ENT Flashcards
1
Q
maxillofacial trauma
A
- Often impressive appearance
- ABC’s - airway risk?
- C-spine a priority
- Facial trauma = head trauma
- Vital signs resolving?
- EtOH common
- Other injuries
2
Q
Maxillofacial trauma - history
A
- What happened and when
- Fall? (why fell?), MVA? Assault?
- LOC? Vomiting? Can’t walk?
- Visual symptoms?
- Facial anesthesia/paresthesia?
- Condition of teeth, bite, blown nose?
- Blown nose – they blew their nose and their face puffed up - air now in sinus
- PMH, meds, tetanus
- Police report made?
- Domestic Violence? Child abuse?
3
Q
Maxillofacial trauma - physical exam
A
- Look from above/below/side for asymmetry
- Whistle, smile, wrinkle forehead
- Eyes
- Visual acuity (Rosenbaum card)
- Periorbital - edema, crepitus, lacerations
- EOM’s
- Pupils, conjunctiva and anterior chamber
- Symmetry, subconjunctival hemorrhage, hyphema
- Mouth
- 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 (put index finger on hard palate and just gently pull to see if there is wiggle)
- Bleeding in mouth?
- Tongue - lacs?
- Nose
- Locate, control bleeding
- Nasoseptal hematoma?
- Palpate medial canthus for mobility
- Ears
- Drainage (blood, CSF?)
- Ear lac?
- Auricular hematoma, Battle sign
- TM’s - hemoptypanum, rupture
- Palpation
- 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
- Tongue blade when you suspect mandible fracture – have them bite down and try to pull the blade out. If you pull it right out and they cant hold it, suspect mandible fracture
4
Q
Managment
A
- ABC’s first - suction
- Consider IV - pain control, Abx; tetanus
- Pain control
- IM/IV or topical (eyes, nose) - avoid po’s
- Imaging - CT preferred over plain film
- Panorex for mandible
- Make a diagnosis before calling a consultant
- Oral Maxillofacial surgeon (OMFS)
- Ophthalmologist
5
Q
Frontal sinus/bone fracture
A
- Significant mechanism
- Step-off, forehead lacs
- High risk for intracrainial injury, dura tear
- Bony crepitus, deformity, subcutaneous air, limited upward gaze, ptosis, sensory deficit forehead
- CT, Abx, OMFS, admit
6
Q
Pediatric considerations
A
- Frontal bone injury more common - check those lacs carefully
- Higher incidence of intracrainial trauma with frontal bone Fx - consider CT head
- Upper cervical spine injury more common than lower in kids
- Non-accidental facial trauma - ?abuse
- Development, cosmetic deformities
7
Q
Nasoethmoidal-orbital fx’s
A
- Small NEO Fx’s easy to miss
- Trauma to bridge, medial orbits
- Associated with lacrimal injury and dural tears
- Pain at medial bridge, w/ EOM’s
- Maybe crepitus, telecanthus
- CT, Abx, OMFS, admit
8
Q
Orbital floor - blow out fx
A
- Orbital floor fx
- Fat, blood into maxillary sinus
- Entrapment of ocular muscles possible (inferior rectus gets stuck)
- Diplopia on upward gaze
- Upward gaze deficit on EOM’s
- 30% have globe rupture
- Management
- CT maxillo-facial and orbits (head?)
- Check eye: vision, hyphema, pressures, subconjunctival hemorrhage, subcutaneous emphysema
- Check infraorbital anesthesia
- OMFS, ophtho consult
- Pain control, tetanus; admit?
- You can have a blow out fracture without entrapment
- Entrapment is when the muscle of the eye is trapped and cant work - you will get double vision when you look up if there is entraptment
9
Q
Retrobulbar hematoma
A
- Collection of blood behind globe
- Trauma, post surgical
- Proptosis, swelling
- CT face/orbits, Ultrasound
- Abx, pain control
- Ophtho consult, admit
- Red Flags: vision loss, pupil irregular, papilledema, IOP up, field deficit = optic neuropathy
- Orbital Compartment Syndrome
- Swelling with optic neuropathy
- Lateral canthotomy to relieve pressure and save vision
10
Q
Periorbital, orbital cellulitis
A
- Unilateral infection around or around (periorbital) and behind (orbital) orbital structures
- Fever, red, swelling
- EOM’s painful
- Proptosis if orbital
- CT orbits all, ULS useful
- Periorbital:
- Abx, +/- admit
- Orbital:
- Serious, vision/life threatening
- Abx (broad spectrum), Ophtho
- consult, admit all
11
Q
nasal fx
A
- Prior nasal trauma, deformity?
