EM: EENT just ENT Flashcards
Infection/inflammation of the external auditory canal and auricle
Otitis externa
Historical findings of otitis externa
- Pruritis
- Otalgia
- Tenderness of external ear, worse with mastication/movement of auricle
- Otorrhea and decreased hearing in more severe presentations
;
Physical exam of otitis externa
- Erythema and edema of external auditory canal, spreading to tragus and auricle
- Clear-purulent discharge with crusting of external canal
- Severe cases: complete occlusion of auditory canal, periauricular edema/erythema, lymphadenopathy
Management of otitis externa
- Analgesics: tylenol/motrin
- Cleansing of external canal with hydrogen peroxide 1:1 with warm saline or water and gentle suction under direct visualization
- Otic drops: acetic acid/hydrocortisone
- Ofloxacin or ciprofloxacin/hydrocortisone
- Ear wick
When would acetic acid/hydrocortisone be contraindicated?
- perforated TM or unable to visual TM
- Can only be used alone in mild disease
When should ciprofloxacin HC be avoided in otitis externa? What could you use instead?
- if suspected or confirmed TM perforation
- Ofloxacin
When is an ear wick indicated?
If swelling severe and prevents full application of ear drops
Clinical presentation of malignant otitis externa
- Potentially life-threatening extension of infection to deeper tissues of EAC
- Red flags: elderly, diabetic/immunocompromised
- Persistent symptoms despite standard therapy (2-3 weeks)
- Severe otalgia and edema; granulation tissue on floor may be seen
- CN VII first to be affected
Diagnosis of malignant otitis externa
CT head with contrast, bone erosion noted on report
Management of malignant otitis externa
- Urgent ENT consult
- IV antibiotics: tobramycin plus piperacillin OR ceftriaxone OR ciprofloxacin
- Pain control: IV opiate usually needed
- Admission with ENT consult
Grandma toby and piper or roce or cipro
Infection of inner ear
Otitis media
Clinical presentation of otitis media
History of otalgia +/- fever, otorrhea, hearing loss
* PE: TM erythema, yellow/white exudate behind intact TM or in canal if TM perforated, retracted or bulging with impaired mobility
Management of otitis media
- Oral antibiotics: amoxicillin (cefdinir or zithromax alternatives)
- Augmentin or cefdinir if recent abx use or recurrent OM
- Analgesics: tylenol/motrin
media= moxi augment it or eat dinner if recent abx or recurrent
Disposition of otitis media
Home to f/u with PCP in 3-5 days
Complication of OM in which infection spreads to mastoid cells
Acute mastoiditis
Clinical presentation of acute mastoiditis
- History of otalgia, fever, postauricular pain and swelling
- PE findings same as OM + protrusion of auricle with loss of postauricular crease, postauricular erythema, swelling and tenderness
Diagnosis of acute mastoiditis
CT head with contrast: mastoid “clouding” early in disease; loss of bony septae of mastoid air cells, destruction/irregularity of mastoid cortex, periosteal thickening
Management of acute mastoiditis
Emergent ENT consult, IV vancomycin and ceftriaxone, admission
three mastifs in vans
complication of OM characterized by bullae formation on TM and deep external auditory canal
Bullous myringitis
History in bullous myringitis
- Severe otalgia
- Intermittent otorrhea due to ruptured bullae
- Hearing loss (reversible)
PE in bullous myringitis
- Intact bullae along TM and EAC
- Blood filled, serous, serosanguineous
- Middle ear effusion
Treatment of bullous myringitis
- Amoxicillin (or cefdinir, zithromax)
- Augmentin or cefdinir if recent abx or recurrent OM
- Tylenol/motrin
same as otitis media!
