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Emergency Medicine > Lecture 2: EENT > Flashcards

Lecture 2: EENT Flashcards

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1
Q

What are the 3 CNs that control eye movement and their corresponding muscles?

A
  • CN3 (Oculomotor): Superior, Medial, Inferior, Inferior oblique
  • CN4 (Trochlear): Superior oblique
  • CN6 (Abducens): Lateral

Superior oblique: Down and out
Inferior oblique: Up and out

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2
Q

What can chronic use of ophthalmic drops result in?

A
  • Chemical conjunctivitis
  • Inflammatory changes to cornea
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3
Q

What oral medications increase the risk for glaucoma?

A
  • Dilating eye drops
  • TCAs
  • MAOIs
  • Antihistamines
  • Antiparkinsonian drugs
  • Antipsychotics
  • Antispasmolytics
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4
Q

What kind of eye injury requires intervention prior to PE?

A

Chemical injury

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5
Q

What is the ideal way to assess VA?

A

With corrective lenses.

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6
Q

When is finger counting or hand motion perception used for VA?

A

VA worse than 20/200.

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7
Q

What test assesses for afferent pupillary defect?

A

Swinging light test

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8
Q

What is normal IOP? When should you NOT check IOP via tonopen?

A
  • 10-20 mmHg
  • CI if globe rupture from trauma
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9
Q

How do you differentiate preseptal cellulitis from orbital cellulitis?

A

Presence of inflammatory proptosis of the eye = orbital.

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10
Q

What recent infections may suggest possible orbital cellulitis?

A
  • Ethmoid sinusitis
  • Maxillary sinusitis
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11
Q

What are the red flags for orbital involvement of an infection?

A
  • Pain with EOM
  • Chemosis
  • Proptosis
  • Increased IOP
  • VA changes
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12
Q

If we suspect orbital cellulitis in a young child who is difficult to examine, what is the ideal imaging?

A

Orbital CT w/ con

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13
Q

Management for periorbital cellulitis OP for older child and up

A
  • Augmentin or cephalexin (clinda for PCN allergy)
  • Hot compresses
  • f/u in 24-48h with oph to make sure it improves
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14
Q

Management of periorbital cellulitis for young children/severe presentation

A
  • Admit
  • IV rocephin OR (unasyn + vanco)
  • PCN allergy: FQ + metro/clinda
  • Oph consult
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15
Q

Management of orbital cellulitis

A
  • Immediate consult
  • IV abx: Rocephin or (unasyn + vanco) or (FQ + metro/clinda)
  • Topical nasal decongestant
  • Lateral canthotomy for increased IOP or optic neuropathy
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16
Q

Describe a hordeolum.

A
  • Stye
  • Acute infection of follicle or meibomian gland
  • Redness
  • Tender
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17
Q

Describe a chalazion.

A
  • Swelling d/t obstructed meibomian gland
  • Hard, non-tender
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18
Q

What are the S/S of both a hordeolum and chalazion?

A
  • Pain
  • Erythema
  • Swelling
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19
Q

How do you treat a hordeolum or chalazion?

A
  • Warm, moist compresses QID
  • Erythromycin ointment
  • Do not manipulate lesion
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20
Q

What diagnostics are indicated in bacterial conjunctivitis?

A
  • Fluorescein exam to r/o herpes, ulcers, abrasions
  • C&S if severe purulence
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21
Q

Management for bacterial conjunctivitis

A
  • Topical abx of TMP-polymyxin B
  • FQ or tobramycin for contact lens d/t pseudomonas
  • Admit for infants < 30d or hyperacute onsets.
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22
Q

What PE finding would suggest viral rather than bacterial conjunctivitis?

A

Watery discharge

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23
Q

Management of viral conjunctivitis

A
  • Cool compresses
  • Topical antihistamine/decongestant
  • Artificial tears

Much less dangerous

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24
Q

What PE findings suggest allergic conjunctivitis primarily over other etiologies?

A
  • Intense itching
  • Papillae on inferior conjunctiva
  • Watery discharge
  • Cobblestoning
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25
Q

What diagnostic is appropriate for allergic conjunctivitis?

A

Fluorescein to r/o herpetic lesions

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26
Q

Management of allergic conjunctivitis

A
  • Cool compresses
  • Antihistamine/decongestants
  • Artificial tears
  • Refer if severe or resistant

Pretty much same as viral

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27
Q

How does anterior uveitis/iritis present?

