ENT Flashcards
initial considerations when you first see the patient
(can be generalized to any visit)
outpatient vs inpatient vs immediate referral
sick vs not sick
•Your patient has a locked jaw, with pain and difficulty swallowing, and malocclusion (poor bite alignment)
what do you do for this patient?
jaw dislocation (clinical Dx)
Anterior Dislocation Most Common
•Imaging only indicated for trauma
you can reduce this
what are some methods to reduce an anterior dislocated jaw?
Method discussed in class:
Put the operator’s thumbs (pad your thumb!) over the molar teeth of the patient and push the dislocated jaw downward and backward. This maneuver takes a lot of effort and usually needs sedation.
- failure not uncommon +bite/disease transmission risk
- Method found in PubMed (ID: 17197953): via extraoral route →once the mandible is dislocated anteriorly, the coronoid process and anterior border of the ramus can be palpated easily over the cheek. By applying steady pressure over this prominent part, the anteriorly dislocated mandible can be reduced easily*
Your patient shows:
Hx: Pruritus, pain, external ear TTP
Erythema and edema external auditory canal
Pain w/ movement of the pinna/tragus or insertion of the speculum
Likley Diagnosis and appropriate Tx?
This is Otitis Externa (Swimmer’s Ear)
Tx: Topical Antibiotic Drops (Ofloxacin, Cipro/Hydrocortisone) apply using a wick/gauze
In which populations would you especially worry about MALIGNANT otitis externa (life threatening)?
Tx is hospital admit with ENT consult and IV Abx
Diagnosed on CT when pain out of proportion to exam or CN involvement seen
Elderly, diabetic, immunocompromised
Top 3 organisms causing AOM?
Streptococcus pneumoniae
- Haemophilus influenzae*
- Moraxella catarrhalis*
Describe exam findings with AOM.
Hx: otalgia, w/ or w/o fever, pain,
PE: Retracted or bulging TM w/ erythema
What is serious complication of AOM that we always need to evaluate for?
Mastoiditis
PE: TTP +/- swelling over mastoid
Dx: CT
Tx: ENT consult, IV abx, +/- surgery
Describe (presentation, PE, Tx):
Bullous Myringitis
→infection that causes painful blisters on the eardrum (tympanum)
Sudden onset of pain, Usually NO fever
PE: TM Inflammation w/ blebs
Tx: Analgesics, abx w/ AOM, Macrolides
Management for a TM perforation
Trauma ( scuba, blow to ear, improper cleaning)
or infection?
Avoid ototoxic meds - gentamicin, neomycin, and tobramycin
Choose suspension rather than solution (later could enter behind TM and cause more damage)
Keep the ear dry. Refer to ENT for follow up if traumatic/dizziness/not healing in 2 weeks
What should you do to prevent this (see picture) from happening in a wrestler who presents with a collection of blood between cartilage and perichondrium on his right pinna?
(auricular hematoma)
Tx: Aspiration or drainage of blood
Compressive dressing
Antibiotics
**. F/U every 48hours in case needs re-draining or dressing changes. Incision may help to continue to drain better than aspiration does
Before/ After picture
What considerations in fixing this ear?
Use ear block so they can tolerate cleaning and repair. No EPI for ear.
Need to approximate cartilage well. Still not going to be pretty.
What foreign bodies are you likely to find in the ears of adults?
- Cotton
- Hearing Aid
- Insects
What foreign bodies are you likely to find in the ears of kids?
Rocks, candy, beads, or anything else that fits
When would you not want to try to get a foreign object out of ear by flushing it out?
Organic matter→ may swell w/ liquids
-don’t want to make wet bc then will have to scrape out mush
Some helpful hints discussed in class to remove foreign bodies from ear:
May have to swaddle kids, even if toddler to preschool (wrap in blanket so can’t flail arms). Have parents help.
