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EMed Exam 2 > ENT Emergencies > Flashcards

ENT Emergencies Flashcards

1
Q

Cause of herpes simplex keratitis

A

HSV-1 Recurrent infection

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2
Q

Sx of herpes simplex keratitis

A
  • Eye Pain
  • Photophobia
  • Blurred/decreased vision
  • Tearing
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3
Q

PE for herpes simplex keratitis

A
  • Conjunctival injection (ciliary flush)
  • Decreased corneal sensation
  • Slit-lamp with fluorescein Dendritic lesions
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4
Q

Dx of herpes simplex keratitis

A

hx and exam

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5
Q

Tx of herpes simplex keratitis

A

urgent opthalmology referral
Topical/oral antivirals (trifluridine, ganciclovir, acyclovir)
NO TOPICAL GLUCOCORTICOIDS
Corneal Transplant (severe scarring or perforation)

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6
Q

UV keratitis (photokeratitis) presentation

A

UV radiation hx (6-12 hr latent period)

  • Bilateral intense eye pain (unable to open them)
  • Photophobia
  • Foreign body sensation
  • Distraught, pacing, rocking secondary to severe pain
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7
Q

PE for UV keratitis

A
  • Penlight: tearing, generalized injection and chemosis of the bulbar conjunctiva
  • Cornea – may be mildly hazy
  • Fluorescein – superficial punctuate staining of the cornea
  • Pupils may be miotic
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8
Q

Treatment: UV keratitis

A

Supportive (resolves 24-72 hrs)
Oral analgesics for severe pain (mild opiod maybe: oxycodone 5-10 mg q 4-6 hrs x 24 hrs)
Lubricant abx ointment
Education-prevention

f/u 1-2 days

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9
Q

Preseptal and orbital cellulitis

A

unilateral periorbital edema w/ erythema, warmth, tenderness

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10
Q

Cellulitis complication of

A

sinusitis
extension of infection from adjacent structure
Local disruption of skin

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11
Q

Preseptal cellulitis sx

A 
(children <5 YO)
tissue anterior of the orbital septum
swelling of eyelids, upper cheek
may not be painful
no pain w/ eye movement
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12
Q

Orbital cellulitis sx

A 
(children >5 YO)
TRUE EMERGENCY!!!
structure deep to the orbital septum
VISION LOSS, IMPAIRED EOMs, DIPLOPIA, AND/OR PROPTOSIS
Fever
Chemosis
Leukocytosis
Pain w/ eye movements
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13
Q

Dx of cellulitis

A

CT scan of orbits and sinuses WITH CONTRAST

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14
Q

Tx of preseptal cellulitis

A

Mild/No systemic symptoms - discharge home
Oral antibiotics
Follow up within 24-48 hrs

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15
Q

Tx of orbital cellulitis/preseptal cellulitis w/ concerning factors

A

Admit
IV abx
Stat optho/ENT consult

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16
Q

Cause of corneal abrasion and ulceration

A

Result from eye trauma, foreign bodies or improper contact lens use

abrasion: thin protective coating of anterior ocular epithelium
ulceration: break in epithelium exposing the underlying corneal stroma

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17
Q

Sx of abrasion/ulceration

A

• Severe eye pain and foreign body sensation
• Can lead to impaired vision secondary to scarring
- ciliary flush/injection if hours old

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18
Q

PE for abrasion/ulceration

A 
Penlight before stain
Visual acuity
EOMs
Fundoscopic exam (confirm red reflex)
Fluorescein exam! - use cobalt blue filter/wood's lamp - defect enhanced
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19
Q

Urgent optho referral for abrasion/ulceration

A

 Signs of penetrating or significant blunt trauma: large,
nonreactive pupil or irregular pupil
 Impaired visual acuity
 Ulceration
 Contact lens wearer
 Ophthalmology ASAP – r/o infiltrate or opacity Daily to r/o infiltrate or ulcer until healed

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20
Q

Tx for abrasion

A

Topic abx

Narcotics optional

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21
Q

Lid laceration usually has

A

ocular injury

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22
Q

Precautions of lid laceration

A

exclude globe injury
low threshold for CT of orbits
don’t attempt complicated lacerations
know eye anatomy!

