ENT Flashcards
priority imaging in maxillofacial trauma
C-spine a priority
history with facial issues
- What happened and when
a. Fall? (why fell?), MVA? Assault? - LOC? Vomiting? Can’t walk?
- Visual symptoms?
- -> IS THE EYE DAMAGED - Facial anesthesia/paresthesia?
- -> The amt of nerves in your face are no joke - Condition of teeth, bite, blown nose?
- PMH, meds (on Coumadin?), tetanus
- Police report made?
- Domestic Violence? Child abuse?
PE for facial injury -ORAL
- -Full, gloved exam
- -Lips - lacs, hematoma,
- Thru/thru, vermillion
- -Trismus or can’t close?
- -Teeth present and intact?
- Where are they?
- -Alveolar ridge, frenulum attachment
–> need to see if this is stable b/c it is differnt than a maxilla fracture
if that is moving get a CT - -Bleeding in mouth?
- -Tongue - lacs? Bleed A LOT!!
PE-Eyes
• Look from above/below/side for asymmetry
• Whistle, smile, wrinkle forehead
• Eyes
Visual acuity (Rosenbaum card – near card; if they can stand do Snellan)
Periorbital - edema, crepitus, lacerations
EOM’s
Pupils, conjunctiva and anterior chamber
Symmetry, subconjunctival hemorrhage (blood vessel breaks between conjunctiva and sclera, hyphema (blood in ant. Chamber)
PE-nose
- -Locate, control bleeding
- -Nasoseptal hematoma?
- -Palpate medial canthus for mobility (worried about sinuses)
PE- ears
- Drainage (blood, CSF?)
- Ear lac?
- Auricular hematoma, Battle sign (ecchymosis behind the ear – basal skull fx)
- TM’s - hemoptypanum, rupture
what do you need to palpate in facial trauma
how to assess for mandible fracture
how to check maxillary arch
Palpate entire face, both hands
Look for tenderness, bony crepitus, subcutaneous air, flattening, anesthesia
Palpate entire orbital rim
check if anterior maxillary arch is stable - if it moves at all, stop
• Intraoral palpation of zygomatic arch
• Tongue blade test for mandible Fx- bite down, twist
If can hold on, likely no Fx
systems you should not forget in ENT assessment
- Scalp, Neck, Neuro exam, CN exam, Chest wall, lungs, heart, abdomen, extremities, pelvis
what should be done
what needs to be administered
what should you avoid
What imaging do you need for the mandible
- ABC’s first - suction
- Consider IV - pain control, Abx; TETANUS
- Pain control
a. IM/IV or topical (eyes, nose) - AVOId po’s - Imaging - CT preferred over plain film
a. Panorex for mandible
before you call a surgeon have a dx
MOA of frontal sinus fx
right above the eyebrows you will have penetration into the brain
- Significant mechanism-MVA
a. Common prior to seat belts
may have forhead lacs
high risk for intracranial injury and bleeding in the brain
sxs with frontal sinus fx
Bony crepitus, deformity, subcutaneous air, limited upward gaze, ptosis, sensory deficit forehead
need to het the bony windows in a CT
frontal bone injury is common in what do we worry about in these populations
children
much higher incidence of intracranial truama
Higher incidence of intracrainial trauma with frontal bone Fx - consider CT head
Frontal bone trauma – worry about the kid’s neck
Upper cervical spine injury more common than lower in kids
worry about to abuse
Nasoethmoidal-orbital fractures occurs form trauma to this
associated with these type of injuries
Small NEO Fx’s easy to miss
Trauma to bridge, medial orbits
Associated with lacrimal injury and dural tears (encephalities or brain infection)
sxs asscoaited with nasoethmoidal-orbital fractures
- Pain at medial bridge, w/ EOM’s
5. Maybe crepitus, telecanthus
mnmgnt of Nasoethmoidal-orbital fractures
(if eyes are further apart than they should be)
6. CT, Abx, OMFS, admit
Orbital Floor – Blow out fx
what do you need to document
you can have this without entrapment but if you have entrapment of this muscle it needs to be repaired
this is when the muscle of the eye does not work
you say look up and one moves and the otherone does not (tethered and stuck)
IS THERE DBL vision on upward gaze*
Orbital Floor – Blow out fx how many have globe rupture
c. 30% have globe rupture
mngmt of orbital floor fx PE and imaging
CT maxillo-facial and orbits (head? If LOC)
Check eye: vision, hyphema, pressures, subconjunctival hemorrhage, subcutaneous emphysema (air b/c maxillary sinus has ruptured and the air escapes)
who do you call and what do you do for orbital floor fx
c. Check infraorbital anesthesia
d. OMFS, ophtho (since there is entrapment) consult
e. Pain control, tetanus; admit?
