L6: ENT Emergencies Flashcards
Dendritic lesions on slit lamp with fluorscein
HSV-1 Keratitis
Herpes Simplex Keratitis presentation
Acute onset: eye pain, photophobia, blurred/decreased vision, tearing
Herpes Simplex Keratitis management
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
Trifluridine
Topical antiviral (HSV-1 keratitis)
UV keratitis aka
photokeratitis
How long does it take for photokeratitis onset after sun exposure?
6-12 hours
UV keratitis presentation
Bilateral intense eye pain Can’t open eyes Photophobia Foreign body sensation Distraught, pacing, rocking secondary to severe pain
Photokeratitis on exam
Penlight→ tearing, generalized injection and chemosis of the bulbar conjunctiva
Cornea→ may be mildly hazy
Fluorescein→ superficial punctate staining of the cornea
+/- miosis
UV keratitis treatment
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
Preseptal or orbital cellulitis presentation
Unilateral periorbital edema with erythema, warmth,
tenderness
+/- Complication of:
Sinusitis
Extension of infection from adjacent structure
Local disruption of skin
Preseptal cellulitis exam
Tissues anterior to the orbital septum
Swelling of eyelids, upper cheek
Orbital cellulitis exam
Structures deep to the orbital septum
Vision loss, impaired EOMs, diplopia
+/- proptosis, chemosis, fever (common)
Preseptal or orbital cellulitis diagnostic studies
CT scan orbits and sinuses with contrast
+/- Leukocytosis
Preseptal cellulitis treatment
Mild/No systemic symptoms→ discharge home
Oral antibiotics
Follow up within 24-48 hrs
Orbital cellulitis treatment (or if preseptal cellulitis is “concerning”
A true emergency
Admit to hospital, IV abx
Consult ophthalmology and ENT
Corneal injuries can result from
eye trauma
foreign bodies
improper contact lens use
Corneal abrasian
Thin protective coating of anterior ocular epithelium
Corneal ulceration
Break in the epithelium exposing the underlying corneal stroma
Corneal abrasian/ulceration presentation
Severe eye pain
Foreign body sensation
Can lead to impaired vision secondary to scarring
Corneal abrasion/ulceration exam
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
Corneal abrasion/ulceration needs to be urgently referred to ophthalmology if
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
Corneal abrasion treatment
1. Topical Antibiotics: Erythromycin ointment Sulfacetamide 10% Polymyxin/trimethoprim Ciprofloxacin Ofloxacin drops QID x 5 days 2. +/- Narcotics NO topical anesthetic or steroid
The only time steroids are indicated in the HEENT lecture
Otitis externa with viral cause Optic neuritis (IV, oral doesn't help)
Don’t be putting topical steroids in the eye pls
If your patient has a lid laceration
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
When to refer a lid laceration to ophthalmologist or surgeon (plastic or oromaxillofacial)
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
How do you treat an UNcomplicated lid laceration?
< 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
What’s an UNcomplicated lid laceration
Superficial lacerations, horizontal, follow skin lines
Orbital floor fracture aka
“Blowout fracture”
Significant findings in an orbital floor fracture
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
On exam, an orbital floor fracture has…
Limitation of EOM
Decreased visual acuity
Severe pain
Inadequate exam→ swelling/altered mental status
Special imaging for an orbital floor fracture
Thin cut coronal CT of the orbits
Orbital floor fracture management
Surgical evaluation Prophylactic antibiotics→ cover sinus pathogens Cold packs→ first 48 hrs Head of bed raised Avoid blowing nose/sniffing
When do you get an open globe rupture?
Occurs following blunt eye injury
During exam of open globe rupture
Avoid pressure to eyeball in eyelid retraction Avoid IOP measurement
Open globe rupture management
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
Ondansetron
IV antiemetic
What is an inflammatory, demyelinating condition→ acute, monocular vision loss (10% bilateral)
High association with multiple sclerosis (MS)
Optic neuritis
Optic neuritis presentation
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
DDx for optic neuritis by age
> 50 years old: DM, giant cell arteritis, autoimmune
Young child: infectious or post infectious cause
If MS is confirmed, then a suspected optic neuritis case gets
MRI brain/orbits with gadolinium
but it’s a “clinical diagnosis”
Optic neuritis treatment
IV methylprednisolone
No oral prednisone→ Doesn’t affect visual outcomes +/- increase risk for recurrence
Acute angle closure glaucoma
Narrowing or closure of the anterior chamber angle→ inadequate drainage of aquous humor–> elevated intraocular pressure (IOP) → damage to the optic nerve
Acute angle closure glaucoma presentation
Decreased vision Halos around lights HA, N/V Severe eye pain Red eye Corneal edema/ cloudiness
Wha’t a gonioscope? What’s it used for?
A special lens for the slit lamp lens→ visualize angle between the iris and cornea for acute angle closure glaucoma
multilayer of exquisitely organized neurons lining the back of the eye
the retina
How could the retina detach?
separates from the epithelium and choroid→ ischemia and progressive photoreceptor
degeneration
A patient with retinal detachment will complain of…
Sudden onset of floaters, cobwebs
Monocular visual field loss
Vision loss
Imaging for retinal detachment
Ultrasound
Retinal detachment management
emergent opthalmologist eval
What do adults who don’t go around sticking stuff in their ears like toddlers, get “foreign bodies” of?
