ENT and Dental Emergencies Flashcards
what organisms commonly cause otitis media?
S. pneumonia, H. influenza, M. catarrhalis
Treatments for Otitis Media (5)
Amoxicillin Augmentin Cefdinir Cefpodoxime Levofloxacin
Complications with Otitis Media
mastoiditis, cholesteatoma, intracranial extension [meningitis/abscess], lateral sinus thrombosis, facial nerve paralysis/paresis
Common bacterial organisms for Otitis Externa
P. aeruginosa [MC]
S. aureus, Enterobacteriaceae, proteus
Common fungal organisms for Otitis Externa
aspergillus
candida
Antibiotic treatment for otitis externa
ofloxacin Cipro/Dex Acetic Acid neo/poly hydrocortisone
when does otitis externa become life threatening?
spreads to involve pinna, surrounding soft tissue and possibly skull base [all the deeper tissue]
What is the predominant organism in malignant otitis externa? What are they seeing more case though of?
P. aeruginosa
MRSA
what could the organism be in malignant otitis externa if the patient is immunocompromised or diabetic?
fungal
which symptom is a bad indicator for malignant otitis externa?
trismus
treatment for malignant otitis externa in children?
imipenem
treatment for malignant otitis externa in adults?
antipseudomonal PCN (pipercillin-tazobactam)
aminoglycoside (tobramycin, gentamicin)
quinolone (Cipro)
cephalosporin (ceftazidime, cefepime)
treatment for funal malignant otitis externa
voriconazole
blood accumulates in the sub-perichondrial space of the ear → tender and fluctuant mass
auricular hematoma
treatent for auricular hematoma
anesthesia (1% lidocaine without epi) →small eliptical incision with #15 blade → express → irrigate → compression dressing
Can also aspirate with 18G needle
If you prescribe an antibiotic for auricular hematoma, what would you give?
cephalexin
quinolone
amoxicillin + clavulanic acid (Augmentin)
what specific spot in the ear do you worry with TM ruptures?
posterosuperior quadrant perforations
4 potential spaces for masticator infections
masseteric/submasseteric
superficial temporal
deep temporal
pterygo-mandibular space
types of organisms seen in masticator space infections
anerobic and aerobic oral streptococcal
Peptostreptococcus, bacteroides, prevotella, porphyromonas, fusobacterium, actinomyes, veillonella, anaerobic spirochetes
prefered diagnostic test for masticator space infections
CT face with contrast
preferred antibiotic for masticator space infection & two others
Clindamycin (preferred)
[ampicillin-sulbactam, penicillin + flagyl]
masticator space infections have a risk of progressing to
mediastinitis
most common location for mandibular dislocation
anteriorly
what should you check in patient with posterior mandibular dislocation?
ears → dislocate posterior can disrupt the auditory canal and create “open dislocation”
what medication should a patient get for mandibular dislocation?
pain relief
muscle relaxant → benzodiazapene
if patient presents with mandibular dislocation secondary to a medication (neuroleptic or antipsychotic) or realted to dystonic reaction, how do you treat?
diphenhyramine
anterior nose bleeds come from →
posterior nose bleeds come from →
Kiesselback plexus
sphenopalatine artery
How to approach a patient with epistaxis, first thing to do?
determine bleed location
posterior MC in elderly, those with inherited coagulopathy, significant posterior pharynx blood, hemorrhaging from both nares
what labs may you want to order for epistaxis?
CBC, Type & Cross, Coagulation studies
what should you do if your patient is hemodynamically compromised and has epistaxis?
