Lecture 9: HEENT Flashcards
Basic Eye Exam:
* What is first?
* What do you stain the eye with?
* Look for what type of sign?
* Why do you do slit lamp exam?
* _ Testing
- Visual acuity first
- Stained exam with fluorescein and tetracaine
- Look for Seidel sign – bleb leakage indicates perforation
- Slit lamp exam-> look at posterior eye
- Pressure testing
What findings will require eye consult and possibly transfer?
Any acute findings such as retinal artery occlusion, iritis or acute closed angle will require eye consult and possibly transfer
Eye
* What are questions you need to ask? (4)
- Size of pupils, are they equal?
- Do they react?
- Is there a globe injury?
- Are there lid injuries?
What is this? How do you manage it?
hyphema
* Immediately put them at 45 degree recline to absorb the blood and manage the BP
Swelling of eye. Awoke with symptoms. Hx of sinus infection
* What is going on with the patietn?
* What should you order?
Preseptal or orbital
* more likely to be orbiral due to sinus infection
* CT with (better for infection) or without (just sinus)
Preseptal/orbital cellulitis:
* What is preseptal?
* What is orbital? Secondary to what?
Preseptal-
* Infection of anterior tissues (lid, lacrimal glands)-> Does not pass muscle
Orbital-
* Infection of deep structures of orbit
* Secondary to rhinosinusitis(86 to 98% of cases) or trauma, surgery, dental infections
PRESEPTAL/ ORBITAL CELLULITIS
* How do you differentiate between the two?
CT scan is usually necessary to differentiate between the two
ORBITAL CELLULITIS: Etiology
* What are the MC organisms? (3)
* Consider what organisms in immunocomproised patients?
- Staph aureus pyogenes, Streptococcus pneumoniae, anaerobic infections
- Consider Aspergillus and Mucor (molds) in immunocompromised patients
Sinitis: viral-> cox, adenovirus, covid but sinus still has lot of bacteria in sinus (increases with smoking, COPD)
What is this?
Left: Orbital becuase eye is red
Right: Orbital (even though it looks like preorbital)
* GET A CT IF UNSURE
PRESEPTAL VS ORBITAL CELLULITIS
* When are you allow to treat as outpatient? (8)
- No fever
- No pain with full extraocular movements
- No chemosis (swollen, red, edematous cornea) or ptosis
- Compliant patient
- No underlying immune problems (HIV, diabetes, Autoimmune stuff etc.)
- Does not appear toxic
- No decreased vision
- No signs of sinusitis
ALL PRESEPTAL
Red flags for orbital? (2)
- Painful movement, ptosis
- Toxic-> systematic issues
PRESEPTAL VS ORBITAL CELLULITIS
* What is the imaging?
* When in doubt do what?
* If preseptal, what does the patient need to do?
- CT Scan or MRI
- When in doubt, admit.
- If preseptal, daily follow up with ophthalmology
What is this?
ORBITAL
What is going on here?
Orbital
* right eye abscess pressing on the Rectus muscle (pain with EOM)
Inpatient treatment of oritbal
* What do you need to order and consult?
* How do you tx infection?
Need blood work, cultures, surgical (ENT/oculoplastics) consult
IV antibiotics:
* Vancomycin (MRSA) + ceftriaxone (typical gram - and + bugs) or ampicillin sulbactam (Dr. S does not like because it takes long time) or piperacillin tazobactam (Good choice because cover flagulets)
* Amphotericin B if fungal (immunocompromise state-> CD4 under 50)
Dacryoadenitis:
* What is it?
* Onset?
* What are the sxs?
* What type of region?
Dacryocystitis
* What is it?
* Onset?
* What are the sxs?
* Where is it?
Worst than dacryoadentitis
Dacryoadenitis
* Infection of what?
* What are the common bugs or issues that cause this? (3)
- Infection of the lacrimal gland
- Viral (mumps), bacterial (staphylococus, gonorrhea), tumor or mass (sarcoid)
Viral MC
Dacryoadenitis
* What are the sxs?
Symptoms include swelling of lid, redness, pain, discharge and/or tearing, preauricular node
Treatment of Dacryoadenitis/cystitis
* What is the supportive care?
* What do you do if fluctuant?
* Refer for what?
- Hot compresses for viral/ bacterial infection
- I & D if fluctuant, likely done by plastics (MORE IN Dacryocystitis)
- Refer for follow up or admit/transfer
Treatment of Dacryoadenitis/cystitis
* What anx needed?