Cerumen plugs
Ear foreign body presentation
Hearing loss, ear pain and drainage
Foreign body management
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
Otitis externa causes:
Bacterial: pseudomonas aeruginosa
Viral: Herpes Zoster Virus
Otitis externa presentation:
Bacterial vs Viral
Bacterial:
Ear fullness, drainage
Tragal motion tenderness/ pain
Viral: Vesicles in ear canal Facial paralysis Hearing loss Vertigo
Viral otitis externa needs
MRI brain→ rule out skull base tumor
Malignant otitis externa is caused by
pseudomonas aeruginosa
High risk for malignant otitis externa
Elderly, DM, immunocompromised
Otitis externa + acutely ill patient, ear canal granulation tissue
Diagnostics for otitis externa
CBC→ leukocytosis
Cultures
Head CT→ osteomyelitis skull base
Malignant otitis externa treatment
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
Complications from malignant otitis externa
Cranial neuropathies, Brain abscess, Meningitis, Septicemia, Death
What can cause tympanic membrane perforation?
otitis media
closed head injury
direct ear trauma
Tympanic membrane perforation presentation
Pain, Hearing loss
N/V
Vertigo, Otorrhea, Tinnitus
Exam for tympanic membrane perforation includes….
Direct visualization of TM
Audiogram
If you suspect head trauma caused a tympanic membrane perforation
CT and check drainage for CSF
Tympanic membrane perforation management
+/- Evaluation by otolaryngology
Water precautions
95% resolve without treatment <25% total surface in 4 weeks
Ofloxacin otic drops
Tympanoplasty→ Refractory cases
Cauliflower ear aka
Auricular hematoma caused by blunt force trauma to auricle
Collection of blood in the cartilage
Auricular hematoma
Auricular hematoma management
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
What is acute inflammation and infection of auricular cartilage caused by Pseudomonas aeruginosa
Perichondritis
Perichondritis presentation
Erythema
Pain
Abscess formation, pus
Systemic symptoms
Perichondritis management
Culture + Sensitivity
+/- Incision + Drainage
Empiric abx→ ciprofloxacin
Nosal foreign body presentation
Asymptomatic, history of insertion (most) \+/- Mucopurulent nasal discharge Foul odor Epistaxis Nasal obstruction→ mouth breathing
Exam and diagnostics for nasal foreign body
Direct visualization of FB
Check lungs CTAB without abnormal breath sounds
Imaging not needed
Xray: suspected button battery or magnet
Nasal foreign body management
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
Which type of epistaxis is more common, anterior or posterior?
Anterior
Anterior epistaxis comes from
Kiesselbach’s Plexus (90%): anastomosis:
- Septal branch of the anterior ethmoidal artery
- Lateral nasal branch of the sphenopalatine artery
- Septal branch of the superior labial branch of the facial artery
Posterior epistaxis comes from
- Posterolateral branches of sphenopalatine artery
2. Carotid artery (rare)
Epistaxis is caused by
Nose picking Low moisture Hyperemia secondary to allergic rhinitis FB Drug use Trauma
Stepwise fashion for epistaxis management
Conservative treatment
Cautery
Nasal packing
Antistaph Abx
Conservative management of epistaxis
Oxymetazoline (Afrin) – 2 sprays
Direct pressure of the alae tight against septum X 10 minutes
No further bleeding→ nasal hydration
Cautery of epistaxis
If source easily identified
Avoid large areas
Remove excess silver nitrate with cotton tip applicator
Risks: Ulceration, septal perforation
Nasal packing for epistaxis
3 days, 5 days if anticoagulated
Meds for epistaxis
Antistap Abx→ Keflex, Augmentin
Nasal trauma possible complications
Early complications→ Hematoma, Abscess, Uncontrolled epistaxis, CSF rhinorrhea
Late complications→ Nasal deformity, Obstruction, Perforation
Nasal trauma exam shows….
Epistaxis CSF rhinorrhea Impaired EOMs Orbital edema/ecchymosis Lacerations Septal hematoma
Imaging for nasal trauma
CT maxillofacial without contrast
to rule out other facial fractures
Who is septal hematoma more common in?
Peds
Inflammation and/or infection of the mastoid air cells
Mastoiditis
Septal hematoma can be caused by
Trauma
Septal surgery
Bleeding disorders
Septal hematoma management
Incision and drainage→ prevent avascular necrosis of the septum Pack nose, Antibiotics Outpatient ENT referral • Remove packing in 24 hrs • Recheck • Re-pack
“soft, tender swelling around septum”
septal hematoma
Mastoiditis presentation
+/- Asymptomatic
Ear pain
Drainage
Tenderness, erythema and edema over the mastoid process
Diagnostics for mastoiditis
CT head
Infection→ Culture
Mastoiditis management
Refer to ENT
Immunocompetent→ start empiric abx
Recalcitrant disease or immunocompromised→ mastoidectomy +/- IV abx
Periodontal abscess imaging
Panoramic radiograph or CT for bone involvement
Periodontal abscess presentation
Fever, Pain
Red, fluctuant swelling of the gingiva, Tenderness to palpation
Periodontal abscess management
Pain management, I+D, F/U with dentist
Oral antibiotics if limited infection
Augmentin or Clindamycin x 7-14 days
Dental avulsion presentation
Avulsion of permanent tooth→ True dental emergency
Pain
Tooth completely displaced from the alveolar ridge
Periodontal ligament severed
Dental avulsion management
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
Tongue laceration
Related to injury that involves the teeth
Oral cavity and tongue are very vascular→ potential for increased bleeding
Tongue laceration management
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