telecanthus means
if eyes are further apart than they should be)
lateral canthomotomy -when would this be indicated and what is it
Orbital Compartment Syndrome
need to cut the lateral canthus to allow more room for the globe
this can be a site saving procedure
RF with retrobulbar hematoma
vision loss, pupil irregular, papilledema, IOP up, field deficit = optic neuropathy
limbus in retrobulbar hematoma
Limbus – where the conjunctiva ends (around the pupil)
what does periorbital, Orbital Cellulitis entail
- Unilateral infection around or around and behind orbital structures
sxs of periorbital, Orbital Cellulitis
- Fever, red, swelling
- EOM’s painful
- Proptosis if orbital
tx of orbital and periorbital
Periorbital:
a. Abx, +/- admit
Orbital Cellulitis-vision and life threatening need to admit
imaging for periorbital cellulitis
CT orbits all, ULS useful
questions you want to ask with nasal fx
Prior nasal trauma, deformity?
- -Can you breathe thru your nose?
- -Blow nose = face swelling?
nasal fx secret
What do you NEED in your chart
Check for nasal-septal hematoma**
a. -If present, must I&D or necrosis of septum ensues
if you see this it is a ENT emergency that needs to be drained or else you will have necrosis of the septum
LOOK UP IN THERE
ENT f/u with nasal trauma
- “Reduction”- specific cases only
8. -ENT f/u 5-7 days after edema subsides
imaging for nasal fx
X-rays- “bucket handle” view - depression?
CT common: other fx’s
tripod fxs involve ….
- Involve the maxilla, the orbit, and the zygomatic arch
significant mechanism
suspected maxillary fx with swelling indicated imaging
- CT for Dx, OMFS consult, Ophtho consult, admit
maxillary fxs are
Common; if isolated =less serious
- Direct blow, swelling
- Periorbital edema, subconj hemorrhage, flat cheek bone
- Intraoral exam
what do we see associated with a tripod fx
Lateral subconjunctival hematoma
Infraorbital anesthesia
Check eye, lateral canthus pulled downward
often seen with Trismus
High-energy, midface, not subtle
LeFort
mnmgt and workup of LeFort
Fracture patterns often mixed
b. Check hard palate/upper teeth mobility
c. CT, Abx, tetanus
d. OMFS and Optho consult
e. Admit for open reduction and fixation
LeFort classifications
I- mustach
II-nose involvement
III-eyes down
big thing you need to assess this on mandible fx
Open or closed?
look at the cortex
open- gingival lacs with tooth disruption
OPEN-extends through the alveolar ridge gumline
sxs with mandible fx
Tender, swelling, trismus, malocclusion, jaw ecchymosis, bite test
unusual to fx in one spot
look for multiple
OPEN= blood in mouth, gingival lacs, teeth loose separated or uneven
pathognomonic signs for open fx
Sublingual hematoma is pathognomonic
and bruising beneath the jaw
tx for mandible fx
open
Open - OMFS, Abx, tetanus, admit
tx for mandible fx closed-
Closed - outpatient f/u
post trauma, seizure or spontaneous with jaw open suspect
TMJ Dislocation
TMJ dislocation can be
Can be bilateral or unilateral – taking a big bite
tx and reduction of the jaw
X-rays if traumatic
-Pain meds, anxiolytics, suction
Downward pressure on the jaw, rock and pull forward - from above or from front of patient
post reduction management of jaw dislocation
-Liquid diet for 3 days, OMFS f/u
differentiating unilateral from bilateral TMJ dislo
jaw away from side of dislocation. Bilateral - protrudes forward
Hearing Loss initial management
- Sudden or gradual?
- Partial or total?
- Unilateral or bilateral
- Associated Sx’s: tinnitus, vertigo, HA, drainage, pain
- Conductive or Sensorineural?
- Look in ear first, then look for the tuning fork
- Weber test - tuning fork on head
- Rinne test - mastoid then next to ear
what are important questions you want to be asking with hearing loss
(usually intracranial issue)?
