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X Emergency Med Exam 2 > ENT Emergencies > Flashcards

ENT Emergencies Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

Cause of herpes simplex keratitis

A

HSV-1

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2
Q

Presentation of herpes simplex keratitis

A

Acute onset of eye pain, photophobia, blurred/decreased vision and clear tearing

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3
Q

What is assumed about herpes simplex keratitis?

A

That it is recurrent (due to a past infection that is living in the trigeminal ganglion)

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4
Q

Physical exam for herpes simplex keratitis

A

Conjunctival infection (ciliary flush)
Decreased corneal sensation
Slit-lamp with fluorescein dendritic lesions

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5
Q

What is ciliary flush?

A

Red/violet ring around the cornea that gets worse as the herpes infection gets worse

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6
Q

Tx for herpes simplex keratitis

A

Urgently refer to ophtho
Use topical or oral antivirals
Corneal transplant (if severe scarring or perforation)

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7
Q

What to remember about the tx of herpes simplex keratitis

A

NO TOPICAL GLUCOCORTICOIDS

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8
Q

Cause of UV keratitis (photokeratitis)

A

UV radiation exposure (epithelial layer takes it in and gets damaged)
-Think with tanning bed, water skiing or skiing without goggles

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9
Q

Presentation of UV keratitis

A

Bilateral intense eye pain (unable to open-maybe during the night it comes on)
Photophobia
FB sensation
Distraught, packing or rocking secondary to severe pain

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10
Q

What is seen on the penlight exam in UV keratitis?

A

Tearing, generalized infection and chemosis (edema) of the bulbar conjunctiva (conjunctivitis would also affect palpebral so differentiates)

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11
Q

Other physical exam components for UV keratitis

A

Cornea (mildy hazy)
Fluorescein (superficial punctuate staining of cornea)
Pupils may be miotic

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12
Q

Tx of UV keratitis

A

Supportive b/c resolve in 24-72 hrs
Oral analgesics for pain (may nee oral opioid like oxycodone but transition to NSAID)
Lubricant abx ointment
Prevention education and f/u in 1-2 days

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13
Q

General presentation of preseptal and orbital cellulitis

A

Unilateral periorbital edema with erythema, warmth and tenderness

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14
Q

What can preseptal and orbital cellulitis result from?

A

Complication of sinusitis, extension of infection from adjacent structure or local disruption of skin

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15
Q

Difference in presentation between preseptal and orbital cellulitis

A

Preseptal (usually <5): tissues anterior to the orbital septum with swelling of eyelids and upper cheek
Orbital (>5): structures deep to the orbital septum so see vision loss, impaired EOMs, diplopia and proptosis!!!–usually will have a fever too

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16
Q

What test will differentiate preseptal and orbital cellulitis?

A

CT scan of orbits and sinuses with contrast! (orbital is a true emergency!)

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17
Q

Tx of preseptal cellulitis

A

Mild/no systemic sxs: discharge home

Oral abx and follow up 24-48 hrs

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18
Q

Tx of orbital cellulitis (or preseptal with concerning factors)

A

Admit and IV abx

Consult ophtho and ENT

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19
Q

What does corneal abrasion/ulceration result from?

A

Eye trauma, FBs or improper contact lens use

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20
Q

What is damaged in a corneal abrasion?

A

Thin protective coating of anterior ocular epithelium

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21
Q

What is damaged in a corneal ulceration?

A

Break in the epithelium exposing the underlying corneal stroma

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22
Q

Sxs of corneal abrasion/ulceration

A

Severe eye pain and FB sensation

Can lead to impaired vision secondary to scarring

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23
Q

Parts of PE for corneal abrasion/ulceration

A 
Penlight exam
Visual acuity
EOMs
Fundoscopic to confirm red reflex
Flourescein exam
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24
Q

What is seen on the penlight exam for corneal abrasion/ulceration?

A

Do this prior to fluorescein stain application!
Anterior chamber is clear, deep and normal contour
Pupil is round with clear tears
Mild conjunctival infection if >2 hrs
Ciliary flush if several hrs old

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25
Q

What is the fluorescein exam?

A

Fluorescein stains the basement membrane which is exposed in areas of epithelial defect
Visualization is enhanced with cobalt blue filter and maybe use Woods lamp

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26
Q

When do you need an urgent ophtho referral with corneal abrasion/ulceration?

A

Signs of penetrating of significant blunt trauma (large, nonreactive pupil or irregular pupil)
Impaired visual acuity
Ulceration
Contact lens wearer (to rule out infiltrate or opacity-do daily until healed)

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27
Q

What are contact wearers at increased risk for?

