EENT Emergencies - Exam 1 Flashcards
______ changes size to control how much light enters the eye
iris
_____ part of the eye lining which prevents light from reflecting all around the eye
retina
______ Helps focus an image on the back surface of the eye
lens
_____ the region with no light-sensitive cells, where blood vessels and the optic nerve join
optic disk
____ the hole in the center of the iris which dilates
in dark conditions
pupil
_____ the clear ‘window’ that allows light to enter
the eye
cornea
the ____ is the pigmented part of the retina located in the very center.
macula
_______ is the center of the macula. What is important to note about it? What does it contain?
fovea
area of the best visual acuity
contains large amount of cones (nerve cells that are photoreceptors with high acuity)
What 4 categories should eye complaints be classified as?
vision changes/loss
change in appearance of the eye
eye pain/discomfort
trauma
What oral medication drug classes increase risk for glaucoma?
dilating eye drops
TCA
MAOIs
antihistamines
antiparksonian drugs
antipsychotics
antispasmolytic agents
What type of eye injury does the intervention need to come before the PE?
chemical injuries!
need to irrigate first and ask questions second
How should visual acuity be assessed if the pt’s corrective lens are NOT available? What should you do if the visual acuity is less than 20/200?
using pinhole testing
use finger counting at 3 ft or hand motion perception at 1-2 ft. If they still cannot see that, then light perception
What should you think if the pt’s nystagmus when assessing while looking at a rotating wheel is NOT symmetric?
the cause is likely neurologic in nature
What is a Marcus- Gunn pupil? What is another name for it? What does it indicate?
when performing a swinging flashlight test, the pupils do not constrict as they should
afferent pupillary defect
Any pathology that prevents light from getting to the CNS, such as opacification of the vitreous with blood, retinal pathology, or optic nerve pathology
What is the best way to look at the conjunctiva, sclera, cornea, anterior chamber, iris, lens?
using a slit lamp because it provides a 3D view of the ocular structures
What is a normal intraocular pressure? When is it CI?
normal is 10-20mmHg
CI in globe rupture or suspected penetrating trauma
How do you determine the difference between preseptal and orbital cellulitis?
proptosis, fever, vision changes and pain EOM will be present in orbital cellulitis
Where is periorbital cellulitis affecting? Why does it usually arise? in pt or out pt?
infection anterior to the orbital septum
arises from sinusitis or contiguous infection due to local skin trauma, insect bite, or hordeolum
outpt
Where does orbital cellulitis affect? Where does it stem from? in pt or out pt?
infection extending behind the orbital septum
Often occurs as a complication of ethmoid or maxillary sinusitis
emergency! in pt therapy
What are red flag symptoms for orbital involvement?
chemosis, proptosis, increased IOP, decreased VA & pupillary response, pain with EOM
What testing is needed if you suspect orbital cellulitis?
Orbital CT WITH contrast if concern for orbital involvement or in young children who are not able to cooperate fully with exam
What is the tx for periorbital cellulitis in adults/older children with mild symptoms? In pt or out pt? When do they need to f/u?
outpatient
oral amoxicillin/clavulanic acid (Augmentin) or cephalexin (Keflex)
PCN allergy: clindamycin (Cleocin)
f/u in 24-48 hours with ophthalmology
What is the tx for young children or severe periorbital cellulitis? in pt or out pt?
in pt!
IV ceftriaxone (Rocephin) OR
ampicillin-sulbactam (Unasyn) PLUS vancomycin
PCN allergy: fluoroquinolone PLUS metronidazole (Flagyl) or clindamycin (Cleocin)
What is the tx for orbital cellulitis? in pt or out pt?
ADMIT, ophthalmology consult
IV ceftriaxone (Rocephin)
OR ampicillin-sulbactam (Unasyn) PLUS vancomycin
PCN allergy: fluoroquinolone PLUS metronidazole (Flagyl) or clindamycin (Cleocin)
What is the difference between hordeolum and chalazion? What is the tx?
hordeolum: acute infection of the eyelash follicle or acute infection of the meibomian gland-> PAINFUL
chalazion: acute, subacute, or chronic swelling caused by the obstruction of the meibomian gland typically not painful
tx: see picture
How does bacterial conjunctivitis present? How do you dx it?
painless mucopurulent discharge
conjunctive is injected and occassional chemosis
fluorescein exam
culture and sensitivity is pus is severe
what is the tx for bacterial conjunctivitis? What if the pt wears contacts?