Trauma, recent infection, meds (bilateral)
NSAIDS,
aminoglycosides,
erythromycin,
Lasix, ASA, antimalarials, chemo
evaluation of sensorineural vs conductive
Conductive - BC>AC
Sensorineural loss - AC>BC or can’t hear it
describtion of Cerumen Impaction
- Well appearing pt
- Fullness, “underwater”
- Have to document that the TM look good after removal
mangement of conductive cerumen impaction
a. Manual – curette
b. Irrigate:
i. 18g angiocath w/o needle
ii. 1part peroxide, 2parts water
iii. Irrigate w/ 30cc syringe
iv. Immediate relief sx’s
Malignant Otitis Externa
- Elderly, DM, immunocomp
3. Unresponsive OE, Pseudomonas
presentation of OME
- Painful, especially with movement of tragus
- Conductive hearing loss +/-
- Thick, granulation tissue in canal, +/- can’t see TM, facial nerve palsy or paralysis
tx of OME
Admit, IV anti-pseudomonals, ENT consult
appearance and management of fungal OE
Chronic OE in DM, immunocompromised
Painful, white or black fuzzy discharge in canal
Suction out canal, antifungal/acetic acid
Perichondritis presentation
Auricle/pinna is infected
Acute, supprative
Auricle tender, warm, swollen - TM normal
Check behind the ear! Think mastoiditis
Perichondritis tx
IV Abx (pseudomonas),
ENT
consider admit
Herpes zoster of face with involvement of auricle and TM
ramsey hunt
Ramsay Hunt Syndrome sxs need to check for
Painful, unilateral
Hearing loss, peripheral facial paralysis or sensory loss
Acyclovir, steroids, pain meds
Check for corneal involvement –
Hutchenson’s sign (zoster lesions on tip of the nose)
Herpes Zoster Oticus
48hr f/u after ENT consult
Just auricle (NOT the TM)= Herpes
Zoster Oticus
Painful, ear canal abscess
Furuncle
furuncle in the ear mngmt
Exquisitely tender
Hair gets infected and you get a zit in your ear canal
Tragal motion tender
Staph Aureus
d. Needle aspirate or I&D
Abx, pain meds
mngmt of FB
Insect: lidocaine drops - mosquito forceps
Kids: may need sedation
Irrigate if not organic
Check TM
Tx for otitis externa
OM sxs and tx
Red, bulging TM, decreased mobility
Amoxicillin still first-line
- Serous otitis media
a. “Fullness”, bubbles, TM not red
b. Decongestants
Painful, clear or red blisters on TM suspect
Painful, clear or red blisters on TM
URI common
Bullous myringitis tx
Mycoplasma or viral - Tx with macrolides (erythromycin or azithromycin)
painful hearing loss and tinnitius suspect
TM Perforation
Post-infection, blunt or penetrating trauma, noise trauma, barotrauma
Painful, hearing loss
Blood, serous fluid or no discharge
Tinnitus, vertigo common
Up to 90% heal on own
TM Perforation will see webber will lateralize to
Weber lateralizes to affected side
TM Perforation tx
Ear dry, no drops, suspension ok
Refer to audiology, ENT
Cholesteatoma what is it exactly
Squamous epithelium mass behind TM
Acquired or congenital
3. Grows, erodes TM, ossicles
why do we care about Cholesteatoma
Grows, erodes TM, ossicles
will lose hearing
big red flag with Cholesteatoma
neuro symptoms
mngmt of Cholesteatoma
CT if suspect, then MRI
ENT for removal
Auricular Hematoma we are worried about
Leads to necrosis if no tx: “cauliflower ear
tx of auricular hematoma
Incise edge, evacuate clot
+/- suture – check with ENT consultant
Dressing packed firmly into contours/behind ear
Pressure dressing
24hr follow-up - check clot recurrence
ear lac mngmgt
- Block the ear or local anesthesia
Suture through skin, not cartilage, to close
Non-absorbable
- 6-0 suture best
- Attempt to retain shape, contour
- Do not debride too aggressively
Mastoiditis mngmt and sxs
Rare, serious, toxic pt
. Complication of unresolved OM
Can be chronic Hearing loss, ear pain, tender fluctuant mastoid, TM red, +/- perf with discharge CT head w/o con IV Abx, ENT consult Kids, toxic = admit
Nasal Furunculosis/Cellulitis mngmt
Infected hair follicle - usually Staph, cover MRSA
- Remove offending hair
TX OF nasal Furunculosis/Cellulitis mngmt
Abscess of cartilage, ala, columella cellulitis
know this anatomy!
