauricular adenopathy: common
  • in stained scrapings and exudates: monocytes
  • assoc sore throat and fever: occasionally
37
Q

Presentation of bacterial conjunctivitis?

A
  • itching: minimal
  • hyperemia: generalized
  • tearing: moderate
  • exudation: profuse
  • preauricular adenopathy: uncommon
  • in stained scrapings and exudates: bacteria, PMNs
  • assoc sore throat and fever: occasionally
38
Q

Presentation of chlamydial conjunctivitis?

A
  • itching: minimal
  • hyperemia: generalized
  • tearing: moderate
  • exudation: profuse
  • preauricular adenopathy: common only in inclusion conjunctivitis
  • in stained scrapings and exudates: PMNs, plasma cells inclusion bodies
  • assoc sore throat and fever: never
39
Q

Presentation of allergic conjunctivitis?

A
  • itching: severe
  • hyperemia: generalized
  • tearing: moderate
  • exudation: minimal
  • preauricular adenopathy: none
  • in stained scrapings and exudates: eosinophils
  • assoc sore throat and fever: never
40
Q

Tx of bacterial conjunctivitis?

A
- non contact wearers:
erythromycin
trimethoprim-polymyxin
- contact wearers (worried about ulcer - pseudomonas):
ofloxacin
ciprofloxacin
41
Q

Tx of viral and allergic conjunctivitis?

A
- viral:
antihistamine/decongestant drops
- allergic:
antihistamine/decongestant drops
mast cell stabilizer/antihistamine drops
42
Q

Sxs of fb? Dx, tx?

A
  • take careful hx
  • sxs: pain, tearing, redness, corneal abrasion
  • dx:
    slit lamp or fluoroscein stain
  • r/o intraocular FB
  • tx: removal, topical abx, may need oral pain meds
43
Q

Corneal abrasion:

sxs, dx, tx?

A
  • get good hx
  • sxs: eye pain, photophobia
  • dx: fluoroscein stain
  • beware of white infiltrates or dendritic lesions: infection or herpes
  • tx:
    topical abx (cipro, erythromycin, polytrim)
  • PO pain meds for a day
44
Q

Vision in acute glaucoma? Presentation?

A
  • markedly blurred
  • can have photophobia
  • steamy cornea
  • pupil is mid-dilated, fixed and irregular
  • NO pupillary light response
45
Q

Presentation of iritis?

A
  • severe photophobia
  • circumcorneal ciliary injection
  • pupil is constricted while in acute glaucoma it is mid-dilated
  • IOP is normal
  • poor pupillary light response
  • tx with paralytic