Topical ophthalmic antibiotic for 5-7 days:
Trimethoprim–polymyxin B
contacts: Fluoroquinolone¹ or tobramycin for contact wearers (covers Pseudomonas)
What is the tx for bacterial conjunctivitis in an infants who is less than 30 days old?
Admit infants <30 d old and those with severe hyperacute onset
consult ophthalmology and start empiric IV abx to cover GC/TC
How does viral conjunctivitis present? How do you dx it?
mild-moderate watery discharge
conjunctival injection, occasional chemosis, small subconjunctival hemorrhages and preauricular lymphadenopathy
Fluorescein exam to r/o herpetic lesion
slit lamp: will show follicles: small, regular, translucent bumps
What is the tx for viral conjunctivitis?
Cool compresses
Naphcon-A - topical antihistamine/decongestant
Artificial tears 5-6 x/d
Educated on contagiousness and self resolution after 1-3 wks
How does allergic conjunctivitis present? How do you dx it?
watery discharge, redness, and intense itching
“cobblestoning” of eyelids with papillae (irregular mounds of tissue with a central vascular tuft) on the inferior conjunctival fornix
Fluorescein exam to r/o herpetic lesion
What is the management of Allergic Conjunctivitis?
Cool compresses QID
Naphcon-A - topical antihistamine/decongestant
Artificial tears 5-6 x/d
Refer to ophthalmology if severe or resistance to therapy
What is anterior uveitis? What is another name for it? What is the cause?
Inflammation of the anterior uveal tract (iris and ciliary body)
iritis
usually result from corneal insult or conjunctivitis. May be idiopathic (50%) , or related to trauma, auto-immune, infections
**What is the hallmark symptom of iritis? What is a common PE finding?
photophobia with consensual photophobia
ciliary flush
conjunctival injection/perilimbal flush
miosis with poor reactivity
diminished VA - due to clouding of aqueous humor
unilateral or bilateral pain
What am I?
How do you dx it?
iritis (anterior uveitis)
slit lamp: will show keratic precipitates and aqueous flare and cells in the anterior chamber resulting from protein deposits
**INFLAMMATORY CELLS AND FLARE
What are they made out of? What dz?
proteins
**iritis
_____ will be present in severe presentation of iritis. Will be the IOP be?
hypopyon
IOP will most likely be normal
What is the tx for iritis? How do they work?
cycloplegia meds +/- topical steroids (but not often part of the tx from the ED, think more ophtha will prescribe)
paralyze ciliary muscles to prevent painful spams and will dilate the pupil
These agents dilate the pupil prevent pain from muscle spasm and keep iris away from lens so the inflammation does not cause adhesion of the iris to the lens.
What are the cycloplegia meds used in iritis? Which one is the agent of choice?
Cyclogyl or cyclopentolate 1%
Longer acting Homatropine 5% agent of choice
corneal ulcers are associated with _______. What are some s/s?
contact lens wearers
pain, redness, tearing, photophobia, blurry vision
How do you dx corneal ulcers?
Fluorescein - staining corneal defect with surrounding white hazy infiltrate, iritis and/or hypopyon
scrape and culture ulcer: ophthalmologist will due
What 4 bacteria are common for corneal ulcers?
pseudomonas
strep pneumo
staph species
moraxella species
What is the tx for corneal ulcers? Do you use an eye patch?
topical fluoroquinolone or tobramycin
topical cycloplegic for pain
NO EYE PATCH
consider antifungal/antiviral/ steroid but steroid should only be prescribed by ophthalmology
What is the presentation of herpes simplex keratoconjunctivitis? How do you dx it? What will it show?
