1- EENT Emergencies Flashcards
(140 cards)
1
Q
What type of herpes is responsible for herpes simplex keratitis?
A
HSV-1 (presumed recurrent)
2
Q
Pt presents w/ acute onset eye pain, photophobia, blurred/ decreased vision, and tearing. What might you be concerned for?
A
Herpes simplex keratitis
3
Q
On PE you note conjunctival injection, ciliary flush, and decreased corneal sensation. What might you be concerned for?
A
Herpes simplex keratitis
4
Q
On slit-lamp with fluorescin of pt with suspected herpes simplex keratitis, what might you notice?
A
Dendritic lesions
5
Q
What is the management for herpes simplex keratitis?
A
Urgent ophthalmology referral
6
Q
What topical and oral med management is given for herpes simplex keratitis?
A
- Topical
- Acyclovir 3% ophthalmic ointment
- Ganciclovir 0.15% gel
- Oral
- Acyclovir 400mg
7
Q
What treatment should be avoided in a pt with herpes simplex keratitis?
A
Topical glucocorticoids
8
Q
What are the indications for a corneal transplant in the treatment of herpes simplex keratitis?
A
Severe scarring or perforation
9
Q
What optical emergency is due to UV radiation exposure, has a latent period of 6-12 hrs and is intensely painful but generally self limited?
A
UV keratitis
10
Q
Pt presents with severe bilateral eye pain (distraught, pacing, rocking, unable to open eyes), photophobia, and foreign body sensation. What are you concerned for?
A
UV Keratitis
11
Q
On PE you note tearing, generalized injection/ chemosis of the bulbar conjunctiva, mildly hazy cornea and miotic pupils. What are you concerned for?
A
UV Keratitis
12
Q
What might be noticed on fluorescein stain on the eye of a pt with UV keratitis?
A
Superficial punctuate staining of the cornea
13
Q
What is the management for UV keratitis?
A
Supportive (resolves in 24-72 hrs)
Oral analgesics for severe pain (mild oral opioid, lubricant abx ointment)
14
Q
After dx of UV keratitis, how soon should a pt f/u to check for improvement?
A
1-2 days
15
Q
What condition is defined as unilateral, periorbital edema with erythema, warmth, and tenderness?
A
Preseptal and orbital cellulitis
16
Q
What condition may be a complication of sinusitis, extension of infection from adjacent structure, or local disruption of the skin?
A
Preseptal and orbital cellulitis
17
Q
What are the most common pathogens that result in preseptal and orbital cellulitis?
A
S. pneumo, S. aureus, S. pyrogenes, H. flu
18
Q
Is preseptal or orbital cellulitis a true emergency?
A
Orbital
19
Q
Pt presents with swelling of eyelids and upper cheek. Are you concerned for preseptal or orbital cellulitis?
A
Preseptal (involves tissues anterior to orbital septum)
20
Q
Pt presents with vision loss, impaired EOMs, diplopia, and proptosis. What ophthalmalogic emergency are you concerned for?
A
Orbital cellulitis (involves structures deep to the orbital septum)
21
Q
How is preseptal and orbital cellulitis diagnosed?
A
CT scan of the orbits and sinuses with contrast
22
Q
In which type of cellulitis (preseptal or orbital) is it more common to have the following sxs?
Eye pain/ tenderness, pain w/ eye movements, proptosis, ophthalmoplegia, vision impairment, chemosis, fever, leukocytosis?
A
Orbital
23
Q
What is the tx for preseptal cellulitis if mild infection or no systemic sxs?
A
Discharge home with oral abx, f/u with ophthalmologist w/i 24-48 hrs
24
Q
What is the tx for orbital cellulitis or preseptal cellulitis with any concerning factors?
A
Admit to hospital, IV abx, consult ophthalmology and ENT
25
What results from eye trauma, foreign bodies or improper contact lens use?
Corneal abrasian and ulceration
26
What is defined as any defect of the corneal surface epithelium (thin protective coating of anterior eye surface)?
Corneal abrasion
27
What is defined as a break in the epithelium exposing the underlying corneal stroma?