A

Pseudomonas infection

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28
Q

Tx for corneal abrasion

A

Topical abx (erythro ointment, sulfacetamide, polymixin, cipro, ofloxacin)
Optional narcotics
NO TOPICAL ANESTHETIC OR STEROID

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29
Q

What is present in 2/3 of lid laceration pts?

A

Ocular injury

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30
Q

What to remember with lid lacerations?

A

Exclude a globe injury
Low threshold for CT of the orbits
Don’t attempt complicated lacerations
Know the anatomy

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31
Q

What is an uncomplicated lid laceration?

A

Superficial laceration that is horizontal and follows skin lines

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32
Q

Tx for uncomplicated lid laceration if <25% of lid can heal by secondary intention

A

Clean and apply triple abx ointment

Consider adhesive surgical tape

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33
Q

Tx for uncomplicated lid laceration if >25% repairs with absorbable plain gut suture

A

Simple interrupted or running sutures within 24 hrs

Remove in 5-7 days if non absorbable

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34
Q

When to refer to ophtho/surgeon with lid lacerations?

A 
Full thickness lid lacerations
Lacerations with orbital fat prolapse
Lacerations through lid margin
Lacerations through tear drainage system
Orbital injury (hemorrhage or chemosis)
FB
Laceration with poor alignment
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35
Q

Another name for orbital floor fracture

A

Blowout fracture

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36
Q

Significant findings for orbital floor fracture

A

Entrapment of inferior rectus muscle
Enopthalmos
Orbital dystopia (eye is lower)
Injury to infraorbital nerve secondary to fracture

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37
Q

What can happen with untreated entrapment of inferior rectus?

A

Ischemia and subsequent loss of muscle function

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38
Q

When might you see enophthalmos?

A

With posterior globe displacement

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39
Q

When does orbital dystopia occur?

A

As entrapped muscle pulls the eye down

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40
Q

What does a pt with injury to intraorbital nerve secondary to the orbital fracture look like?

A

Decreased sensation to cheek, upper lip and upper gingiva

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41
Q

In which patients do you a thin cut coronal CT on the orbits?

A 
Evidence of fracture on exam (step off or extreme pain)
Limitation of EOMs
Decreased visual acuity
Severe pain
Inadequate exam due to swelling or AMS
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42
Q

Tx for orbital floor fracture

A

Surgical eval
Prophylactic abx to cover sinus pathogens
Cold packs for first 48 hrs
Raise head of bed
Avoid blowing nose/sniffing (extra pressure)

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43
Q

After what does an open globe rupture happen?

A

Blunt eye injury (think baseball player)

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44
Q

Diagnostic for open globe rupture

A

Axial and coronal CT of the eye without contrast

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45
Q

Tx for open globe rupture

A

Initiate abx, NPO, no solutions in eye
Emergent ophtho consult and transfer to tertiary trauma center
Eye shield (no manips)
Bed rest
IV emetics
Pain meds (avoid NSAIDs b/c increase bleeding risk)
Sedation as needed

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46
Q

What is optic neuritis associated with?

A

Inflammatory demyelinating condition with high association with multiple sclerosis

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47
Q

Sxs of optic neuritis

A

Acute, monocular vision loss sometimes bilaterally (hrs to days and pks within 1-2 wks)
Eye pain worse with eye movement
Afferent pupillary defect (direct response to light is sluggish in affected eye)
Dyschromatopsia (loss/reduced color vision)

48
Q

Differentials for optic neuritis over 50 YO

A

DM, giant cell arteritis, autoimmune

49
Q

Differentials for optic neuritis in young kids

A

Infectious or post infectious causes

50
Q

How to confirm MS association with optic neuritis?

A

MRI of brain/orbits with GAD

51
Q

Tx for optic neuritis

A

Corticosteroids (IV methylprednisolone)

Do not recommend oral prednisone (may increase risk of recurrence)

52
Q

Intraocular pressure for acute angle glaucoma

A

Normal is 8-12 and in close angle it is >30 mmHg

53
Q

Presentation of acute angle closure glaucoma

A 
Decreased vision and halos around lights
HA, severe eye pain, red eyes
N/v
Corneal edema and cloudiness
Mid dilated pupil 4-6 mm that reacts poorly to light
Shallow anterior chamber
*immediate ophtho eval
54
Q

What not to do on exam for acute angle closure glaucoma?