DM, immunocomp - admit
Nasal Foreign Bodies tx
Infants, little kids: parent occludes opposite nostril and blows into mouth
vasoconstrict with Neo-synephrine or Afrin mixed with lidocaine (not w/ Cocaine)
Blow after vasoconstriction
Alligator forceps, ear curette, Dermabond on end of q-tip or small foley cath passed beyond object – inflate – pull out
no luck–> call ENT
Organic FB
Organic FB? Irrigate gently - say “eng”
eeeengg
BIG epistaxis mangement
nterior (90%) or posterior (serious bleed)?
90% of nosebleeds occur here
Coumadin? Trauma?
-90% at Kiesselbach’s plexus (anterior bleed)
anterior bleed
Blow nose gently–> - get clots out
b. -Sit forward/pinch
if it won’t stop bleeding
Gown, glasses, light, suction
Soak several Q-tips in 4% Cocaine or Neo-Synephrine w/ 4% Lido
-Apply to nostril
Tranexamic acid topical - new
Silver Nitrate cautery stick mngmt
- Silver Nitrate cautery stick
a. -Minimum, one side only
b. Don’t cauterize the septum
-Abx ointment over site, saline nasal spray
inserting a nasal tampon
Tampon packing (start with tampon, then rhino rocket if that doesn’t work)
straight and down
Insert along floor of nasal cavity – lube w/ abx oint
Moisten after insertion - expands to space
24hr f/u, Abx, saline drops
alternative to nasal tampon
Rhino Rocket - tampon alternative
i. Mesh covered, inflate w/ saline
c. Still bleeding? Nasal balloon + ENT
management of sinusitis
- Unilateral, face pain, purulent d/c, teeth pain, HA; Sx’s +/- 7days
- Vast majority viral - Abx if fever, hx chronic
- Decongestants
- Not imaged in ED*
a. CT preferred
b. Plain xrays if no CT
dental fx described by
Describe what is exposed
a. Enamel only
b. No further Tx
c. Dental referral
d. Ellis I, Class I, etc
what is a ELLIS II
See yellow dentin exposed
b. Cover with cement
c. Dental consult
d. 24hr f/u
e. Ellis II, Class 2, e
Ellis III management
Dental consult now
b. Cover with cement or isolate tooth with moist, sterile gauze
c. 24hr f/u - discuss necrosis, tooth loss
Concussion what is the mngmt
painful but not loose, no ED Tx, dental f/u
Subluxation what is it and what is the mngmt
loose
a. Push very loose back in - stabilize/splint
b. PCN VK, dental f/u 24hrs
tooth avulsion
totally out
<15min – gently clean tooth, socket - push back in
15min - 2hrs - soak tooth in milk, clean socket, replace
c. >2hrs - same with discussion
d. PCN VK, dental f/u 24hrs
e. No tooth? Get a CXR
Alveolar Ridge Fracture need to
Subluxed or avulsed teeth
–>Lift lip, check buccal space. Hematoma
Alveolar Ridge Fracture signs and tx
Ridge moves with palpation
Panorex; then/or CT IV Abx, pain control OMFS consult
Dental Abscess or Infection mngmt
Facial edema, pain, tender tooth
Block tooth locally if possible (bupivicaine)
I&D in ED only if clearly pointing or buccal space is full, fluctuant
Dental referral 24hrs
RF in dental pain
If fever, trismus, big swelling, face redness:
OMFS now
rx for dental abscess
PCN/Amox/ Clindamycin pain meds, warm rinses
Definitive tx is pulling the tooth
dry socket mangmenet
Block the tooth, irrigate socket with warm NS
Gently pack socket with ¼” plain packing gauze soaked in clove oil or dry socket paste
Dentist 24hrs
Painful necrosis socket, 2-4 days post extraction
dry socket
Necrotizing Ulcerative Gingivitis (Trench Mouth)
what does this look like
Fetid breath (can’t even get near them, it’s smells horrible), bleeding gums, fever, pain, immunocomp
Punched out” interdental papilla
rx of trench mouth
Flagyl, Chlorhexidine rinse, dental and PMD f/u for w/u
most important consideration with lip lac
Cross vermillion?