- Can you breathe thru your nose?
- Blow nose = face swelling?
- Clinical Dx – minor = no xray
- Suspect NEO Fx or other pathology – CT max/face/orbits
- Check for nasal-septal hematoma
- If present, must I&D or necrosis of septum ensues à
- Document if not present
- “Reduction”- specific cases only
- ENT f/u 5-7 days after edema subsides
12
Q
zygomatic arch
A
- Common; if isolated =less serious
- Direct blow, swelling
- Periorbital edema, subconj hemorrhage, flat cheek bone
- Intraoral exam
- X-rays- “bucket handle” view - depression?
- CT common: other fx’s
- OMFS f/u - cosmesis
13
Q
tripod fracture
A
- Significant mechanism, facial swelling
- Lateral subconjunctival hematoma
- Infraorbital anesthesia
- Check eye, lateral canthus pulled downward
- Trismus
- Consider head injury
- CT for Dx, OMFS consult, Ophtho consult, admit
14
Q
maxilla fractures
A
- High-energy, midface, not subtle
- LeFort Fx’s
- Fracture patterns often mixed
- Check hard palate/upper teeth mobility
- CT, Abx, tetanus
- OMFS and Optho consult
- Admit for open reduction and fixation
- Persistent nose bleed common
- Intracranial injury common – CT head too
15
Q
mandible anatomy and mandible fxs
A
- Open or closed?
- Multiple fx’s common
- Tender, swelling, trismus, malocclusion, jaw ecchymosis, bite test
- Sublingual hematoma is pathognomonic
- Panorex; then/or CT
- Open = blood in mouth, gingival lacs, teeth loose separated or uneven
- Open - OMFS, Abx, tetanus, admit
- Closed - outpatient f/u
16
Q
TMJ dislocation
A
- Jaw stuck open - post trauma, seizure or spontaneous
- Hx of same?
- Unilateral - jaw away from side of dislocation. Bilateral - protrudes forward
- X-rays if traumatic
- Pain meds, anxiolytics, suction
- Reduction: Downward pressure, rock and pull forward - from above or from front of patient
- Liquid diet for 3 days, OMFS f/u
17
Q
hearing loss
A
- Sudden or gradual?
- Partial or total?
- Unilateral or bilateral?
- Trauma, recent infection, meds (bilateral)
- NSAIDS, aminoglycosides, erythromycin, Lasix, ASA, antimalarials, chemo
- Associated Sx’s: tinnitus, vertigo, HA, drainage, pain
- Conductive or Sensorineural?
- Look in ear first, then look for the tuning fork
- Conductive loss is common
- Cerumen (most common), TM perf, OE, SOM, FB
- Weber test - tuning fork on head
- Conductive - heard best in affected ear
- Sensorineural - heard best in good ear
- Rinne test - mastoid then next to ear
- Conductive - BC>AC
- Sensorineural loss - AC>BC or can’t hear it
18
Q
Cerumen Impaction
A
- Well appearing pt
- Fullness, “underwater”
- Removal:
- Manual – curette
- Irrigate:
- 18g angiocath w/o needle
- 1part peroxide, 2parts water
- Irrigate w/ 30cc syringe
- Immediate relief sx’s
- Check TM after
19
Q
Malignant otitis externa
A
- Osteomyelitis of ear canal
- Elderly, DM, immunocomp
- Unresponsive OE, Pseudomonas
- Painful, especially with movement of tragus
- Conductive hearing loss +/-
- Thick, granulation tissue in canal, +/- can’t see TM, facial nerve palsy or paralysis
- Admit, IV anti-pseudomonals, ENT consult
20
Q
Fungal OE and perichondritis
A
- Fungal OE
- Chronic OE in DM, immunocompromised
- Painful, white or black fuzzy discharge in canal
- Suction out canal, antifungal/acetic acid
- Perichondritis
- Acute, supprative
- Auricle tender, warm, swollen - TM normal
- Check behind the ear! Think mastoiditis
- IV Abx (pseudomonas), ENT, consider admit
21
Q
Ransay Hunt Syndrome
A
- Herpes zoster of face with involvement of auricle and TM
- 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)
- 48hr f/u after ENT consult
- Just auricle = Herpes Zoster Oticus
22
Q
ear canal problems
A
- Furuncle
- Painful, ear canal abscess
- Tragal motion tender
- Staph Aureus
- Needle aspirate or I&D
- Abx, pain meds
- Foreign Body
- Insect: lidocaine drops - mosquito forceps
- this gives the insect a heart attack so the
- Kids: may need sedation
- Irrigate if not organic
- Check TM
- Tx for otitis externa
- Insect: lidocaine drops - mosquito forceps
23
Q
otitis media
A
- Red, bulging TM, decreased mobility
- Amoxicillin still first-line
- Serous otitis media
- “Fullness”, bubbles, TM not red
- Decongestants
-
Bullous myringitis
- Painful, clear or red blisters on TM
- URI common
- Mycoplasma or viral - Tx with macrolides
- This is an emergency!
