ENT Emergencies Flashcards
1
Q
ENT Emergencies
A
Maxillofacial trauma Facial, periorbital infections Ear Emergencies Nose and Sinus Disorders Oral Cavity and Pharyngeal Disorders
2
Q
Maxillofacial Trauma
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ABC’s - airway risk? C-spine a priority Facial trauma = head trauma Vital signs resolving? EtOH common
3
Q
Maxillofacial Trauma - History
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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? PMH, meds, tetanus Police report made? Domestic Violence? Child abuse?
4
Q
Maxillofacial Trauma -Physical Exam
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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
5
Q
Physical Exam - Oral
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Lips - lacs, hematoma, thru/thru, vermillion(where lip becomes face) -Trismus or can’t close? -Teeth present and intact? Where are they? -Alveolar ridge, frenulum attachment -Bleeding in mouth? -Tongue - lacs?
Tongue blade test for mandible Fx- bite down, twist
If can hold on, likely no Fx
6
Q
Physical Exam -Nose
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Nose
- Locate, control bleeding
- Nasoseptal hematoma?
- Palpate medial canthus for mobility(palpate the bridge of the nose and if it moves the pt gets a CT)
7
Q
Physical Exam -Ears
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Ears
- Drainage (blood, CSF?)
- Ear lac?
- Auricular hematoma, Battle sign
- TM’s - hemoptypanum, rupture
8
Q
Physical Exam -Other
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Don’t forget other organ systems Scalp Neck Neuro exam, CN exam Chest wall, lungs, heart, abdomen Extremities, pelvis
9
Q
Management of Maxillofacial trauma
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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
(sometimes the test to start with is the CT)
10
Q
Frontal Sinus/Bone Fracture
A
High risk for intracrainial injury, dura tear
Bony crepitus, deformity, subcutaneous air, limited upward gaze, ptosis, sensory deficit forehead
(look for a Galia tear)
CT, Abx, OMFS, admit
11
Q
Pediatric Considerations with bone fractures
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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
12
Q
Nasoethmoidal-orbital Fx’s
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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
13
Q
Orbital Floor – Blow Out Fx
A
you can have a orbital floor fracture and not have a blow out.
Fat, blood into maxillary sinus
Entrapment of ocular muscles (inferior rectus)
Diplopia on upward gaze
Upward gaze deficit on EOM’s
30% have globe rupture
(pt will have double vision due to one eye is looking up and the other is not)
14
Q
Orbital floor fx
Management
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Management CT maxillo-facial and orbits (head?) Check eye: vision, hyphema, pressures, subconjunctival hematoma, subcutaneous emphysema Check infraorbital anesthesia OMFS, ophtho consult Pain control, tetanus; admit
15
Q
Retrobulbar Hematoma
and red flags
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Collection of blood behind globe
Trauma, post surgical
Proptosis, swell
Red Flags: vision loss, pupil irregular, papilledema, IOP up, field deficit = optic neuropathy
16
Q
Orbital Compartment Syndrome
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Swelling with optic neuropathy
Lateral canthotomy to relieve pressure and save vision
17
Q
Retrobulbar Hematoma -management
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CT face/orbits, ULS
Abx, pain control
Ophtho consult, admit
18
Q
Periorbital, Orbital Cellulitis
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This is an infection not a trauma
Unilateral infection around or around and behind orbital structures Fever, red, swelling EOM’s painful Proptosis if orbital CT orbits all, ULS useful Periorbital: Abx, +/- admit
19
Q
Orbital Cellulitis
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Orbital:
Serious, vision/life threatening
Abx (broad spectrum), Ophtho
consult, admit all
20
Q
Nasal Fx’s -management
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CT max/face/orbits
- Check for nasal-septal hematoma
- If present, must I&D or necrosis of septum ensues
- “Reduction”- specific cases only
- ENT f/u 5-7 days after edema subsides
21
Q
Zygomatic Arch
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Common, if isolated =less serious
Direct blow, swelling
Periorbital edema, subconj hemorrhage, flat cheek bone
22
Q
Zygomatic Arch -management
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Intraoral exam
X-rays- “bucket handle” view - depression?
CT common: other fx’s
OMFS f/u - cosmesis
23
Q
Tripod Fracture
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Significant mechanism, facial swelling Lateral subconjunctival hematoma Infraorbital anesthesia Check eye, lateral canthus down Trismus Consider head injury
24
Q
Tripod Fracture -management
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CT for Dx, OMFS consult, Ophtho consult, admit
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Maxilla Fractures
LeFort Fx’s
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Fracture patterns often mixed
Check hard palate/upper teeth mobility
CT, Abx, tetanus
OMFS and Optho consult
Admit for open reduction and fixation
Intracranial injury common – CT head too
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26
Mandible Fx’s
Open or closed?
