EENT emergencies

Question 1

Diff areas of epistaxis?

Answer 1

• Keisselbach’s plexus: anterior

- sphenopalatine plexus: posterior

Question 2

How should pt be sitting w/ epistaxis? Why?

Answer 2

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

Question 3

Sig of posterior bleed as opposed to anterior bleed?

Answer 3

• 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

Question 4

Hx questions to ask pt w/ epistaxis?

Answer 4

• 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?

Question 5

Underlying causes of epistaxis?

Answer 5

• 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?

Question 6

Tx of epistaxis - step 1?

Answer 6

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

Question 7

Step 2 tx of epistaxis?

Answer 7

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)

Question 8

Step 3 tx of epistaxis?

Answer 8

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

Question 9

Step 4 tx of epistaxis?

Answer 9

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

Question 10

Step 5 tx for epistaxis?

Answer 10

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

Question 11

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

Answer 11

• posterior bleed

- consult ENT emergently

Question 12

Tx of posterior epistaxis?

Answer 12

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

Question 13

Complications of posterior epistaxis?

Answer 13

• difficulty swallowing
• otitis media
• necrosis of nasal mucosa, TSS

Question 14

Nasal fx: how is dx made? Management?

Answer 14

• 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

Question 15

Complications secondary to nasal fx?

Answer 15

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

Question 16

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

Answer 16

• 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

Question 17

Complications that occur from untx septal hematoma?

Answer 17

• saddle nose deformity
• septal abscess
• septal perf

Question 18

Presentation of external otitis?

Answer 18

• 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

Question 19

CNS origin of vertigo?

Answer 19

• 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

Question 20

Ear origin - vertigo?

Answer 20

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

Question 21

What is meniere’s disease?

Answer 21

• 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

Question 22

What is acute labyrinthitis? Recovery time?

Answer 22

• 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

Question 23

What is BPV?

Answer 23

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

Question 24

Characteristics of acute tonsilitis? Tx?

Answer 24

• 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

Question 25

Centor criteria - more likely to be bacterial?

Answer 25

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

Question 26

What is epiglottitis? presentation?

Answer 26

• 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

Question 27

Presentation of peritonsillar abscess? Dx, tx?

Answer 27

• 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

Question 28

Characteristics of croup?

Answer 28

• 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

Question 29

What is ludwig’s angina?

Answer 29

• 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

Question 30

Dental emergencies - management?

Answer 30

• 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

Question 31

Ocular conditions that reqr immediate rx?

Answer 31

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

Question 32

Presentation of acute angle closure glaucoma?

Answer 32

• 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

Question 33

Presentation of CRAO?

Answer 33

• 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

Question 34

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

Answer 34

• 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!

Question 35

Characteristics of retinal detachment? Fundoscopic findings?

Answer 35

• 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

Question 36

Presentation of viral conjunctivitis?

Answer 36

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

Question 37

Presentation of bacterial conjunctivitis?

Answer 37

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

Question 38

Presentation of chlamydial conjunctivitis?

Answer 38

• 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

Question 39

Presentation of allergic conjunctivitis?

Answer 39

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

Question 40

Tx of bacterial conjunctivitis?

Answer 40

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

Question 41

Tx of viral and allergic conjunctivitis?

Answer 41

- viral:
antihistamine/decongestant drops
- allergic:
antihistamine/decongestant drops
mast cell stabilizer/antihistamine drops

Question 42

Sxs of fb? Dx, tx?

Answer 42

• 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

Question 43

Corneal abrasion:

sxs, dx, tx?

Answer 43

• 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

Question 44

Vision in acute glaucoma? Presentation?

Answer 44

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

Question 45

Presentation of iritis?

Answer 45

• 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