Accumulation of blood between the skin adn the cartilage of tha uricle due to blunt trauma
Hematoma
Clinical presentaiton of hematoma
- Swelling
- Pain
- Ecchymosis of auricle
Management of hematoma and complciation
- Consult ENT: immediate I&D with evacuation of hematoma followed by compressive dressing to prevent reaccumulation
- If left untreated: scarring with deformity leading to cauliflower ear
History and physical exam on foreign body in the ear
History of insertion of FB, visualization of FB, sensation of movement in ear, ear pain or loss of hearing
* PE: FB visualized, look for signs of TM perforation and infection
Management of foreign body in the ear
- Immobilize live insects with lidocaine prior to removal
- FB removal with forceps or hooked probe under visualization or suction
- irrigation with warm water or saline for small non organic objects (organic might soak up liquid)
- Consult ENT if TM perforation present or object can’t be removed
S/S of tympanic membrane perforation
- History of barotrauma, blunt/penetrating/acoustic trauma, lightning strikes
- Sudden onset of pain and hearing loss
- +/- bloody otorrhea, vertigo, tinnitus
- Rupture of TM, ensure full visualization of TM and canal
Management of TM perforation
- Most heal spontaneously
- Uncomplicated TM perforations can be discharged home:blunt or noise trauma that are isolated injuries and ENT follow up in 7-10 days
- Penetrating TM ruptures- f/u with ENT in 24 hours
- Otic abx if foreign material remains in canal
What are the 2 classifications of epistaxis?
- Anterior bleed: visualized on external exam MC @ Kiesselbach plexus
- Posterior bleed: unable to directly visualize, blood from bilat nares or in posterior pharynx, failure to control with anterior packing MC @sphenopalatine artery
- Use nasal speculum to attempt visualization of bleed
Management of epistaxis
- If severe bleed/hemodynamic instability: type and crossmatch blood (MC in posterior bleed and anticoag)
- Place in sniffing position: lean forward, neck in neutral position, nose straight
- Direct pressure after nose blow (to evacuate clots) via intranasal vasocontrictor –> oxymetazoline or phenylephrine followed by pinching nose for 10-15 minutes without disturbing pressure
What can you do if epistaxis is anterior and direct pressure has failed and bleeding vessel visualized?
Chemical cauterization with 1:1 oxymetazoline and lidocaine then silver nitrate on bleeding vessel
What are CI for chemical cauterization?
Active hemorrhage, bilateral bleeding, recent cauterization (within last 4-6 weeks)
What is used for epistaxis if chemical cautery fails?
- Thrombogenic foams and gels (gelfoam and surgical) applied directly to bleeding mucosa
- Floseal: thrombin injected directly into bleeding nare and nare filled completely, breaks down after 3-5 days
What are indications for nasal packing to treat epistaxis?
- Failure of chemical cautery
- Gel/foam not available
- Posterior epistaxis suspected
What are the 3 types of packing
Epistaxis ballon: easier to use and more comfortable, fabric with cellulose for platelet aggregation
Nasal tampons/sponge: coat with antibiotic, insert along nasal floor, irrigate if doesn’t expand, and tape to face, remove in 2-3 days
Ribbon gauze: last packing resort, most uncomfortable for patient and most difficult to insert
What is a posterior packing alternative?
- 14-French foley catheter
What are complications of epistaxis?
- Vasovagal syncope
- Dislodgement of packing
- Recurrent bleeding
- Sinusitis
- Toxic shock syndrome
When would you admit and consult ENT for epistaxis?
- Posterior packing required or anterior epistaxis not controlled
If packing will be present >48 hours, what should you add to epistaxis treatment?
Amoxicillin/clavulanic acid (or cephalosporin or bactrim for PCN allergy)
What is follow up for epistaxis?
all packing removed in 2-3 days by ENT or ED 2 days ideal
What is patient education for epistaxis?
