ENT/Ophthalmic Lecture Flashcards
Cellulitis/abscess to bilateral sublingual and submandibular space
*upward displacement of the tongue
often caused by poor dental hygiene
Ludwig’s Angina
Only option to secure Lugwig Angina airway?
Emergency trach ASAP
(cannot intubate or cric these pts)
MC age group for retropharyngeal abscesses
used to be kids (~under 3)
but now with the HiB vaccine, more common in adults who were not vaccinated as kids
“hot potato voice”
cannot swallow own secretions
tripod
especially if unimmunized
Retropharyngeal abscess
OR
Epiglottitis
Trismus
Tripod position
Drooling
Sore throat odynophagia
Thumb sign
Epiglottitis
MC age for epiglottitis?
Use to be kids, but now with HiB vaccine, 40 yo adults who were not vaccinated as kids are MC
Localized cellulitis of supraglottic area with potential for abscess formation
Epiglottitis
Spectrum of symptoms from mild pain to SOB, depending on amount of swelling
Uvula deviation
+/- stridor, drooling, trismus
Peritonsillar abscess
Disruption of conjunctival blood vessels
may occur from trauma, sneezing, gagging or Valsalva
will resolve spontaneously in 2 weeks
Subconjunctival hemorrhage
Present with a foreign body sensation
Tearing, photophobia, blepharospasm, severe pain
can be seen under fluorescein slit lamp
Corneal abrasion
Eye foreign bodies can usually be removed with a…
moist cotton applicator
Superficial conjunctival lesions are treated with erythromycin ointment for how long?
2-3 days
Contact lens abrasions are treated with ciprofloxacin, ofloxacin or tobramycin drops to cover ____________
pseudomonas
Should you wear an eye patch for an abrasion?
NO
True or False..
Topical anesthetics for home use are strictly contraindicated!!!
True
Ophthalmology follow up is advised within _____ hours for all corneal abrasions
24 hours
Fine needle tip
Eye spud
Eye burr
(after applying a topical anesthetic)
can be used for…
removing corneal foreign bodies
Rust rings are associated with metallic foreign bodies and may be removed with an….
eye burr
trauma which causes….
Abnormal anterior chamber depth
Irregular pupil
Blindness
..indicate what? (unti proven other wise)
Ruptured globe
Blood in the anterior chamber
can occur spontaneously (sickle cell or coagulopathy pts) or following trauma
blood in the iris
Hyphema
Place the pt upright to allow the blood to settle inferiorly
Place protective eye shield
Pupillary dilation may be indicated
always consult with ophthalmology
Hyphema
Inferior and medial wall (lamina papyracea) of the orbit may be fractured from blunt trauma
Blowout fractures
True or False…
1/3 of blowout fractures are associated with ocular trauma
True
Exam shows…
-Evidence of inferior rectus entrapment (diplopia on upward gaze)
-Parasethesia of infraorbital nerve
-subcutaneous emphysema (esp when sneezing or blowing nose)
Blowout fracture
Image of choice for a blowout fracture?
CT
What complication must you worry about with a blowout fracture?
Entrapment of inferior rectus muscle
Can result from both blunt and penetrating trauma
Hisk risk mechanisms:
Hammering metal on metal
Use of high-speed machinery
Explosion related injuries
Ruptured globe
Severe subconjunctival hemorrhage
Irregular or tear drop shaped pupil
Afferent pupillary defect
Shallow or deep anterior chamber, compared to other eye
Hyphema
Limitation of EOM
Extrusion of globe contents
Lens dislocation
Significant reduction in visual acuity
Ruptured globe
Fluorescein streaming (Seidel’s test) is pathognomonic for…
Ruptured globe
(although it may be absent)
Should you measure IOP in a ruptured globe pt?
NO!!
Place pt upright
NPO
Protective metallic eye shield
IV broad spectrum abx
Analgesia
Sedation
Anti-emeic
Tetanus
ED Management for ruptured globe
Eye should be immediately flushed in prehospital setting
Sterile normal saline or Ringer’s lactate Morgan Lens irrigation should be continued in ED upon arrival until the pH is normal (7.0-7.4)
Management for chemical burn to eye
(Acid and Alkali burns are managed similarly)
Once pH is normal, fornices should be swept to remove residual particles and any necrotic conjunctiva
pH should be recheck in 10 mins
Chemical ocular injury
After irrigation, a full slit lamp exam should be done
IOP should be measured
Pain meds
Tetanus
Chemical ocular injury
Presents with…
Eye pain
HA
Cloudy vision
Colored halos around lights
Cloudy or steamy appearance of cornea
Conjunctival injection
A fixed, mid-dilated pupil
increased IOP of 40-70 mmHG
Acute angle closure glaucoma
normal IOP= 10-20 mmHg
what is the IOP in acute angle closure glaucoma?
