HEENT

Question 1

ophthalmologic vital signs

Answer 1

-Visual acuity: what is the vision of each eye?
-Objective data i.e. 20/20
-Subjective data: “Grossly normal” “decreased”
-Determine the details of the vision change

-Intraocular pressure: each eye because the difference between two eyes is more important
-Normal is 10-21mmHg

-Pupils:
-Assess for symmetry in ambient light
-Assess response to light

Question 2

A 6-year-old boy presents to the Emergency Department (ED) with a red, swollen, painful left eye since he woke up this morning. His mum states that he is usually fit and well but currently has a nasty cold and is off school.

On examination, there is erythema and partial ptosis of the left eye due to swelling of the lower and upper eyelids. The child can move the affected eye without any pain or restriction of movements. There is no proptosis, and visual acuity is normal in both eyes. Visual fields, cranial nerve examination and pupillary response are also all unremarkable.

Temperature 37.8, BP 100/80, HR 90, RR 17, Sats 99%

Answer 2

preseptal cellulitis

-Which of the following are recognized complications of the above (select all)?
Cavernous sinus thrombosis
Meningitis
Orbital cellulitis
Necrotizing fasciitis

all of the above

Question 3

inflammatory eyelid conditions

Question 4

Case 1:
A 6-year-old patient reports left eye pain with significant upper eyelid swelling and erythema after experiencing a mosquito bite 4 days prior.

Answer 4

preseptal cellulitis

Question 5

cellulitis of the eye

Answer 5

-3 methods of infection
-Skin disruption (abrasion, cut, burn)
-Local infection spread (sinusitis)
-Hematogenous spread (common < 2 years old)

-Staph, strep
-Two types:
-Periorbital cellulitis -> common
-Orbital -> emergency

Question 6

periorbital / preseptal cellulitis

Answer 6

-Common infection of the soft tissue around the globe
-Staph, group A strep, strep pneumo
-Usually from injury (scratches, bug bites), local spread from URI, stye, blepharitis, conjunctivitis
-Painful (mild), no EOM pain
-Fever, erythema, lid edema
-Young = do a septic workup
-PO Augmentin, clinda

Question 7

orbital / post septal cellulitis

Answer 7

-Infection behind the orbital septum
-Usually from secondary spread (sinusitis, dental infections, dacryocystitis, orbital surgery, endogenous sources)
-Staph, strep, pseudomonas, enterococcus, H. flu
-May appear toxic, mod-severe pain, painful EOM

-Physical exam:
-Erythema (“violaceous” lids)
-Swelling
-Proptosis,
-Ptosis
-Limited extraocular movements (diplopia)
-Chemosis
-Suspect compression optic neuropathy if there is also an afferent pupillary defect, ↓ visual acuity, visual field deficit and ↑ IOP

-Clinical diagnosis, confirm with CT scan orbits
-Labs including blood cultures
-Tx: IV clinda or cefuroxime, admission, ophtho consult for possible debridement
-Complications: Meningitis, abscesses, cavernous sinus thrombosis, cranial nerve deficits, orbital compartment syndrome

Question 8

red eye

Answer 8

-10 cant miss red eyes:
-Scleritis
-Anterior uveitis / Iritis
-Keratitis (ulcer, UV, herpes, HZO, bacterial)
-Endophthalmitis
-Glaucoma
-Hyphema
-Hypopyon
-Orbital cellulitis

-Breakdown:
-Extra-ocular?
-External eye?
-Internal eye?

-If external/internal:
-Painful?
-Painless?

-Which structures are involved?

Question 9

A 27 year-old woman woke up this morning with her eyelids stuck together. She has a gritty feeling on the surface of her eyes, has ongoing discharge and her eyes look red.

She finds the bright lights of the emergency department a little uncomfortable.

Answer 9

conjunctivitis

Question 10

episcleritis and scleritis

Answer 10

-Episcleritis (top pic)
-Sudden onset
-Mild eye pain, bright red
-Superficial episcleral vessel
-Self limited
-Blanches with 2.5% phenylephrine (constriction) -> diagnostic
-Supportive, Consider topical NSAIDs

-Scleritis (bottom pic)
-Rare but emergent (vision threatening)
-Underlying autoimmune disease
-Severe pain, blurry vision, photophobia, violet/bluish globe , scleral edema
-dx- put in the phenylephrine -> no constriction
-Oral steroids, NSAIDs, emergent ophtho

