ENT Emergencies Flashcards
ENT Emergencies
Maxillofacial trauma Facial, periorbital infections Ear Emergencies Nose and Sinus Disorders Oral Cavity and Pharyngeal Disorders
Maxillofacial Trauma
ABC’s - airway risk? C-spine a priority Facial trauma = head trauma Vital signs resolving? EtOH common
Maxillofacial Trauma - History
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?
Maxillofacial Trauma -Physical Exam
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
Physical Exam - Oral
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
Physical Exam -Nose
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)
Physical Exam -Ears
Ears
- Drainage (blood, CSF?)
- Ear lac?
- Auricular hematoma, Battle sign
- TM’s - hemoptypanum, rupture
Physical Exam -Other
Don’t forget other organ systems Scalp Neck Neuro exam, CN exam Chest wall, lungs, heart, abdomen Extremities, pelvis
Management of Maxillofacial trauma
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)
Frontal Sinus/Bone Fracture
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
Pediatric Considerations with bone fractures
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
Nasoethmoidal-orbital Fx’s
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
Orbital Floor – Blow Out Fx
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)
Orbital floor fx
Management
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
Retrobulbar Hematoma
and red flags
Collection of blood behind globe
Trauma, post surgical
Proptosis, swell
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
Retrobulbar Hematoma -management
CT face/orbits, ULS
Abx, pain control
Ophtho consult, admit
Periorbital, Orbital Cellulitis
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
Orbital Cellulitis
Orbital:
Serious, vision/life threatening
Abx (broad spectrum), Ophtho
consult, admit all
Nasal Fx’s -management
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
Zygomatic Arch
Common, if isolated =less serious
Direct blow, swelling
Periorbital edema, subconj hemorrhage, flat cheek bone
Zygomatic Arch -management
Intraoral exam
X-rays- “bucket handle” view - depression?
CT common: other fx’s
OMFS f/u - cosmesis
Tripod Fracture
Significant mechanism, facial swelling Lateral subconjunctival hematoma Infraorbital anesthesia Check eye, lateral canthus down Trismus Consider head injury
Tripod Fracture -management
CT for Dx, OMFS consult, Ophtho consult, admit
Maxilla Fractures
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 Intracranial injury common – CT head too
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
TMJ Dislocation
Jaw stuck open - post trauma, seizure or spontaneous
- Hx of same?
- Unilateral - jaw away from side of dislocation. Bilateral - protrudes forward
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
Hearing Loss. what drugs can cause it?
NSAIDS, aminoglycosides, erythromycin, Lasix, ASA, antimalarials, chemo
Associated Sx’s: tinnitus, vertigo, HA, drainage, pain