Unilateral photophobia, pain, eye redness, diminished VA, Preauricular lymphadenopathy and may have vesicular eruption of eyelid
fluorescein staining: will show dendritic lesion or geographic ulcer
What does the dendritic lesion or geographic ulcer occur due to?
occurs due to epithelial erosion (differentiates from pseudodendrite in HZV ophthalmicus)
What is the tx for HSK in an infants less than 30 days old? eyelid involvement? conjunctival involvement? corneal involvement?
Infants <30 days old - admit with urgent ophthalmologic consult
Eyelid involvement - oral antiviral
Conjunctival involvement - topical trifluridine (Viroptic) with erythromycin ophthalmic to prevent secondary bacterial infections
Corneal involvement - urgent ophthalmology consult. Topical or oral antiviral will be initiated per ophthalmology recommendation and need to see ophthalmology in 24-48 hours
**What medication class needs to be avoided in HSK? What is the complication if not treated promptly?
**avoid topical steroids!
corneal scarring if not treated promptly
What is herpes zoster ophthalmicus? what is another name for it?
HZV involving the V1 division of the trigeminal nerve
Ramsay Hunt Syndrome
_______ is a painful vesicular rash on erythematous base involving the upper eyelid and tip of the nose. What dz is it commonly seen with?
Hutchinson sign
Herpes Zoster Ophthalmicus
Fever, malaise, HA
Red eye, blurred vision, eye pain/photophobia
keratitis, anterior/posterior uveitis
Painful vesicular rash on erythematous base
+/- optic neuritis
What am I?
What will the IOP be?
Herpes Zoster Ophthalmicus
IOP will be elevated
How do you dx Herpes Zoster Ophthalmicus? What will be seen?
fluorescein staining
pseudodendrite (no epithelial erosion)
What are the major differences between pseudodendrite and true HSV dendrite?
*pseudodendrites are smaller in size
*elevated without central ulceration
*do not have terminal bulbs
*and have relative lack of central staining (in comparison to true HSV dendrite)
What is the tx for herpes zoster ophthalmicus? What is the pt is under 40?
consult!
if severe admit for IV acyclovir
cool compresses, oral antivirals, erythromycin ointment, cycloplegic agents
under 40 need a full work up looking for signs of an immunocompromised state
What is ultraviolet keratitis? When does it usually occur?
Death of the corneal epithelial cells due to exposure to UV light
think tanning bed or arc welding
What are the s/s of ultraviolet keratitis? How do you dx? What will it show?
slow onset of FB sensation and mild photophobia, 6-12 hours after exposure, progressing to severe pain/photophobia
blepharospasm, tearing, conjunctival infection
slit-lamp: diffuse punctate corneal edema and abrasions
What is the management of ultraviolet keratitis? When should the pt’s symptoms start to improve?
+/- eye patch
cycloplegic, oral analgesic, topical abx
improve after 24-36 hours after treatment
What is the cause of corneal abrasions? How do you dx?
an insult/trauma to the cornea leading to a superficial or deep epithelial defect
fluorescein stain with slit lamp to look for ocular FB
What is the management for a corneal abrasion? What is the pt wears contacts? What should you NOT give the pt?
ketorolac drops
add erythromycin or FQ/tobramycin ointment
Rx for topical anesthetics are CONTRAINDICATED
How do you dx corneal foreign body? What are some s/s?
will need to EVERT the eyelid
slit lamp to look for less obvious FB
edema of th elids, conjunctive and cornea
If the FB is present for longer than 24 hours, what are you likely to see? if you see hyphema/microhyphema, what does it suggest?