* What if pen allergic?
* What do children need?
- Cephalexin (Keflex) or Cefaclor (Ceclor)
- Erythromycin for penicillin allergic
- Children need IV antibiotics
Shotgun injury to eye, presents to the trauma bay.
* What do you need to do for this patient?
Consult ophthalmologist because they need to go to OR because if patients does not go to OR they will get septal invasion and having eye problems-> VISION LOST
PENETRATING EYE INJURIES (OPEN GLOBE)-
* What hx questions do you need to take on patient? (5)
* What do you place on eye? Do not remove what?
- Allergies
- Significant past medical history
- Medications
- Eye shield- DO NOT REMOVE OBJECT!
- Tetanus toxoid up to date
- Last food and drink/ LMP
IMPORTANT FOR SURGERY
PENETRATING EYE INJURIES (OPEN GLOBE)
* What do you need get hx of before injury? What should if give if eye is painful?
Vision and history of vision before injury – if painful give topical analgesic
* Painful in even conjunctivitis or septal cellulits-> document that you cannot do vision
PENETRATING EYE INJURIES (OPEN GLOBE)
* What anx do you give?
* What do you need to do for surgery?
* Order what?
IV antibiotics: variable (caused by something like animal/human bite)
* Ceftriaxone or cephalon
* Vancomycin and (ceftazidine OR fluoroquinalone)-> allergy profile
NPO+ Blood type (type and screen)
Order CT Orbit scan, without contrast (because looking for FB)
Patient hit in the eye with a racket ball. Not wearing eye protection
* What is going on with the patient?
Infraorbital fracture
* inferior rectus m. is trap
BLOWOUT FRACTURE
* What is the mc area?
* Can have entrapment of what?
* What may be present?
- Most common area: fracture of the inferior orbit (floor)
- Can have entrapment of inferior rectus or inferior oblique muscles
- Diplopia may be present
BLOWOUT FRACTURE
* What is the txt? (4)
- Needs surgery and ophthalmology referral
- Augmentin/ Azithromycin (need this because inferior floow connects to maxillary sinus-> dirty so this helps prevent orbital cellulitis
- HOB elevated
- Avoid nose blowing
What is going on with this patient?
Temporal arteritis
TEMPORAL ARTERITIS (Giant Cell Arteritis)
* Typically a hx of what?
* Common in what ages?
* What are sxs?(5)
- History of autoimmune disease
- Older patients- RARE before age 50
- Temple pain (palpable), headache, loss of vision, jaw claudication
- Ear pain can also be a symptom
TEMPORAL ARTERITIS (Giant Cell Arteritis)
* What can you get to eval aneurysm?
* Causes what?
* Increase risk of what?
* Double risk of what?
- Get US to eval aneurism
- Causes blindness due to ischemia
- ↑Risk of thoracic aneurysms x17 times.
- Double risk of abdominal aneurysms
TA Lab Evaluation and Treatment
* Elevated what?
* What is definitive test?
* Should not delay what?
- Elevated ESR and CRP
- TA biopsy is definitive test for diagnosis but can be negative.
- Do not delay steroid therapy until biopsy results
TA Lab Evaluation and Treatment
* What is the medication?
* Start meds when?
* Admit for what?
- Early high IV dose steroids (methylprednisolone 1 Gram IV)
- Start before biopsy
- Admit for Neuro-ophthalmologist/ Neurologist/ Rheumatologist evaluation
What does a retinal artery occlusion show? Retinal detachment show?
* Who should you call for both of these?
- Retinal artery occlusion: Cherry red spot
- Retinal detachment: Start with floaters and reduced vision (can use US to look for it)
- Call ophthalmology
Conjunctivitis
* Usually result of what?
* MCC?
* Consider bacterial when?
- Usually as a result of direct inoculation
- MCC is viral (typically adenovirus)
- Consider bacterial if <2yo (S. aureus) and most will have purulent exudate
Differential: STI, chronic conjunctivitis, autoimmune,contact lenses use, allergies, episcleritis
Conjunctivitis
* Always do what?
* What is first line?
- Always stain all eye complaints and document pressures
- Baby shampoo scrubbing and warm compresses are first-line
Conjunctivitis
* Typically therapy is what? (anx)
Typical therapy is antibiotics (ointment preferred) and ophthalmology referral
* Erythromycin or Tobramycin
* Cipro for contact lenses keratitis(pseudomonas coverage)
- You see a 24yo WM welder for evaluation of right eye pain, tearing and blurry vision. He was grinding metal and is here for further evaluation.