A

No pupillary dilation b/c might exacerabate this

55
Q

Gold standard testing for acute angle closure glaucoma

A

Gonioscopy (special lens for slit lamp so that they can visualize angle between iris and cornea in order to diagnose it)

56
Q

Tx for acute angle closure glaucoma

A

Refer pt to ophtho if available in 1 hr
If >1 hr delay empirically treat (dif flashcard with meds!!)
Oral or IV acetazolamide (check pressures 30-60 min after)

57
Q

Dosing to empirically treat acute angle closure glaucoma by lowering the pressure

A

1 min: .5% timolol
2 min: 1% apraclonidine
3 min: pilocarpine

58
Q

What happens with retinal detachment?

A

ischemia and progressive photoreceptor degeneration

59
Q

Presentation of retinal detachment

A

Sudden onset of floaters (cobweb)
Monocular visual field loss
Vision loss

60
Q

Most common causes of “FB” in ear

A

Kids: actual FB
Adults: cerumen plug

61
Q

Presentation of FB in ear

A

Hearing loss

Ear pain and drainage

62
Q

Tx for FB in ear

A

ID the fb (remove if can see it, neutralize bugs with mineral oil, do not irrigate organic material)
Ciprodex or cipro HC gtts if otitis externa

63
Q

Most common cause of acute otitis externa

A

Pseudomonas

64
Q

Presentation of bacterial otitis externa

A

Ear fullness and drainage

Pain with tragal motion tenderness

65
Q

Tx of otitis externa

A 
Debridement
Abx drops (cipro HC maybe with wick)
66
Q

Viral cause of otitis externa

A

Ramsey hunt (herpes zoster virus)-suspicious when not better with abx

67
Q

Presentation of viral otitis externa

A

Vesicles in ear canal
Facial paralysis
Hearing loss
Vertigo

68
Q

Tx of viral otitis externa

A

Antivirals
Steroids
MRI of brain to r/o skull base tumor

69
Q

Who is at high risk for malignant otitis externa?

A

Elderly
Diabetics
Immunocompromised

70
Q

Presentation of malignant otitis externa

A

(also pseudomonas)
AOE sxs but pt is acutely ill
Ear canal granulation tissue sloughing off

71
Q

Diagnostics for malignant otitis externa

A

Leukocytosis on CBC
Cultures
Head CT (osteomyelitis-skull base)

72
Q

Tx for malignant otitis externa

A 
Admit and debridement
Parenteral abx (Cipro 6-8 wks_
73
Q

Complications associated with malignant otitis externa

A 
Cranial neuropathies
Brain abscess
Meningitis
Septicemia
Death
74
Q

Causes of tympanic membrane perf

A

Otitis media (b/c it was bulging and then perfed)
Closed head injury
Direct ear trauma

75
Q

Presentation of tympanic membrane perf

A

Pain
Hearing loss
N/v, vertigo
Otorrhea and tinnitus

76
Q

Exam for tympanic membrane perf

A

Direct visualization of TM
Audiogram
Appropriate components if suspect head trauma (CT and check for CSF drainage)

77
Q

Tx for tympanic membrane perf

A

Most resolve without tx (<25% total SA will be within 4 wks)
Ofloxacin otic drops if indicated
Tympanoplasty in refractory cases

78
Q

Cause of auricular hematoma

A

(cauliflower ear)

Due to blunt force trauma to the auricle (so presents wth collection of blood in the cartilage)

79
Q

Tx for auricular hematoma

A

Drain/ aspirate ASAP
> 7 days (otolaryngologist or plastic surgeon)
F/u eval Q24 hrs for 3-5 days
No sports for 7 days and f/u if worse

80
Q

What is perichondritis?

A

Acute inflammation and infection of auricular cartilage

Usually due to pseudomonas (do C&S)

81
Q

Presentation of perichondritis

A

Erythem and pain
Abscess formation
Systemic sxs

82
Q

Tx for perichrondritis

A 
I&amp;D if indicated
Empiric abx (cipro)
83
Q

Presentation of nasal FB

A 
Mucopurulent nasal discharge
Foul odor
Epistaxis
Nasal obstruction
Mouth breathing
84
Q

What must be checked with nasal FB?

A

That lungs are CTAB w/o abnormal breath sounds

85
Q

When do you need diagnostics with a nasal FB?

A

Usually not if it is fully visible

Is suspect button battery or magnet then get x-ray

86
Q

Tx for nasal FB

A

Restrain child to get good visualization
Retrieve with alligator forceps or suction
No irrigation if organic
Refer to ENT if more than 2 unsuccessful attempts!
Re-examine after 1 FB removed to look for second

87
Q

Types of epistaxis

A

Anterior and posterior
Anterior is more common
Most can be conservative tx
Most at Kiesselbach’s plexus

88
Q

Causes of epistaxis

A 
Nose picking
Low moisture
Hyperemia secondary to allergic rhinitis
FB
Drug use or trauma
89
Q

What is Kiesselbach’s plexus?