Margin of error is 2mm at MAX!!
a. Approximate first
b. First suture must line up
mangemetnt of lip laceration
Irrigate, sew outer part first
Irrigate again, and then sew mucosa
anesthesia an stitches of lip lac
Anesthesia: regional block
Infra-orbital nerve (upper) – fantastic
Mental nerve (lower)
- Absorbable 4-0 for mucosa
- Non-absorbable 6-0 for lip and skin
Oral mucosal lacs: repair
- Oral mucosal lacs: repair only large or flapping – rest will heal
mnmgnt for tongue Lacerations (your own teeth get your tongue)
- Small, mid-tongue: control bleed, ice, may not need sutures
- Thru/thru, at edge, w/ flap, large lac: suture
anesthesia and sutures for tongue lac
a. Use lidocaine/bupivicaine w/ epi
b. Lingual nerve block for anterior 2/3 tongue – lingual side 2nd lower molar
c. Local as alternative: painful
- Absorbable 4-0 suture (can use non-absorbable); bury knot
- Complex – consider layered closure
Sialolithiasis MC
Sialolithiasis = Salivary gland stones – obstruction
Most Common: Wharton’s duct
Wharton’s duct is the submandibular duct – floor of the mouth
concerns with Sialolithiasis
tx
Sudden edema, pain; possible infection
a. Mouth pain and tongue pain
Abx, lemon drops, analgesia, ENT f/u
Sialoadenitis
Mumps
Viral prodrome, mostly involves parotid gland
i. Stenson’s duct is the parotid duct – next to upper 2nd molar
b. Non-immunized kids/adults
Bilateral cellulitis of submandibular space
x. Ludwig’s Angina
Ludwig’s Angina MC origin
Odontogenic origin common (lower tooth usually in the front with a big abscess)
Fever; painful, tense, red edema under chin; trismus, dysphagia, dysphonia
tongue displaced upward, edema of floor of mouth, edema of submental space
big concern and mangement of ludwigs
- Rapid progression, polymicrobial
- Airway the big concern
- CT is test of choice, IV Abx
- ENT, admit, airway precautions
Uvulitis presentation
- Sore throat, FB sensation
- Uvula is big, red, angry looking; may touch tongue and cause gag
Position is midline tho if it is JUST the uvula - Think allergy, angioedema first
ts of uvulitis
Abx for strep, consider steroids
Pain meds, slippery foods, close f/u
pharyngitis centor score
NO COUGH
EXUDATE
TENDER LYMPH NODES
SORE THROAT
if you have 4 treat 3?
uvula not midline suspect
Peritonsilar Abscess
cellulitis vs abscess
Sore throat, “hot potato” voice, trismus, fever
- Unilat peritonsilar & soft palate redness, fluctuance
- Uvula is NOT midline
- Uvular deviation away from abscess
Peritonsilar Abscess mangment
18g needle, 3 puncture sites
Beware “big red”
ULS the swelling for fluid with transvaginal probe
7. Topical anesthesia then inject w/ lido w/ epi
Abx, pain meds, 24hr f/u (abscess can recur)
if you have a dry tap treat for cellulitis
tx for cellulitis of uvula
Dry tap? Tx for cellulitis (Clindamycin)
- Neck pain (pain when look up), dysphagia, fever
pain and sx’s out of proportion to exam
xiii. Retropharyngeal Abscess
1. Kids and adults
Retropharyngeal Abscess imaging
CT neck is best, diagnostic
- Airway concerns
- ENT, IV Abx, admit
worse sore throat of my whole life
fever
haven’t eaten and doesn’t look like a sore throat
RPA or epiglottitis (not immunized)
immunization that has really diminished epiglottitis
H.flu vaccine
common sxs of epiglottis
Rapid onset, sore throat, fever
Drooling, voice changes, positioning
imaging for epiglottitis
Soft tissue neck - portable if worried
- If has it – IV, monitor, airway equipment
- Abx, steroids, ENT, admit
FB sensation at rest, worse with swallowing
Laryngoscope, fiber optic scope, mirror
Soft tissue neck, CXR
- Often abrasion only (it isn’t itself there)
- Pulmonary or GI consult
a. Go fishing