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23
Q

Tx for superficial laceration (horizontal, follow skin lines)

A

<25% of eyelid: heal on own by secondary intention; clean, triple abx ointment, adhesive?

> 25% of eyelide: repair w/ 6-0 fast absorbable plain gut suture

  • simple interrupted or running sutures w/i 24 hrs
  • if non absorbable suture used, remove 5-7 days
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24
Q

When to refer lid laceration

A
  • Full thickness lid lacerations (suspicion for penetrating injury to globe)
  • Lacerations with orbital fat prolapse
  • Lacerations through lid margin
  • Lacerations through the tear drainage system
  • Orbital injury (Subconjunctival hemorrhage, chemosis)
  • Foreign body
  • Laceration with poor alignment
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25
"blowout" fx
orbital floor fx
26
Presentation of orbital floor fracture
entrapement of inferior rectus muscle - untreated = ischemia and loss of muscle function Enopthalmos (may develop w/ posterior globe displacement) Orbital dystopia (eye is lower) - may occur as entrapped muscle pulls eye down Injury to infraorbital nerve secondary to fx - decreased senation: cheek, upper lip, upper gingiva
27
Dx of orbital floor fx
Thin cut coronal CT of orbits in patients with: - evidence of fx on exam - limitation of EOM - decreased visual acuity - severe pain - inadequate exam (swelling,/AMS)
28
Tx of orbital floor fx
* Surgical evaluation * Prophylactic antibiotics to cover sinus pathogens * Cold packs – first 48 hrs * Head of bed raised * Avoid blowing nose/sniffing
29
Open globe rupture cause
blunt eye injury (punching, baseball, etc.)
30
PE of open globe rupture tips
* Likelihood of open globe injury * Avoid pressure to the eyeball - Eyelid retraction - IOP measurement
31
Dx of open globe rupture
axial and coronal CT of eye w/o contrast
32
CT w/ contrast
cellulitis
33
Tx of open globe rupture
``` Abx Emergent! optho consult transfer to trauma center EYE SHIELD avoid manipulation Bed rest NPO! No solutions in eye ``` ``` IV antiemetics (ondansetron 4mg) Pain med (no NSAIDS- bleed risk) Sedation prn (lorazepam 0.05 mg/kg - max 2 mg) ```
34
Optic Neuritis
inflammatory, demyelinating condition causing acute, monocular vision loss
35
Optic neuritis associated w/
MS
36
Sx of optic neuritis
* Vision loss - hours to days, peaking within 1-2 weeks * Eye pain worse with eye movement * Afferent pupillary defect - direct response to light is sluggish in the affected eye * Dyschromatopsia - loss/reduced color vision
37
Dyschromatopsia
loss/reduced color vision
38
Ddx for optic neuritis
>50: DM, Giant cell arteritis, autoimmune young child: infectious/post infectious
39
Dx of optic neuritis
Clinical: hx and optho exam MS confirmed by MRI brain/orbits w/ GAD
40
Tx of optic neuritis
CORTICOSTEROIDS (IV methylprednisolone) no oral prednisone- does not help visual outcomes, increases recurrent
41
Acute angle closure glaucoma
• Narrowing or closure of the anterior chamber angle • Normal angle provides aqueous humor drainage • Narrowing of the pathway - Leads to elevated intraocular pressure (IOP) - Damage to the optic nerve
42
Normal IOP
8-12 mm Hg
43
IOP in closed angle claucome
>30 mmHg
44
Sx of acute angle closure glaucoma
* Decreased vision * Halos around lights * Headache * Severe eye pain * Nausea and vomiting * Red eye * Corneal edema/cloudiness * Mid-dilated pupil 4-6mm that reacts poorly to light * Shallow anterior chamber
45
PE for acute angle closure glaucoma
* emergent optho eval * Visual acuity * Evaluation of the pupils * IOP * Slit lamp * Visual field testing pupillary dilation left for optho - may exacerbate
46
Dx of acute angle closure glaucoma
Gonioscopy (visualize angle b/w iris and cornea)
47
Tx of acute angle closure glaucoma
