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Exam 1 - EENT Emergencies Flashcards

1
Q

What are some exam findings associated with Herpes Simplex Keratitis?

A
  • Conjunctival injection
  • Ciliary flush
  • Decreased corneal sensation
  • Dendritic lesions on slit-lamp with fluorescein stain
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2
Q

What is the treatment for Herpes Simplex Keratitis?

A

Urgent Ophthalmology referral

Topical antiviral:

  • Acyclovir 3% ophthalmic ointment
  • Ganciclovir 0.15% gel

OR

Oral antiviral:
- Acyclovir 400 mg

***NO TOPICAL GLUCOCORTICOIDS

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3
Q

What are exam findings associated with UV Keratitis?

A
  • Penlight: tearing, generalized injection and chemosis of the bulbar conjunctiva
  • Cornea may be mildly hazy
  • Superficial punctuate staining of the cornea with fluorescein
  • Pupils may be miotic
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4
Q

What is the treatment for UV Keratitis?

A
  • Typically self-limited within 24-72 hours
  • Oral analgesics for severe pain (consider mild opioid for severe pain and lubricant antibiotic ointment)
  • Prevention with eye protection
  • Follow-up in 1-2 days
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5
Q

What are the most common pathogens associated with preseptal and orbital cellulitis?

A
  • S. pneumoniae
  • S. aureus
  • S. pyogenes
  • H. influenzae
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6
Q

What is affected in orbital cellulitis and what are some symptoms associated with it?

A
  • Structures deep to the orbital septum
  • Eyelid swelling, vision loss, pain with eye movements, impaired EOMs, diplopia, fever, and/or proptosis

***TRUE EMERGENCY

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7
Q

How is preseptal and orbital cellulitis diagnosed?

A

CT scan of the orbits and sinuses with contrast

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8
Q

What is the treatment for a mild preseptal cellulitis with no systemic symptoms?

A
  • Oral antibiotics

- Follow up with ophthalmologist in 24-48 hours

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9
Q

What is the treatment for orbital cellulitis or preseptal cellulitis with concerning factors?

A
  • Admit to hospital
  • IV antibiotics
  • Consult ophthalmology and ENT
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10
Q

What is the treatment for a corneal abrasion?

A
  • Topical lubricants
  • Topical abx (erythromycin ointment)
  • Consider oral pain medication

***NO topical anesthetic, steroid, or patching

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11
Q

When should you get an urgent ophthalmology consult for a corneal abrasion or ulceration?

A
  • Signs of penetrating or significant blunt trauma: large, nonreactive pupil or irregular pupil
  • Impaired visual acuity
  • Ulceration
  • Contact lens wearer
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12
Q

What is the treatment for superficial eyelid lacerations?

***these are horizontal and follow skin lines

A

If < 25% of lid, can heal by secondary intention

  • Clean and apply triple abx ointment
  • Can consider adhesive surgical tape

> 25%, repair with 6-0 fast absorbable plain gut suture

  • Simple interrupted or running suture within 24 hours
  • If non-absorbable suture used, remove in 5-7 days
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13
Q

When should you refer an eyelid laceration to an ophthalmologist or plastic/oromaxillofacial surgeon?

A
  • Full thickness lid lacerations
  • 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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14
Q

What are significant findings associated with an orbital floor “blowout” fracture?

A
  • Entrapment of the inferior rectus muscle
  • Enopthalmos (receeding of eye)
  • Orbital dystopia (eye is lower)
  • Injury to infraorbital nerve secondary to fracture (decreased sensation to cheek, upper lip, upper gingiva)
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15
Q

How is an orbital floor fracture diagnosed?

A

Thin cut coronal CT or the orbits on patient with:

  • Evidence of fracture on exam
  • Limitation of EOM
  • Decreased visual acuity
  • Severe pain
  • Inadequate exam due to swelling/altered mental status
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16
Q

What is the treatment for an orbital floor fracture?

A
  • Surgical evaluation
  • Prophylactic abx
  • Cold packs for first 48 hours
  • Head of bed raised
  • Avoid blowing nose/sniffing
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17
Q

How is an open globe rupture diagnosed?

A

Axial and coronal CT of the eye without contrast

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18
Q

What should you be careful of during an exam if you suspect an open globe rupture?

A

Avoid pressure on the eyeball

  • Eyelid retraction
  • IOP measurement
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19
Q

What is the treatment for an open globe rupture?