Corneal ulceration
28
What are the sxs of a corneal abrasion and ulceration?
Severe eye pain and foreign body sensation
29
What can corneal abrasion and ulceration lead to?
Impaired vision secondary to scarring
30
If suspicion of corneal abrasion or ulceration, when is the penlight exam performed?
Prior to fluorescein stain application
(should also perform visual acuity, EOMs, fundoscopic)
31
What will be noted on fluorescein exam of a pt with suspected corneal abrasion or ulceration?
Basement membrane exposed in areas of epithelial defect
32
How can visualization of a corneal abrasion or ulceration be enhanced?
Cobalt blue filter/ Wood's lamp
33
What is the treatment for corneal abrasion?
Topical lubricants and topical abx +/- oral pain meds
(erythromycin ointment, sulfacetamide 10%, polymyxin/ trimethoprim, ciprofloxacin, ofloxacin drops QID x 5 days)
34
What should be avoided if suspicion of corneal abrasion?
Topical anesthetic/ steroid, patching
35
When should you refer for an **urgent ophthalmology consult** for a pt with a corneal abrasion or ulcertaion? (4)
* Penetrating/ significant blunt trauma (large, nonreactive/ irregular pupil)
* Impaired visual acuity
* Ulceration
* Contact lens wearer
36
What is the protocol for a contact lens wearer with corneal abrasion?
Ophthalmology ASAP to r/o infiltrate/ opacity, daily f/u to r/o infiltrate/ ulcer until healed
37
A lid laceration that is horizontal and follows skin lines would likely be classified as what?
Superficial/ uncomplicated
38
Uncomplicated lid laceration affecting \< 25% indicated what management?
Heal by secondary intention
(clean, apply abx ointment, consider surgical tape/ adhesives)
39
Uncomplicated lid laceration affecting \> 25% indicates what management?
Repair w/ 6-0 fast absorbable plain gut suture
(simple interrupted/ running if w/i 24 hrs, if non-absorbable suture used- remove in 5-7 days)
40
What is the protocol for lid lacerations if:
Full thickness, w/ orbital fat prolapse, through lid margin, through tear drainage system, orbital injury, foreign body, or poor alignment?
Refer to ophthalmologist or surgeon
41
You should keep a high threshold for suspicion of what for all full thickness lid lacerations?
Penetrating injury to globe
42
What are the significant findings a/w an orbital floor fracture (aka "blowout" fracture)? (4)
Entrapment of inferior rectus muscle, enopthalmos (if post globe displacement), orbital dystopia (eye is lower), injury to infraorbital nerve secondary to fracture
43
Untreated entrapment of the inferior rectus muscle (as seen with orbital floor fracture) can result in what?
Ischemia and subsequent loss of muscle function
44
Orbital floor fracture w/ decreased sensation to cheek, upper lip, and upper gingiva would indicate what finding?
Injury to infraorbital nerve
45
What diagnostic study is used for an orbital floor fracture?
(if evidence of fracture on exam, limitation of EOM, decreased visual acuity, severe pain, inadequate exam due to swelling/ AMS)
Thin cut coronal CT
46
What is the management for orbital floor fracture? (5)
* Surgical eval
* Prophylactic abx
* Cold packs (first 48 hrs)
* Raise head of bed
* Avoid blowing nose/ sniffing
47
Open globe rupture often occurs following what?
Blunt eye injury
48
What should be avoided on PE if suspicion of open globe rupture?
Avoid pressure to eyeball
49
What diagnostic study is used for an open globe rupture?
Axial and coronal CT of the eye without contrast
50
What is the management for open globe rupture?
Transfer to tertiary trauma center, **emergent ophthalmology consult**, avoid manipulation , meds
(also eye shield, bed rest, NPO, no solutions in eye)
51
What meds are used in the treatment of an open globe rupture?
Abx, IV antiemetics, pain meds, sedation prn
52
What is defined as an inflammatory, demyelinating condition that causes acute, monocular vision loss and has a high associated with MS?
