ENT Emergencies Flashcards
What is the primary concern in facial, head, or neck trauma?
Airway
Avoid ________ tracheal intubation
Nasal
Besides epistaxis, what is the best way to control hemorrhage control?
Direct pressure
What is the significance of CSF rhinorrhea?
Direct communication with the CNS due to disruption of the bony barrier and a tear in the dura
How do you distinguish nasal discharge from CSF?
Look for “halo” sign
Test glucose
Septal Hematomas in Adults Occur From?
Significant trauma
Nasal fracture
Septal Hematomas in Children Occur From?
Simple falls
Minor altercations
Treatment of Septal Hematomas
Drain & pack
Antibiotics
Which antibiotic do you use for the treatment of a septal hematoma?
Augmentin
If abscess- Clindamycin & admit
What condition can result in bilateral hematomas?
Cartilage fracture
Complications if a septal hematoma is not drained
Saddle-nose deformity
Septal perforation
Septal abscess
Septal abscess may spread to:
Paranasal & intracranial structures
What is the most common fracture within the head?
Nasal Fracture
Signs & Symptoms for Nasal Fracture
Edematous Tender Displacement Crepitus Epistaxis
What is the time frame to perform a closed reduction for a nasal fracture?
2-10 days
What causes an auricular hematoma?
Direct trauma to the auricle
Separation of cartilage from perichondrium
Treatment for Auricular Hematoma
Drain
What happens when an auricular hematoma doesn’t get drained?
Cauliflower Ear
Causes of Cauliflower Ear
Failure to drain hematoma Simulation of cartilage growth Laceration through cartilage Infection High piercings
How can you prevent cauliflower ear?
Protective head gear
What is the management of an ear laceration?
Single layer closure through skin & perichondrium but not cartilage
Pressure dressing
Close follow up
Findings of a Middle Ear Injury
Hemotympanum Amber or clear middle ear effusion Otorrhea Hearing deficit Nystagmus Ataxia Retroauricular hematoma Facial nerve deficit
Basilar skull fractures can be secondary to a fracture in which bones?
Temporal
occipital
Sphenoid
Ethmoid
Which bone is involved in 75% of basilar skull fractures?
Temporal bone
What finding is indicative of basilar skull fracture and middle ear injury?
Hemotympanum
What is a huge sign of a basilar skull fracture?
Battle sign
What do you need to evaluate ottorhea?
Whether it’s blood or CSF
What is the 2nd most common facial fracture?
Mandibular fracture
How to evaluate a patient with a mandibular fracture?
Evaluate the bite Tooth fractures or avulsions Trauma of tongue Sublingual ecchymosis Tongue blade test
Management of Mandibular Fractures
Airway management
Hemostasis
Surgical consult
Workup of Mandibular Fractures
History
Physical Exam
Xray
CT scan
First steps in a blunt trauma to the neck
Airway stable?
Patient stable?
Can a patient with blunt trauma to the neck deteriorate rapidly?
Yes
Impending airway obstruction
Most common blunt injuries to the neck
MVA
Forward thrust
Initial Evaluation of Blunt Trauma to the Neck
ATLS principles Intubation hazard Respiratory distress Avoid cricothyroidotomies Detailed H&P if stable
Important History in the Diagnosis of Laryngeal Injury
Change in voice Pain Dyspnea Dysphagia Odynophagia Hemoptysis Inability to tolerate the supine position
Key Physical Exam Findings in the Diagnosis of Laryngeal Injury
Respiratory rate Stridor Contusions, abrasions in neck skin Subcutaneous emphysema Tracheal deviation Air bubbles or exposed tracheal cartilage
What to do with UNSTABLE patients with laryngeal injury?
Tracheotomy
Neck exploration
What to do with STABLE patients with laryngeal injury?
Direct laryngoscopy
CT
Bronchoscopy
Esophagoscopy
Medical Management of Laryngeal Injury
24 hours close observation Elevated head of bed Voice rest Anti-reflux meds Serial flexible fiberoptic exams Antibiotics for laryngeal mucosa disruption
Symptoms of a Nasal FB
Unilateral rhinitis
Foul odor
Epistaxis
Pain
Diagnosis of a Nasal FB
Direct visualization
Xray
Treatment of a Nasal FB
Removal with forceps or suction
Where is the most common site of epistaxis?
Kiesselbach’s plexus
Which nose bleeds are more severe?
Posterior bleed
Possible Underlying Causes of Local Epistaxis
Trauma Epistaxis digitorum FB Medications Vascular malformation Chronic sinusitis Neoplasm Polyps Irritants
Possible Underlying Causes of Systemic Epistaxis
Hemophilia Hypertension Leukemia Liver disease Anticoagulants Blood dyscrasias
Initial Management of Epistaxis
Blow nose to clear clots
Spray topical vasoconstrictor
Lean forward and direct compression for 20 minutes
Examine nose with nasal speculum
Is an anterior or posterior bleed more common?
Anterior
Is an anterior or posterior bleed more serious?
Posterior
Steps to Stopping Epistaxis
Direct Compression
Cautery
Nasal packing or nasal tampon
How soon should you follow up with a patient after nasal packing or nasal tampon is placed?
24-48 hours
What can happen if nasal packing is too tight?