IV bloodwork, transfusion, reverse coagulopathy, manage BP, may need surgery
First step in treating epistaxis
direct nasal pressure → blow nose, give Afrin, “sniffing position”, pinch soft nares for 15 min or give nose clamps
How many times you should try step 1 for treating epistaxis before it is considered a failure?
twice → 15 minutes each
second step in treating epistaxis
chemical cautery (silver nitrate swabs) →anesthetize nasal mucosa with topical 1:1 0.05% oxymetazoline & 4% lidocaine solution (may have 1-2% epi) → apply to bleeding site for 1-3 second and ONE SIDE OF SEPTUM ONLY
third step in treating epistaxis
thrombogenic foams and gels gelfoam or surgicel (bioabsorbable and don’t need removal) floseal (hemostatic gelatin matrix with thrombin) tranexamic acid (new stuff)
fourth step in treating epistaxis
Anterior packing
what is used in anterior nose packing?
rapid rhino → anterior balloon inserted straight back in the nose and inflated with 5-10 cc of AIR
fifth step in treating epistaxis
posterior packing and ENT consult
complications associated with epistaxis
pressure necrosis
infection
hypoxia
cardiac dysrhythmias
when can you discharge a patient with epistaxis?
bleeding is controlled + hemodynamically stable + observation > 1 hour
Discharge instructions for epistaxis
ENT visit in 1-2 days give Afrin and instructions on use INR monitoring if on Warfarin No NSAIDs for 72 hours antibiotic if packing > 48 hours → Augmentin
True or False, we can reduce nasal fractures in the ER
false → refer to ENT
common complication of nasal fractures
septal hematoma → hematoma lifts the perichondrium and disrupts blood flow to the septum
what is one thing you need to document for in the note for patient with nasal fracture?
if septal hematoma is present or not
Patient has dental fracture - what is the goal of management?
preserve pulpal vitality
what type of dental fracture requires intervention?
enamel-dentin fracture (70% of tooth fractures) → look for yellow/creamy colored exposure
If your patient can’t see a dentist within 24 hours for an enamel dentin fracture, what should you do?
cover exposed dentin with DenTemp or calcium hydroxide (Dycal)
What tooth fracture presents with tooth bleeding?
enamel-dentin-pulp fracture
which tooth fracture will usually need pain control?
enamel-dentin-pulp fracture
6 types of tooth luxations
concussion subluxation extrusive luxation lateral luxation intrusive luxation avulsion
tenderness and no tooth mobility
concussion
tooth mobility without dislodgement
subluxation
partial tooth dislodgement
extrusive luxation
tooth displacement towards lip or tongue with alveolar fracture
lateral luxation
tooth displacement into the socket with liagment damage
intrusive luxation
tooth displacement from the socket
avulsion
treatment for tooth concussion
NSAID and dentist consult
treatment for tooth subluxation
warn that they are at higher risk for necrosis, see dentist
no splinting
treatment for extrusive luxation
reposition and stabilize → may need local anesthesia
splint with zinc oxide periodontal dressing (Coe-Pak)
see dentist within 24 hours
treatment for lateral tooth luxation
temporary splint with relatively stable → dentist consult ASAP
treatment for intrusive tooth luxation
soft diet + meticulous oral hygeine + chlorohexidine rinse BID
will likely self erupt or be extracted by dentist
treatment for tooth avulsion
replantation ASAP @ scene of injury
Antibiotic for tooth avulsion
Doxycycline for adults
amoxicillin if < 12 years
If tooth has been dry for > 60 minutes why should you try to replace it?
preserve alevolar bone contour and aesthetics → tooth loss is expected
Approach for managing luxation of primary
never replant avulsed primary teeth
1 cause of pharyngitits/tonsillitis
viral → rhinovirus
guidance for who to test and treat for strep pharyngitis
CENTOR criteria
CENTOR criteria includes
age (3-14 years)
tonsillar swelling or exudates
swollen and tender anterior cervical lymph nodes
+/- cough (+ cough more associated with bacterial)
temperature (>100.4)
what is responsible for the 5-15% cases of pharyngitis in adults?
GABHS → streptococcus pyogenes
Common presentation of Streptococcus pharyngitis in adults
sore throat, painful swallowing, chills, fever
tonsillar/pharyngeal edeam (62%)
tonsillar exudates (32%)
enalrged cervical lymph nodes (76%)
may have cough (25%) but less likely to have rhinorrhea
why do you give antibiotics for GABHS?
What does it not prevent?
prevent complications and rheumatic fever
glomerulonephritis
first line treatment for GABHS?
PenVK PO
Amoxicillin PO
benzathine PCN 1.2 million units IM
If your patient has GABHS infection and PCN allergy then they get?
