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ENT > ENT emergenies > Flashcards

ENT emergenies Flashcards

1
Q

Primary concern with facial, head or neck trauma?

A
  • maintain airway
  • avoid nasal tracheal intubation
  • consider: endotracheal intubation, laryngeal mask airway, cricothyroidotomy
  • avoid NG tubes (or any tube in the nose) until the extent of the injury is determined (don’t want to lose tubes in the brain!!)
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2
Q

Hemorrhage control?

A
  • shock rarely develops from facial bleeding alone
  • apply direct pressure
  • may need nasal packing for epistaxis
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3
Q

What PE findings are you looking for with ENT fractures - nose specifically?

A
  • CSF rhinorrhea
  • septal hematoma
  • nasal fracture
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4
Q

Significance of CSF rhinorrhea?

- how do you distinguish b/t clear nasal d/c and CSF?

A
  • direct communication with CNS exists due to disruption of bony barrier and tear in dura
  • significant risk for CNS infection
  • distinguish:
    clinical hx
    filter paper - look for halo sign
  • test for glucose with glucose oxidase paper
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5
Q

When can a septal hematoma occur in adults, children?

A
  • occur from trauma to anterior nasal septum
  • adults: sig trauma and nasal fracture
  • children: can occur with simple falls or minor altercations
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6
Q

Tx of septal hematomas?

A
  • drain and pack
  • abxs (augmentin) - if abscess suspected IV clindamycin and admission
  • cartilage fracture: can result in formation of bilateral hematomas
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7
Q

Complications from not draining a septal hematoma?

A
  • saddle nose deformity
  • septal perforation
  • septal abscess: may spread to paranasal and intracranial structures resulting in intracranial abscess, orbital cellulitis, cavernous sinous thrombosis
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8
Q

Nasal fracture:

dx, what to look for on PE?

A
  • most commonly fractured bone in the face
  • dx usually based on PE
  • nose usually edematous and tender
  • look for displacement, crepitus, and epistaxis
  • inspection with nasal speculum mandatory to rule out septal hematoma
  • manage (closed reduction) 2-10 days post injury to allow for reduction of swelling
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9
Q

In an ENT trauma - what should you look for in and around the ears?

A
  • auricular hematoma
  • hemotympanum
  • battle sign
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10
Q

What is auricular hematoma?

Tx?

A
  • direct trauma to auricle
  • caused by separation of cartilage from perichondrium resulting in avascular necrosis
  • drain within 7 days, compression dressing, daily follow up for few days, abx to cover staph
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11
Q

Etiologies of cauliflower ear?

A
  • failure to drain hematoma
  • stimulation of cartilage growth
  • laceration through cartilage
  • infection
  • high piercings
  • prevention with protective head gear for wrestling, boxing, rugby, and martial arts is key
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12
Q

Tx of ear laceration?

A
  • can do single layer closure through skin and perichondrium but not cartilage (risk of hyperstim. cartilage)
  • pressure dressing to prevent hematoma
  • close f/u
  • can use posterior auricular block for anesthesia
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13
Q

Findings of middle ear injury?

A
  • hemotympanum
  • amber or clear middle ear effusion
  • otorrhea (clear or bloody ear canal drainage)
  • hearing deficit by Weber and rinne tuning fork tests
  • nystagmus
  • ataxia
  • retroauricular hematoma (battle sign)
  • facial nerve deficit may be sign of basilar skull fracture or assoc with middle ear injury
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14
Q

Basilar skull fracures - what bones are involved?

A
  • can be secondary to fracture in temporal, occipital, sphenoid, or ethmoid bones
  • temporal bone: involved in 75% of basilar skull fractures
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15
Q

What is a hemotympanum indicative of?

A
  • basilar skull fracture and middle ear injury
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16
Q

What is Battle sign indicative of?

A
  • basilar skull fracture

- occurs 6-12 hrs after injury

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17
Q

Ottorhea - examination?

A
  • eval for blood or CSF
  • may have hemorrhagic ottorhea from TM rupture or other middle ear injury
  • leave penetrating fbs there until further eval with imaging
  • leave clots in EAC if other signs of middle ear injury (ENT to eval)
  • eval for further injury - skull fracture
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18
Q

What would you look for in trauma pt while doing the oral and mandibular exam?

A
  • mandibular deviation, malocclusion of teeth, paresthesia, tongue blade test
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19
Q

Eval of mandibular fracture?

A
  • 2nd most common facial fracture
  • eval the bite - tongue blade test
  • tooth fractures or avulsions
  • look for trauma of tongue and sublingual ecchymosis
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20
Q

Management and workup of mandibular fracture?

A
  • management: airway management, hemostasis, surgical consult
  • workup: hx, PE, xray, or CT scan
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21
Q

First thing you need to do with pt that has blunt trauma to the neck?

A
  • pt may deteriorate rapidly: leading to impending airway obstruction
  • first thing - determine if airway and pt are stable or unstable!
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22
Q

Most common etiologies of blunt trauma to neck?