Avoid NSAIDs for 3-4 days
s/s of viral pharyngitis
- Fever
- Odynophagia
- Petechial or vesicular lesions along soft palate and tonsils
- Cough
- Rhinorrhea
- Nasal congestion
s/s of bacterial pharyngitis
- Fever
- Headache
- Sore throat
- Odynophagia
- Tonsillar exudates/erythema
- Cervical lymphadenopathy
If 2 or more what are met perform a strep test. What is this?
Centor criteria: tonsillar exudates, tender anterior cervical adenopathy, absence of cough, fever
younger than 15 adds a point older than 15 but younger than 45 0 point, older than 45 -1
What is almost always viral pharyngitis?
ulcers
treatment of pharyngitis/tonsillitis?
based on rapid strep results
* non-bacterial: antipyretics, analgesics, IV fluids if dehydrated
* Bacterial: single dose of PCN G or amoxicillin (keflex/cefdinir/cephalosporins if PCN allergic reaction of rash and azithromycin/clindamycin if anaphylaxis)
Patient education for pharyngitis/tonsillitis
- Change toothbrush after 24 hours
- Not contagious any longer after 24 hours of treatment
- Strep will go away on its own without antibiotics, however will remain contagious for 2-3 weeks after symptoms
History for peritonsillar abscess`
- Fever
- Malaise
- Sore throat
- Odynophagia
- Dysphagia
- Hot potato voice
- Otalgia +/- trismus
Physical exam for peritonsillar abscess
- UNilateral tonsillar enlargement
- Palatal and uvula edema
- Contalateral deflection of uvula
- Tender ipsilateral anterior lymphadenopathy
- Drooling
- Dehydration
Diagnostic studies for peritonsillar abscess
- Imaging often not needed due to classic presentation of disease
- Intraoral US: confirms presence of abscess when differentiating between cellulitis and abscess
- CT scan with contrast of neck
Management of peritonsillar abscess
- Needle aspiration or I&D (consult ENT if necessary)
- Non-toxic patients with successful drainage and who can tolerate PO meds can be discharged with oral abx
- PCN VK + metronidazole for 10 days (clindamycin + metronidazole for PCN allergy)
- Toxic patients: sepsis workup, IV pip/taz
peritons- pen on the metro
Collection of pus in space anterior to prevertebral fascia that extends from the base of the skull to tracheal bifurcation
Retropharyngeal abscess
History for retropharyngeal abscess
- Look for source: recent intraoral procedure, trauma, foreign bodies, or extension from odontogenic infection
- Sore throat
- Dysphagia
- Neck pain/torticollis
- Stridor in children
Physical exam of retropharyngeal abscess
- Muffled voice
- Cervical adenopathy
- Respiratory distress
Diagnostic studies for retropharyngeal abscess
- Lateral soft tissue neck x-ray: thickening and protrusion of retropharyngeal wall
- CT neck with IV contrast: GOLD standard (do if xray not definitive with high suspicion) –> early findings: nonsuppurative edema, mild fat stranding, linear fluid, minimal mass effect; later findings: necrotic nodes with central low attenuation and ring enhancement
Management of retropharyngeal abscess
- Prepare for emergent airway placement
- Urgent ENT consult for surgical intervention and admission
- IV fluids, NPO
- IV clindamycin or cefoxitin`
you gotta clin that retro(pharyngeal) fox
Inflammatory condition of the epiglottis, often infectious in nature
Epiglottitis
History in epiglottitis
- 1-2 day progressive dysphagia, odynophagia, and dyspnea
- +/- drooling, inspiratory stridor, fever
- Symptoms worse when supine, improved when upright
- Tripod: upright, leaning forward, neck extended with mouth open
Physical exam in epiglottitis
- Tachycardia
- Cervical adenopathy
- Tenderness of the anterior neck with gentle palpation of the larynx and upper trachea
Diagnostic studies for epiglottisi
- Lateral soft tissue neck x-ray
- THUMBPRINT SIGN
- transnasal fiberoptic laryngoscopy ** gold standard for confirming diagnosis, risk of airway obstruction during exam
Management of epiglottitis