A
  • Unilateral/bilateral pain
  • Photophobia with consensual photophobia HALLMARK
  • Conjunctival injection/ciliary flush
  • Miosis with poor reactivity
  • Diminished VAs
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28
Q

What diagnostics are appropriate for anterior uveitis?

A
  • Slit-lamp: keratic precipitates (Inflammatory cells), aqueous flares (protein)
  • Hypopyon check
  • Fluorescein stain
  • IOP measurement (usually normal)
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29
Q

Management of anterior uveitis/iritis

A
  • Cycloplegics (dilate pupil to keep iris from lens)
  • Topical prednisolone
  • Refer to oph

Cyclogyl or cyclopentolate or homatropine (DOC) for cycloplegic

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30
Q

When are topical steroids NOT indicated for anterior uveitis?

A
  • Corneal abrasion
  • Infectious
  • Elevated IOP
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31
Q

S/S of a corneal ulcer

A
  • Pain
  • Redness
  • Tearing
  • Photophobia
  • Blurry vision
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32
Q

Diagnostics for corneal ulcer and expected findings

A
  • Fluorescein: staining defect with white hazy infiltrate, iritis, and/or hypopyon
  • Culture ulcer
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33
Q

Management of corneal ulcer

A
  • Ophthalmic FQ (ofloxacin or cipro or tobramycin)
  • Topical cycloplegic
  • AVOID eye patching
  • Consult oph for immunocompromised
  • AVOID TOPICAL STEROIDS
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34
Q

S/S of HSV keratoconjunctivitis

A
  • Unilateral photophobia
  • Pain, redness
  • VA loss
  • Preauricular LAN
  • Vesicular eruption around eye
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35
Q

Diagnostics for HSV keratoconjunctivitis and expected finding

A

Fluorescein stain with dendritic lesion uptake or geographic ulcer

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36
Q

Management of HSV keratoconjunctivitis

A
  • Eyelid involvement: oral antiviral
  • Conjunctival involvement: topical trifluridine with erythromycin ointment
  • Corneal involvement: urgent oph consult
  • AVOID topical steroids

If < 30d old, admit

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37
Q

What is HZV ophthalmicus?

A

HZV infection of V1 of trigeminal

Ramsay Hunt syndrome

I think of shingles entering nerves to differentiate between HSV vs HZV

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38
Q

S/S of HZV ophthalmicus

A
  • Painful vesicular rash on erythematous vase involving upper eyelid and tip of nose hutchinson sign
  • Fever, malaise, HA
  • Red eye, blurred vision, eye pain/photophobia
  • Keratitis, uveitis
  • Elevated IOP

Hunt at the zoo, so you know its zoster and not simplex

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39
Q

Diagnostics for HZV ophthalmicus and expected findings

A

Fluorescein stain showing pseudodendrites.

Small, no central ulceration, no terminal bulbs, no central stain.

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40
Q

Management of HZV ophthalmicus

A
  • Consult
  • If severe: admit for IV acyclovir
  • Skin involvement: Cool compresses, oral antivirals for short-term rash, topical abx (bacitracin/erythromycin)
  • Ocular involvement: erythromycin ointment, cycloplegics, opioids, cool compresses
  • If anterior uveitis present: topical steroids via oph
  • If occurring in patient < 40y, work up for immunocompromised state
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41
Q

S/S of subconjunctival hemorrhage

A
  • Bright red blood under bulbar conjunctiva
  • Hx of trauma by sneeze, cough, valsalva, HTN
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42
Q

Management of subconjunctival hemorrhage

A

Reassurance

2-3 weeks to self-resolve

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43
Q

S/S of UV keratitis

A
  • Slow onset of FB sensation and mild photophobia
  • Blepharospasm, tearing, conjunctival injection

Foreign body

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44
Q

Risk factors for UV keratitis

A
  • Welding
  • Tanning
  • Prolonged sun exposure
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45
Q

Dx of UV keratitis

A
  • Slit lamp showing diffuse, punctate corneal edema
  • Fluorescein showing punctate corneal abrasions
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46
Q

Management of UV keratitis

A
  • +/- eye patching
  • Cycloplegic, oral analgesics, topical abx
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47
Q

S/S of corneal abrasion

A
  • Tearing, photophobia, pain
  • Blepharospasm
  • Often need topical anesthetic
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48
Q

Dx of corneal abrasion

A
  • Look for any ocular FBs
  • Fluorescein
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49
Q

Management of corneal abrasion

A
  • Ketorolac drops
  • Erythromycin ointment
  • FQ/tobramycin for contact lens
  • DO NOT RX topical anesthetics
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50
Q

What may occur if a FB persists in an eye > 24 hrs?