- After you get visual acuity and stain his eye, you see this:
metal FB
* Early on because no rust ring
* Get imaging + tetanus update
Corneal FB
* What are three ways to remove it?
- Cotton swab
- Tip of needle (at least 22ga)
- Burr tool
Corneal FB
* If you suspect metal FB by history but cannot see it, what do you do?
* After eye consult, cover with what?
* Always do what?
- If you suspect metal FB by history but cannot see it -> order Orbital CT
- After eye consult, cover with ABX (ointment!)
* Need a follow up for full stain to make sure the patient is not getting worst - Always evert eyelids
Corneal abrasion:
* What should you do for every signal eye complaint?
* How do you tx
- Stain the eye
- Ointment of erythromycin, tobromycin or cipro if allergic
Chalazion and Hordeolum
* both technically what?
* Advise what?
- Both are technically “styes”
- Advise to discontinue make-up use
Chalazion
* What is it?
* May require what?
* Treat with what?
Chalazion (less of a stye)
* Noninfectious (granuloma) Meibomian/Zeis gland occlusion (generally painless)
* May require incision
* Treat with warm compresses & steroids
Hordeolum
* What are they?
* usually what?
* May lead to what?
* Treat with what?
Hordeolum (more of a stye)
* Most are Infectious from eyelash follicle obstruction (few can be sterile)
* Usually painful
* May lead to blepharitis or preseptal cellulitis
* Treat with warm compresses, massage and if not better -> topical ABX
horrible hordeolum
Pinguecula and Pterygium
* both are what?
* Develop due to what?
* What is the difference?
- Both are protein and fat deposits in the conjunctiva
- Develop due to UV exposure
- Pinguecula: Does not cross corneal limbus
- Pterygium: Crosses the corneal limbus
Trick: Y (pterYgium) would you cross the line
Nose Injuries
* If there are fractures, what do you need to look for? What do you need to do with them?
* Any clear drainage that could be what?
Fracture-> look for Septal hematoma
* These need to be aspirated or will cause septal necrosis.
Any clear drainage that could be CSF fluid (Filter paper halo or glucose)
How do you txt?
- Topical lidocaine then aspirate
OR
- Inject lidocaine and cut
Septal Hematoma In Nasal Fracture
* Usually related?
* Risk of what within 3 days?
* Risk of what? (2)
- Usually trauma related
- Risk of hematoma infection within 3 days
- Risk of septal perforation
- Risk of saddle nose
Septal Hematoma:
* How do you txt it?
* What is the expection?
- Needle aspiration (or #15 scalpel) under topical anesthesia with 18 or 20 gauge needle.
- Except in patients who present immediately, specimens should be sent for gram stain and aerobic/ anaerobic cultures.
Septal Hematoma
* What meds should you give?
* Incise/ aspirate what?
* Bilateral staggered incisions should be made what?
- Antibiotics (cover typical respiratory pathogens)
- Incise/ aspirate the mucosa over the area of greatest fluctuance without incising cartilage.
- Bilateral staggered incisions should be made for bilateral hematomas to avoid a through-and-through perforation
- cephalexin 250-500 mg QID and
- amoxicillin/clavulanate 250-500 mg TID.
- clindamycin 150-300 mg QID
- trimethoprim/sulfamethoxazole DS BID
Epistaxis
* What are some causes?
- Traumatic: Blunt force
- Spontaneous: URI, anticoagulants, HTN
Anterior: Commonly seen in winter months dt thinner nasal walls
Posterior: Anticog problems
Epistaxis txt of unilateral and bilateral?
- Unilateral: Requires packing and likely dc
- Bilateral: Likely requires admission and ENT consult
Epistaxis
* Always cover for what with nasal rockets?
* What is alternative
* Good idea to check what on a patient on anticoagulation?
* Imaging for what?
CT brain: for canadian head CT rules or C-spain clearnance
Mouth
* What are common issues?
- Dental trauma
- Bleeding
- Secretions
- Foreign bodies must identify and remove
- Jaw dislocations
- Tongue and mucosa injuries
- Injuries to the palate or floor of the mouth
If you have tongue frenulum issue then what do you need to look for?
Tongue frenulum = Fx Mandible
Mandibular fracture if torn frenulum.
What is going on? What do you do?