A
  • Emergent ophthalmology consult
  • Avoid manipulation
  • Eye shield and no solutions in eye
  • Bed rest
  • NPO
  • Abx
  • IV antiemetics (ondansetron)
  • Pain medications (avoid NSAIDs)
  • Sedation prn (lorazepam)
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20
Q

What is optic neuritis and what can it cause?

What is it highly associated with?

A
  • Inflammatory, demyelinating condition
  • Causes acute, monocular vision loss
  • Highly associated with MS
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21
Q

What are symptoms associated with optic neuritis?

A
  • Vision loss (peaks within 1-2 weeks)
  • Eye pain worse with eye movement
  • Afferent pupillary defect (direct response to light is sluggish)
  • Dyschromatopsia (loss/reduced color vision)
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22
Q

What is the treatment for optic neuritis?

A
  • Corticosteroids (IV methylprednisolone)

DO NOT recommend oral prednisone as does not affect visual outcomes and may increase risk for recurrence

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23
Q

What can acute angle closure glaucoma lead to?

A
  • Leads to elevated IOP as aqueous humor cannot drain

- Damage to optic nerve

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24
Q

What is a normal IOP compared to an IOP seen in closed angle glaucoma?

A

Normal: 8-21 mmHg

Closed angle glaucoma: > 30 mmHg

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25
What are some sypmtoms associated with closed angle glaucoma?
- Decreased vision - Halos around lights - Headaches, nausea, vomiting - Severe eye pain - Red eye - Corneal edema/cloudiness - Mid-dilated pupil 4-6 mm which reacts poorly to light - Shallow anterior chamber
26
What should you avoid in cases of closed angle glaucoma?
Pupillary dilation should be deferred as this may exacerbate the condition
27
What is the gold standard diagnostic test for closed angle glaucoma?
Gonioscopy
28
What is the treatment for acute angle closure glaucoma?
Emergency ophthalmology evaluation If > 1 hour delay, empirically treat with pressure lowering eye drops - 1 min: 0.5% timolol - 2 min: 1% apraclonidine - 3 min: pilocarpine Oral or IV acetazolamide - Check pressure 30-60 minutes after giving treatment
29
What is the presentation associated with retinal detachment?
- Sudden onset of floaters (may describe as cobwebs) - Monocular visual field loss - Vision loss
30
What is the treatment for a retinal detachment?
Emergent ophthalmology evaluation
31
What is the most common causative agent of AOE?
Bacterial: | Pseudomonas aeruginosa
32
What is the presentation associated with AOE?
- Ear fullness - Drainage - Ear pain and tragal motion tenderness
33
What is the treatment for AOE?
- Debridement - Abx drops (Ciprodex or CiproHC) +/- otowick ***watch for malignant otitis
34
What is the most common causative agent of viral AOE?
Ramsey-Hunt | - Herpes zoster virus
35
What are symptoms associated with viral AOE?
- Vesicles in ear canal - Facial paralysis - Hearing loss - Vertigo
36
What is the treatment for viral AOE?
- Antivirals - Steroids - MRI brain to rule out skull base tumor
37
What populations are at the highest risk for malignant otitis externa?
Elderly, diabetics, immunocompromised
38
What presentation is associated with malignant otitis externa?
- Symptoms consistent with AOE (ear fullness, tragus pain, drainage) but patient appears acutely ill - Ear canal granulation tissue
39
How is malignant otitis externa diagnosed?
- CBC shows leukocytosis - Cultures - Head CT shows to rule out osteomyelitis at the skull base
40
What is the treatment for malignant otitis externa?
- Admit - Debridement - Parenteral abx - ENT evaluation
41
What course of abx are given for malignant otitis externa?
- Ciprofloxacin 400 mg IV Q 8 hours - Change to 750 mg PO Q 12 hours prior to discharge - Treatment is 6-8 weeks
42
What is the treatment for a TM perforation?
- Most resolve without treatment (if <25 % total surface, will heal within 4 weeks) - Ofloxacin otic drops if indicated (puncture from dirty object) - Tympanoplasty in refractory cases
43
What is the treatment for auricular hemotoma/"Cauliflower Ear"?
- Drain/aspirate - If > 7 days, refer to otolaryngologist or plastic surgeon - Follow-up every 24 hours for 3-5 days - Refrain from sports for 7 days
44
What is perichondritis? What is the causative agent of perichondritis?
Acute inflammation and infection of the auricular cartilage Pseudomonas aeruginosa
45
What is the treatment for perichondritis? What diagnostic studies should you obtain?