A

WBC ring forms in anterior corneal chamber

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51
Q

Presence of what suggests globe perforation due to corneal FB?

A

Hyphema or microhyphema

Do seidel test if suspected. (cobalt blue light)

Hyphemas present with pain, subconjunctival is often painless

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52
Q

When would a CT orbit be added for suspected corneal FB?

A

If we think its intraocular or globe rupture

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53
Q

Management of corneal FB

A
  • Consult if hyphema present
  • Remove FB (unless pt uncooperative or drunk)
  • F/u with oph in 24h if rust ring, central FB, or deep
  • f/u with oph in 48h if symptoms persist
  • Update tetanus
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54
Q

When would a consult for lid laceration be warranted?

A
  • Lid margin involvement
  • Within 6-8mm of medial canthus
  • Lacrimal duct or sac involvement
  • Inner surface of lid
  • Ptosis
  • Tarsal plate invovement
  • Levator palpebrae muscle involvement (horizontal lac with ptosis)
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55
Q

Management of lid lac

A
  • No sutures of lid margin < 1mm
  • Soft, absorbable/nonabsorbable 6/7-0 sutures (SMALL)
  • Oral keflex and erythromycin ointment
  • Cold compresses
  • Discharge with oph f/u in 24h
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56
Q

What usually precipitates a globe rupture?

A

History of high spd FB or penetrating injury

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57
Q

PE findings associated with globe rupture

A
  • Severe subconjunctival hemorrhage
  • TEAR DROP pupil
  • Limited EOM
  • Extrusion of globe content
  • Seidel test (if wound is unsealed)
58
Q

Dx of globe rupture

A

CT scan of orbit

59
Q

Management of globe rupture

A
  • Eye shield, NPO, upright
  • Vanco + ceftazidime + zofran (avoid IOP increases)
  • Emergent oph consult

zo van dime globe

60
Q

Why should you not use fingers to examine blunt eye trauma?

A

It will worsen IOP

61
Q

Complications associated with blunt eye trauma

A
  • Ruptured globe
  • Postseptal hemorrhage
  • Hyphema
  • Orbital blowout fx
62
Q

Features of orbital blowout fx

A
  • Fx of inferior/medial orbital wall
  • Entrapment of inferior rectus muscle
  • Restricted upward/lateral gaze
  • Bruising around the eye
63
Q

Dx of blunt eye trauma

A

CT facial bones without contrast

64
Q

Management of blunt eye trauma

A
  • Discharge home if normal VA and normal anatomy
  • Traumatic iritis: tx with prednisolone acetate and cycloplegic
  • Emergent Oph consult if rupture, postseptal hemorrhage, hyphema, orbital blowout, or intraocular FB
65
Q

Approach to chemical ocular injury

A
  1. Eye irrigation
  2. Physical
66
Q

Management of chemical ocular injury

A
  • Cycloplegic
  • Opioids
  • Emergent oph consult: increased IOP, chemosis, conjunctival blanching, epithelial defect, corneal edema, opacification, exposure to HCl, lye or concrete
67
Q

Which glaucoma type is acute?

A

Narrow angle/closed angle/acute angle closure

68
Q

What part of the eye does glaucoma involve?

A

Trabecular meshwork: draining aqueous humor via anterior chamber

69
Q

What makes aqueous humor?

A

Ciliary body

70
Q

What is the characteristic finding of glaucoma on fundoscopic exam?

A

Cupping of the optic disk

71
Q

Define glaucoma

A

Eye diseases characterized by neuropathy to optic nerve, with or without IOP elevation

72
Q

What is the primary and secondary leading causes of blindness?

A
  1. Cataracts
  2. Glaucoma
73
Q

What are the usual predisposing events to acute angle closure glaucoma?

A
  • Exposure to dark room
  • Reading
  • Dilating agents (anticholinergics)
  • Cocaine
74
Q

How does acute angle closure glaucoma present?