Question 11

subconjunctival hemorrahge

Answer 11

-Any strain such as sneezing, coughing, straining, trauma
-Consider bleeding disorder if no inciting event
-Flat, red spots
-NO PAIN!!!!!!!!!!!!!!!!!!!
-No treatment , can be managed without ophtho

-Differentiate from a blood chemosis:
-Circumferential and raised
-Scleral perforation, coagulopathy, cavernous sinus thrombosis

Question 12

anterior uveitis and iritis

Answer 12

-Inflammation of the iris, ciliary body, or choroid (internal structures)
-Etiology: Infectious, post-traumatic, autoimmune (associated with HLA-B27)!!
-Symptoms: often unilateral & sudden
-Decrease vision
-Severe deep aching eye pain!
-!Both direct AND consensual photophobia (light makes pupil constrict -> pain)
-Varying redness (ciliary flush! with iritis) -> does not spare the area outside the pupil)
-anesthetic drops wont work bc the inflamed area is deep

-Pupils can be misshapen , miosis common
-Slit lamp = cell and flare (WBCs in anterior chamber, sometimes hypopyon) -> oblique light in the anterior chamber looks foggy
-Treatment: topical cycloplegics (dilate the pupil) and topical steroids with ophtho consult in ER

Question 13

keratitis

Answer 13

-Inflammation of the cornea
-Causes: infections, sjogren’s, UV exposure, drug toxicity, overuse of contacts, dry eye
-Eye pain, Blurry vision, foreign body sensation, redness, ↓ visual acuity
-Hazy or broken corneal light reflection
-“Perilimbic flush” = circumferential redness of the sclera at edge of cornea
-Usually pain improved with topical tetraicaine
-Prophylactic antibiotics due to susceptibility to infection

-HSV Keratitis:
-Fluorescein reveals dendritic! pattern (usually involves just the cornea)
-May have herpetic vesicles on the lids, conjunctiva (rare)
-Treatment: Antivirals, cycloplegics, ophtho consult, no steroids

-Herpes zoster ophthalmicus (HZO):
-also dendritic
-Trigeminal distribution
-V1 involves the nose and the eyes
-“Hutchinson sign”
-Acyclovir, erythromycin, steroids, emergent ophtho consult -> vision threatening

-UV keratitis:
-Welders, snow blindness, UV tanning
-Delayed presentation 6-12 hrs
-HA, blurry vision, tearing
-Relief with topical anesthetic
-Fluorescein exam: Superficial punctate! keratitis (Diffuse, bilateral, punctate corneal lesions)
-Tx: Patch, analgesics, cycloplegics (help with ciliary spasm), topical antibiotics

-!!Corneal ulcer:
-Serious corneal infection usually seen in contact lens use (pseudomonas)
-SOFT/ HAZY EDGES (abrasion does not have this)
-Pain, photophobia, excessive tears, foreign body sensation
-Hazy white spot = ulcer until proven otherwise
-True ocular emergency - call ophtho
-!Topical and IV antibiotics
-!NO CONTACTS

Question 14

Answer 14

superficial punctate keratitis
-UV keratitis

Question 15

chemical burns

Answer 15

-Irrigation irrigation irrigation!
-Morgan lens
-Nasal cannula
-Goal pH 7.0 (check after first hour of irrigation)

-!ALKALI substances are more destructive than acidic
-Tetracaine for pain
-Tetanus booster

-Acid- coagulation necrosis
-Alkali- liquefactive necrosis

-Call ophtho
-Needs full cornea, iris, limbus check
-IOP check (alkali can cause glaucoma)

Question 16

blinding aching vomiting:
A middle-aged woman presents to the emergency department complaining of decreased vision and an aching pain in her left eye. She says it came on after an argument with her husband earlier in the evening. The eye pain has progressed to a frontal headache. She could hardly read anything on a Snellen’s chart, and while you were assessing her visual acuity she started to vomit.

Answer 16

acute closed angle glaucoma
-fixed dilated pupil
-cloudy cornea

Question 17

acute angle glaucoma

Answer 17

-!Red/painful eye, vomiting, headache, AMS
-!Precipitated by going into a dark room, or using mydriatics
-Canal of Schlemm is narrowed, cannot drain fluid
-Vision threatening

-Exam
-Systemically unwell
-Steamy hazy cornea
-!Mid-dilated, non-reactive pupil
-!Elevated IOP >40-70 (normal 10-21mmHg)
-May have a rock hard globe