24
Q
TM perforation
A
- 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
- Weber lateralizes to affected side
- Ear dry, no drops, suspension ok
- Refer to audiology, ENT
25
Q
Cholesteatoma
A
- Squamous epithelium mass behind TM
- Acquired or congenital
- Grows, erodes TM and ossicles
- Hearing loss, pain, d/c; neuro sx’s = red flag
- Risks: chronic OM, perf’s
- CT if suspect, then MRI
- ENT for removal
26
Q
auricular hematoma
A
- Post-traumatic, hematoma between skin and cartilage
- Leads to necrosis if no tx: “cauliflower ear”
- Incise edge, evacuate clot
- +/- suture – check with ENT consultant
- Dressing packed firmly into contours/behind ear
- Pressure dressing
- 24hr follow-up - check clot recurrence
27
Q
auricle laceration
A
- 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
28
Q
mastoiditis
A
- 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
29
Q
nasal furunculosis/cellulitis
A
- Infected hair follicle - usually Staph, cover MRSA
- Remove offending hair
- Aspirate or I&D if localized, pointing
- Abx (MRSA), warm compress, 24h f/u
- Abscess of cartilage, ala, columella cellulitis
- DM, immunocomp - admit
30
Q
nasal foreign bodies
A
- Options:
- 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
- Organic FB? Irrigate gently - say “eng”
- Kids may need procedural sedation
- Check ears too!
- No luck? ENT
31
Q
Epistaxis
A
- Anterior or posterior?
- Coumadin? Trauma?
- Anterior:
- 90% at Kiesselbach’s plexus - anterior
- Mild-moderate bleeding
- Blow nose - get clots out
- Sit forward/pinch
- Won’t stop?
- Gown, glasses, light, suction
- Soak several Q-tips in 4% Cocaine or Neo-Synephrine w/ 4% Lido
- Apply to nostril
- Silver Nitrate cautery stick
- Minimum, one side only
- Abx ointment over site, saline nasal spray
- Tranexamic acid topical - new
- Tampon packing
- Insert along floor of nasal cavity – lube w/ abx oint
- Moisten after insertion - expands to space
- 24hr f/u, Abx, saline drops
- Rhino Rocket - tampon alternative
- Mesh covered, inflate w/ saline
- Still bleeding? Nasal balloon + ENT
- Abx ointment for lube
- Vitals, monitor, Tetanus
- 24hr f/u, abx w/ Rhino Rocket
- Admit if posterior, massive, re-bleed
- Moisten tampon prior to removal
32
Q
sinusitis
A
- 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*
- CT preferred
- Plain xrays if no CT
33
Q
Dental fractures
A
- Ellis I, Class I, etc
- Describe what is exposed
- Enamel only
- No further Tx
- Dental referral
- Ellis II, Class 2, etc
- Hot/cold/air sensitive
- See yellow dentin exposed
- Cover with cement
- Dental consult
- 24hr f/u
- Ellis III, Class 3, etc
- Pulp exposed - see blood
- Dental consult now
- Cover with cement or isolate tooth with moist, sterile gauze
- 24hr f/u - discuss necrosis, tooth loss
34
Q
Concussion, subluxation, avulsion of teeth
A
- Concussion = painful but not loose, no ED Tx, dental f/u
- Subluxation = loose
- Push very loose back in - stabilize/splint
- PCN VK, dental f/u 24hrs
- Avulsion - totally out
- <15min – gently clean tooth, socket - push back in
- 15min - 2hrs - soak tooth, clean socket, replace
- >2hrs - same with discussion
- PCN VK, dental f/u 24hrs
- No tooth? Get a CXR
35
Q
alveolar ridge fracture
A
- Subluxed or avulsed teeth
- Lift lip, check buccal space
- Hematoma
- Ridge moves with palpation
- Panorex; then/or CT
- IV Abx, pain control
- OMFS consult
36
Q
dental abscess or infection
A
- 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
- If fever, trismus, big swelling, face redness: OMFS now
- PCN/Amox/ Clindamycin pain meds, warm rinses
37
Q
dry socket, necrotizing ulcerative gingivitis (trench mouth)
A
- Dry socket
- Painful necrosis socket, 2-4 days post extraction
- 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
- Necrotizing Ulcerative Gingivitis (Trench Mouth)
- Fetid breath, bleeding gums, fever, pain, immunocomp
- “punched out” interdental papilla
- Flagyl, Chlorhexidine rinse, dental and PMD f/u for w/u
38
Q
Lip lacerations
A
-
Cross vermillion?