If FB is present for >24 hours WBCs may migrate into the cornea anterior chamber cause causing a white ring around the FB or a flare/cellular deposit respectively
globe perforation
What is the Seidel test?
if you see Hyphema/microhyphema suggest globe perforation of a corneal foreign body the dye looks like it is leaking and penetrates further into the eye
order ______ if you suspect intraocular FB or globe rupture
CT orbit
What is the management for a corneal foreign body?
instill topical anesthetic to bilat eyes (prevents reflexive blinking in unaffected eye)
use an 18-25-gauge needle, under slit lamp or other microscopic view to remove FB
remove rust ring¹ if present unless pt can be seen by ophthalmology within 24 hours
When do you need to f/u with ophthalmology for a corneal FB?
f/u 24 hours if rust ring present, FB is in central line of vision or deep in corneal stroma
f/u in 48 hours if symptoms persist
for lid lacerations, when do you need to consult oculoplastic sx? 7 things?
involving the lid margin (>1mm)
within 6 to 8 mm of the medial canthus
involving the lacrimal duct or sac
involving the inner surface of the lid
associated with ptosis
involving the tarsal plate
involving the levator palpebrae muscle
What is the management for lid lacerations?
stitch using 6-0 or 7-0 absorbable sutures if lid edge margins are larger than 1mm
oral cephalexin and erythromycin ointment
cold compresses
f/u with ophthalmology in 24 hours
What will the pupil look like if the globe has ruptured? What dx should you order?
tear shaped pupil
CT scan of the orbit
What is the tx for globe rupture?
eye shield
keep upright and NPO
IV vanc and ceftazidime (or fluoro for PCN allergy) with IV ondansetron
When is a postseptal hemorrhage commonly seen? Where does the blood accumulate? Will the IOP be elevated?
after a blunt eye trauma on a pt who is on anticoags
in the space behind the orbital septum
yes! IOP increases
What is an hyphema?
blood accumulates in the anterior chamber of the eye
What is an orbital blowout fracture?**What does it result in? What does it cause?
fracture of the inferior/medial orbital wall
results in entrapment of the inferior rectus muscle
causes restriction of upward or lateral gaze
What are the indications to order a facial bones CT w/o in blunt eye trauma?
suspected postseptal hemorrhage
hyphema
orbital blow out fracture
step off of orbital rim
concern for globe rupture not fully evident on PE
intraocular FB
If the pt suffered blunt eye trauma but visual acuity is normal and ocular anatomy is fully functional, what do you do?
discharge home to f/u with ophthalmology within 48 hours
What is the tx for chemical ocular injury?
eye irrigation!!!
topical anesthetic, attach morgan lens and irrigate with 2 liters of normal saline, then check pH
How long do you need to irrigate an eye after chemical injury? What do you do next?
Irrigation continues until the pH returns to 7.4 for 30 minutes
weep with moistened cotton-tipped applicator to ensure there are no residual particles
What is the send home tx for chemical ocular injuries? When do they need to f/u? What 3 things would warrant an emergent ophthalmology consult?
Cycloplegic, opioid pain meds
Erythromycin ophthalmic ointment
Update Td
f/u within 24 hours
chemical was hydrofluoric acid, lye or concrete
What kind of substances are considered especially toxic to the eye?
alkali chemicals are way WORSE than acidic ones
What is another name for narrow angle glaucoma? ______ is responsible for draining the aqueous humor from the eye via the anterior chamber
acute angle closure glaucoma
trabecular meshwork
What is the definition of glaucoma? What is a very common associated ophthalmologic finding?
neuropathy to the optic nerve, with or without elevation in intraocular pressure
cupping of the optic disk
What is the underlying cause of acute angle closure glaucoma? What are some common precipitating events?
An obstruction of aqueous humor outflow - results from the lens or the peripheral iris blocking the trabecular meshwork
something that leads to pupillary dilation:
exposure to dark room (movie theater)
reading
use of dilating agents, inhaled anticholinergics
use of cocaine
What is the clinical presentation of AACG?
sudden onset!!!
eye pain with HA
**colored halos around light
**fixed midposition pupil
hazy cornea
Increased IOP
affected eye is very firm to palpation
**What is the gold standard of dx for AACG? What does it show?
Gonioscopy
Views the iridocorneal angle
What is the initial management for AACG? What are the administering directions?
immediate consult!!
supine position
timolol, apraclonidine, acetazolamide eye drops.
must wait 1 minute between administration of each drop
In AACG, timolol, apraclonidine, acetazolamide eye drops have already been given and the IOP remains over ____ after 30 minutes. What do you do next?