-Emergent ophthalmology consult
-Pain control

-Goal is to ↓ IOP: mnemonic STAMP
-Supine- lower head of bed
-Timolol: topical b-blocker eye drops
-Acetazolamide 500mg IV (carbonic anhydrase inhibitor)
-Mannitol 1g/kg IV (osmotic decompression )
-Pilocarpine eyedrop

Question 18

hypopyon and endophthalmitis

Answer 18

-Hypopyon (pic):
-WBCs in anterior chamber
-Often follows eye surgery
-Associated with corneal ulcers , endophthalmitis, uveitis, Behcets disease
-White exudate within the anterior chamber
-Emergent ophtho

-Endophthalmitis
-Inflammation of the anterior AND posterior chambers (whole globe)
-True ocular emergency
-Pus formation in vitreous and aqueous humors
-Usually complication of intraocular surgeries
-Redness, pain, decreased vision, photophobia
-Emergent ophtho
-TX: Intravitreal antibiotics

Question 19

1. Mid-dilated unreactive pupil, steamy cornea, peri-orbital pain, nausea, vomiting, ↑ IOP
2. Small irregular pupil with deep eye pain that is worse with movement and accommodation, consensual photophobia, and positive slit lamp “cell and flare”
3. Deep seated eye pain that is worse at rest and night, pain on eye palpation, violaceous appearance of the sclera
4. Proptosis, congested chemosis, painful external ophthalmoplegia, visual loss with relative afferent pupillary defect

Answer 19

1. glaucoma
2. anterior uveitis- MS
3. scleritis
4. orbital cellulitis

Question 20

eye trauma

Answer 20

-History
-Mechanism – bite, foreign body?
-Symptoms – pain, tearing, altered vision?

-Examination
-Visual acuity
-Assess superficial structures
-Use magnification and staining if needed
-Rule out serious injury- CT head or c-spine needed?
-Explore wound fully prior to closure

-Superficial lacs near the eye can be managed in ER
-Universal precaution
-Closure with 6-0 non-absorbable sutures
-Tetanus prophylaxis

Question 21

eyelid abrasion

Answer 21

-Minor cuts can be glued shut with dermabond
-Prevent glue leakage with a carefully cut tegaderm
-If it accidentally gets into the eye, remove immediately with petroleum jelly (acetone works well too, but that will burn!)

Question 22

eyelid laceration

Answer 22

-Consult optho if the laceration involves the:
-lid margin,
-canalicular system,
-levator or canthal tendons,
-orbital septum (if there’s fat protruding through an eyelid),
-significant tissue loss

Question 23

corneal abrasion

Answer 23

-Scratch of the corneal epithelium
-Sxs: Pain, tearing, FB sensation, photophobia, red eye
-Important history: Contact lens use
-Visual acuity may decrease if central abrasion
-Apply tetracaine in the ER for pain control

-Diagnose: fluorescein stain and woods lamp

-Topical antibiotics
-Erythromycin (does not cover pseudomonas, common in contact lens use)
-Ciprofloxacin- use for contact wearers
-Tobramycin
-Gentamicin

-24-48 hr ophtho follow up

-Do NOT:
-Wear contacts
-Place a shield over the eye (↑ infection risk)
-Send home with topical tetracaine (↓ healing rate)
-Add a topical steroid (↓ healing rate)

-Can have recurrent pain a few days later if the healed cornea sloughs off

Question 24

Answer 24

-ice rink sign and the importance of eyelid EVERSION

Question 25

superficial foreign body removal

Question 26

corneal laceration and glove rupture

Answer 26

-Corneal laceration = Full thickness laceration of the anterior chamber -Globe rupture = Full thickness laceration of the globe -Teardrop pupils -Flat anterior chamber -Seidel sign: fluorescein swirls due to leaking aqueous humor -DO NOT TONO PEN (check eye pressure), DO NOT PATCH (yes metal shield) -Immediate consult -IV antibiotics, analgesia, anti-emetics, tetanus, imaging for globe

Question 27

A 35 year-old martial artist presents with loss of vision in his right eye after being on the wrong end of a spinning back fist. Examination of the right eye reveals: He is unable to detect light when the eyelids are passively opened. There is a relative afferent pupillary defect affecting the right eye. Extraocular movements are markedly reduced. Tonometry reveals an intraocular pressure of 45 mmHg. (10-21 normal)

Answer 27

-retrobulbar hematoma

Question 28

retrobulbar hematoma

Answer 28

-Blunt trauma causing a hematoma behind the eye -Findings: -Proptopsis -Decrease visual acuity -Non-reactive pupil -IOP>40 -Lateral canthotomy -emergent