- Approximate first
- Must line up
- Thru and thru?
- Irrigate, sew outer
- Irrigate again, sew mucosa
- Anesthesia: regional block
- Infra-orbital nerve (upper)
- Mental nerve (lower)
- Absorbable 4-0 for mucosa
- Non-absorbable 6-0 for lip and skin
- Oral mucosal lacs: repair only large or flapping – rest will heal
39
Q
tongue lacerations
A
- Small, mid-tongue: control bleed, ice, may not need sutures
- At edge, w/ flap, large lac: suture
- Anesthesia:
- Use lidocaine or bupivicaine w/ epi
- Lingual nerve block for anterior 2/3 tongue – lingual side 2nd lower molar
- Local as alternative: painful
- Absorbable 4-0 suture (can use non-absorbable); bury knot
- Complex or thru/thru: call OMFS
40
Q
sialolithiasis, sialoadenitis
A
- Sialolithiasis = Salivary gland stones – obstruction
- Common: Wharton’s duct
- Sudden edema, pain; possible infection
- See stone? Try to massage it out
- Abx, lemon drops, analgesia, ENT f/u
- Sialoadenitis = Mumps
- Viral prodrome, mostly involves parotid gland
- Non-immunized kids/adults
- Wharton’s duct is the submandibular duct – floor of the mouth
- Stenson’s duct is the parotid duct – next to upper 2nd molar
41
Q
Ludwig’s angina
A
- Bilateral cellulitis of submandibular space
- Odontogenic origin common
- Fever; painful, tense, red edema under chin; trismus, dysphagia, dysphonia
- Tongue displaced upward, edema of floor of mouth, edema of submental space
- Rapid progression, polymicrobial
- Airway the big concern
- CT is test of choice, IV Abx
- ENT, admit, airway precautions
42
Q
uvulitis
A
- Sore throat, FB sensation
- Uvula is big, red, angry looking; may touch tongue and cause gag
- Position is midline tho
- Think allergy, angioedema first!
- Abx for strep, consider steroids
- Pain meds, slippery foods, close f/u
43
Q
pharyngitis, tonsilitis: GRP A strep
A
- Modified Centor Score includes age: 3-14yrs = 1pt, 15-44yrs = 0, >45yrs = minus 1pt
- Used in lieu of throat culture in ED (use rapid strep test if have it)
- One point each for: fever, tender/swollen anterior cervical nodes, exudate, absence of cough
- Abx if 4 or greater
- PCN allergic? 1st Gen Cephalosporin, Clinda or Macrolide
44
Q
Peritonsilar abscess
A
- Sore throat, “hot potato” voice, trismus, fever
- Unilat peritonsilar & soft palate redness, fluctuance. Visual Dx
- Uvula is NOT midline
- Uvular deviation away from abscess
- Cellulitis vs. abscess
- ULS the swelling for fluid
- Topical anesthesia then inject w/ lido w/ epi
- 18g needle, 3 puncture sites
- Beware “big red”
- Dry tap? Tx for cellulitis (Clindamycin)
- Abx, pain meds, 24hr f/u
45
Q
retropharyngeal abscess
A
- Kids and adults
- Neck pain (pain when look up), dysphagia, fever
- Pharynx looks almost normal – pain and sx’s out of proportion to exam
- Soft tissue neck less common
- CT neck is best, diagnostic
- Airway concerns
- ENT, IV Abx, admit all
46
Q
epiglottitis
A
- No H.flu vaccine
- Rapid onset, sore throat, fever
- Drooling, voice changes, positioning
- Pharynx looks almost normal – pain and sx’s out of proportion to exam
- Soft tissue neck, get portable if worried
- CT is best test, if stable
- If has it – IV, monitor, airway equipment
- Abx, steroids, ENT, admit
47
Q
swallowed foreign bodies
A
- Aspirated vs swallowed
- The fish bone
- FB sensation at rest, worse with swallowing
- Laryngoscope, fiber optic scope, mirror
- Soft tissue neck, CXR
- Often abrasion only
- Pulmonary or GI consult
- go fishing