Optic neuritis
53
Pt presents with vision loss (hrs- days), eye pain worse w/ eye movement, afferent pupillary defect, and dyschromatopsia. What are you concerned about?
Optic neuritis
54
What is the treatment for optic neuritis?
Corticosteroids (IV methylprednisone)
| (NOT oral prednisone- no effect on visual outcomes and may increase recurrence risk)
55
What is defined as narrowing or closure of the anterior chamber anlge leading to elevated IOP and damage to the optic nerve?
Acute angle closure glaucoma
56
What is normal IOP? What is IOP in closed angle glaucoma?
N = 8-21 mmHg
Closed angle glaucoma = \> 30 mmHg
57
Pt presents w decreased vision, halos around lights, HA, severe eye pain, N/V, red eye, corneal edema/ cloudiness, mid-dilated pupil, and a shallow anterior chamber. What are you concerned for?
Acute angle closure glaucoma
58
What specific exam should be deferred if suspected angle closure glaucoma?
Pupillary dilation (may exacerbate condition)
59
What is the gold standard for dx of acute angle closure glaucoma?
Gonioscopy (slit lamp lens- visualization of angle between iris and cornea)
60
What is used in the treatment of acute anlge closure glaucoma?
Emergent ophtho eval, pressure lowering eyedrops (if \>1 hr delay), oral/ IV acetazolamide (check 30-60 min after admin)
61
What pressure lowering eyedrops are given at 1, 2 and 3 min for acute angle closure glaucoma if \> 1 hr delay?
1 min- 0.5% tomolol
2 min- 1% apraclonidine
3 min- pilocarpine
62
Retinal detachment (retina separates from epithelium and choroid) results in what?
Ischemia and progressive photoreceptor degeneration
63
Pt presents with sudden onset of floaters (cobweb), monocular visual field loss, and vision loss. What are you suspicious for?
Retinal detachment
64
What is the treatment for retinal detachment?
Emergent eval with ophthalmologist
65
What will be seen on US of retinal detachment?
Detached retina seen floating in vitreous with tethering at optic nerve
66
Pt presents with hearing loss, ear pain, and ear drainage. What is the likely cause?
EAC FB
(children- FBs, adults- cerumen plugs)
67
What is the treatment for EAC FB?
Otoscope exam- remove FB under direct visualization
Neutralize bugs w mineral oik
Check for otitis externa
68
If organic material noted on otoscopic exam, what should be avoided?
Do not irrigate- may cause infection
69
If evidence of OE on otoscope exam of pt with FB in EAC, what should you give?
Ciprodex or Cipro HC drops
70
What is the most common cause of AOE?
Bacterial (P. aeruginosa)
71
Pt presents with ear fullness, drainage, and pain (tragal motion tenderness). What are you concerned for?
AOE
72
What is the management for AOE?
Debridement, abx drops (Ciprodex/ Cipro HC +/- otowick), watch for malignant otitis
73
Pt presents with vesicles in ear canal, facial paralysis, hearing loss, and vertigo. What are you concerned for?
Viral AOE (Herpes zoster aka Ramsey-Hunt)
74
What is the treatment for viral AOE (Herpes zoster)?
Antivirals, steroids, MRI brain (r/o skull base tumor)
75
What is the most common cause of malignant OE?
P. aeruginosa
76
Pt presents with ear fullness, drainage, and pain but appears acutely ill. You note granulation tissue in the ear canal. What are you concerned for?
Malignant OE
77
What is diagnostic of malignant OE?
CBC- leukocytosis, cultures, head CT (r/o osteomyelitis- skull base)
78
What is the treatment for malignant OE?
Admit, debridement, parenteral abx, ENT eval
79
What parenteral abx are used in the treatment of malignant OE?
Cipro 400mg IV q 8 hrs
Change to 750mg PO q 12 hrs prior to discharge
Tx prolonged (6-8 weeks)
80
The following are complications of what?
Cranial neuropathies, brain abscess, meningitis, septicemia, death
Malignant OE
81
Otitis media, closed head injury, and direct ear trauma are all possible causes of what?
TM perforation
82
Pt presents with pain, hearing loss, N/V, vertigo, otorrhea, and tinnitus. What are you concerned for?
