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Unit 2 Emerg/Surg > L6: ENT Emergencies > Flashcards

L6: ENT Emergencies Flashcards

1
Q

Dendritic lesions on slit lamp with fluorscein

A

HSV-1 Keratitis

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2
Q

Herpes Simplex Keratitis presentation

A

Acute onset: eye pain, photophobia, blurred/decreased vision, tearing

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3
Q

Herpes Simplex Keratitis management

A 
Urgent ophthalmology referral
General measures
Topical or oral antivirals
Trifluridine 1% (topical)
Ganciclovir 0.15% gel (topical)
Acyclovir (oral)
NO TOPICAL GLUCOCORTICOIDS
Severe scarring or perforation→ Corneal transplant
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4
Q

Trifluridine

A

Topical antiviral (HSV-1 keratitis)

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5
Q

UV keratitis aka

A

photokeratitis

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6
Q

How long does it take for photokeratitis onset after sun exposure?

A

6-12 hours

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7
Q

UV keratitis presentation

A 
Bilateral intense eye pain 
Can’t open eyes
Photophobia
Foreign body sensation
Distraught, pacing, rocking secondary to severe pain
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8
Q

Photokeratitis on exam

A

Penlight→ tearing, generalized injection and chemosis of the bulbar conjunctiva

Cornea→ may be mildly hazy

Fluorescein→ superficial punctate staining of the cornea

+/- miosis

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9
Q

UV keratitis treatment

A

Supportive→ resolves in 24-72 hrs

Mild oral opioid: Oxycodone 5-10mg Q 4-6 hrs X 24 hrs

Lubricant antibiotic ointment

F/U in 1-2 days

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10
Q

Preseptal or orbital cellulitis presentation

A

Unilateral periorbital edema with erythema, warmth,
tenderness

+/- Complication of:
Sinusitis
Extension of infection from adjacent structure
Local disruption of skin

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11
Q

Preseptal cellulitis exam

A

Tissues anterior to the orbital septum

Swelling of eyelids, upper cheek

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12
Q

Orbital cellulitis exam

A

Structures deep to the orbital septum

Vision loss, impaired EOMs, diplopia

+/- proptosis, chemosis, fever (common)

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13
Q

Preseptal or orbital cellulitis diagnostic studies

A

CT scan orbits and sinuses with contrast

+/- Leukocytosis

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14
Q

Preseptal cellulitis treatment

A

Mild/No systemic symptoms→ discharge home
Oral antibiotics
Follow up within 24-48 hrs

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15
Q

Orbital cellulitis treatment (or if preseptal cellulitis is “concerning”

A

A true emergency
Admit to hospital, IV abx
Consult ophthalmology and ENT

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16
Q

Corneal injuries can result from

A

eye trauma
foreign bodies
improper contact lens use

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17
Q

Corneal abrasian

A

Thin protective coating of anterior ocular epithelium

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18
Q

Corneal ulceration

A

Break in the epithelium exposing the underlying corneal stroma

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19
Q

Corneal abrasian/ulceration presentation

A

Severe eye pain
Foreign body sensation
Can lead to impaired vision secondary to scarring

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20
Q

Corneal abrasion/ulceration exam

A

Penlight→ before to fluorescein stain:
Anterior chamber - clear, deep and normal contour
Pupil round, Clear tears
Mild conjunctival injection if > 2 hrs
Ciliary flush if several hrs old
Visual Acuity
EOMs
Fundoscopic Exam→ confirm red reflex
Fluorescein exam:
Stains the basement membrane→ exposed in areas of epithelial defect
Visualization enhanced with cobalt blue filter: Woods lamp

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21
Q

Corneal abrasion/ulceration needs to be urgently referred to ophthalmology if

A

Signs of penetrating or significant blunt trauma: large,nonreactive pupil or irregular pupil

Impaired visual acuity, Ulceration

Contact lens wearer:
to r/o infiltrate or opacity, daily to r/o infiltrate or ulcer until healed

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22
Q

Corneal abrasion treatment

A 
1. Topical Antibiotics: 
Erythromycin ointment
Sulfacetamide 10%
Polymyxin/trimethoprim
Ciprofloxacin
Ofloxacin drops QID x 5 days
2. +/- Narcotics
NO topical anesthetic or steroid
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23
Q

