ENT Emergencies Flashcards
Cause of herpes simplex keratitis
HSV-1
Presentation of herpes simplex keratitis
Acute onset of eye pain, photophobia, blurred/decreased vision and clear tearing
What is assumed about herpes simplex keratitis?
That it is recurrent (due to a past infection that is living in the trigeminal ganglion)
Physical exam for herpes simplex keratitis
Conjunctival infection (ciliary flush)
Decreased corneal sensation
Slit-lamp with fluorescein dendritic lesions
What is ciliary flush?
Red/violet ring around the cornea that gets worse as the herpes infection gets worse
Tx for herpes simplex keratitis
Urgently refer to ophtho
Use topical or oral antivirals
Corneal transplant (if severe scarring or perforation)
What to remember about the tx of herpes simplex keratitis
NO TOPICAL GLUCOCORTICOIDS
Cause of UV keratitis (photokeratitis)
UV radiation exposure (epithelial layer takes it in and gets damaged)
-Think with tanning bed, water skiing or skiing without goggles
Presentation of UV keratitis
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
What is seen on the penlight exam in UV keratitis?
Tearing, generalized infection and chemosis (edema) of the bulbar conjunctiva (conjunctivitis would also affect palpebral so differentiates)
Other physical exam components for UV keratitis
Cornea (mildy hazy)
Fluorescein (superficial punctuate staining of cornea)
Pupils may be miotic
Tx of UV keratitis
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
General presentation of preseptal and orbital cellulitis
Unilateral periorbital edema with erythema, warmth and tenderness
What can preseptal and orbital cellulitis result from?
Complication of sinusitis, extension of infection from adjacent structure or local disruption of skin
Difference in presentation between preseptal and orbital cellulitis
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
What test will differentiate preseptal and orbital cellulitis?
CT scan of orbits and sinuses with contrast! (orbital is a true emergency!)
Tx of preseptal cellulitis
Mild/no systemic sxs: discharge home
Oral abx and follow up 24-48 hrs
Tx of orbital cellulitis (or preseptal with concerning factors)
Admit and IV abx
Consult ophtho and ENT
What does corneal abrasion/ulceration result from?
Eye trauma, FBs or improper contact lens use
What is damaged in a corneal abrasion?
Thin protective coating of anterior ocular epithelium
What is damaged in a corneal ulceration?
Break in the epithelium exposing the underlying corneal stroma
Sxs of corneal abrasion/ulceration
Severe eye pain and FB sensation
Can lead to impaired vision secondary to scarring
Parts of PE for corneal abrasion/ulceration
Penlight exam Visual acuity EOMs Fundoscopic to confirm red reflex Flourescein exam
What is seen on the penlight exam for corneal abrasion/ulceration?
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
What is the fluorescein exam?
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
When do you need an urgent ophtho referral with corneal abrasion/ulceration?
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)
What are contact wearers at increased risk for?
Pseudomonas infection
Tx for corneal abrasion
Topical abx (erythro ointment, sulfacetamide, polymixin, cipro, ofloxacin)
Optional narcotics
NO TOPICAL ANESTHETIC OR STEROID
What is present in 2/3 of lid laceration pts?
Ocular injury
What to remember with lid lacerations?
Exclude a globe injury
Low threshold for CT of the orbits
Don’t attempt complicated lacerations
Know the anatomy
What is an uncomplicated lid laceration?
Superficial laceration that is horizontal and follows skin lines
Tx for uncomplicated lid laceration if <25% of lid can heal by secondary intention
Clean and apply triple abx ointment
Consider adhesive surgical tape
Tx for uncomplicated lid laceration if >25% repairs with absorbable plain gut suture
Simple interrupted or running sutures within 24 hrs
Remove in 5-7 days if non absorbable
When to refer to ophtho/surgeon with lid lacerations?
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
Another name for orbital floor fracture
Blowout fracture
Significant findings for orbital floor fracture
Entrapment of inferior rectus muscle
Enopthalmos
Orbital dystopia (eye is lower)
Injury to infraorbital nerve secondary to fracture
What can happen with untreated entrapment of inferior rectus?