TM perforation
83
What is important to perform on PE if suspicion for TM perf besides direct visualization of TM?
Audiogram, CT/ CSF drainage (if suspect head trauma)
84
Although 95% of TM perforations resolve without treatment, what might be indicated for management?
Orolarlyngology, water precautions, abx (ofloxacin otic drops), tympanoplasty (refractory)
85
For a TM perf, if \< 25% of total surface is involve, spontaneous tx should occur in how long?
Within 4 weeks
86
Cauliflower ear is aka? And due to what?
Auricular hematoma, due to blunt force trauma to auricle
87
Pt presents with collection of blood in the cartilage of the ear and hx of blunt force trauma to the auricle. What are you concerned for?
Auricular hematoma
88
What is the treatment for auricular hematoma?
Drain/ aspirate ASAP, f/u eval q 24 hrs for 3-5 days, pt edu
89
What pt edu should be provided for auricular hematoma?
Refrain from sports for 7 days
90
What is defined as acute inflammation and infection of the auricular cartilage?
Perichondritis
91
What is the most common pathogen a/w perichondritis?
P. aeruginosa
92
Pt presents with erythema, pain, abscess formation, and systemic sxs. (ear) What are you concerned for?
Perichondritis
93
What diagnostic study is used for perichondritis?
C and S
94
What is the treatment for perichondritis?
I and D if indicated, empiric abx (Ciro)
95
Do pts with a nasal foreign body typically present with sxs or asx?
Asx
96
Pt presents with mucopurulent nasal discharge, foul odor, epistaxis, nasal obstruction, and mouth breathing. What are you concerned for?
Nasal foreign body
97
For pt with nasal foreign body, exam includes direct visualization of FB as well as what?
Make sure lungs are CTAB w/o abn breath sounds
98
Are diagnostic tests typically indicated with nasal FB?
Not if fully visible. Xray if suspect button battery or magnet
99
What is the management for nasal FB once the child is adequately restrained and there is good visualization of the FB?
Manually retrieve w/ alligator forceps or suction
Avoid irritation if FB is organic matter
If \>2 unsuccessful attempts, refer to ENT
100
What should you do once removing a nasal FB?
Re-examine to r/o a 2nd one
101
Bloody nose is aka and classified as what?
Epistaxis, classified as anterior or posterior (location of bleed)
102
Are anterior or posterior nose bleeds more common?
Anterior (Kiesselbach's plexus)
103
Nose picking, low moisture, hyperemia secondary to allergic rhinitis, FB, drug use, or trauma are possible causes of what?
Epistaxis (nose bleed)
104
The anastomosis of 3 primary vessels (septal branch of ant ethmoidal artery, lateral nasal branch of sphenopalatine artery, and septal branch of superior labial branch of facial artery) is known as what?
Kiesselbach's plexus (location for anterior epistaxis)
105
Where does a posterior epistaxis most commonly arise from?
Posterolateral branches of sphenopalatine artery
(less commonly from carotid artery)
106
What is considered conservative treatment for epistaxis?
Afrin- 2 sprays
Direct pressure (tight against septum) x 10 min
Nasal hydration if no further bleeding
107
What might be included in the management of epistaxis if the source of bleeding is easily identified?
Cautery (avoid large areas and remove excess silver nitrate)
108
What are the risks of cautery in the treatment of epistaxis?
Ulceration, septal perforation
109
In the use of nasal packing for epistaxis, how long after placement should you remove the packing?
3 days in N pt, 5 days for anticoagulated pt
110
What abx might be used in the management of epistaxis?
Anti-staph (Keflex, Augmentin)
(along w/ entire course of packing)
111
The following are important to ask as part of hx in eval of what?
Time frame, mech of injury, direction of force, prior nasal surgery/ trauma
Nasal trauma
112
The following are important to include on PE of what?
Epistaxis, CSF rhinorrhea, impaired EOMs, orbital edema/ ecchymosis, lacerations, septal hematoma
Nasal trauma
113
What diagnostics are used in the management of nasal trauma?