Nasal suction tip works best if round object. Try sucking, flushing, scooping, whatever need to do to get out
Dermabond (superglue in with long Q-tip and let dry on object (2min) so that can withdraw object). **2 min is an eternity to hold child still
Two types of nosebleeds (epistaxis) and which is most common, most serious?
1. Anterior nosebleeds (90+%)
-Kiesselbach’s Plexus (Nose picking zone). Causes: Trauma, FB, picking, tumor, lack of humidity, oxygen
2. Posterior nosebleeds (serious, needs w/u)
-Blood pouring down throat, not coming out front OR blood pouring out nose but you don’t see any anterior source
Management of a nose bleed that isn’t stopping:
Have blow nose very hard (get blood out)→use afrin,→use lidocaine with epi to help vasoconstrict, soak packing material in aminocaproic acid (busts clot), silver nitrate to cauterize anterior plexus
Quick clot is coated to help stop bleeding→may stop bleeding well enough that don’t need to pack nose (RTC precautions and tell not to blow nose)
Pack with “rhino rockets” Moisten with water→tell pt not going to like, but will stop bleeding, expand balloon until pt tells to stop (bc can’t tolerate)→inflate a bit more 5min later. Want to put in straight back (towards ear at slight angle). Longer packing available if posterior bleed.
Don’t have balloons small enough for kids
W/U for posterior epistaxis:
- ABCs
- IV access
- Labs - CBC, Type and Screen, Coags
- Packing
- ENT Consult
- Observation
**admit if would have to pack bilaterally as pt won’t tolerate this
How would you treat this?
(nasal Fx)
- Good H &P
- R/o Septal Hematoma
- Imaging not always needed
- Ice, Analgesics
- F/U w/ ENT
- Warn patients about ecchymosis/swelling
►reduce once swelling goes down in a few days
What is this and how is it treated?
SEPTAL HEMATOMA
Can affect airway
May cause deformity/damage to the cartilage
Tx - drainage (Let patient decide if wants to numb, or if just wants you to try to do quickly without local anesthesia)
⇒ENT follow up
Describe Sx of sinusitis and complications that need to be ruled out.
Sx: Congestion, facial pain, pressure, nasal discharge, dental pain, +/- fever
Complications (need to R/O):
•Meningitis, cavernous sinus thrombosis, abscess, orbital cellulitis, osteomyelitis.
What Sx do patients with cerum impaction usually have?
hearing loss, pressure/pain, tinnitus
What is a Le Fort fracture?
What do you need to do if you find this/these?
Fractures of the midface, which collectively involve separation of all or a portion of the maxilla from the skull base.
This requires a lot of trauma, so think about brain bleeds, CSF leaks, etc
Below are all the places might Fx jaw.
When would you treat one of these fractures with Abx?
comminuted mandible fractures
comminuted= A fracture in which a bone is broken, splintered, or crushed into a number of pieces.
What do you need to worry about with someone who got punched in the eye?
Orbital Fx→ inferior/medial portion is weakest /most likely to break
Consider globe injury
Document EOM →entrapment= tethered extraocular muscle
Phone a friend (ENT vs plastics)
Abx, Analgesics, Follow up
When do you refer to dentist for dental trauma (and how urgently)?
- Enamel Only: refer for outpatient dental follow up
- Through dentin: cover with Dycal and f/u within 24 hours
- Exposed Pulp: immediate dental referral and start antibiotics (can be hard to get pt in immediately, so you need to make some phone calls on his/her behalf)
What is a good management option for someone who comes into ED (especially on weekends/evenings) with DENTAL pain?
Offer nerve block (tell pt have something that can instantly take away pain with nerve block)→ if med seeking will say afraid of needles and want dilaudid
2 types of nerve blocks: infraorbital & mental
What do you need to do for this oral abscess?
Drain
Antibiotics
Dental Follow Up
What do you need to do for this patient?