Mandible fracture -> look for second fx
* Need IV ABX ASAP and call MaxFace Sx.
Dental injuries
* Seen with what?
* R/O what?
- Assaults
- Dental caries
- R/O abcess, ludwig angina (into submanibular space) -> see drooling, trismis and unable to handle secreations
* EMERGENCY
Dental injuries
* What are two ways of describing locations?
- Numbers
- Names
What do you do if the tooth completely knocked out? (3 options)
- First, try to put it back in its socket.
- The next best option is putting it in a glass of milk.
- If milk isn’t available, hold the tooth in your cheek pouch (saliva is better than tap water).
Tooth knockout:
* Do not let what? Why?
* When should reimplantation occur?
Don’t let it dry (periodontal cells will die)
Reimplantation should occur within 20-30 minutes for best results, most studies suggest to be within 18hours.
* Up to 2 weeks from trauma can happen
Dental Pain Management
* usually includes what?
* What is difficult to control? Why?
* Can over avulsion with what?
* _ block
- Usually includes antibiotics
- Pain difficult to control long term due to nerve exposure or pulpitis
- Can cover avulsion with wax
- Dental block
Fill in for how to do these
Fill in for how to do this block
Fill in how to do for regional block
What is going on here? When do you need to fix it?
Tongue lacerations (common trauma, and seizures)
* Suture if over the size of piece of corn
Tongue Lacerations
* Look for what?
* Excessive bleeding can cause what?
* How do you tx the pain?
Look for retained FB (teeth)
Excessive bleeding can cause swelling, so protect airway
Don’t be cruel, treat the pain
* Topical lidocaine soaked 2x2~5mins
* Infiltrate wound with lidocaine
* May have to sedate a child
Tongue Lacerations
* Generally close if laceration is what? What suture do you use?
* Prophylax with what?
- Generally close if laceration hole fits a piece of corn or its gaping
- Use absorbable suture (Chromic gut, vicryl)
- Prophylax with ABX (augmentin or 2nd/3rd cephlo-> ceftriaxone
Pinna Hematoma
* What is the cause?
* Results in what?
- Blunt trauma shears the perichondrium from the underlying cartilage and tears adjoining blood vessels
- Result: tissue necrosis and asymmetrical formation of new cartilage->“cauliflower ear”
Treatment of pinna hematoma:
* If up to 24-48 hours old and, <2 cm:
* If >24-48 hours:
* Place what?
* Suture with what?
- If up to 24-48 hours old and, <2 cm: aspiration with 18 gauge needle and syringe (after topical anesthesia)
- If >24-48 hours, I & D of hematoma or aspiration
- Place drain/ leave space to drain, 18 gauge catheter 1cm left in place
- Suture with mattress suture
Treatment of pinna hematoma
* Common bacteria?
* What meds do you give (adults vs peds)
* What do you need to cover the ear with?
* Refer to who?
Give oral antibiotics to cover Staph, Strep, and Pseudomonas species
* Adult: levofloxacin IV, Cipro PO or clindamycin
* Peds: amoxicillin/clavulanate
Pressure dressing
Refer to ENT for daily F/U.
How do you do a needle aspiration of an auricular hematoma?
What is the process of covering the ear from ear hematoma?
What is going on?
Mastoiditis
Mastoiditis
* How do you dx?
* Call who?
* Usually a dx of what?
* Will require what?
- Clinical diagnosis, can confirm with CT
- Call ENT
- Usually a diagnosis of admission/transfer
- Will require IV ABX (ceftriaxone or clindamycin) and likely surgical drainage->Need to clean out area because if not then higher risk of encephalitis
Foreign Bodies
* What do you do with bugs?
* What can you do to decrease dicomfort and anxiety when trying to get FB?
* What is the alt?
- Kill whatever if it is still alive->Insects can be drowned in lidocaine
- Use otoscope tip to pass instruments to orifice to avoid contact to wall which will cause discomfort or anxiety
- Can use suction, lavage (calorics) or refer to ENT
Lavage: can cause vertigo
Pharyngitis Differential
* What are 5 ddx?
- Viral
- Group A streptococcus
- Mononucleosis
- Gonorrhea
- CMV
Diagnosis pharynitis
* PE is not always what?
* False negative in what?
* How long does it take for culture?
- Physical exam is not always reliable, although few findings are very specific
- Rapid strep test- 10 % false negative
- Culture- 48 hours
Diagnosis pharynitis
* When can mono spot test be negative? What are other abnormal lab values?