Multiple fx’s common
Tender, swelling, trismus, malocclusion, jaw ecchymosis, bite test
Sublingual hematoma is pathognomonic(so look under the tongue)
Panorex best
Open = blood in mouth, gingival lacs, teeth loose separated or uneven
Open - OMFS, Abx, tetanus, admit
Closed - outpatient f/u
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TMJ Dislocation
Jaw stuck open - post trauma, seizure or spontaneous
- Hx of same?
- Unilateral - jaw away from side of dislocation. Bilateral - protrudes forward
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TMJ Dislocation -management
- 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
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Hearing Loss. what drugs can cause it?
NSAIDS, aminoglycosides, erythromycin, Lasix, ASA, antimalarials, chemo
Associated Sx’s: tinnitus, vertigo, HA, drainage, pain
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Hearing Loss -PE
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Conductive or Sensorineural?Look in ear first, then look for the tuning fork
Conductive loss is common
Cerumen, 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
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31
Cerumen Impaction
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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
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32
Malignant Otitis Externa
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
33
Fungal OE and Perichondritis
Infection of the auricle its self.Fungal OE
Chronic OE in DM, immunocompromised
Painful, white or black fuzzy discharge in canal
Suction out canal, antifungal/acetic acid
Supprative perichondritis
Auricle tender, warm, swollen - TM normal
IV Abx, ENT, consider admission
34
Ear Canal -Furuncle
Painful, red, maybe pointing abscess
| Needle aspirate or I&D if possible; Abx, pain meds
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Ear Canal -Foreign Body
Insect: lidocaine drops - mosquito forceps
Kids: may need sedation
Irrigate if not organic
Check TM
Tx for otitis externa
never try to take a live bug out of the ear....put some Lidocaine in the ear and kill it first.
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Otitis Media
Red, bulging TM, decreased mobility
| Amoxicillin still first-line
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Otitis Media -Serous otitis media
Serous otitis media
“Fullness”, bubbles, TM not red
Decongestants
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Otitis Media
| Bullous myringitis
Painful, clear or red blisters on TM
URI common
Mycoplasma or viral - Tx with macrolides
39
TM Perforation
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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
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40
TM Perforation -management
Ear dry, no drops, suspension ok
| Refer to audiology, ENT
41
Cholesteatoma
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Squamous epithelium mass behind TM
Acquired or congenital
Grows, erodes TM, ossicles
Hearing loss, pain, d/c; neuro sx’s = red flag
Risks: chronic OM, perf’s
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42
Cholesteatoma -management
CT if suspect, then MRI
| ENT for removal
43
Auricular Hematoma
Post-traumatic, hematoma between skin and cartilage
Leads to necrosis if no tx: “cauliflower ear”
Incise edge, evacuate clot
No suture
Dressing packed firmly into contours/behind ear
Pressure dressing
24hr follow-up - check clot recurrence
(colliflower ear=auricular hematoma was not properly drained and this happens)
44
How to tx Auricle Laceration
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Block the ear or local anesthesia
Suture through skin, not cartilage, to close
Non-absorbable
6-0 best
Attempt to retain shape, contour
Do not debride too aggressively
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45
Ramsay Hunt Syndrome
Herpes zoster of face with involvement of auricle and TM
Painful, unilateral
Hearing loss, peripheral facial paralysis or sensory loss
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Ramsay Hunt Syndrome -management
| Hutchenson’s sign?
Acyclovir, steroids, pain meds
Check for corneal involvement – Hutchenson’s sign (zoster lesions on tip of the nose)(pt will most likely have zoster on eye so check)
48hr f/u after ENT consult
47
Mastoiditis
Rare, serious, toxic pt
Complication of unresolved OM
Hearing loss, ear pain, tender fluctuant mastoid, TM red, +/- perf with discharge
48
Mastoiditis -management
CT head w/o con
IV Abx, ENT consult
Kids, toxic = admit
49
Nasal Furunculosis/Cellulitis
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
50
Nasal Foreign Bodies -management
Infants, little kids: parent occludes opposite nostril and blows into mouth
Vasoconstrict with Neo-synephrine or Afrin mixed with lidocaine (careful w/ Cocaine)
Blow after vasoconstriction
Alligator forceps, ear curette, Dermabond or small foley cath passed beyond object – inflate – pull out
Organic FB? Irrigate gently - say “eng”
Check ears too
No luck? ENT
51
Epistaxis Mild-moderate bleeding
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Anterior or posterior?