Question 29

hyphema

Answer 29

-Blood in the anterior chamber of the eye -Traumatic or spontaneous -Sickle cell (must be admitted for exchange transfusion) -More blood = can cause permanent corneal staining = can increase IOP -staining can cause permanent red vision -Pain, red, blurry, photosensitivity… same as most -Management -Elevated head of bed = layers the blood -Eye shield -Treat bleeding disorders -If hyphema half or more = admit and ophtho -If hyphema is small = expedited outpatient ophtho evaluation -MC complication: Rebleeding (sickle cell) -DDX: Open globe injury

Question 30

A 52 year-old man presents with sudden onset loss of vision in his right eye. He has no other symptoms. There is no pain. There was no preceding trauma. PMH: hypertension, hyperlipidemia and angina. Meds: aspirin, atenolol, and atorvastatin. He can barely detect hand movements with his right eye and has a relative afferent pupillary defect. Fundoscopy shows this appearance:

Answer 30

Question 31

central retinal artery occlusion (CRAO)

Answer 31

-“Stroke of the eye,” usually embolic -Consider: Sickle cell, Temporal arteritis, Glaucoma -Sudden, painless, monocular visual loss -Monocular blindness (partial, segmental, total) -Often preceded by episode of amaurosis fugax -Afferent pupillary defect (swinging light test) -Pale retina, fixed, dilated pupil -Cherry red spot on the macula -Management: Immediate ophtho consult -Gentle massage globe (dislodge emboli) low evidence -↓ IOP to move emboli (acetazolamide, mannitol, timolol) -↑ pCO2 to dilate retinal artery (hyperventilation) -Increase oxygen with 100% on non-rebreather -!Ophtho consult: Anterior chamber paracentesis -!Admit with a stroke work up -Can cause permanent vision loss if > 2 hours

Question 32

central retinal vein occlusion (CRVO)

Answer 32

-“DVT of the eye” -!Slower onset, painless, monocular vision loss -!Varying severity (mild blurry vision -> complete vision loss) -Risk factors: >50yo, smoker, hypercoagulable state, glaucoma, vein compression (thyroid/orbital tumors) -Fundoscopy exam: -Retinal hemorrhages / cotton wool spots / macular or optic disc edema -Dilated retinal venous system "blood & thunder" retina -Check bilaterally = do not miss papilledema -No acute treatment - urgent consult, consider ASA and ↓ IOP if elevated

Question 33

Answer 33

-Monocular vision loss: -Optic nerve, globe, retina, CRAO, CRVO, temporal arteritis -Bitemporal hemianopsia: -Optic chiasma problem e.g. pituitary tumor, aneurysm -Homonymous hemianopsia: -Optic tract problem (CVA)

Question 34

vitreous hemorrhage

Answer 34

-Bleeding within the vitreous humor of the eye -Etiology: Abnormal vessels (neovascularization) that spontaneously bleed, normal vessels under stress (trauma, concomitant retinal detachment) -Painless, sudden, red haze or hue vision, floaters, cobwebs, shadows -Worse in morning due to posterior settling

Question 35

retinal detachment

Answer 35

-Tear in the retina allowing vitreous to separate the retina from the choroid -RF: male, History of RD, DM, sickle cell, family hx, near sighted, advanced age -!Painless vision loss -!"Lowering of a curtain", flashes, floaters, webs, decreased peripheral vision -Signs: Grey retina with folds, vitreous hemorrhage (though cannot rule out with fundoscopy) -Macula intact: -Central vision is preserved, peripheral vision is poor. Blindness is still reversible and time sensitive, stat ophtho consult. -Macula involved: -Central vision is poor, and permanent vision loss is unavoidable

Question 36

temporal arteritis (giant cell arteritis, GCA)

Answer 36

-Diagnosis requires 3/5 of the following: -Age >50 years -Localized headache, new onset -Temporal artery tenderness or ↓ pulse -ESR >50 -Biopsy showing arteritis -Sensitive finding: Jaw claudication. -Headache in 85%: gradual, unilateral near temple, worse at night -Impaired vision in 50%: blindness can occur in untreated patients -Physical exam: -Warmth, tenderness over temple -May have afferent pupillary defect -Pale, edematous optic disc -Treatment -Ophtho consult -No vision loss: High dose prednisone 60mg (may take months) -Vision loss: Solumedrol 1000mg IV daily for 3 days -ASSOCIATED WITH POLYMYALGIA RHEUMATICA - proximal limb weakness