IOP remains over 40 after 30 minutes give mannitol IV
When are carbonic anhydrase inhibitors (acetazolamide) CI?
CI in sickle cell and sulfa allergy
What is the MOA for all timolol, apraclonidine, acetazolamide? (beta blocker, alpha 2 agonist, carbonic anhydrase inhibitor)
blocks production of aqueous humor
What is the MOA of pilocarpine? When is it effective?
facilities outflow of aqueous humor by inducing mitosis (pupil gets smaller)
but isnt effective until IOP is below 50
What is the definitive tx for AACG?
laser peripheral iridotomy
What is optic neuritis? Is it painful or painless? What is a key PE finding?
Inflammation along the optic nerve
vision loss is often PAINLESS but can have painful EOM
reduction in color vision
What is a special eye test that is associated with optic neuritis?
Red desaturation test - look at dark red object with unaffected eye, then look at same object with affected eye and it will look pink/lighter red
and
(+) afferent pupillary defect
What will the funduscopic exam reveal for optic neuritis? What is the management?
swollen and edematous optic disk (30% of pts)- anterior ON
normal appearing optic disk indicates a retrobulbar ON
emergent consult with ophthalmology and neurology
How will central retinal artery occlusion present? What will usually be in the history?
Sudden PAINLESS monocular vision loss
history of amaurosis fugax (transient vision loss)
What will the fundoscopy reveal in central retinal artery occlusion?
retina will infarct and become pale, less transparent, and edematous
macula remains red - “cherry red spot”
Segmented arterioles - “boxcarring”
What dz is “cherry red spot” associated with?
central retinal artery occlusion
What dz is “boxcarring” associated with? What are they?
central retinal artery occlusion
segmented arterioles
How long does the pt have before permanent vision loss occurs with central retinal artery occlusion?
4 hours after onset
What is the presentation of central retinal vein occlusion? What will fundoscopic exam reveal?
Sudden PAINLESS monocular vision loss
vision loss is variable ranging from vague blurring to rapid loss
optic disc edema, diffuse retinal hemorrhages “blood-and-thunder fundus”
(+) afferent pupillary defect
“blood-and-thunder fundus” What dz? What is the tx?
central retinal vein occlusion
ophthalmology consult with f/u in 24 hours
What is the presentation of retinal detachment? What will the fundoscopic exam show?
Sudden onset of painless monocular vision changes with “floaters”, “flashes of light”, dark veil/curtain
fundoscopy will be normal due to majority of detachments occur in the peripheral retina which is not visualized on fundoscopy, VA and visual fields by confrontation will be abnormal
______ is helpful to assist dx for retinal detachment. What is the tx?
beside US
Urgent consult (w/i 24 hours) with ophthalmology for a dilated eye exam
“floaters”, “flashes of light”, dark veil/curtain. What dz?
retinal detachment
pruritus, otalgia, and tenderness of the external ear that is worse with _____ and ______ of the auricle. What am I? _____ and _____ are present in more severe presenations
mastication and movement
otitis externa
otorrhea and decreased hearing
What is the tx for otitis externa?
tylenol/motrin
cleansing of the external canal with 1:1 hydrogen peroxide and warm water
acetic acid/hydrocortisone ear drops
or
ofloxacin (Floxin)
or
ciprofloxacin/hydrocortisone (Cipro HC)
_____ and ______ are CI if suspected TM perforation or unable to visual TM. ______ is SAFE to TM perforations
acetic acid/hydrocortisone
ciprofloxacin/hydrocortisone
ofloxacin
_______ is a potentially life-threatening extension of infection to deeper tissues of the of the EAC. What are 2 red flags?
Malignant Otitis Externa
elderly and diabetic immunocompromised patients
______ is often present in the hx of a pt with malignant otitis externa. What will you find on PE? What CN is the first to be affected?
Persistent symptoms despite standard therapy (2-3 wks)
Severe otalgia and edema; granulation tissue on floor of EAC may be seen
VII is first
______ confirms diagnosis of Malignant Otitis Externa. What will be noted on the report?
head CT WITH contrast
“bone erosion”
What is the management for malignant otitis externa?
urgent ENT consult!!!