Ischemia and subsequent loss of muscle function
When might you see enophthalmos?
With posterior globe displacement
When does orbital dystopia occur?
As entrapped muscle pulls the eye down
What does a pt with injury to intraorbital nerve secondary to the orbital fracture look like?
Decreased sensation to cheek, upper lip and upper gingiva
In which patients do you a thin cut coronal CT on the orbits?
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
Tx for orbital floor fracture
Surgical eval
Prophylactic abx to cover sinus pathogens
Cold packs for first 48 hrs
Raise head of bed
Avoid blowing nose/sniffing (extra pressure)
After what does an open globe rupture happen?
Blunt eye injury (think baseball player)
Diagnostic for open globe rupture
Axial and coronal CT of the eye without contrast
Tx for open globe rupture
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
What is optic neuritis associated with?
Inflammatory demyelinating condition with high association with multiple sclerosis
Sxs of optic neuritis
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)
Differentials for optic neuritis over 50 YO
DM, giant cell arteritis, autoimmune
Differentials for optic neuritis in young kids
Infectious or post infectious causes
How to confirm MS association with optic neuritis?
MRI of brain/orbits with GAD
Tx for optic neuritis
Corticosteroids (IV methylprednisolone)
Do not recommend oral prednisone (may increase risk of recurrence)
Intraocular pressure for acute angle glaucoma
Normal is 8-12 and in close angle it is >30 mmHg
Presentation of acute angle closure glaucoma
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
What not to do on exam for acute angle closure glaucoma?
No pupillary dilation b/c might exacerabate this
Gold standard testing for acute angle closure glaucoma
Gonioscopy (special lens for slit lamp so that they can visualize angle between iris and cornea in order to diagnose it)
Tx for acute angle closure glaucoma
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)
Dosing to empirically treat acute angle closure glaucoma by lowering the pressure
1 min: .5% timolol
2 min: 1% apraclonidine
3 min: pilocarpine
What happens with retinal detachment?
ischemia and progressive photoreceptor degeneration
Presentation of retinal detachment
Sudden onset of floaters (cobweb)
Monocular visual field loss
Vision loss
Most common causes of “FB” in ear
Kids: actual FB
Adults: cerumen plug
Presentation of FB in ear
Hearing loss
Ear pain and drainage
Tx for FB in ear
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
Most common cause of acute otitis externa
Pseudomonas
Presentation of bacterial otitis externa
Ear fullness and drainage
Pain with tragal motion tenderness
Tx of otitis externa
Debridement Abx drops (cipro HC maybe with wick)
Viral cause of otitis externa
Ramsey hunt (herpes zoster virus)-suspicious when not better with abx
Presentation of viral otitis externa
Vesicles in ear canal
Facial paralysis
Hearing loss
Vertigo
Tx of viral otitis externa
Antivirals
Steroids
MRI of brain to r/o skull base tumor
Who is at high risk for malignant otitis externa?
Elderly
Diabetics
Immunocompromised
Presentation of malignant otitis externa
(also pseudomonas)
AOE sxs but pt is acutely ill
Ear canal granulation tissue sloughing off
Diagnostics for malignant otitis externa
Leukocytosis on CBC
Cultures
Head CT (osteomyelitis-skull base)
Tx for malignant otitis externa
Admit and debridement Parenteral abx (Cipro 6-8 wks_
Complications associated with malignant otitis externa
Cranial neuropathies Brain abscess Meningitis Septicemia Death
Causes of tympanic membrane perf
Otitis media (b/c it was bulging and then perfed)
Closed head injury
Direct ear trauma
Presentation of tympanic membrane perf
Pain
Hearing loss
N/v, vertigo
Otorrhea and tinnitus
Exam for tympanic membrane perf
Direct visualization of TM
Audiogram
Appropriate components if suspect head trauma (CT and check for CSF drainage)
Tx for tympanic membrane perf
Most resolve without tx (<25% total SA will be within 4 wks)
Ofloxacin otic drops if indicated
Tympanoplasty in refractory cases
Cause of auricular hematoma
(cauliflower ear)
Due to blunt force trauma to the auricle (so presents wth collection of blood in the cartilage)
Tx for auricular hematoma
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
What is perichondritis?