Question 37

optic neuritis

Answer 37

-Demyelinating inflammation of optic nerve -Decreased vision / monocular vision loss -Afferent pupillary defect -!Painful extraocular movements -!Loss of color (red) vision, or contrast -Unilateral optic disc swelling (papillitis) -MRI or CT head -MS until proven otherwise!! -Lyme, herpes, syphilis, autoimmune disease, methanol poisoning, B12 deficiency, diabetes, ethambutol -Neuro or ophtho consult -IV corticosteroids

Question 38

papilledema

Answer 38

-Bilateral optic disc swelling due to ↑ ICP -Causes: Malignant HTN, IIH (idiopathic intracranial htn), mass, hydrocephalus , mass, bleed -IIH- elevated opening pressure on LP -Presenting symptoms: Headache, diplopia, nausea, vomiting -Vision is usually preserved, can be blurry -Fundoscopy: Bilateral blurred disc margins + loss of venous pulsations -US: Optic nerve sheath >5 mm usually indicative of papilledema

Question 39

foreign body in ear

Answer 39

-“Ear pain" -Insects: Drown in mineral oil or lidocaine -Use alligator forceps or curette -Small round objects: Dermabond to the end of a stick -Other options: Flush with warm water -Not an emergency, can follow up ENT -Exception: button battery, alive bugs, organic material (can swell)

Question 40

tympanic membrane perforation

Answer 40

-Complication of infection OR traumatic: Barotrauma, blunt trauma, penetrating trauma, noise, lightnings -Trauma: Sudden decreased hearing, vertigo, drainage -Self-heals for 6-8 weeks , does not need antibiotics -IV valium can help with the dizziness -Dry ear precautions (no ear drops, no swimming, cotton ball in ear or waterproof plug) -Management: -Most heal without complications -Antibiotics if infectious underlying cause -Sometimes require surgical repair -> ENT follow up

Question 41

perichondritis

Answer 41

-Infection of auricular cartilage -Pseudomonas is responsible for almost 100% of piercing related perichondritis -Staph, strep -Often trauma, can be secondary to local infections or abrasions -Painful, swollen, red, deformed, ± fever -Antibiotics (ciprofloxacin) -ENT consult, may require I&D -Complications: Abscess, necrosis, deformity

Question 42

12 year old male with right ear pain x 3 days. No drainage. +pressure. Recent URI 5 days. Febrile 100.7F otherwise normal vitals EAC normal No proptosis No LAD

Question 43

acute otitis media

Answer 43

-Infection behind the TM -Recent/concurrent URI -Most common in infants/children -Symptoms -Otalgia and hearing loss -Children: irritable, fussy, pulling at the ear -PE: impaired mobility of TM, bulging/red TM -If TM perforation: may be drainage or crusting of EAC -Manipulation of pinna is uncomfortable (NOT severe) -Bullous myringitis = blisters on TM (mycoplasma) -Clinical diagnosis -Treatment: Analgesics, hydration, antibiotics, consider T-tube -Complications: Mastoiditis, meningitis, facial nerve paralysis, intracranial abscess

Question 44

mastoiditis

Answer 44

-MC complication of AOM -Abscess within the mastoid bone -Clinical diagnosis: -Postauricular edema, erythema, tenderness -Proptosis of the ear -Thin-cut CT temporal bone -2 weeks of antibiotics -Possible surgical drainage -Can cause meningitis, skull osteomyelitis, venous sinus thrombosis, brain abscess, facial nerve palsies

Question 45

35 year old with left ear pain after using qtips 3 days ago. Throbbing pain. No drainage.

Question 46

acute otitis externa

Answer 46

-External auditory canal infection -Swimming, water exposure, excessive ear cleaning, hearing aids, headphones -!Pseudomonas!, S. epidermis -Red, swollen ear canal that may extend to pinna -Significant drainage, debris, granulation tissue in EAC -!Manipulation of the pinna causes exquisite pain -Must check the TM, should be normal -Treatment: -Debridement -Topical antibiotics: neomycin/hydrocortisone suspension, ciprodex -Consider ear wick (merocel) placement if very swollen

Question 47

otomycosis (fungal otitis externa)

Answer 47

-Can be caused by and/or exacerbated by topical antibiotics -Topical acetic acid or topical antifungal -Keep dry!

Question 48

37 year old female with SLE presents with 2 weeks of right ear pain. She went to urgent care last week and got polymyxin drops which she completed. But she is worried it is getting worse. There is more pain especially at night and it hurts to chew and feels zings over her cheekbone. She even woke up to some white drainage on the pillow. She denies any fevers but reports headache and ringing in her ear.  What is most likely? Appropriate tx? Why does she have this? Why jaw and chewing?