1st generation cephalosporin (cefazolin, cephalexin)
clindamycin
what can be given to manage pain associatedwith GABHS?
PO or IM dexamethasone
what can uvula edema present with?
GABHS, peritonsillar abscess, epiglotitis
Treatment for isolated uvular edema that is uncomfortable
dexamethasone (single dose)
collection of purulent material between tonsillar capsule, superior constrictor, and palatopharyngeal muscles → can be complication from strep or occur on its own
peritonsillar abscess
microorganism common with peritonsillar abscesses
polymicrobial → MC Fusobacterium necrophorum
major physical exam finding for peritonsillar abscess
contralateral displacement of swollen uvula
treatment for peritonsillar abscess
needle aspiration, I&D, surgical tonsillectomy (rare)
treatment for peritonsillar abscess
(against GABHS & anaerobes → F. necro)
Pen VK + metronidazole
clindamycin
piperacillin-tazobactam IV (if toxic or PO intolerant)
for pain → methylprednisolone or dexamethasone
how to perform needle aspiration for peritonsillar abscess?
lidocaine or benzocaine-tetracaine topical spray to mucosa → inject lidocaine + Epi with 25G needle → 18G neede lateral to tonsil NO MORE THAN 1 CM DEEP → pus is seen if encounter cavity
Triad for epiglottitis
Drooling, Dysphagia, Distress [3 D’s]
how to confirm diagnosis of epiglottitis
lateral soft tissue x-ray or transnasal fiber laryngoscopy
immediate treatment options for epiglottitis
intubate awake
awake tracheostomy or cricothyrotomy
pharmacological treatment for epiglottitis
methylprednisolone
cefotaxime + vancomycin
space anterior to prevertebral fascia that extends from the base of the skull to tracheal bifurcation
retropharyngeal space
organism MC seen with retropharyngeal abscess
polymicrobial → GABS, MSSA, MRSA, H. flui, bacteroides, peptostreptococcus , fusobacterium
test of choice if you suspect retropharyngeal abscess
CT neck with contrast
How do you differentiate retrophayngeal abscess from epiglottitis?
lack thumbprint sign and will have very swollen prevertebral muscle
treatment for retropharyngeal abscess
clindamycin or Cefotitin
piperacillin-tazobactam or ampicillin-sulbactam
MC cause of odontogenic abscess
polymicrobial → strep viridans, peptostreptococcus, prevotella, staphylococci
Ludwing’s Angina is infection of what 3 spaces
submental space
sublingual space
submandibular space
Patient with Ludwig’s Angina has necrotizing fascitits, how do you manage it?
IMMEDIATE surgery → fasciotomy, debridement, IV antibiotics
Bones that make up the 4 walls of the orbit
superior → frontal bone
lateral → zygoma + sphenoid
medial → ethmoid
inferior → zygoma + maxilla
second most common fractured facial bone
mandible (1st is nasal)
6 regions of the mandible
body (21%) angle (36%) ramus parasymphyseal (17%) coronoid condyle
on exam the hard palate and upper teeth move
Le Fort I Fracture
on exam, movement of nose, teeth, and hard palate
Le Fort II Fracture
Patient with Le FortII fracture may have sensory deficit where?
below the eyelids and numbness and tingling of the face → infraorbital nerve canal
where are Le Fort III fractures?
extend through frontozygomatic suture lines → across orbit and through the base of the nose and ethmoid region
What commonly occurs with Le Fort III fractures?
airway compromise (edema and hematoma)
MC site for orbital blowout fractures
maxilla
patient has diplopia on upward gaze
trapped inferior rectus m
Patient has blowout fracture and anesthesia
possible infraorbital nerve entrapment
Most concerning finding that is suggestive of inferior orbital displacement through the orbital floor
enophthalmous
study of choice if your patient has blowout fracture
CT of face
what should patient with blowout fracture avoid?
valsalva, bending over, nose blowing
You can discharge a patient with blowout fracture and tell them to follow up with maxillofacial surgeon or ENT if…
there is no muscle entrapment or enophthalmos