- Incision and drainage - Empiric abx (Ciprofloxacin) - Obtain culture and sensitivity
46
What presentation is associated with a nasal foreign body?
- Mucopurulent nasal discharge - Foul odor - Epistaxis - Nasal obstruction - Mouth breathing
47
Are anterior or posterior nosebleeds more common? Where do most occur?
Anterior are more common. Up to 90% occur at Kiesselbach's plexus
48
Where do posterior epistaxis most commonly arise from? Least common?
Most common: Posterolateral branches of the sphenopalaine artery. Least common: Carotid artery
49
What is the treatment for epistaxis?
Conservative treatment: - Oxymethazoline (Afrin) - 2 sprays - Direct pressure tight against septum x 10 minutes - If no further bleeding, encourage nasal hydration and avoid trauma to area Cautery if source easily identified: - Avoid large areas - Remove excess silver nitrate with cotton tip applicator Nasal packing
50
If using nasal packing for epistaxis management, when should it be removed and what antibiotics should you prescribe?
Timing of removal: - Normal patient: 3 days - Anticoagulated patient: 5 days Anti-staphylococcal abx: - Keflex, Augmentin - Entire course of packing
51
If patient presents with nasal trauma, what diagnostic studies should you order?
CT scan maxillofacial w/o contrast to rule out any additional facial fractures
52
What is the treatment for nasal trauma?
- Repair skin lacerations immediately - If significant swelling, consider waiting 4-6 weeks until resolved before surgical correction - Attempt a closed reduction immediately to maximize airway and improve aesthetics - Elevate head of bed - Cold compress - Pain management - Obtain photos for progress comparisons - Follow-up 3-5 days
53
What will be seen on exam if patient has a septal hematoma?
Soft, tender swelling along the septum
54
What is the treatment of a septal hematoma? What can occur if a septal hemotoma is not treated?
- Incision and drainage - Pack nose - Abx - Outpatient ENT referral to remove packing in 24 hours and recheck
55
What can occur if a septal hemotoma is not treated?
- Avascular necrosis of the septum | - May cause septal perforation and/or "saddle nose" deformity
56
What is the presentation of mastoiditis?
- May be asymptomatic - Postauricular erythema, tenderness, swelling, fluctuance, mass - Protrusion of auricle - Otalgia - Fever
57
How is mastoiditis diagnosed?
- Clinically with characterisitc findings | - If no characteristic findings, CT head w/ contrast and possible cultures
58
What is the treatment for mastoiditis?
- ENT referral - May start empiric abx if immunocompetent - Mastoidectomy and consideration of IV abx if recalcitrant disease or immunocompromised
59
What is the treatment for a periodontal abscess?
- Pain management - Incision and drainage - Oral abx if limited infection (Augmentin or Clindamycin x 7-14 days) - Follow-up with dentist
60
If unable to re-implant a displaced tooth, what should you do?
Immediately store tooth in balanced saline solution, cold milk, or container of patient saliva until seen by dentist
61
How do you treat an avulsion of a permanent tooth?
- Maintain vitality of periodontal ligament - Handle tooth by crown - Rinse in saline - Insert into empty socket and hold in place with gauze - Urgent dental consultation - Tetanus prophylaxis and abx therapy
62
When would you consider repairing a tongue laceration?
- Large ( > 1 cm) - Extends into the muscular layer or goes completely through the tongue - Deep on the lateral border - Large flaps or gaps - Significant hemorrhage - Any that may cause dysfunction with improper healing
63
What type of tongue lacerations would you NOT consider for repair?
- < 1 cm - Non-gapping - Assessed to be minor
64
What type of sutures do you use for tongue lacerations and should you prescribe abx?
Absorbable suture material - 3-0 or 4-0 chromic gut or vicryl Prescribe abx
65
What can enhance your visualization of a corneal abrasion or ulceration?
Cobalt blue filter on fluorescein exam with Wood's lamp
66
If patient is >50 years old with optic neuritis, what should you consider as a cause? What about in a young child?
>50: DM, giant cell arteritis, autoimmune Young child: infectious or post infectious cause
67
What are some risks associated with cautery treatment for epistaxis?
Ulceration, septal perforation
68
What diagnostic study should you obtain if patient presents with periodontal abscess?
Panoramic radiograph or CT for bone involvement

Emergency/Surgery (3 decks)

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