The only time steroids are indicated in the HEENT lecture

A 
Otitis externa with viral cause
Optic neuritis (IV, oral doesn't help)

Don’t be putting topical steroids in the eye pls

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24
Q

If your patient has a lid laceration

A

They probably have an associated ocular injury

High threshold of suspicion for penetrating injury to globe in the setting of all full thickness lid lacerations

Don’t attempt complicated lacerations, refer em

“Low threshold for CT”= just CT the orbits

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25
Q

When to refer a lid laceration to ophthalmologist or surgeon (plastic or oromaxillofacial)

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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26
Q

How do you treat an UNcomplicated lid laceration?

A

< 25% of lid can heal by secondary intention, clean and apply triple antibiotic ointment
+/- adhesive surgical tape or adhesives

> 25% repair with 6-0 fast absorbable plain gut suture
Simple interrupted or running sutures within 24 hrs
Non absorbable suture used→ remove in 5-7 days

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27
Q

What’s an UNcomplicated lid laceration

A

Superficial lacerations, horizontal, follow skin lines

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28
Q

Orbital floor fracture aka

A

“Blowout fracture”

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29
Q

Significant findings in an orbital floor fracture

A

Entrapment of the inferior rectus muscle
→ ischemia→ loss of muscle function

Enophthalmos→ +/- develop with posterior globe displacement

Orbital dystopia (eye is lower)
Entrapped muscle pulls eye downward

Injury to infraorbital nerve secondary to fracture→ decreased sensation: cheek, upper lip, upper gingiva

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30
Q

On exam, an orbital floor fracture has…

A

Limitation of EOM
Decreased visual acuity
Severe pain
Inadequate exam→ swelling/altered mental status

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31
Q

Special imaging for an orbital floor fracture

A

Thin cut coronal CT of the orbits

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32
Q

Orbital floor fracture management

A 
Surgical evaluation
Prophylactic antibiotics→ cover sinus pathogens
Cold packs→ first 48 hrs
Head of bed raised
Avoid blowing nose/sniffing
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33
Q

When do you get an open globe rupture?

A

Occurs following blunt eye injury

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34
Q

During exam of open globe rupture

A

Avoid pressure to eyeball in eyelid retraction Avoid IOP measurement

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35
Q

Open globe rupture management

A 
Abx, NPO
Emergent ophthalmology consult
Transfer to tertiary trauma center
Eye shield
Bed rest
IV antiemetics – (ondansetron 4mg)
Pain medication
Sedation prn (lorazepam .05mg/kg – max 2mg)
Avoid: manipulation, solutions in eye, NSAIDS
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36
Q

Ondansetron

A

IV antiemetic

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37
Q

What is an inflammatory, demyelinating condition→ acute, monocular vision loss (10% bilateral)
High association with multiple sclerosis (MS)

A

Optic neuritis

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38
Q

Optic neuritis presentation

A

Vision loss → hours to days, peaking 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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39
Q

DDx for optic neuritis by age

A

> 50 years old: DM, giant cell arteritis, autoimmune

Young child: infectious or post infectious cause

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40
Q

If MS is confirmed, then a suspected optic neuritis case gets

A

MRI brain/orbits with gadolinium

but it’s a “clinical diagnosis”

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41
Q

Optic neuritis treatment

A

IV methylprednisolone

No oral prednisone→ Doesn’t affect visual outcomes +/- increase risk for recurrence

42
Q

Acute angle closure glaucoma

A

Narrowing or closure of the anterior chamber angle→ inadequate drainage of aquous humor–> elevated intraocular pressure (IOP) → damage to the optic nerve

43
Q

Acute angle closure glaucoma presentation

A 
Decreased vision
Halos around lights
HA, N/V
Severe eye pain
Red eye
Corneal edema/ cloudiness
44
Q

Wha’t a gonioscope? What’s it used for?

A

A special lens for the slit lamp lens→ visualize angle between the iris and cornea for acute angle closure glaucoma

45
Q

multilayer of exquisitely organized neurons lining the back of the eye

A

the retina

46
Q

How could the retina detach?

