ENT emergencies Flashcards
ENT emergencies
maxillofacial trauma facial, periorbital infxns ear emergencies nose & sinus d/o's oral cavity & pharyngeal d/o's
maxillofacial trauma
often impressive appearance ABC's- airway risk? C-spine a priority facial trauma= head trauma VS resolving? EtOH common other injuries
maxillofacial trauma Hx
what happened & when? fall? why fall? MVA? Assault LOC? vomiting? can't walk? visual sx's? facial anesthesia/paresthesia? condition of teeth, bite, blown nose (avoid doing this, may lead to air in areas it shouldn't be) PMH, meds, tetanus police report made? domestic violence? child abuse?
maxillofacial trauma PE
look from above/below/side for ASYMMETRY
whistle, smile, wrinkle forehead
eyes: visual acuity (Rosenbaum card), periorbital (edema, crepitus, lacerations), EOM’s, pupils, conjunctiva, anterior chamber (symmetry, subconjunctival, hemorrhage, hyphema)
PE of oral cavity
full, gloved exam lips- lacs, hematoma, thru/thru, vermillion trismus or can't close? teeth present & intact? where are they? alveolar ridge, frenulum attachment bleeding in mouth tongue-lacs
PE of nose
locate, control bleeding
nasoseptal hematoma
palpate medial canthus for mobility
PE of ears
drainage (blood, CSF)
ear lac?
auricular hematoma, Battle sign
TM’s- hemoptypanum, rupture
PE & palapation
palpate entire face, both hands
look for tenderness, bony crepitus, subq air, flattening, anesthesia
plapate entire orbital rim
check if anterior maxillary arch is stable-if it moves at all, stop!
intraoral palpation of zygomatic arch
how do you check for a mandible fx?
use a tongue blade & ask them to bite down on it & try to pull it out. if they can bite down on it & hold onto it, likely no fx
don’t forget other organ sx’s- do quick look over
scalp neck neuro exam, CN exam chest wall, LUs, heart, abdomen extremities, pelvis
mngt of maxillofacial trauma
ABC's, suction consider IV- pain ctrl, Abx; tetanus pain ctrl- IM/IV or topical (eyes, nose)- avoid po's imaging- CT preferred over plain film make dx before calling consultant
preferred CT image for mandible?
Panorex
frontal sinus/bone fx
significant mechanism needed
step-off, forehead lacs
high risk for intracranial injury, dura tear
bony crepitus, deformity, subq air, limited upward gaze, ptosis, sensory deficit forehead
CT, Abx, OMFS, admit
pediatric considerations
frontal bone injury more common- check those lacs carefully
higher incidence of intracranial trauma w/ frontal bone fx- consider CT head
upper C-spine injury more common than lower in kids
non-accidental facial trauma? abuse?
development, cosmetic deformities- consider these
nasoethmoidal-orbital Fx’s
small NEO Fx's easy to miss trauma to bridge, medial orbits associated w/ lacrimal injury & dural tears pain at medial bridge, w/ EOM's maybe crepitus, telecanthus CT, Abx, OMFS, admit
orbital floor blow out Fx
orbital floor fx
fat, blood into maxillary sinus
entrapment of ocular muscles (inferior rectus)
what you will see w/ entrapment of ocular muscles (inferior rectus)
diplopia on upward gaze
upward gaze deficit on EOM’s
30% have globe rupture
mngt of orbital floor blow out fx
CT maxillo-facial & orbits (head) check eye: vision, hyphema, pressures, subconjunctival heamtoma, subq emphysema check infraorbital anesthesia OMFS, ophtho consult pain control, tetanus; admit?
retrobulbar hematoma
collection of blood behind the globe
retrobulbar hematoma d/t ?
trauma, post surgical
S&S of retrobulbar hematoma
proptosis
swelling
mgnt of retrobulbar hematoma
CT face/orbits, ULS
Abx, pain ctrl
ophtho consult, admit
red flags in retrobulbar hematoma
vision loss pupil irregular papilledema IOP up field deficit= optic neuropathy
orbital compartment syndrome
swelling w/ optic neuropathy
lateral canthotomy to relieve pressure & save vision
periorbital, orbital cellulitis
unilateral infxn around or around & behind orbital structures
S&S of periorbital, orbital cellulitis
fever, red, swelling
EOM’s painful
proptosis if orbital
mgnt of periorbital, orbital cellulitis
CT orbits all, ULS useful
periorbital: Abx, =/- admit
orbital: serious, vision/life threatening; Abx (broad spectrum), ophtho consult, admit all
nasal fx’s
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
nasal-septal hematoma
check in nasal fx’s
if present, must I&D or necrosis of septum ensues
mgnt of nasal fx’s
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
intraoral exam
x-rays: get “bucket handle” view- depression?
CT common: other fx’s
OMFS f/u- cosmesis
tripod fx
significant mechanism, facial swelling lateral subconjunctival hematoma infraorbital anesthesia check eye, lateral canthus down trismus consider head injury CT for Dx, OMFS consult, ophtho consult, admit
maxilla fx’s
high-energy, midface, not subtle
LeFort fx’s
intracranial injury common- CT head too
LeFort fx’s
facture patterns often mixed check hard palate/upper teeth mobility CT, Abx, tetanus OMFS & ophtho consult admit for open reduction & fixation
LeFort fx 1
across maxilla
Lefort fx 2
across nasal bridge, under orbits
LeFort fx 3
goes thru orbits & nasal bridge
mandible fx’s
open/closed? multiple fx's common tender, swelling, trismus, malocclusion, jaw, ecchymosis, bite test sublingual hematoma is pathognomonic panorex best
what is pathognomonic of mandible fx
sublingual hematoma
open mandible fx
blood in mouth
gingival lacs
teeth loose, separated or uneven
tx for open mandible fx
OMFS
Abx
tetanus
admit
closed mandible fx magnt
outpt f/u
TMJ dislocation
jaw stuck open- post trauma, seizure or spontaneous
hx of same
unilateral TMJ dislocation
jaw away from side of dislocation
bilateral TMJ dislocation
protrudes forward
dx & mgnt of TMJ dislocation
x-rays if traumatic pain meds, anxiolytics, suction reduction: downward pressure, rock & pull forward- from above or from front of pt liquid diet for 3 days OMFS f/u