Coumadin? Trauma?
-90% at Kiesselbach’s plexus
-Mild-moderate bleeding
-Blow nose - get clots out
-Sit forward/pinch
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52
Epistaxis --Won’t stop?
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
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other Epistaxis Options
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Tampon packingRhino Rocket - tampon alternativeStill 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
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54
Sinusitis
Unilateral, face pain, purulent d/c, teeth pain, HA; Sx’s +/- 7days
Vast majority viral - Abx if fever, hx chronic
Decongestants
CT over plain
xrays
(Dont give antibiotics automatically, its viral!!!!)
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Know the teeth numbers slide 44
44
56
Ellis I Fracture
Enamel only
No further Tx
Dental referral
57
Ellis II Fracture
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Hot/cold/air sensitive
See yellow dentin exposed
Cover with cement
Dental consult
24hr f/u
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58
Ellis III Fracture
Pulp exposed - see blood
Dental consult now
Cover with cement or isolate tooth with moist, sterile gauze
24hr f/u - discuss necrosis, tooth loss
59
Concussion the tooth is hit but its not loose
Subluxation loose tooth
Avulsion the tooth is out.
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
2hrs - same with discussion
No tooth? CXR
(NEVER EVER SCRUB THE TOOTH CLEAN JUST WASH IT OFF THEN STICK IT BACK IN THE KIDS MOUTH)
60
Alveolar Ridge Fracture
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Subluxed or avulsed teeth
Lift lip, check bucal space
Hematoma
Ridge moves with palpation
Panorex, CT
IV Abx, pain control
OMFS consult
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61
Dental Abscess or Infection
Facial edema, pain, tender tooth, fever
I&D only if clearly pointing or buccal space is full, fluctuant
Dental referral 24hrs
PCN VK, pain meds, warm rinses
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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
63
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
64
Lip Lacerations Cross vermillion?
Approximate first
| Must line up
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Lip Lacerations -Thru and thru?
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Irrigate, sew outer
Irrigate again, sew mucosa
Absorbable 4-0 for mucosa
Non-absorbable 6-0 for lip and skin
Oral mucosal lacs: repair only large or flapping – rest will heal
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66
Tongue Lacerations -small
Small, mid-tongue: control bleed, ice, may not need sutures
67
Tongue Lacerations -thru and thru
Thru/thru, at edge, w/ flap, large lac: suture
Anesthesia:
Lingual nerve block for anterior 2/3 tongue – at 2nd molar
Local lidocaine w/ epi alternative
Absorbable 4-0 suture, bury knot
Complex – consider layered closure
68
Sialolithiasis, Sialoadenitis
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Sialolithiasis = Salivary gland stones – obstruction
Common: Wharton’s duct
Edema, pain, possible infection
See stone? Try to massage it out
Abx, lemon drops, analgesia, ENT f/u
Sialoadenitis = Mumps
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69
Ludwig’s Angina
Bilateral cellulitis of submandibular space
Fever, painful edema under chin, trismus, dysphagia, dysphonia
Tongue displaced, edema of floor of mouth, fullness, edema of submental space
CT is test of choice
ENT, admit, airway precautions, IV ABx
70
Uvulitis
Sore throat, FB sensation
Think allergy, angioedema
Abx for strep, consider steroids
Pain meds, slippery foods, close f/u
71
Peritonsilar Abscess
Sore throat, “hot potato” voice, trismus, fever
Unilat peritonsilar & soft palate redness, fluctuance
Uvular deviation away from abscess
Cellulitis vs. abscess
ULS for fluid
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Spray anesthesia then inject w/ lido w/ epi
18g needle, 3 puncture sites
Beware “big red”
Dry? Tx cellulitis
Abx, pain meds24hr f/u
(ITS VERY IMPORTANT TO DETERMINE IF THE UVULA IS MIDLINE OR NOT
YES IT IS? TONSILITIS
NO ITS NOT? Peritonsilar abcess
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72
Retropharyngeal Abscess
Neck pain (pain when look up), dysphagia, fever
Pharynx looks almost normal – pain and sx’s out of proportion to exam
Soft tissue neck first ok: but CT neck is diagnostic
Airway concerns
ENT, IV Abx, admit
73
Epiglottitis
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No H.flu vaccine
Rapid onset, sore throat, fever,
Drooling, voice changes, positioning
Pharynx doesn’t match
Soft tissue neck - portable if worried
If has it - monitor, airway equipment
Abx, steroids, ENT
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74
Swallowed Foreign Bodies
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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 to go fishing
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