IV abx:
tobramycin plus piperacillin
OR
ceftriaxone
OR
ciprofloxacin
IV opiate usually needed
admission
What are the 3 MC organisms for otitis media?
strep pneu
H. flu
M. cat
What is the tx for otitis media? What is the pt recently had abx?
amoxicillin
alt: cefdinir, zithromycin
Recent Abx use or recurrent OM:
amoxicillin/clavulanic acid (Augmentin) or cefdinir
______ is a complication of OM in which the infection spreads to the _____ cells
acute mastoiditis
mastoid
What is a common PE finding for acute mastoiditis?
protrusion of the auricle with loss of postauricular crease
postauricular erythema, swelling and tenderness
____ confirms the dx of acute mastoiditis. What will the report show?
head CT WITH contrast
mastoid “clouding” early in disease; loss of bony septae of the mastoid air cells, destruction/irregularity of the mastoid cortex, periosteal thickening
What is the tx for acute mastoiditis?
Emergent ENT consult
IV vancomycin and ceftriaxone (Rocephin)
Admission
What is bullous myringitis? What is it characterized by? What is common in the hx?
A complication of OM characterized by bullae formation on the TM and deep external auditory canal
severe otalgia (ear pain), intermittent otorrhea due to ruptured bullae
hearing loss (reversible)
in bullous myringitis where are common places to find the bullae? What is the tx?
along the TM and external auditory canal
amoxicillin
What is the tx for an auricle hematoma?
Immediate I&D with evacuation of the hematoma followed by compressive dressing to prevent reaccumulation
If the FB in the ear is a bug, what do you need to do first before removing it?
mmobilize live insects with lidocaine 2% solution before removal via forceps, hooked probe or suction
______ can be used in addition to forceps, hooked probe or suction for non-organic objects. Why?
irrigation with warm water or saline
organic objects may absorb the liquid and swell
Sudden onset of pain and hearing loss
History of barotrauma, blunt/penetrating/acoustic trauma
+/- bloody otorrhea, vertigo, tinnitus
What am I?
What is the tx?
When do you need to f/u with ENT?
When are abx needed?
tympanic membrane perforation
most TM ruptures will heal spontaneously
Penetrating TM ruptures - f/u with ENT in 24 hours
Otic antibiotics are needed only if foreign material remains in canal or middle ear
What are the 2 classifications of epistaxis? Where are the MC sites for each?
anterior: Kesselbach plexus and can be seen on visual exam
posterior: sphenopalatine artery: unable to be seen directly
What do you do for a severe epistaxis? What is the MC pt type?
type and crossmatch blood
MC in posterior bleed and pts taking anticoagulants
What position do epistaxis patients need to be placed in?
Place in “sniffing” position - lean forward, neck in neutral position, nose straight
What is the tx for an anterior epistaxis?
evacuate all clots via nose blow
apply intranasal vasoconstrictor:
oxymetazoline 0.05% or phenylephrine 0.25% - 2 sprays/nostril
pinch nose for 10-15 minutes without disturbing pressure or use hands-free tongue depressor device
If intranasal vasoconstrictor fails to control anterior epistaxis, what do you do next?
chemical cauterization utilize after 2 attempts at direct pressure have failed AND the bleeding vessel is visualized
What are the 3 CI to chemical cauterization?
active hemorrhage
bilat bleeding
recent cauterization (within last 4-6 wks)
If direct pressure and chemical cautery both fail, what do you try next?
Thrombogenic Foams And Gels:
Gelfoam and Surgicel (oxidized cellulose)
FloSeal (hemostatic gelatin matrix mixed with human thrombin)
How long does FloSeal last?