A

separates from the epithelium and choroid→ ischemia and progressive photoreceptor
degeneration

47
Q

A patient with retinal detachment will complain of…

A

Sudden onset of floaters, cobwebs
Monocular visual field loss
Vision loss

48
Q

Imaging for retinal detachment

A

Ultrasound

49
Q

Retinal detachment management

A

emergent opthalmologist eval

50
Q

What do adults who don’t go around sticking stuff in their ears like toddlers, get “foreign bodies” of?

A

Cerumen plugs

51
Q

Ear foreign body presentation

A

Hearing loss, ear pain and drainage

52
Q

Foreign body management

A

Identify foreign body→ remove under direct visualization
Neutralize bugs with mineral oil
Do not irrigate organic material→ may cause infection

Check for otitis externa
Ciprodex or CiproHC gtts

53
Q

Otitis externa causes:

A

Bacterial: pseudomonas aeruginosa
Viral: Herpes Zoster Virus

54
Q

Otitis externa presentation:

Bacterial vs Viral

A

Bacterial:
Ear fullness, drainage
Tragal motion tenderness/ pain

Viral: 
Vesicles in ear canal
Facial paralysis
Hearing loss
Vertigo
55
Q

Viral otitis externa needs

A

MRI brain→ rule out skull base tumor

56
Q

Malignant otitis externa is caused by

A

pseudomonas aeruginosa

57
Q

High risk for malignant otitis externa

A

Elderly, DM, immunocompromised

Otitis externa + acutely ill patient, ear canal granulation tissue

58
Q

Diagnostics for otitis externa

A

CBC→ leukocytosis
Cultures
Head CT→ osteomyelitis skull base

59
Q

Malignant otitis externa treatment

A

Admit, Debridement, ENT eval

Parenteral abx: Cipro 400mg IV Q8 hrs→ change to 750mg PO Q 12 hrs prior to discharge x 6-8 weeks

60
Q

Complications from malignant otitis externa

A

Cranial neuropathies, Brain abscess, Meningitis, Septicemia, Death

61
Q

What can cause tympanic membrane perforation?

A

otitis media
closed head injury
direct ear trauma

62
Q

Tympanic membrane perforation presentation

A

Pain, Hearing loss
N/V
Vertigo, Otorrhea, Tinnitus

63
Q

Exam for tympanic membrane perforation includes….

A

Direct visualization of TM

Audiogram

64
Q

If you suspect head trauma caused a tympanic membrane perforation

A

CT and check drainage for CSF

65
Q

Tympanic membrane perforation management

A

+/- Evaluation by otolaryngology

Water precautions

95% resolve without treatment <25% total surface in 4 weeks

Ofloxacin otic drops

Tympanoplasty→ Refractory cases

66
Q

Cauliflower ear aka

A

Auricular hematoma caused by blunt force trauma to auricle

67
Q

Collection of blood in the cartilage

A

Auricular hematoma

68
Q

Auricular hematoma management

A

Drain/aspirate ASAP
> 7 days→ Otolaryngologist or plastic surgeon
Follow eval Q 24 hrs for 3-5 days, or ASAP if worsening
Refrain from sports for 7 days

69
Q

What is acute inflammation and infection of auricular cartilage caused by Pseudomonas aeruginosa

A

Perichondritis

70
Q

Perichondritis presentation

A

Erythema
Pain
Abscess formation, pus
Systemic symptoms

71
Q

Perichondritis management

A

Culture + Sensitivity
+/- Incision + Drainage
Empiric abx→ ciprofloxacin

72
Q

Nosal foreign body presentation

A 
Asymptomatic, history of insertion (most)
\+/- Mucopurulent nasal discharge
Foul odor
Epistaxis
Nasal obstruction→ mouth breathing
73
Q

Exam and diagnostics for nasal foreign body

A

Direct visualization of FB
Check lungs CTAB without abnormal breath sounds
Imaging not needed
Xray: suspected button battery or magnet

74
Q

Nasal foreign body management

A 
Child must be adequately restrained 
Good visualization
Manually retrieve with alligator forceps or suction→ re-examine to rule out second FB
Avoid irrigation if FB is organic matter
>2 unsuccessful attempts→ refer to ENT
75
Q

Which type of epistaxis is more common, anterior or posterior?