A
  • Sudden onset eye pain
  • Blurred vision colored halos around lights, N/V
  • HA
  • Fixed midposition pupil
  • Hazy cornea
  • Increased IOP (firm eye)
75
Q

Gold standard test for acute angle closure glaucoma

A

Gonioscopy showing iridocorneal angle

76
Q

Management of acute angle closure glaucoma

A
  1. Oph consult
  2. Supine position
  3. Pharmacologic therapy
  4. Definitive: Laser peripheral iridotomy
77
Q

Pharmacologic tx of acute angle closure glaucoma

A
  1. Topical BB (timolol) and a2-agonist (apraclonidine) (block production)
  2. Acetazolamide (block production)
  3. Mannitol (decrease IOP by reducing volume)
  4. Pilocarpine once IOP < 50 to increase outflow

pile out the car (outflow)

78
Q

When should acetazolamide be given IV for acute angle closure glaucoma?

A
  • IOP > 50
  • Severe vision loss
  • Unable to tolerate PO
79
Q

How does optic neuritis present (ON)?

A
  • Painless vision loss
  • Color vision usually more commonly affected
  • VA should be altered via red desaturation test
  • Positive afferent pupillary defect
  • Edematous/swollen optic desk in anterior ON
  • Normal optic desk in retrobulbar ON
80
Q

How does Central Retinal Artery Occlusion present?

A
  1. Sudden, monocular painless vision loss (Amaurosis fugax)
  2. Positive RAPD
  3. Infarcted retina, pale, less transparent, and edematous
  4. Cherry red spot on fovea
  5. Boxcarring, segmented arterioles
81
Q

Management for CRAO

A

Emergent oph and neuro consult

82
Q

How does Central retinal vein occlusion present?

A
  • RAPD
  • Optic disc edema
  • Diffuse retinal hemorrhages (Blood and thunder fundus)
83
Q

Management of CRVO

A

Oph consult

84
Q

How does retinal detachment present?

A
  • Sudden onset of painless, monocular vision changes
  • Floaters, flashes of light, dark veil/curtain
  • Only PE changes are VA and visual field by confrontation

Bedside US can be helpful

85
Q

Management of retinal detachment

A

Urgent consult within 24h ophthalmology for dilated eye exam

86
Q

Presentation of AOE

A
  • Pruritis, otalgia, and tenderness of external ear
  • Otorrhea and decreased hearing in severe
  • Erythema and edema of external auditory canal
  • Clear/purulent discharge
  • Severe cases: complete occlusion of auditory canal
87
Q

Management of AOE

A
  • Analgesics: tylenol/motrin
  • Cleansing of external canal
  • Otic drops: acetic acid/hydrocortisone
  • Ofloxacin or ciprofloxacin drops
  • Ear wick for swelling
88
Q

When is acetic acid/hydrocortisone contraindicated in AOE? Ciprofloxacin?

A
  • CI in perforated TM
  • CI if TM can’t be seen
  • Cipro cannot be used in perforated TM either.
89
Q

What red flags suggest malignant otitis externa?

A
  • Elderly
  • Diabetic/immunocompromised
  • Persistent symptoms despite standard therapy
  • Severe otalgia/edema
  • Granulation tissue on floor of canal
90
Q

If malignant otitis externa is suspected, what diagnostic imaging should be ordered?

A

CT head w/ con showing bone erosion

91
Q

Management of malignant otitis externa

A
  • ENT consult
  • IV (tobramycin + piperacillin) or rocephin or cipro
  • IV opiate
92
Q

How does AOM present?

A
  • Otalgia
  • Otorrhea, possible fever, hearing loss
  • TM erythema
  • Retracted/bulging TM
93
Q

Top 3 causative organisms for AOM?

