EM ORL 3: Pearls

Question 1

most successful method of reduction of anterior temporomandibular joint dislocation

Answer 1

wrist pivot method
(97% vs conventional’s 87%)

Question 2

pressure applied in conventional method of reduction of anterior temporomandibular joint dislocation

Answer 2

downward and backward (toward the patient)

Question 3

explain the wrist pivot method of reduction of anterior temporomandibular joint dislocation

Answer 3

1. The patient sits, as does the operator
2. the healthcare provider’s thumbs are placed on the mentum, applying UPWARD FORCE, while the fingers apply DOWNWARD FORCE on the LOWER MOLARS, forcing the body of the mandible INFERIORLY.
3. The operator flexes the wrist, and thus the mandible rotates and the condyle goes inferiorly, allowing the condyle to slip back into the mandibular fossa

Question 4

antibiotics in rhinosinusitis

Answer 4

in general, antibiotics should be reserved for patients with purulent nasal secretions and severe symptoms for ≥7 to 10 days

Question 5

a true dental emergency

Answer 5

total displacement of a tooth from its socket
-replantation at the scene is the treatment of choice
-handle only the crown portion of the tooth, gently rinse the tooth for a maximum of 10 secs with sterile normal saline, then replace imediately into the socket
-anterior teeth are most commonly affected

Question 6

remarks on tongue laceration

Answer 6

Simple linear lacerations <1 cm involving the central portion of dorsal surface of the tongue and that do not gape open heal well without repair

Question 7

in pharyngitis 3 notable exceptions where testing may be indicated

Answer 7

suspected
1. influenza
2. infectious monocleosis
3. acute retroviral syndrome

Question 8

criteria for pharyngitis

Answer 8

CENTOR CRITERIA
absend of cough: +1
swollen and tender anterior cervical LN: +1
temp >38C: +1
tonsillar exudates/swelling: +1

age:
3-14y: +1
15-44y: 0
≥45y: -1

interpretation:
0-1: ≤10% risk of GABHS, no further testing or antibiotics indicated
2-3: 11-35% risk of GAHBS, perform throat cultre or RADT
≥4: 50% risk of GAHBS, consider empiric tx with antibiotcs

Question 9

remarks on treatment of GABHS pharyngitis

Answer 9

antibiotic therapy improves symptoms within 24-48 hours and prevents suppurative complications and rheumatic fever in most patients

but does NOT prevent GLOMERULONEPHRITIS

GABHS has NEVER been resistant to penicillin, so penicillin remains the recommended first-line drug
-single IM dose of benzathin Pen G 1.2M units
-pen VK 500mg bid for 10 ays
-amoxicillin

a single dose of PO or IM dexamethasone in immunocompentent patients with moderate to severe pharyngitis decreases time to pain relief and to complete resolution of pain, without significant increase in side effects

Question 10

one complication of pharyngitis

Answer 10

LEMIERRE’S SYNDROME
-caused by /Fusobacterium necophorum/, a gram neg anaerobe
-compliccation of pharyngitis causing suppurative thrombophlebitis of the IJV
-resistance to macrolides is high

mgt:
-contrasted CT of the neck
-metronidazole + ceftriaxone, or
-pip-taz
-consideration for surgical drainage

Question 11

Quincke’s edema

Answer 11

uvula edema
if it is an isolated finding and symptoms are uncomfortable to the patient, DEXAMETHASONE, can be given as a single dose in the ED

Question 12

relation of ICA and tonsil

Answer 12

The internal carotid artery usually lies laterally and posterior to the posterior edge of the tonsil

and so a drainage needle should penetrate no more than 1 cm

Question 13

remarks on odontogenic infections/abscess

Answer 13

polymicrobial
most common bacteria are:
-Streptococcus viridans
-Peptostreptococcus
-Prevotella
-Stephylococci

Most dep neck infections originate from an odontogenic source, usually the MANDIBULAR TEETH

Question 14

Remarks on neck masses in adults

Answer 14

in adults >40 y/o, up to 80% of lateral neck masses persistent for >6 weeks are malignant

Patients with airway compromise or significant dysphagia and odynophagia should be evaluated by FLEXIBLE NASOPHARYNGOLARYNGOSCOPY BEFORE CT scan

Question 15

remarks on posttonsillectomy bleeding

Answer 15

although bleeding can be seen within 24 hours of surgery, most significant hemorrhage occurs betweeen postop days 5 and 10.

There is significantly higher incidence of bleeding in patients >12y

Posttonsillectomy bleeding can be fatal and requires prompt intervention with control of the airway. An otolaryngologist should be consulted early

Question 16

remarks on tracheoinnominate artery fistula

Answer 16

most will present within the first 3 weeks after tracheostomy, with the peak incidence bet the first and second week

hemorrhage control should first be attempted by hyperinflating the cuff

UTLEY MANEUVER
1. endotracheally intubate while simultaneously removing tracheostomy tube
2. cuff of et tube should be placed distal to the source of bleeding
3. hemorrhage control is then attempted by placing a finger into the stoma
4. dissecting along the trachea and then compressing the innominate artery against the posterior manubrium

tamponade of the hemorrhage should be maintained during transport to the operating room

Question 17

changing a tracheostomy tube

Answer 17

If the tracheostomy is <7 days old, the tract will not be mature and manipulation may easily create a false passage within the soft tissue of the neck

In addition, a tract may easily collapse at any time in patients with obese necks or neck masses

If the situation is not emergent and the tracheostomy is <7 days old, tracheostomy tubes should be changed by a surgeon familar with the procedure

Question 18

remarks on laryngectomy patients

Answer 18

laryngectomy patients are unable to phonate or breath when the laryngectomy tube is occluded

laryngectomy patients can be emergently intubated by placing en ET tube into the tracheostoma

Do not advance the tube too far, because the adult carina may be only 4 to 6 cm from the tracheostoma