``` optho! If >1 hr delay give abx: - 1 min: timolol - 2 min: apraclonidine - 3 min: pilocarpine ``` Oral and IV acetazolamide!!!! - check pressure at 30-60 min after tx
48
F/u after glaucoma tx
check pressure 30-60 min after tx
49
Retinal detachment
retina separates from epithelium and choroid resulting in ischemia and progressive photoreceptor degeneration (vision loss)
50
Presentation of retinal detachment
* Sudden onset of floaters – cobweb * Monocular visual field loss * Vision loss
51
Tx of retinal detachment
emergent eval w/ optho
52
Ear FB cause
children - FB | adults- cerumen plugs
53
Presentation of ear FB
hearing loss | ear pain/drainage
54
Exam/tx for FB in ear
ID FB - remove under direct visualization - neutralize bugs w/ mineral oil - do not irrigate organic material - may cause infection check for OE: ciprodex or cipro HC gtts
55
Usually cause of AOE
pseudomonas aeruginosa
56
Presentation of AOE
* Ear fullness * Drainage * Pain – tragal motion tenderness
57
Tx for AOE
• Debridement • Antibiotic drops - Ciprodex or CiproHC) +/- otowick • Watch for malignant otitis
58
Viral AOE cause
Ramsey-Hunt (Herpes zoster virus)
59
Presentation of viral AOE
* Vesicles in ear canal * Facial paralysis * Hearing loss * Vertigo
60
Tx of viral AOE
* Antivirals * Steroids * MRI brain to rule out skull base tumor
61
viral AOE associated w/
brain tumor
62
At risk for malignant OE
elderly DM immunocompromised
63
Presentation of Malignant OE
• Symptoms consistent with AOE but patient appears acutely ill • Ear canal granulation tissue
64
Dx of malignant OE
• CBC shows leukocytosis • Cultures • Head CT - Osteomyelitis - skull base
65
Tx for malignant OE
``` • Admit • Debridement • Parenteral antibiotics - Ciprofloxacin 400mg IV Q 8 hrs - Change to 750mg PO Q 12 hrs prior to discharge - Tx prolonged – 6-8 weeks - ENT eval ```
66
Complications of malignant OE
* Cranial neuropathies * Brain abscess * Meningitis * Septicemia * Death
67
TM perforation causes
OM Closed head injury direct ear trauma
68
presentation of TM perforation
* Pain * Hearing loss * Nausea/Vomiting * Vertigo * Otorrhea * Tinnitus
69
PE for TM perforation
Direct visualization of TM Audiogram if suspect head trauma= CT, check for CSF drainage
70
Tx for TM perforation
eval by otolarlyngology (if needed) Water precautions most resolve w/o tx abx (ofloxacin otic drops) - if indicated Tympanoplasty- refractory cases
71
Cauliflower ear
auricular hematoma
72
Auricular hematoma
blunt force trauma to auricle; presents w/ blood in cartilage
73
Tx of auricular hematoma
``` I&D ASAP!!! >7 days: otolaryngologist or plastic surgeon referral educate: - refrain from sports for 7 days - f/u right away if worsening ```
74
F/u for auricular hematoma
q 24 hours for 3-5 days
75
Perichondritis
Acute inflammation and infection of the auricular cartilage
76
cause of perichondritis
pseudomonas aeruginosa
77
Presentation of perichondritis
* Erythema * Pain * Abscess formation * Systemic symptoms
78
Dx of perichondritis
C&S
79
Tx of perichondritis
``` I&D if indicated Empiric abx (Cipro) ```
80
Presentation of nasal FB
* Mucopurulent nasal discharge * Foul odor * Epistaxis * Nasal obstruction * Mouth breathing
81
Exam for nasal FB
direct visualization of FB | make sure lungs are CTAB w/o abnormal breath sounds
82
Nasal FB dx
no needed if FB is visible button batter/magnet: order x-ray!
83
Tx of nasal FB
* Child must be adequately restrained * Must have good visualization * Manually retrieve with alligator forceps or suction * Avoid irrigation if FB is organic matter * If more than 2 unsuccessful attempts - refer to ENT * Always re-examine after 1 FB removed to rule out a second one... * Educate!!!
84
Most common nose bleed
anterior epistaxis
85
Most nosebleeds occur where?
Kiesselbach's plexus
86
Causes of epistaxis