A

Anterior

76
Q

Anterior epistaxis comes from

A

Kiesselbach’s Plexus (90%): anastomosis:

  1. Septal branch of the anterior ethmoidal artery
  2. Lateral nasal branch of the sphenopalatine artery
  3. Septal branch of the superior labial branch of the facial artery
77
Q

Posterior epistaxis comes from

A
  1. Posterolateral branches of sphenopalatine artery

2. Carotid artery (rare)

78
Q

Epistaxis is caused by

A 
Nose picking
Low moisture
Hyperemia secondary to allergic rhinitis
FB
Drug use
Trauma
79
Q

Stepwise fashion for epistaxis management

A

Conservative treatment
Cautery
Nasal packing
Antistaph Abx

80
Q

Conservative management of epistaxis

A

Oxymetazoline (Afrin) – 2 sprays
Direct pressure of the alae tight against septum X 10 minutes
No further bleeding→ nasal hydration

81
Q

Cautery of epistaxis

A

If source easily identified
Avoid large areas
Remove excess silver nitrate with cotton tip applicator
Risks: Ulceration, septal perforation

82
Q

Nasal packing for epistaxis

A

3 days, 5 days if anticoagulated

83
Q

Meds for epistaxis

A

Antistap Abx→ Keflex, Augmentin

84
Q

Nasal trauma possible complications

A

Early complications→ Hematoma, Abscess, Uncontrolled epistaxis, CSF rhinorrhea

Late complications→ Nasal deformity, Obstruction, Perforation

85
Q

Nasal trauma exam shows….

A 
Epistaxis
CSF rhinorrhea
Impaired EOMs
Orbital edema/ecchymosis
Lacerations
Septal hematoma
86
Q

Imaging for nasal trauma

A

CT maxillofacial without contrast

to rule out other facial fractures

87
Q

Who is septal hematoma more common in?

A

Peds

88
Q

Inflammation and/or infection of the mastoid air cells

A

Mastoiditis

89
Q

Septal hematoma can be caused by

A

Trauma
Septal surgery
Bleeding disorders

90
Q

Septal hematoma management

A 
Incision and drainage→ prevent avascular necrosis of the septum
Pack nose, Antibiotics
Outpatient ENT referral
• Remove packing in 24 hrs
• Recheck
• Re-pack
91
Q

“soft, tender swelling around septum”

A

septal hematoma

92
Q

Mastoiditis presentation

A

+/- Asymptomatic
Ear pain
Drainage
Tenderness, erythema and edema over the mastoid process

93
Q

Diagnostics for mastoiditis

A

CT head

Infection→ Culture

94
Q

Mastoiditis management

A

Refer to ENT

Immunocompetent→ start empiric abx

Recalcitrant disease or immunocompromised→ mastoidectomy +/- IV abx

95
Q

Periodontal abscess imaging

A

Panoramic radiograph or CT for bone involvement

96
Q

Periodontal abscess presentation

A

Fever, Pain

Red, fluctuant swelling of the gingiva, Tenderness to palpation

97
Q

Periodontal abscess management

A

Pain management, I+D, F/U with dentist
Oral antibiotics if limited infection
Augmentin or Clindamycin x 7-14 days

98
Q

Dental avulsion presentation

A

Avulsion of permanent tooth→ True dental emergency
Pain
Tooth completely displaced from the alveolar ridge
Periodontal ligament severed

99
Q

Dental avulsion management

A

Unable to re-implant immediately→ store tooth: balanced saline solution, cold milk, container of patient’s saliva→ urgent dental consult

Reinsert: Maintain periodontal ligament, handle tooth by crown→ gently rinse in saline→ insert into the empty socket→ hold in place with gauze

Success of re-implantation: 85-97% at 5 min
Nearly 0% at 1 hour

Tetanus prophylaxis and antibiotic therapy

100
Q

Tongue laceration

A

Related to injury that involves the teeth

Oral cavity and tongue are very vascular→ potential for increased bleeding

101
Q

Tongue laceration management

A

Not considered for repair
< 1 cm, Non-gaping, minor in the clinical judgment of the examiner

Consideration for repair
Large (>1cm), Extend into the muscular layer or completely through the tongue

Deep on the lateral border

Large flaps or gaps, Significant hemorrhage

Possible dysfunction with improper healing

Use absorbable suture material→ 3-0 or 4-0 chromic gut or vicryl
Antibiotics

Unit 2 Emerg/Surg (8 decks)

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