Necrosis
Who should place posterior packing?
ENT
Should patients with a posterior bleed be admitted or sent home?
Admitted
Epistaxis Complications
Severe bleeding Shock Sinusitis OM Pressure necrosis Toxic Shock Syndrome
What is the most common etiology of auricular cellulitis?
S. aureus
Pseudomonas
Which patients are at a high risk for auricular cellulitis?
Diabetics
Etiologies for Barotrauma
Flying
Diving
Blast injuries
Treatment for Barotrauma
Supportive
Keep ear dry
Recheck in 4 weeks
Audiometry evaluation
What is the most common cause of TM rupture?
Infection
Treatment for TM Rupture
Keep ear dry until TM healed
Most heal spontaneously
Antibiotic drops
Antibiotics for TM Rupture
Ofloxicin drops
Oral antibiotics
Which antibiotics are contraindicated in a TM rupture and why?
Gentamicin
Neomycin sulfate
Tobramycin
Ototoxicity
Presentation of Epiglottitis
Drooling Fever Hoarseness Dysphagia Stridor
Evaluation of Epiglottitis
Diagnosis clinical
Lateral xray?
Call ENT or surgeon
Treatment of Epiglottitis
Emergent ENT referrel
IV antibiotics
Intubation
Common Bugs of Epiglottitis
H. flu type B Strep pneumo Strep agalactiae Staph aureus Strep pyogenes M. cat
What is the main characteristic of epiglottitis?
Thumb print sign
Presentation of Peritonsillar Abscess
Severe unilateral throat pain Fever Dysphagia "Hot potato" voice Halitosis Neck pain Ear pain on affected side Headache Trismus
Management of Peritonsillar Abscess
Supportive therapy
Work up
Immediate ENT referral for I&D
What type of supportive therapy is needed in peritonsillar abscess?
Airway
Fever
Pain
Hydration
Workup for Peritonsillar Abscess
+/- lateral neck xray
+/- CT with contrast
Anatomic Area of Retropharyngeal Abscess
Base of skull to the tracheal bifurcation
Define Retropharyngeal Abscess
Deep tissue neck infection
Serious/ Life-threatening Consequences of Retropharyngeal Abscess
Asphyxia
Spread of infection
Etiology of Retropharyngeal Abscess in Children
Usually from a lymph node that drains the H&N
Etiology of Retropharyngeal Abscess in Adults
Penetrating trauma
Infection in the mouth/teeth
Lymph nodes that drain the H&N
Signs & Symptoms of Retropharyngeal Abscess
Fever Dysphagia Neck pain Decrease cervical ROM Cervical lymphadenopathy Sore throat Poor oral intake Muffled voice Respiratory distress Stridor (children) Inflammatory torticollis
Workup of Retropharyngeal Abscess
Lateral soft tissue X-ray of neck
CT scan
Treatment of Retropharyngeal Abscess
Immediate ENT consult
I&D
IV hydration
IV antibiotics
IV Antibiotics in Retropharyngeal Abscess
Clindamycin
Ampicillin-sulbactam (Unasyn)
Retropharyngeal Abscess Complications
Extension of infection into mediastinum
Pleural/pericardial effusion
Upper airway asphyxia
Sudden rupture
Define Ludwig’s Angina
Infection of the submandibular space
Progressive cellulitis of soft tissues of neck & floor of mouth
Etiology of Ludwig’s Angina
Odontogenic
Staph
Strep
Bacteroides
Signs & Symptoms of Ludwig’s Angina
Dental pain Recent hx of dental procedures Neck swelling Neck pain Change in voice Dysphagia Glossitis Dyspnea Tacypnea Stridor
Physical Exam Findings of Ludwig’s Angina
Bilateral submandibular swelling
Protruding tongue
Diagnostics of Ludwig’s Angina
Clinical
CT
Treatment of Ludwig’s Angina
Intubation
I&D
Broad spectrum antibiotics
Time Frame for a Laryngeal FB Removal
ASAP
Time Frame for a Bronchial FB Removal
Same day as diagnosis
Time Frame for an Esophageal FB Removal
Variable
What is the Cause of Pott’s Puffy Tumor?
Complication of frontal sinusitis
Trauma
What can Pott’s Puffy Tumor lead to?
Intracranial abscess
Venous sinus thrombosis
Workup of Pott’s Puffy Tumor?
CT
Treatment of Pott’s Puffy Tumor
Referrel to ENT
Drainage
Debridement
IV antibiotics
Etiologies of 7th Nerve Palsy (Bell’s Palsy)
Idiopathic
Lyme Disease
HSV
Herpes zoster
What do you need to rule out with 7th nerve palsy (Bell’s Palsy)?
Tumor
Treatment for Bell’s Palsy
Steroids
+/- acyclovir
Common Bugs for Facial Cellulitis
Strep
Staph
Treatment for Facial Cellulitis
Antibiotics
What Does Facial Cellulitis Involve?
Deeper dermis & subcutaneous fat
What Does Erysipelas Involve?
Upper dermis & superficial lymphatics
Are Erysipelas Lesions Raised?
Yes
Treatment for Erysipelas
IV antibiotics for Strep & Staph
Complication of infections in the “triangle” of the face
Septic cavernous thrombosis