A
  • MVA
  • sports
  • GSW
  • assault
  • bicycle

mechanism of injury: forward thrust
(in MVA - seat belts and air bags decrease incidence)

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23
Q

Initial eval of pt with blunt trauma to neck

A
  • ATLS principles
  • intubation hazardous
  • respiratory distress: tracheotomy under local anesthesia
  • avoid cricothyroidotomies: worsen injury
  • if no acute breathing difficulties: get detailed hx and careful PE
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24
Q

History ?s in dx laryngeal injury?

A
  • change in voice
  • pain
  • dyspnea
  • dysphagia
  • odynophagia
  • hemoptysis
  • inability to tolerate the supine position
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25
Q

PE for dx laryngeal injury?

A
  • RR
  • stridor
  • neck skin: contusions, abrasions, or line pattern
  • subq emphysema
  • tracheal deviation
  • open wound: air bubbles (tracheal disruption), exposed tracheal cartilage
  • don’t probe open wounds: may dislodge a hematoma
26
Q

Dx laryngeal injury - studies?

A
  • unstable: tracheotomy and neck exploration
  • stable pts: flexible fiberoptic laryngoscopy in ER
    CT scan, direct laryngoscopy, bronchoscopy, and esophagoscopy
27
Q

Medical management for laryngeal injury?

A
  • min of 24 hr close observation
  • head of bed elevation
  • voice rest
  • anti-reflux meds
  • serial flexible fiberoptic exams
  • abxs for laryngeal mucosa disruption
28
Q

When a pt that has suspected laryngeal trauma is exhibiting respiratory distress what should be performed?

A
  • tracheotomy

- anticipate and calle ENT or surgeon

29
Q

Sxs, dx, and tx of nasal fb?

A
  • sxs: unilateral rhinitis, foul odor, epistaxis, pain
  • dx: direct visualization (nasal speculum or rhinos copy) or Xray
  • tx: remove with forceps or suction
30
Q

Most common sites for epistaxis?

A
  • most common site of bleeding is in the anterior portion: kiesselbach’s plexus
  • posterior bleeds tend to be more severe and harder to tx: sphenopalatine artery
31
Q

Underlying causes of epistaxis?

A
  • local: trauma, epistaxis digitorum, fbs, meds, vascular malformation, chronic sinusitis, neoplasm, polyps, irritants
  • systemic: hemophilia, htn, leukemia, liver disease, **anticoagulants, blood dyscrasias
32
Q

Initial management of epistaxis?

A
  • have pts blow nose to clear clots
  • spray with topical vasoconstrictor like Afrin (oxymetazoline)
  • lean forward and pinch the nares together for at least 20 min continuously
  • examine nose with nasal speculum to locate site of bleeding
33
Q

Anterior vs posterior bleeding?

A
  • big deal b/c txs diff
  • difficult to tell but most bleeds are anterior (visual inspection of nares is mandatory)
  • may need to pack anterior then examine pt to look for continued brisk bleeding then it is most likely posterior
34
Q

Next steps of tx anterior nasal bleed if pinching nares didn’t work

A
  • cautery - silver nitrate sticks
  • if this doesn’t work - place packing or nasal tampon
  • leave in place for 48 hrs
  • f/u reqd in 24-48 hrs
  • necrosis may occur if packing too tight
35
Q

Posterior packing?

A
  • need to call ENT

- most of these pts are admitted to hospital

36
Q

Complications of epistaxis?

A
  • severe bleeding- shock could be from warfarin
  • sinusitis, otitis media
  • pressure necrosis from packing
  • TSS
37
Q

Auricular cellulitis? Etiologies?

who is at risk?

A
  • most common etiology is S. aureus and pseudomonas
  • painful
  • diabetics at high risk
  • difficult to tx due to poor blood supply
  • inflammatory causes related to seronegative arthritis at times indistinguishable from infection usually ear lobe is spared
38
Q

Etiology and tx of barotrauma?

A 
- etiology:
flying, diving, blast injuries
- tx:
supportive, keep ear dry, recheck in 4 weeks to determine if TM is healed
audiometry eval
39
Q

TM rupture - most common cause, tx?

A
  • if assoc with vertigo or facial nerve deficit, immediate referral is indicated
  • infection MC cause
    tx:
    -keep ear dry until TM is healed
    -most heal spontaneously (recheck in 4 weeks)
  • abx drops: ofloxicin for 3-4 days, oral abx may be indicated as well
  • gentamicin, neomycin sulfate, tobramycin CI b/c of ototoxicity
40
Q

Etiology, and presentation of epiglottitis?

A
  • H flu type B, strep pneumo, strep agalactiae, staph aureus, strep pyogenes, M cat
  • presentation:
    drooling, fever, hoarseness, difficulty swallowing, stridor
41
Q

Eval and tx of epiglottitis?

A
  • dx can be clinical, lateral neck xray may help support suspicion (thumb sign), think ahead call ENT or surgeon
  • tx: emergent ENT referral (IV abx and possible intubation)
42
Q

What is peritonsiallar abscess (Quincy)? What can be a complication?