* Nose picking * Low moisture * Hyperemia secondary to allergic rhinitis * FB * Drug use or Trauma
87
Vessel's in Kiesselbach's Plexus (anterior epistaxis)
* Septal branch of the anterior ethmoidal artery * Lateral nasal branch of the sphenopalatine artery * Septal branch of the superior labial branch of the facial artery
88
Posterior epistaxis vessels
posterolateral branches of sphenopalatine artery less commonly from carotid artery
89
Tx for nosebleed
conservative (blow nose) • Oxymetazoline (Afrin) – 2 sprays • Direct pressure of the alae tight against septum X 10 minutes • If no further bleeding, nasal hydration Cautery if doesn't stop: - avoid large areas - remove excess silver nitrate w/ cotton tip applicator Nasal packing? Abx (antistaph - Kefleex, augmentin; entire course of packing)
90
Risks of nasal cautery
ulceration | septal perforation
91
Nasal packing timing
Remove in 3 days (normal) or 5 days (anticoagulated patient)
92
Given w/ packing
Abx (prevent TSS) - cover staph (keflex, augmentin) - during entire course of packing
93
Nasal trauma hx
* Time frame * Mechanism of injury * Direction of force (pattern of fracture) * Prior nasal surgery or trauma
94
PE for nasal trauma
* Epistaxis * CSF rhinorrhea * Impaired EOMs * Orbital edema/ecchymosis * Lacerations * Septal hematoma
95
Dx for nasal trauma
CT scan maxillofacial w/o contrast (r/o facial fx)
96
Early complications of nasal trauma
* Hematoma * Abscess * Uncontrolled epistaxis * CSF rhinorrhea
97
Late complication of nasal trauma
* Nasal deformity * Obstruction * Perforation
98
Tx for nasal trauma
repair lacerations if significant swelling: wait 4-6 weeks before surgical correction Attempt closed reduction immediately: maximize airway, improve aethetics Elecate HOB cold compress Pain management Photos
99
F/u for nasal trauma
3-5 days
100
Causes of septal hematoma
trauma septal surgery bleeding disorders more common in pediatrics
101
Presentation of septal hematoma
nasal obstruction | pain
102
PE for septal hematoma
soft, tender swelling along septum
103
Tx for septam hematoma
I&D (prevent avascular necrosis) pack nose abx outpatient ENT referral (remove packing in 24 hrs, recheck, re-pack)
104
Untreated septal hematoma result
septal perforation | saddle nose deformity
105
Presentation of mastoiditis
May be asymptomatic ear pain drainage tenderness, erythema, edeam over mastoid
106
Dx for mastoiditis
CT head | Culture if infection
107
Tx for mastoidits
REFER TO ENT! may start empiric oral abx if immuno-competant mastoidectomy and IV abx if recalcitrant disease or immunocompromised
108
Presentation of periodontal abscess
* Fever * Pain * Red, fluctuant swelling of the gingiva * Tenderness to palpation
109
Dx of periodontal abscess
panoramic radiograph OR CT for bone involvement
110
Tx for periodontal abscess
Pain management I&D oral abx if limited infection (augmentin/clinda x 7-14 days) F/u w/ dentist
111
Presentation of dental injury
* Pain * Tooth is completely displaced from the alveolar ridge * Periodontal ligament is severed
112
If you can't reimplant, what do you do with tooth?
Balanced saline solution cold milk container of patient's saliva until seen by dentist
113
Tx of dental injury
``` • Maintain the vitality of the periodontal ligament • Handle tooth by crown • Gently rinse in saline • Insert tooth into the empty socket - Hold in place with gauze - Success of re-implantation - 85-97% at 5 min - Nearly 10 0% at 1 hour • Urgent dental consultation ``` TETANUS PROPHYLAXIS AND ABX THERAPY
114
When to repair tongue laceration
>1 cm - extend in to mm. - completely through tongue - deep on lateral boarder - large flaps/gaps - significant hemorrhage - dysfunciton w/ improper healing
115
Closure type of tongue laceration
absorbable suture - 3-0, 4-3 chromic gut suture give abx

EMed Exam 2 (6 decks)

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