Question 49

otitis externa (necrotizing) (malignant)

Answer 49

-Osteomyelitis of the temporal bone/skull, rapidly progressive -Pseudomonas aeruginosa -Suspect in immunocompromised (DM) -!!Exquisite pain and discharge , out of proportion to findings -Granulation tissue and bony-cartilaginous junction if pathognomonic -Possible CNVII palsy -CT and admission most often -Needs 4-6 weeks of ORAL ciprofloxacin (topical not enough)

Question 50

facial droop

Answer 50

Question 51

ramsay hunt syndrome

Answer 51

-Herpes zoster of the ear -Ipsilateral lower face nerve palsy -Severe complications: -Meningitis, encephalitis, Guillain barre, stroke syndrome, -Acyclovir, steroids -F/u ENT

Question 52

47 y/o female presenting to the ED with epistaxis. No history of epistaxis. Has active bleeding from both nostrils. Vitals WNL How would you manage this patient?

Question 53

nosebleed

Answer 53

-Initial steps: -!Hold pressure below the nasal bridge -The ENTIRE fleshy part -Should be uncomfortable -Tongue depressor blade option -Lean head slightly forward -Ice on forehead or occiput -Wait for 10-20 minutes -Counsel proper technique -Avoid self packing -Look in the nose and the throat -Treatment options: An escalation -!Afrin spray (oxymetazoline) + pressure + time = manages a majority of bleeds -Surgicel/Surgiflo -Silver nitrate cautery (never on septum) -Vaseline gauze or xeroform gauze -Packing: Merocel, Nasal tampon, Rhinorocket -Foley or 7.0cm size rhinorocket -ENT consult / transfer

Question 54

epistaxis after care

Answer 54

-Counsel patient on topical decongestant + holding pressure for home bleeds -Nasal moisture and hygiene is crucial for mucosal healing and reducing recurrent bleeding -Frequent OTC nasal saline spray, nasal saline gel -Humidifier on your face! -Avoid digital manipulation -Nasal precautions: no blowing, no straw sucking, no sneezing, no lifting, no pushing, no bending -If packed: antibiotics to prevent TSSS

Question 55

67yo Asian female with atrial fibrillation on coumadin presents with epistaxis x 2 hours. She was watching TV when it happened. She reports a “cold” for the last few days. She has not stopped bleeding for two hours. She is dizzy and nauseated. Vitals: BP 132/48, HR 109, Sat 98%, Temp 98.4F What are your next steps? -What are your next steps? Do you want labs? INR is 3, should we reverse it? What if you failed the initial steps to manage the bleed? Is prophylaxis needed?

Question 56

nasal foreign body

Answer 56

-Potential acute airway issue -Removal important -Mostly in children -!Unilateral mucopurulent and foul-smelling nasal discharge -Do not dislodge it posteriorly -Beware the button battery – must be removed within 6 hours -Easy first attempt: Parent’s kiss -Requires further intervention? -!Remove with forceps via direct visualization -Nasal speculum, headlight -Removal with: Forceps!, small hooks, suction, katz extractors or even Flexible nasopharyngoscopes (Good for beads ) -Pearl: If FB present for weeks, localized granulation may cause bleeding on removal. Use a topical decongestant (for vasoconstriction) or topical anesthetic (viscous lidocaine) prior to removal for these patients -If FAILED attempt at removal: Can follow up with ENT within one week for outpatient removal -Special consideration: organic materials can swell while retained -Disc batteries can cause caustic burns and septal perforation, if unable to remove, consult ENT (otolaryngology) emergently -If accidentally aspirated -> may cause focal lung sounds, hypoxia -> emergent/urgent bronchoscopy

Question 57

stridor

Answer 57

-serious emergency of the airway -high pitched abnormal upper respiratory sound -inspiratory or expiratory or both -In children: -Epiglottitis -Sitting forward, tripod, drooling, tachypnea -Don’t examine, call anesthesia/peds/ENT ASAP -Usually HiB -IV ceftriaxone -Can also be croup -Barking seal-like cough, low fever, worse at night -Other stridor in children to think about: -Anaphylaxis -Foreign body -Neck abscess -Congenital abnormalities compressing the airway

Question 58

stridor management

Answer 58

-ABC approach -Flexible nasoendoscopy to assess the airway -Adjuncts to help breathing: -Nebulized epinephrine -IV steroids -Extreme cases: intubation or tracheostomy

Question 59

20 year old male presents with fever, sore throat, and fatigue for one week. His oropharynx is red without exudate. He has posterior cervical lymphadenopathy. The has mild tenderness with LUQ palpation. Rapid strep and rapid mono tests are negative. What is the most likely diagnosis? What is the proper treatment???