FloSeal will begin to break down after 3-5 days and provides complete healing in apps 8 wks
When is nasal packing indicated? What is the most comfortable option? What is it coated in?
failure of chemical cautery
gel/foam not available
posterior epistaxis suspected
Epistaxis balloon (Rapid Rhino): fabric is coated with cellulose, promoting platelet aggregation
If nasal packing is used, how long does it usually stay in place? ______ is last resort and most uncomfortable for the patient
2-3 days
ribbon gauze
_______ is used as a posterior packing alternative. Briefly describe the process.
14-French foley catheter
______ complication is more likely with posterior nasal packing. When are prophylactic abx recommended? When should packing be removed? What is the pt education?
toxic shock syndrome
recommended if packing will be present >48 hours-> Augmentin
packing must be removed in 2-3 days by ENT
avoid NSAIDs for 3-4 days
How would viral pharyngitis present?
fever, odynophagia, petechial or vesicular lesions along soft palate and tonsils
cough, rhinorrhea, nasal congestion
How would bacterial pharyngitis present?
fever, headache, sore throat, odynophagia,
tonsillar exudates/erythema, cervical lymphadenopathy
What are the Centor Criteria to test for strep?
-tonsillar exudates
- tender anterior
cervical adenopathy - absence of cough
- fever
See ulcers in the mouth, what should this make you think?
ulcers are almost always viral!!
**What bacteria causes strep pharyngitis?
**Caused by Group A Beta-hemolytic Strep:
Strep pyogenes
What is the tx for strep pharyngitis? give options for PCN rash and PCN anaphylaxis
Single dose of PCN G 1.2 million units IM
OR
amoxicillin 500 mg BID x 10d
can also due Cephalexin (Keflex)/ Cefdinir / Cephalosporins if rash allergic to PCN
Azithromycin / Clindamycin is anaphylaxis reaction to PCN
What are the important pt education point regarding strep pharyngitis?
Tell pt change toothbrush after 24 hours
Not contagious any longer after 24 hours of treatment
Strep will “go away” on it’s own without antibiotics
However, a patient will remain contagious for 2-3 weeks after symptoms abate
What 3 structures form a collection of purulent material between in a peritonsillar abscess?
tonsillar capsule
the superior constrictor
palatopharyngeus muscle
What s/s will the pt complain of for a peritonsillar abscess?
Fever, malaise, sore throat, odynophagia, dysphagia, “hot potato” voice, otalgia, +/- trismus (limited ability to open the mouth)
**What PE finding is consistent with peritonsillar abscess?
**Contralateral deflection of uvula
Tender ipsilateral anterior lymphadenopathy
drooling
unilateral tonsillar enlargement
_____ is used to differentiate between cellulitis and abscess. ______ can also be ordered
intraoral US
CT scan of the NECK (not c-spine)
What is the tx for peritonsillar abscess?
Needle aspiration or I&D (consult ENT if necessary) can be discharged after successful drainage if pt can tolerate PO medications
PCN VK PLUS metronidazole (Flagyl) for 10 days
OR
clindamycin + metronidazole
What is the tx for severe/toxic peritonsillar abscess pts?
same needle/I&D
sepsis work-up, IV piperacillin-tazobactam (Zosyn)
_______ is a collection of pus in the space anterior to the _____ that extends from the base of the _____ to the ______
Retropharyngeal Abscess
prevertebral fascia
skull
tracheal bifurcation
What will Retropharyngeal Abscess present like on PE?
muffled voice
cervical adenopathy
respiratory distress
look for source of infection: recent intraoral procedure, trauma, foreign bodies (fishbone/pencil), or extension from odontogenic infection
______ dx study should be ordered first if you suspect retropharyngeal abscess.** ______ is the gold standard
lateral soft tissue neck xray
**neck CT WITH CONTRAST
What will the xray show of a pt with Retropharyngeal Abscess? What will a CT show in the early stages? later findings?
thickening and protrusion of the retropharyngeal wall
early findings: nonsuppurative edema, mild fat stranding, linear fluid, minimal mass effect
later findings: necrotic nodes with central low attenuation and ring enhancement
What is the tx for retropharyngeal abscess?
Prepare for emergent airway placement
Urgent ENT consult for surgical intervention and admission
IV fluids, NPO
IV clindamycin or cefoxitin
Alt: piperacillin-tazobactam (Zosyn) or ampicillin-sulbactam (Unasyn)
What is the hx for a pt with epiglottitis? What makes the symptoms worse? better?