40-70 mmHg
Timolol (topical beta blocker)
Apraclonidine (topical alpha agonist)
Acetazolamide
Mannitol
Topical pilocarpine
…can all be used in management of?
Acute angle closure glaucoma
(lowers IOP)
For a diagnosis, need 2+ of the following:
Eye pain
Blurred vision
N/V
Intermittent halos
Acute angle closure glaucoma
For a diagnosis, need 3+ of the following:
IOP > 21 mmHg
Conjunctival injection
Corneal epithelial edema
Mid-dilated, non reactive pupil
Acute angle closure glaucoma
Causes include:
Embolus
Thrombosis
Giant-cell arteritis
Vasculitis
Sickle cell dz
Vasospasm (migraines) glaucoma
Hypercoaguable states
Low retinal blood flow
Trauma
Central artery occlusion
amaurosis fugax= painless, transient monocular or binocular visual loss (caused by blood clot or a peice of plaque)
..this often precedes what?
Central retinal artery occlusion
Vision loss is often painless, with complete or near complete vision loss
Afferent pupillary defect
Fundascopic exam reveals a pale fundus with narrowed arterioles with segmented flow (“box cars”) with bright red macula (“cherry red spot”)
Central retinal artery occlusion
ED managament= ocular massage (digital pressure for 15 seconds followed by sudden release)
Central retinal artery occlusion
MC cause of blindness in western world
Herpes simplex keratitis
Seen as linear branching lesion under fluorescein dye and slit lamp
tx= acyclovir
Herpes simplex keratitis
Causes:
Infection
Demyelination
Autoimmune disorders
may present with various degrees of vision loss (often with poor color perception), pain during EOM , visual field cuts and afferent pupillary defect
Optic neuritis
Diagnosis made with red desaturation test (after staring at a bright red object with the normal eye only, the object may subsequently appear pink or light red in the affected eye)
Optic neuritis
Flashing lights
Floaters
A dark curtain or veil
Diminished visual acuity
Retinal detachment
True or False…
Vision loss from acute glaucoma is irreversible
True
Cellulitis involving the submandibular spaces and the sublingual spaces that can spread to the neck and mediastinum, causing airway compromise, overwhelming infection and death
tx= broad spectrum abx
airway management ASAP
Ludwig’s angina
Gold standard image for retropharyngeal abscess
CT with IV contrast
(allows differentiation between cellulitis and abscess)
1-2 days hx of worsening dysphagia, odynophagia and dyspnea (worse w supine)
Upright, leaning forward position
drooling, inspiratory stridor
lateral soft tissue radiographs may show a “thumbprint sign”
Epiglottitis
Tx:
Remain in upright position
Supplemental humidified oxygen
Ceftriaxone IV
Steroids may be given to reduce airway inflammation
Epiglottitis
Infection ususally polymicrobial
Fever, sore throat, torticollis, dysphagia
Neck pain, stiffness, muffled voice, cervical LAD, respiratory distress
improvement with lying supine with neck in slight extension
(sitting up may worsen dyspnea)
Retropharyngeal abscess
(tx= IV clinda)
uvula deviation
+/- stridor, drooling, trismus
tx= drainage, abx
Peritonsillar abscess
Polymicrobial infection that develops betwen the tonsillar capsule and the superior constrictor and palatopharyngeus muscle
risk factors: smoking, periodontal dz, chronic tonsillitis, repeat courses of abx
MC in young adults during winter and spring months
Peritonsillar abscess
Needle aspiration of purulent material is diagnostic and therapeutic for peritonsillar abscesses and will treat more than __% of these pts
90%
(give Penicillin post drainage)
Oxymetazoline can be used in the tx of…
Epistaxis
Complication of infection spreading from the middle ear
otalgia
fever
postauricular erythema, swelling, tenderness
*can have CN V, VI, VII palsy
Mastoiditis
(CT scan will show extend of bony involvement)
AOM tx
Amoxicillin 250-500 mg PO TID x 7-10 days
ALWAYS check for this with nasal trauma
**if left untreated, can result in abscess formation of necrosis of the nasal septum
tx= local incision and drainage with anterior nasal pack
Septal hematoma
MC source of nose bleeds
Kesselbach’s plexus
parainfluenza type 1 causes…
croup
“steeple sign” = croup