Question 60

pharyngitis

Answer 60

-sore throat -Usually viral URI! causing inflammation -Contagion precautions! -Symptoms -Mild-moderate sore throat -Painful swallowing -Possible referred pain to ears, neck, jaw -Possible fevers, chills, myalgias -Exam: Congestion, fever, tonsil enlargement, posterior pharynx injected/red, cervical lymphadenopathy -Interventions: possible throat culture, cbc, bmp, monospot testing, fluvid testing -Meds: OTC NSAIDs, salt-water gargles, lozenges, consider decadron 10mg IM for severe pain -Exudative tonsillitis: -Strep throat -Centor criteria (fever, exudates, no cough, anterior cervical LAD) -Amoxicillin -Mononucleosis -EBV; less commonly CMV, HIV, HBV, toxo -Fever, fatigue, tonsillar exudate, anterior or posterior cervical LAD -Monospot test (heterophile antibody test) is low sensitivity and high specificity -Does not work in children <5yo since they do not have antibodies -Refrain from sports 21 days

Question 61

Which of the following are considered signs of airway obstruction Erythema Edema Tongue/floor of mouth induration Dysphonia Drooling Dyspnea Stridor

Question 62

deep neck infections

Answer 62

PTA, RPA, and ludwigs angina

Question 63

peritonsillar abscess (PTA)!!!

Answer 63

-Abscess of the tonsil and soft tissue surrounding it -Recent or current strep, acute tonsillitis -!Muffled “hot potato” voice -!Uvula deviation -!Trismus = cannot open jaw d/t pterygoid muscle irritation -!Inflamed unilateral tonsil: fluctuant, swollen, red, loss of landmarks -May be drooling, halitosis -Diagnosis: Clinical good ENT exam!, can get CT or U/S -Definitive treatment is drainage!: Needle aspiration vs. I&D -Obtain a wound culture -Complication: hitting the carotid -Send home with antibiotics !(clindamycin or ampicillin/sulbactam 10-14 days)

Question 64

Answer 64

-internal carotid is right behind -be CAREFUL

Question 65

38 year old male with T2DM presents with fever, rigors, painful swallowing Marked trismus is noted on exam His throat looks… fine? Xray is shown What is the most likely diagnosis?

Question 66

38 year old male with T2DM presents with fever, rigors, painful swallowing Marked trismus is noted on exam His throat looks… fine? Xray is shown What is the most likely diagnosis?

Answer 66

Question 67

retropharyngeal abscess (RPA)

Answer 67

-History: -< 6 years old -Preceding strep throat, OM, tonsillitis -Post op complication (dental, endoscopy) -S&S: Sore throat, fever, neck pain, dysphagia, odynophagia, neck stiffness (meningitis mimic) -Physical exam: -!Pain / limitation of neck extension/flexion -Unilateral posterior pharyngeal edema & erythema -Stridor, pooling secretions, sniffing position, voice change  bad -Diagnosis: Lateral neck XR or CT scan w/ contrast -Management: -Antibiotics (clindamycin) -ENT consult (surgical incision & drainage) -Intubate if signs of impaired airway -Complication: Mediastinitis, Lemierre’s syndrome, Obstruction

Question 68

epiglottitis (supraglottitis)**

Answer 68

-Etiologies: -HiB (Haemophilus influenzae B) * before vaccines -Strep or staph aureus -RAPID onset 12-24 hrs of: -Fever -Sore throat -Muffled voice -Anxious and ill-appearing -Lateral neck XR: Thumbprint sign -Management: -Early airway management -Emergent ENT consult -O2, nebulized meds -Ceftriaxone (3rd gen cephalosporin) -Admit if airway compromise

Question 69

croup (laryngotracheitis)

Answer 69

-Symptoms: -Fever, stridor, "barky cough“ -NOT drooling -Appear generally well -AP Soft tissue neck XR: "Steeple" sign -Treatment: -Humidified O2 -!Nebulized racemic epinephrine & albuterol -Observe 2 hours -If low O2 sat or young (<3 months old): Nebs, steroids, admit

Question 70

60 year old female with history of HTN presents with facial swelling. She is in distress. There is swelling of her tongue, lips. She is tripoding, tachypneic, and drooling with stridorous respirations. She has an O2 sat in the 80s. Patient on lisinopril for her HTN.