A
  • Strep pneumo
  • H. flu
  • M. cat
94
Q

Management for AOM

A
  • Amoxicillin (Cefdinir if allergy)
  • If recent abx use or recurrent OM, augmentin/cefdinir
  • Analgesics
95
Q

Presentation of acute mastoiditis

A
  • Otalgia
  • Fever
  • Postauricular pain
  • Postauricular swelling, erythema, and tenderness
96
Q

Dx of acute mastoiditis

A
  • CT head with contrast
  • Mastoid clouding
  • Loss of bony septae
  • Destruction/irregularity of mastoid cortex
  • Perisoteal thickening
97
Q

Management of acute mastoiditis

A

IV vanco + rocephin

rocking the van’s mast

98
Q

Presentation of bullous myringitis

A
  • Severe otalgia
  • Intermittent otalgia
  • Intact bullae along the TM and EAC (external auditory canal)
  • Middle ear infusion
99
Q

Management of bullous myringitis

A

Same as OM

100
Q

Presentation of auricular hematoma

A
  • Accumulation of blood between skin and cartilage of auricle d/t blunt trauma
  • Swelling, pain, and ecchymosis of auricle
101
Q

Management of auricular hematoma

A
  • Consult ENT: immediate I&D
  • Compressive dressing after
  • If left untreated, scarring and cauliflower ear
102
Q

Management of ear FB

A
  • Immobilize live insects with 2% lido
  • Use forceps or hooked probe or suction
  • Irrigation with warm water or saline for non-organic objects
103
Q

Presentation of TM perforation

A
  • Hx of barotrauma
  • Sudden onset of pain and hearing loss
  • +/- bloody otorrhea, vertigo, tinnitus
  • Rupture of TM
104
Q

Management of TM perforation

A
  • Most heal spontaneous
  • Uncomplicated = discharge home
  • Complicated = penetrating TM rupture = 24h f/u with ENT
105
Q

Presentation of anterior epistaxis

A
  • Visualized on external exam
  • MC at kiesselbach plexus
106
Q

Presentation of posterior epistaxis

A
  • Unable to directly visualize bleed
  • Failure to control bleeding
  • MC at sphenopalatine artery
  • Use nasal speculum
107
Q
A
108
Q

Management of epistaxis

A
  • Type and crossmatch blood if hemodynamically unstable, which is MC in posterior bleed and pts taking AC
  • Place in sniffing position
  • Direct pressure application w/ intranasal vasoconstrictor

Oxymetazoline or phenylephrine

109
Q

Chemical management of anterior epistaxis

A
  • Utilize after 2 failed attempts of direct pressure with visualized vessel
  • Anesthetize with 3 swabs soaked in 1:1 of oxymetazoline and lidocaine
  • Apply silver nitrate stick

CI in active hemorrhage, bilateral bleeding, recent cauterization

110
Q

If chemical cautery fails for epistaxis tx, what else can we do?

A
  • Thrombogenic foam
  • Oxidized cellulose
  • Floseal gelatin matrix
  • Nasal packing via balloon, tampon, or ribbon packing.
111
Q

Among the 3 nasal packing options, which is the absolute last resort and why?

A

Ribbon gauze, due to its difficulty in usage and comfort.

112
Q

In posterior epistaxis, chemical cautery cannot be used. What is the alternative to posterior nasal packing?

A

Catheter with balloon.

113
Q

When are prophylactic abx indicated for nasal packing? What is the abx?

A
  1. Indicated for packing > 48h
  2. Augmentin (cephalosporin or bactrim)

Ideally, ENT removes it in 2 days.

Advise pt to not take any NSAIDs for 3-4d

Its like txing sinusitis in case

114
Q

Centor criteria symptoms and purpose

A
  1. Age
  2. Tonsillar exudate
  3. Tender Anterior cervical LAN
  4. Absence of cough
  5. Fever
  6. Purpose: Whether pharyngitis is due to strep and how to manage.

Young age is +1, middle is 0, old is -1

115
Q

What specific symptoms suggest Viral pharyngitis?

A
  • Cough
  • Rhinorrhea
  • Nasal congestion
  • Vesicular lesions

Viral URI symptoms

116
Q

What specific symptoms suggest bacterial pharyngitis?

A
  • Tonsillar exudate
  • lack of cough
  • Anterior Cervical LAN
  • Sore throat

MCC: Strep pyogenes (GAS)

117
Q

What centor score should you start to maybe consider a rapid strep?

A

At least 2 or more

Optional beginning at 2

118
Q

Tx for viral pharyngitis and bacterial pharyngitis

A
  • Viral: Supportive
  • Bacterial: Single dose of PCN G or amoxicillin 500mg 10d BID (keflex/cefdinir)
119
Q

Patient education for pharyngitis

A
  • Change toothbrush
  • Not contagious after 24h of tx
  • Self-resolving in 2-3 weeks but will remain contagious without tx.
120
Q

What S/S suggest peritonsillar abscess?