A
  • complication of tonsillitis
  • can extend into deep neck structures and occlude the airway
  • airway occlusion may be more pronounced in children due to smaller airway
43
Q

Presentation of peritonsillar abscess?

A
  • severe unilateral throat pain, fever, difficulty swallowing, hot potato voice, halitosis, neck pain, ear pain on affected side, HA and trismus
44
Q

Management of peritonsillar abscess?

workup?

A 
- supportive therapy:
airway, fever, pain and hydration
- work up: dx is mainly clinical 
\+/- lateral neck xray to rule out other causes, +/- CT scan with contrast
- immediate ENT referral for IND 
- IV abxs (clindamycin)
45
Q

What is a retropharyngeal abscess?

A
  • deep tissue neck infection (usually strep of staph - rapid spread)
  • serious and can be life threatening: asphyxia, spread of infection
46
Q

Etiology of retropharyngeal abscess in children and adults?

A
  • children: usually from lymph node that drains the head and neck
  • adults: penetrating trauma (chicken bone), from an infection in mouth/teeth, lymph nodes that drain the head and neck
47
Q

Signs and sxs of retropharyngeal abscess?

A
  • fever
  • dysphagia
  • neck pain
  • limitation of cervical motion
  • cervical lymphadenopathy
  • sore throat
  • poor oral intake
  • muffled voice
  • respiratory distress
  • stridor more likely in children
  • inflammatory torticollis
48
Q

Work up of retropharyngeal abscess?

A
  • lateral soft tissue xray of neck during inspiration

- ct scan of neck is gold std!

49
Q

Tx of retropharyngeal abscess?

A
  • immediate ENT consult
    -tx is surgical incision and drainage
  • IV hydration and IV abx to be started in ER: clindamycin adult dose 600-900 mg IV q 8 hrs
    or
    ampicillin sulbactam (unasyn) adult dose 1500-3000 mg q 6 hrs
50
Q

Complications of retropharyngeal abscess?

A
  • extension of infection into mediastinum: pleural or pericardial effusion
  • upper airway asphyxia
  • sudden rupture: aspiration pneumonia, widespread infection - sepsis
51
Q

What is Ludwig’s angina? complications?

A
  • infection of submandibular space (floor of mouth under tongue)
  • rapidly progressive gangrenous cellulitis of soft tissues of neck and floor of mouth
  • swelling of soft tissues and elevation of posterior development of tongue causes airway obstruction
  • etiology: odontogenic 90% of cases (staph, strep, and bacteriodes)
52
Q

Signs and sxs of ludwigs angina?

A
  • dental pain, recent hx of dental procedures, neck swelling, neck pain, change in voice, difficulty swallowing, tongue swelling, dyspnea, tachypnea, stridor
  • life threatening emergency
  • PE:
    bilateral submandibular swelling, protruding tongue (not good!)
53
Q

Dx and tx of ludwigs angina?

A
  • clinical dx: CT to determine degree of abscess

- tx: intubation, IND, broad spectrum abxs: combo of PCN, clindamycin, and metronidazole

54
Q

FB aspiration? Tx?

A
  • most common in less than 5 yos
  • smaller objects aspirated
  • larger objects swallowed
  • laryngeal objects: airway emergency
  • remove in controlled fashion
  • laryngeal: ASAP
  • bronchial same day as dx
  • esophageal: variable
55
Q

What is Pott’s puffy tumor?

workup?

A
  • complication of frontal sinusitis or trauma
  • most commonly in kids and teens
  • osteomyelitis of frontal bone
  • can lead to intracranial abscess or venous sinus thrombosis
  • work up: CT
  • immediate referral for surgical drainage, debridement, and IV abx
56
Q

&th nerve palsy? (bells palsy)
hallmark?
etiologies?
tx?

A
  • most cases idiopathic
  • hallmark: sudden onset
  • consider lyme disease in endemic areas
  • HSV or herpes zoster may be cause
  • 80% recover to normal or near normal fxn
  • steroids +/- acyclovir
  • rule out tumor
57
Q

Facila cellulitis?

A
  • involves deeper dermis and subq fat
  • most common: strep and staph
  • can progress rapidly
  • tx with abx: bactrim, keflex
  • f/u
  • admit if RFs
58
Q

Erysipelis?

A
  • involves upper dermis and superficial lymphatics
  • these lesions are raised above level of surrounding skin
  • usually assoc with systemic sxs
  • IV abxs for strep and staph
59
Q

Complications of infections involving medial third of face?

A
  • can be complicated by septic cavernous thrombosis, since veins in region are valveless
60
Q

Denta; emergencies?

A
  • pts present with acute dental pain from caries or fractures
  • put avulsed teeth back in socket if possible
  • little if any ED tx available other than analgesia
  • abx if you suspect dental abscess
  • apical dental blocks
  • find local dentist and know referral procedures

ENT (11 decks)

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