* What NAAT?
* What do you order for CMV
- Mono spot test- can be negative early, lymphocytosis and atypical lymphocytes
- GC NAAT
- IgM, IgG for CMV (CD4 under 50)
When to treat with antibiotics for pharygitis? (5)
- Fever
- Pus on tonsils
- Adenopathy
- Hyperemia – increased blood flow to tissue
- High WBC count
What is the centor criteria?
1)age 3-14 years
2)tonsillar exudates or swelling
3)tender anterior cervical adenopathy
4)absence of cough
5)history of fever
Mononucleosis
* What causes it? (organism)
* What is high?
* What is txt?
* Avoid what? (2)
- Epstein- Barr virus
- lymphocytosis
- Treatment: supportive therapy, +/- oral/ IV prednisolone
- Avoid contact sports for 4-6 months (can rupture spleen)
- Avoid amoxicillin (cause rash)
Cytomegalovirus (CMV)
* Like what?
* What is the txt?
- Mono like syndrome when negative for mono
- Supportive treatment
Treatment of GABHS
* What is the txt? PCN allergy?
- Penicillin X 10 days for adults and peds
- Cephalexin 500mg BID x 10 days
- Increased resistance to PCN G
- Azithromycin in PCN allergy
Peritonsillar Abscess (PTA)
* Ages?
* What is it?
* What are the sxs?
- Anyone aged 10-60 years
- Infectious abscess of the soft palate
- Soft palate erythematous, edematous, “Hot potato–sounding” voice
- Dysphagia
- Displaced uvula laterally
Bounded by the tonsillar pillars anteroposteriorly, the piriform fossa inferiorly, and the hard palate superiorly
Peritonsillar Abscess (PTA)
* What is the txt?
* What imaging can you do?
- CT with contrast
- Txt: under 2cm-> steriod and anx and then over 2cm then steroids and drainage
* Give steriods before drainage
anx (clindamycin, amox clav, vanco, linezolid)
Peritonsillar abscess:
* What are the mc aerobic species?
* What are the most common anaerobic species?
- most common aerobic species: Streptococcus species (especially Streptococcus pyogenes), Staphylococcal, H. Influenza
- most common anaerobic species: Prevotella species and Peptostreptococcus species
I think this is low yield
Treatment PTA with experienced Clinician or ENT
* Obtain what?
* Then How do you aspirate?
Retropharyngeal abscess
* What is happening in the basic ER exam?
* What are late findings on exam?
* What is usually necessary?
- Pain out of proportion to basic ER exam
* Dysphasia, fever, but tonsil is midline and everything is okay - Late findings on exam: stridor and stiff neck
- Look with laryngoscope or glidoscope
- CT Soft Tissue Neck usually necessary (with contrast)
Retropharyngeal abscess
* What is necessary to protect?
* Call who?
* What meds?
- Protect airway is necessary
- Call ENT for consult
- IV ABX (Ceftriaxone or Clinda)
- IV steroids
Presenting Symptoms/Signs of Para”pharyngeal” Space (8)
Carotid artery erosion=> delay in txt
Etiology of Retropharyngeal abscess
* Infected what? (4)
- Infected MOLARS – most common
- Infected tonsils
- Infected sinuses
- Lymphatic spread
Reason why every single dental pain gets anx
What is this? How can you tell if there is submaniblar involvement
- Parapharyngeal Space Abscess
- Submandiblar: Pain Tounge Mvts (think ludwig’s with this)
What is going on? Who does this happen in?
Buccal Space Abscess
* Inner check disease-> under the skin with the tissue itself
* Babies and adults with trauma to face (usually did not get txt)
Ludwig’s Angina
* What is it?
* What happens to the tongue?
* It is usually caused by what?
- Ludwig’s angina is a bilateral board-like swelling of the submandibular, submental and sublingual spaces.
- The tongue is elevated/edematous
- It is usually caused by infection of the second and third molar teeth.
Ludwig’s Angina
* Typically occurs in who?
* There is what?
* On x-ray, there may be what?
- Typically occurs in diabetics
- There is a brawny induration of the area without palpable fluctuance.
- On x-ray, there may be gas in the tissue.
* CT is better though
What are the sxs of ludwig angina?
Whole thing has to be excised. Intubate all!!!
What is the txt of ludwig angina
This patient needs I&D, high doses of antibiotics, steriods and airway observation
* Anaerobic infection.