1-2 day progressive dysphagia, odynophagia and dyspnea
+/- drooling, inspiratory stridor, fever
symptoms worse when supine, improved when upright
**What is a common position you might find your pt sitting in for epiglottitis?
Tripod: upright, leaning forward, neck extended with mouth open
What will the PE reveal on a pt with epiglottitis?
tenderness of the anterior neck with gentle palpation of the larynx and upper trachea
cervical adenopathy
tachycardia
_____ should be ordered first in epiglottitis. **What will it show?
lateral soft tissue neck xray
obliteration of the vallecula - “thumbprint” sign
**_______ is the gold standard test to confirm dx of epiglottitis. What is the associated risk?
Transnasal fiberoptic laryngoscopy
risk of airway obstruction during exam
What is the tx for epiglottitis? **What abx specifically?
IV cefotaxime PLUS vancomycin
IV methylprednisolone 125 mg - reduce inflammation and edema
What is an odontogenic abscess? What are some common s/s?
Extension of a dental abscess into a surrounding structure or deep neck space
trismus, fever, edema of the upper neck/floor of mouth, displacement of the tongue, airway compromise, hx of dental pain/abscess
if the odontogenic abscess is superficial can use ______ to confirm. If deep space infection use ________.
superficial infection - bedside US to confirm
deep space infection - CT neck with IV contrast
What are 2 complications of odontongenic abscesses?
Ludwig’s angina
Necrotizing infection
**_______ is cellulitis of the sublingual and submaxillary space. What do you need to do very early in the presentation?
Ludwig’s angina
obtain definitive airway due to the rapidly progressing nature of the dz
_________ toxic appearing with hemodynamic instability, skin discoloration, crepitus of the subcutaneous tissue, fever, confusion. What should you do next?
Necrotizing infection
requires immediate surgical fasciotomy!!
What is the tx for non-toxic with superficial (dental abscess)?
Oral PCN VK or amoxicillin 500 mg TID x 10 days
PCN alt: clindamycin 300 mg TID x 10 days
What is the tx for a toxic appearing, deep space infection or a complication of a odontongenic infection?
Urgent ENT consult and admission
IV fluids, NPO
IV antibiotics (broad-spectrum):
-ampicillin-sulbactam PLUS clindamycin PLUS ciprofloxacin
_______ is the MC food that becomes lodged in the esophagus
meat
What diagnostic study should you order for a swallowed FB?
“Foreign body film” - chest and abdomen
How can you tell if the coin is in the trachea or esophagus based on the xray?
coins will show circular face on AP when in the esophagus
compared to a coin in the trachea which will show the circular face on the lateral view
Once an object has passed the ______ it can usually move through the GI tract successfully. What factors increase risk of the object becoming obstructed?
pylorus
irregular or sharp object
object larger than >2.5 cm wide or > 6 cm long
What 7 things warrant URGENT endoscopy for esophageal FBs?
If the FB is past pylorus and meets no “red flags” for obstruction, what is the tx?
expectant therapy: wait and see
can do serial xrays if radiopaque until complete passage
What is the tx if the FB is located at the distal esophagus?
IV glucagon, 1-2 mg in adults, may relax the lower sphincter and allow passage of the object
What is the tx for a sharp object that is already distal to the duodenum and the pt is asymptomatic?
daily xrays until passage
if passage doesn’t occur within 3 days - consult surgery
consult surgery immediately if s/s of perforation
What is the tx for a sharp object that is proximal to the duodenum?
if present in the esophagus, stomach or duodenum - immediate endoscopy is needed
What is the tx for a button battery that is found in the esophagus? If past the esophagus?
True emergency requiring prompt removal due to perforation that can occur within 6 hours of ingestion
past: f/u in 24 hours for repeat exam, repeat xrays in 48 hours to ensure passage through pylorus
How can you tell the difference between a coin and button battery on xray?
coin will be completely solid and button battery will have double ring- Halo sign.
What is the tx for “body packers” aka narcotic ingestion? What procedure is CI?
xray to confirm and admit for observation until packet reaches the rectum
endoscopy is CI due to risk of rupture