Question 71

facial swelling differentials

Answer 71

-Orbital/Periorbital space -Cavernous Venous Thrombosis! -Pre- / Orbital Cellulitis! -Myxedema Coma! -Subcutaneous -Facial Cellulitis -Submandibular Space -Ludwig’s Angina!! -Parotitis (including Mumps) -Salivary Gland pathology -Intra-oral -Angioedema!!! -Odontogenic infection -Miscellaneous causes -Trauma -Superior Vena Cava Syndrome -Malignancy -Bold/red = can't miss diagnosis!

Question 72

angioedema

Answer 72

-Leaky, permeable blood vessels -Subq lip, face, larynx, tongue, bowel swelling -No other organ systems involved -Not well understood- Common trigger: Anaphylaxis, ACE-I, TPA, Hereditary -Steroids, diphenhydramine, famotidine- Epinephrine 0.3mg IM in adults if a/w anaphylaxis -!!!!Are they on their way toward upper airway obstruction and need intubation? -Early intubation if swelling of vocal cords -Symptoms of SOB, stridor, voice change, dysphagia

Question 73

submandibular facial swelling

Answer 73

-sialolithiasis (stone) / sialadenitis (inflammation) -Jaw pain and swelling -Often unilateral and episodic x weeks -Increasing salivation, worse with anticipation of eating -Historical question to ask: Dehydration, fasting, anticholinergic use, Sjogren’s -Palpate the floor of the mouth to find the stone (submandibular gland, 90%) -“Whartons duct” -Gland tenderness -Pus in bacterial sialadenitis -Clinical diagnosis, Ultrasound, CT -Management: -Stay hydrated, apply heat, massage the gland to milk the duct -Stones= Sucking on lemons --> increase salivation -Sialadenitis = IV antibiotics

Question 74

parotitis

Answer 74

-submandibular facial swelling -Less common -Firm and erythematous swelling in pre and post auricular areas, often at the angle of the jaw -Risk factors: Older, dehydration, poor oral hygiene, salivary stones -Microbiology: staph aureus most common, polymicrobial, mumps -Suppurative subtype has pus -Rare -Requires antibiotics -Push inside the cheek to see if pus comes out -Facial palsy can occur -IV antibiotics

Question 75

odontalgia

Answer 75

-Often due to cavity involving the pulp or nerve tissue -Sudden or gradual -Sharp or dull -Can radiate to ear, jaw, temple, neck -Untreated -> necrosis and abscess -Antibiotics and analgesics with PROMPT dental follow up

Question 76

dental abscess

Answer 76

-h/o dental pain and tender tooth first -Pain, facial swelling, warmth, tenderness, fetid breath -Often radiates pain to ear -Often given antibiotics, if large/ fluctuant must be drained by dental -Mandibular: abx + f/u ENT -Maxillary: more concern for sinus/cranial extension, ENT consult, possible admit

Question 77

A 44 year-old man presents to the ED 2 days after having an infected left mandibular second molar tooth extracted by his dentist. The patient has difficulty swallowing, neck pain, fevers and chills. He is a smoker, has poorly controlled type 2 diabetes mellitus, hypertension and hyperlipidemia. HR 112/min, BP 115/75 mmHg, RR 26/min, SpO2 93% , T 38.7°C He is tender around his neck and throat but is able to swallow saliva, albeit with considerable pain. Oral examination reveals an elevated tongue with marked submandibular and sublingual swelling:

Question 78

ludwigs angina

Answer 78

-Emergency! Can progress to sepsis, airway compromise -Causes: dental infection/procedure , polymicrobial -Rapidly progressive cellulitis of the floor of the mouth -Sxs: Pain, drooling, dysphonia, fever, trismus, hot potato voice, stridor (late sign) -PE: often sick or toxic appearing -!Cellulitis of redness, brawny neck edema -!Raised firm area under the tongue causing tongue protrusion or elevation (no tongue swelling) -!Neck/throat tenderness -!Submandibular “woody” induration, crepitus, tenderness -Often get CT scan of neck, labs -Intubate early, broad spectrum IV antibiotics, PROMPT ENT / oral surgery consult for possible surgical I&D, ICU admission

Question 79

16 year old male presenting with right sided upper abdominal pain x 1 day. Reports recently being treated with penicillin for a sore throat, now resolved. No fevers, chills, trauma, cough, shortness of breath, chest pain, nausea, vomiting, diarrhea. BMP normal CBC