- Emergent ENT consult and admission
- Prepare for emergent airway placement (cardio monitors, do not leave unattended, should remain upright)
- Humidified oxygen, IV fluids
- IV cefotaxime + vancomycin (severe PCN allergy - resp FQ)
- IV methylprednisolon to reduce inflammation and edema
Epic van but it has taxes and meth
Extension of dental abscess in a surrounding structure or deep neck space, can be retropharyngeal, parapharyngeal, floor of mouth
Odontogenic abscess
Clinical presentaiton of odontogenic abscess
- Hx of dental pain/abscess
- Erythema edema of the labia or buccal gingiva, intraoral or dento-cutaneous fistula
- Tismus, fever, edema of upper neck/floor of mouth, displacement of tongue, airway compromise
- Sore throat
- Dysphagia
- Dyspnea (retro-pharyngeal)
Diagnostic imaging for odontogenic abscess
- Superficial infection- bedside US
- Deep space - CT neck with IV contrast
Complications of odontogenic abscess
Ludwig’s angina: cellulitis of sublingual and submaxillary space that is rapidly progressive and needs airway established
Necrotizing infection: toxic with hemodynamic instability, skin discoloration, crepitus of SQ tissu, confusion –> needs immediate surgical fasciotomy
Management of odontogenic abscess
Non-toxic appearing: oral PCN VK or amoxicillin (clindamycin if PCN allergy)
Toxic: urgent ENT consult and admission, IV fluids, NPO, IV abx –> amp-sulbactam + clindamycin +ciprofloxacin
well odont pens have a moxi or una clin cip
What is the MC food that becomes lodged in esophagus
Meat
Clinical presentation of swallowed foreign bodies
- Children: refusal or inability to eat, vomiting, gagging and choking, stridor, neck or throat pain, drooling
- Adults: retrosternal pain, dysphagia, vomiting, choking, coughing, aspiration if attempting to wash down FB
Physical exam of swallowed foreign bodies
Assess airay, nasopharynx, oropharynx, neck and chest
FB may be visualized in oropharynx
Diagnostic studies of swallowed foreign bodies
- Foreign body film: chest and abd with radiopaque objects, coins with circular face on AP/PA in the esophagus and if trachea will show circular face in lateral view
- CT chest without contrast: will show non-opaque objects and provide information on perforation and signs of infection
Interpretation of imaging for swallowed foreign object
- If passes pylorus can usually move through GI tract
- Increased risk of obstruction past pylorus if irregular or sharp or wide/long
Management of swallowed FB
- Assess for airway compromise and risk of aspiration
- Determine need for urgent endoscopy
- Expectant therapy: if object past pylorus and meets no red flags for obstruction
Distal esophagela objects: IV glucagon may relax lower sphincter and allow passage
Successful endoscopy without complications: discharge home
What should be done for food impaction
Complete esophageal obstruction –> emergency endoscopy
Partial obstruction: treat expectantly with f/u in 12-24 hours to ensure passage, if no passage endoscopy required
What should be done for coin ingestion
Coins in esophagus should be removed with endoscopy
What shoul dbe done for sharp objects
- If in esophagus, stomach, or duodenum, immediate endoscopy
- If distal to duodenum and asymptomatic daily xrays until passage
- If passage not within 3 days, general surgery
- COnsult surgery immediately if s/s of perforation: pain, emesis, fever, GI bleed
What should be doen for button battery ingestion
True emergency! Prompt removal if in esophaguse will cause rapid mucosal injiury and necrosis, perforation within 6 hours of ingestion
* If passed esophagus f/u in 24 hours for repeat exam
* Repeat x rays at 48 hours to ensure passage through pyloruys
What should be done for narcotic ingestion
- Commonly ingested inside condom
- Rupture can be fatal
- Endoscopy CI due to risk of rupture
- Often visible on plain film
- Admit for observation until packet reaches rectum