A

Anterior epistaxis
Anastamosis of 3 vessels (septal branch of anterior ethmoidal artery, lateral nasal branch of sphenopalantine artery and septal branch of superior labial branch of facial artery)

90
Q

Where does a posterior epistaxis occur?

A

Usually posterolateral branch of sphenopalatine artery

less commonly is carotid artery

91
Q

Conservative tx for epistaxis

A

Oxymetazoline (Afrin) for 2 sprays
Direct pressure of the alae tight against septum for 10 min
Nasal hydration if no more bleeding

92
Q

When do you do cautery with epistaxis?

A

If you can easily visualise and ID it (avoid large areas, remove excess silver nitrate with cotton tip applicator)

93
Q

Risks of cautery with epistaxis

A

Ulceration and septal perf

94
Q

Removal of nasal packing

A

3 days in a normal pt and 5 days in anticoagulated pt

95
Q

Abx also given with nasal packing for epistaxis

A

Antistaphylococcal (Keflex, Augmentin)

Entire course of packing (prevent toxic shock syndrome)

96
Q

History important for nasal trauma

A

Time fram
MOI
Direction of force (pattern of fracture)
Prior nasal surgery or trauma

97
Q

What is seen on PE for nasal trauma?

A 
Epistaxis
CSF rhinorrhea
Impaired EOMs
Orbital edema/ecchymosis
Lacerations
Septal hematoma
98
Q

Diagnostics for nasal trauma

A

CT scan maxillofacial (WITHOUT contrast) to rule out other facial fractures

99
Q

Early complications with nasal trauma

A

Septal hematoma
Abscess
Uncontrolled epistaxis
CSF rhinorrhea

100
Q

Late complications of nasal trauma

A

Nasal deformity
Obstruction
Perf

101
Q

Tx of nasal trauma

A

Repair skin lacerations immediately
If significant swelling, wait 4-6 wks until resolved for surgical correction
Attempt closed reduction immediately (maximize airway and improve aesthetics)
Elevate head of bed, cold compress, pain management
F/u in 3-5 days

102
Q

Causes of septal hematoma

A

Trauma
Septal surgery
Bleeding disorders

103
Q

Presentation of septal hematoma

A

(more common in peds)

Nasal obstruction and pain with soft tender swelling along the septum

104
Q

Tx of septal hematoma

A

I&D (prevent vascular necrosis of septum)
Pack nose
Abx
ENT referral (remove packing in 24 hrs, recheck and repack)

105
Q

What can happen with untreated septal hematomas?

A

May cause septal perf and/or saddle nose deformity

106
Q

Presentation of mastoiditis

A

Maybe asymptomatic with normal exam
Ear pain
Drainage
Tenderness, erythema and edema over mastoid process

107
Q

Diagnostics for mastoiditis

A

CT head without contrast

Culture if needed for infection

108
Q

Tx of mastoiditis

A

Refer to ENT
Empiric oral abx if immunocompetent
Mastoidectomy and maybe IV abx if recalcitrant disease or immunocompromised

109
Q

Presentation of periodontal abscess

A

Fever
Pain
Red, fluctuant swelling of gingiva
TTP

110
Q

Diagnostics for periodontal abscess

A

Panoramic radiograph or CT for bone involvement

111
Q

Tx for periodontal abscess

A

Pain management
I&D
Oral abx if limited infection (augmentin or clinda 7-14 days)
F/u with dentist

112
Q

Presentation of tooth avulsion

A

Pain
Tooth is completely displaced from alveolar ridge
Periodontal ligament severed

113
Q

What to do if cannot reimplant tooth immediately

A

Store tooth in balanced saline solution, cold milk or container of their saliva until can get to dentist

114
Q

Tx for dental avulsion

A

Maintain vitality of periodontal ligament
Handle tooth by crown
Rinse in saline
Insert tooth into empty socket (hold in place with gauze– if reimplant within 5 min good but success is 0% if wait an hour)
Tetanus prophylaxis and abx therapy

115
Q

What usually occurs with tongue laceration?

A

Injury to teeth too (oral cavity and tongue are very vascular so lots of bleeding)

116
Q

When would you repair a tongue laceration?

A

Large (>1 cm)–extends into muscle layer or completely through tongue
Deep on lateral border
Large flaps or gaps
Significant hemorrhage
Any that may cause dysfunction with improper healing
(use absorbable suture 3-0 or 400 chromic gut thingy and give abx)

117
Q

When do you NOT repair a tongue laceration?

A

<1 cm
Non-gaping
Assessed to be minor by examiner

X Emergency Med Exam 2 (6 decks)

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