CT maxillofacial without contrast
(r/o any additional facial fractures)
114
What **early** complications are a/w nasal trauma?
Hematoma, abscess, uncontrolled epistaxis, CSF rhinorrhea
115
What **late** complications are a/w nasal trauma?
Nasal deformity, obstruction, perforation
116
What is included in the treatment of nasal trauma?
Repair skin lacerations, attempt closed reduction (maximize airway and improve aesthetics) BUT if significant swelling consider waiting 4-6 weeks before surgical correction
(also elecate head of bed, cold compress, pain management, photos)
117
What is the f/u for a pt with nasal trauma?
3-5 days
118
What are the causes of a septal hematoma?
Trauma, septal surgery, bleeding disorders
119
Pediatric pt presents with nasal obstruction and pain. On PE you note soft, tender swelling along the septum. What are you concerned for?
Septal hematoma
120
What is included in the treatment of a septal hematoma?
I+D (prevents avascular necrosis), pack nose, abx, outpatient ENT referral (remove packing in 24 hrs, re-check, re-pack)
121
Untreated nasal hematomas may cause what?
Septal perforation and/ or "saddle nose" deformity
122
How is mastoiditis defined?
What is the timefram for acute mastoiditis and what is this often a complication of?
Suppurative infection/ inflammation of mastoid air cells
Acute = sxs \< 1 month, complication of AOM
123
Pt presents with ear pain and drainage along with tenderness, erythema, and edema over the mastoid process. What should you be concerned for?
Mastoiditis (can also be asx w/ N exam)
124
On PE you note postauricular erythema, tenderness, swelling, fluctuance, a mass, as well as protrusion of auricle, oralgia, and fever. What are you concerned for?
Mastoiditis
125
What diagnostic studies are used for mastoiditis (if not characteristic finding)?
CT head w/ contrast (visualize temporal bone changes), culture if infection
126
What is the treatment of mastoiditis?
**Refer to ENT**, empirial oral abx if IMC, mastoidectomy/ consideration of IV abx if recalcitrant disease/ IMC
127
Pt presents with fever and pain, as well as red, fluctuant swelling of the gingiva and TTP. What are you concerned for?
Periodontal abscess
128
What diagnostics are used in the management of periodontal abscess?
Panoramic radiograph or CT for bone involvement
129
What is the treatment for periodontal abscess?
Pain management, I+D, oral abx (limited infection, Augmentin/ Clinda x 7-14 days), f/u with dentist
130
What dental injury is a true dental emergency?
Avulsion of permanent tooth
131
Pt presents with pain, a completely displaced tooth from alveolar ridge, and a severed periodontal ligament. What are you concerned for?
Dental injury (avulsion of permanent tooth)
132
In the management for an avulsion of a permanent tooth, if unable to re-implant immediately, what should you store the tooth in?
Balanced saline solution, cold milk, or pts saliva
(until seen by dentist)
133
What is included in the management of a dental injury (avulsion of permanent tooth)?
**Urgent dental consult**, maintain vitality of periodontal ligament, handle tooth by crown, rinse in saline, re-implant tooth
134
How do you re-implant an avulsed tooth?
Inset into empty socket and hold in place with gauze
(85-97% success at 5 min, nearly 100% at 1 hr)
135
What should be included in the management of an avulsed tooth to avoid complications?
Tetanus prophylaxis and abx
136
Tongue lacerations are usually related to injury that involves what?
The teeth
137
Under what circumstances should repair of a tongue laceration be considered?
* Large (\> 1 cm, extends into muscular layer, completely through tongue)
* Deep on lateral border
* Large flaps/ gaps
* Significant hemorrhage
* Possibility of dysfunction w/ improper healing
138
When is repair of a tongue laceration **not** considered?
(heal by secondary intention)
\< 1cm, non-gaping
(also "assessed to be minor in clinical judgement")
139
What suture should be used in a tongue laceration repair?
Absorbable, 3-0 or 4-0 chromic gut or vicryl
140
What should be included in the management of a tongue laceration if it was the result of an injury?
Abx (tetanus prophylaxis)