- Decide if is Thrush or leukoplakia
* Hx of abx use, or is this 30pack year smoker that worried about oral cancer*?
leukoplakia CANNOT be scraped off
- Treat appropriately:
Fungal infection (candida): Antifungal rinses→Nystatin, Lozenges→Clotrimazole
leukoplakia: usually benign, but can occur next to cancers, so refer patient to dentist
What two (categories) of things commonly cause parotitis?
Infections: Staph, TB, paramyxovirus (mumps), many other viruses (other viruses won’t cause epidemics)
Blockage - stone, mucous plug, lymph node (+/- with infection)
→an image can show if parotid gland is blocked by a stone
Treatment for Parotitis:
Depends on cause.
- supportive care
- sialogogues (something to make salivate),
- +/- antibiotics,
- +/- stone removal
Centor Score: who to treat based on likelihood of strep infxn
Fever (+1)
Exudates (+1)
Cervical LAD (+1)
Absence of a cough (+1)
Age < 15 (+1)
Age > 44 (+1)
0-1 Points - Nothing (< 10% GAS)
2-3 Point - Test (15- 30% GAS)
>4 - Treat (>50% GAS)
Potential (rare) consequences of not aggressively treating strep pharyngitis:
rheumatic fever
guttate psoriasis
post-streptococcal glomerulonephritis
Describe presentation and treatment for a peritonsillar abscess.
Sx: Severe Sore Throat, Trismus (“lock jaw”), Uvula Deviation, Asymmetric Swelling, Muffled Voice
Tx - Drainage, antibiotics, steroids, ENT consult/follow up
Pearls for draining a peritonsillar abscess:
Use intubating blade to hold tongue down (have pt hold this→ tell him to get as far back as can without gagging)
Give Pt sucker, “Mr. thirsty”, so take care of own secretions. Frees up both your hands, keeps pt busy and helping you. Can give med to dry up secretions.
Use hurricane (topical spray) and block before aspirating.
Measure on CT how far to go in to drain. Use bumper on 18 gauge needle so can’t go too far in and can’t hit carotid.
Call ENT→pt with peritonsillar abscess and you have drained it. They will love you for not having to come in emergently→ since drained, can see next day
Post-drainage:→give dexamethasone and abx. Usually do not have to re-drain.
Presentation of Ludwig’s Angina:
often in pt’s with DM or immunocompromised
usually after mouth injury or tooth abscess
- Pain/swelling to floor of mouth, describe “fullness under tongue”
- Difficulty with speech
- Trismus
- Neck Pain/Swelling
- Redness
- Tongue deviation
- Fever/Chills
- “sniffing” position
**Tx - IV Abx, admit, ENT consult
Your patient has a “thumbprint” sign on x-ray.
He also has: Drooling, dysphagia, +/- fever, stridor
- Muffled, HOT POTATO VOICE
- Sore throat, rapid progression
- SICK appearance
What SHOULD you do and what should you NOT do?
Epiglottitis, caused by Haemophilus influenzae type B
Things you DO: ENT/Anesthesia consult→possible intubation, keep patient calm, turn off lights to help relax, IV fluids (nothing orally)
What NOT to do: do NOT put anything down throat or do anything to further compromise airway
What respiratory condition, common in kids under 2yo, especially in winter, involves coughing, wheezing, congestion, and fever but we can only offer supportive care (nasal suctioning)?
bronchiolitis
**do admit if O2 sats dropping during sleep
**can do a chest x-ray if suspcision of PNA
**RSV/influenza testing okay if widely circulating
What is the most appropriate initial management for an acute peritonsillar abscess?
incision and drainage
During a busy Saturday night shift at your local ED, a 24 y/o intoxicated male presents after being involved in an altercation with 2 other individuals. On examination you notice that the patient has difficulty looking up and is complaining of blurred vision. What do you expect to see on a facial CT?
Inferior orbital wall fracture
The majority of nosebleeds originate from where?
Kiesselbach’s plexus