Acute inflammation and infection of auricular cartilage
Usually due to pseudomonas (do C&S)
Presentation of perichondritis
Erythem and pain
Abscess formation
Systemic sxs
Tx for perichrondritis
I&D if indicated Empiric abx (cipro)
Presentation of nasal FB
Mucopurulent nasal discharge Foul odor Epistaxis Nasal obstruction Mouth breathing
What must be checked with nasal FB?
That lungs are CTAB w/o abnormal breath sounds
When do you need diagnostics with a nasal FB?
Usually not if it is fully visible
Is suspect button battery or magnet then get x-ray
Tx for nasal FB
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
Types of epistaxis
Anterior and posterior
Anterior is more common
Most can be conservative tx
Most at Kiesselbach’s plexus
Causes of epistaxis
Nose picking Low moisture Hyperemia secondary to allergic rhinitis FB Drug use or trauma
What is Kiesselbach’s plexus?
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)
Where does a posterior epistaxis occur?
Usually posterolateral branch of sphenopalatine artery
less commonly is carotid artery
Conservative tx for epistaxis
Oxymetazoline (Afrin) for 2 sprays
Direct pressure of the alae tight against septum for 10 min
Nasal hydration if no more bleeding
When do you do cautery with epistaxis?
If you can easily visualise and ID it (avoid large areas, remove excess silver nitrate with cotton tip applicator)
Risks of cautery with epistaxis
Ulceration and septal perf
Removal of nasal packing
3 days in a normal pt and 5 days in anticoagulated pt
Abx also given with nasal packing for epistaxis
Antistaphylococcal (Keflex, Augmentin)
Entire course of packing (prevent toxic shock syndrome)
History important for nasal trauma
Time fram
MOI
Direction of force (pattern of fracture)
Prior nasal surgery or trauma
What is seen on PE for nasal trauma?
Epistaxis CSF rhinorrhea Impaired EOMs Orbital edema/ecchymosis Lacerations Septal hematoma
Diagnostics for nasal trauma
CT scan maxillofacial (WITHOUT contrast) to rule out other facial fractures
Early complications with nasal trauma
Septal hematoma
Abscess
Uncontrolled epistaxis
CSF rhinorrhea
Late complications of nasal trauma
Nasal deformity
Obstruction
Perf
Tx of nasal trauma
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
Causes of septal hematoma
Trauma
Septal surgery
Bleeding disorders
Presentation of septal hematoma
(more common in peds)
Nasal obstruction and pain with soft tender swelling along the septum
Tx of septal hematoma
I&D (prevent vascular necrosis of septum)
Pack nose
Abx
ENT referral (remove packing in 24 hrs, recheck and repack)
What can happen with untreated septal hematomas?
May cause septal perf and/or saddle nose deformity
Presentation of mastoiditis
Maybe asymptomatic with normal exam
Ear pain
Drainage
Tenderness, erythema and edema over mastoid process
Diagnostics for mastoiditis
CT head without contrast
Culture if needed for infection
Tx of mastoiditis
Refer to ENT
Empiric oral abx if immunocompetent
Mastoidectomy and maybe IV abx if recalcitrant disease or immunocompromised
Presentation of periodontal abscess
Fever
Pain
Red, fluctuant swelling of gingiva
TTP
Diagnostics for periodontal abscess
Panoramic radiograph or CT for bone involvement
Tx for periodontal abscess
Pain management
I&D
Oral abx if limited infection (augmentin or clinda 7-14 days)
F/u with dentist
Presentation of tooth avulsion
Pain
Tooth is completely displaced from alveolar ridge
Periodontal ligament severed
What to do if cannot reimplant tooth immediately
Store tooth in balanced saline solution, cold milk or container of their saliva until can get to dentist
Tx for dental avulsion
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
What usually occurs with tongue laceration?
Injury to teeth too (oral cavity and tongue are very vascular so lots of bleeding)
When would you repair a tongue laceration?
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)
When do you NOT repair a tongue laceration?
<1 cm
Non-gaping
Assessed to be minor by examiner