A
  • Hot potato voice
  • Odynophagia/dysphagia
  • Contralateral deflection of uvula
  • Drooling
  • Unilateral tonsillar enlargement
  • Fever
121
Q

Dx of peritonsillar abscess

A
  • Clinical, but if needed:
  • Intraoral U/S to differentiate cellulitis from abscess
  • CT con of the neck (Not C-spine)
122
Q

Management of peritonsillar abscess

A
  • Needle aspiration or I&D
  • Non-toxic: PCN VK + metro for 10d if PO tolerable. (clinda/metro)
  • Toxic: sepsis w/u with Zosyn

Mouth + anaerobe coverage

123
Q

S/S of a retropharyngeal abscess

A
  • Muffled voice
  • Cervical adenopathy
  • Respiratory distress key differentiating factor from peritonsillar abscess
  • Stridor
  • Neck pain/torticollis
124
Q

Dx of retropharyngeal abscess

A
  • Neck XR: Thickening and protrusion of retropharyngeal wall
  • GOLD STANDARD TEST: CT NECK w/ con
125
Q

Findings seen for retropharyngeal abscess via CT Neck w/ con

A
  • Early: nonsuppurative edema, mild fat stranding, linear fluid, minimal mass effect.
  • Later: Necrotic nodes, low attenuation, ring enhancement
126
Q

Management for retropharyngeal abscess

A
  • Prep for airway placement
  • IVF + NPO
  • IV clinda/cefoxitin (zosyn or unasyn)
127
Q

S/S of epiglottitis

A
  • Progressive dysphagia, odynophagia, dyspnea
  • Tripoding
  • Anterior neck tenderness (larynx/upper trachea)
  • Tachycardic
128
Q

Dx of epiglottitis

A
  • Neck XR: thumbprint sign
  • transnasal fiberoptic laryngoscopy is gold standard
129
Q

Management of epiglottitis

A
  • Prep for airway
  • Humdified O2, IVF
  • IV cefotaxime + vanco (respiratory FQ)
  • IV methylprednisolone 125mg

Tax the meth van with 3 wheels (tripoding)

Bacterial etiology

130
Q

Etiology of odontogenic abscess

A

Extension of dental abscess into retro or parapharyngeal spaces or floor of mouth.

131
Q

S/S of odontogenic abscess

A
  • Hx of dental pain/abscess
  • Erythema/edema of labia/buccal gingiva or intraoral (tooth abscess)
  • Ludwig’s angina (trismus, fever, edema of floor, displacement of tongue)
  • Retro-parapharyngeal abscess: sore throat, dysphagia, dyspnea
132
Q

Dx of odontogenic abscess

A
  • Beside US if superficial
  • CT Neck w/ con if deep
133
Q

Two main complications of odontogenic abscess

A
  • Ludwig’s angina: cellulitis of sublingual/mandibular space = verify airway
  • Necrotizing infection: toxic appearance w/ hemodynamic instability = surgical fasciotomy ASAP.
134
Q

Management of odontogenic abscess

A
  • Non-toxic & superficial: Oral PCN VK or amoxicillin 500mg TID x10d (clinda)
  • Toxic, deep or complication: IVF, NPO, unasyn + clinda + cipro
135
Q

MC food lodged in esophagus

A

Meat

136
Q

Dx of swallowed FB

A
  • “foreign body film” for radiopaque
  • CT w/o con for non-radiopaque
137
Q

What object features make obstruction risky if it gets past the pylorus?

A
  • Irregular/sharp
  • Wider than 2.5cm
  • Longer than 6cm
138
Q

Management of swallowed FB in distal esophagus

A

IV glucagon to relax LES and hopefully allow it to pass

Provided no red flags for obstruction

139
Q

Management of food impaction, coins, or sharp objects swallowed

A
  • Emergent endoscopy
  • Consult sx
140
Q

Management of swallowed battery

A
  1. If in esophagus, REMOVE ASAP
  2. If in stomach, f/u in 24h
  3. Takes 48-72 hrs to pass
141
Q

Management of swallowed narcotics

A
  1. NO endoscopy
  2. Admit for obs until it reaches rectum

Emergency Medicine (29 decks)

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