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EMED Unit II > 1 ENT Emergencies > Flashcards

1 ENT Emergencies Flashcards

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1
Q

Herpes Simplex Keratitis is caused by…

A

HSV-1

Presumed recurrent

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2
Q

Acute onset of herpes simplex keratitis is characterized by these Sx…

A

Eye pain

Photophobia

Blurred/decreased vision

Tearing

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3
Q

Physical exam findings for herpes simplex keratitis

A

Conjunctival injection (ciliary flush)
Decreased corneal sensation
Slit-lamp with fluorescein Dendritic lesions

Diagnosis primarily based on Hx and exam findings
Requires urgent opto referral

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4
Q

Treatment for herpes simplex keratitis

A

General measures

Topical or oral ANTIVIRALS (equally effective - only one drop fits in eye)
• Trifluridine 1% (topical)
• Ganciclovir 0.15% gel (topical)
• Acyclovir (oral)

NO TOPICAL GLUCOCORTICOIDS!!!

Corneal transplant eventually if severe scarring or perforation

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5
Q

Pt with severe eye pain following outdoor activity (ie - snow skiing w/o goggles, water sports)

A

UV Keratitis (aka photokeratitis)

Due to UV radiation exposure

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6
Q

UV keratitis has a latent period of ______

A

6-12 hours

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7
Q

Clinical presentation of UV keratitis

A

BL intense eye pain (unable to open them)

Photophobia (will have eyes closed)

Foreign body sensation

Distraught, pacing, rocking, secondary to SEVERE pain

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8
Q

Physical exam findings for UV Keratitis

A

Penlight: tearing, generalized injection and chemosis (edema/swelling) of the bulbar conjunctiva

Cornea - may be mildly hazy

Fluorescein - superficial punctuate staining of the cornea (generalized staining instead of a lesion like with herpes)

Pupils may be miotic

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9
Q

Treatment for UV Keratitis

A

Supportive - should resolve in 24-72 hours

Oral analgesics for severe pain***
• May need mild oral opioid (Oxycodone 5-10mg q4-6h x 24h)

Lubricant abx ointment***
• Erythromycin

Education on prevention

F/u in 1-2 days to check for improvement

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10
Q

Unilateral periorbital edema with erythema, warmth, and tenderness

A

Preseptal and orbital cellulitis

May be a complication of:
• Sinusitis
• Extension of infection from adjacent structure
• Local disruption of skin (ie bug bite)

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11
Q

________ cellulitis is more common with children under five

________ cellulitis is more common with children over five and adults

A

Preseptal (involves tissues anterior to the orbital septum —> swelling of eyelids, upper cheek)

Orbital (involves structures deep to the orbital septum)

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12
Q

Which is worse: preseptal or orbital cellulitis?

A

Orbital - TRUE EMERGENCY

Can lead to vision loss, impaired EOMs, diplopia, and/or proptosis

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13
Q

Diagnostic studies for preseptal and orbital cellulitis

A

CT scan of the orbits and sinuses WITH contrast

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14
Q

Clinical features of preseptal cellulitis

A

Eyelid swelling w/ or w/o erythema

MAY have eye pain/tenderness

No pain with EOM

No proptosis

No ophthalmoplegia

No visual impairment

Chemosis only rarely

+/- Fever, Leukocytosis

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15
Q

Clinical features of orbital cellulitis

A

Eyelid swelling w/ or w/o erythema

Deep eye pain/tenderness

Pain with EOM

Usually occurs with proptosis (may be subtle)

Fever usually present

+/- ophthalmoplegia

+/- visual impairment

+/- Chemosis

+/- Leukocytosis

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16
Q

Treatment for preseptal cellulitis

A

Mild/no systemic Sx - discharge home
Oral abx
F/u within 24-48h

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17
Q

Treatment for orbital cellulitis (or preseptal with any concerning factors

A

Admit to hospital
IV abx
Consult opto and ENT

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18
Q

_______ and ________ are both the result of eye trauma, foreign bodies, or improper contact lens use

A

Corneal abrasion

Corneal ulceration

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19
Q

Corneal abrasions involve…

A

Thin protective coating of anterior ocular epithelium

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20
Q

Corneal ulceration involves…

A

Break in the epithelium exposing the underlying corneal stroma

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21
Q

Sx of both corneal abrasions and ulcerations

A

Severe eye pain and foreign body sensation

Can lead to impaired vision secondary to scarring

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22
Q

Physical exam findings for corneal abrasions and ulcerations

A

Penlight exam: prior to fluorescein stain application
• Anterior chamber clear, deep, and normal contour
• Pupil round
• Clear tears
• Mild conjunctival injection if >2 hrs
• Ciliary flush if several hours old

Test visual acuity and EOMs

Fundoscopic exam if attempted to confirm red reflex

Fluorescein exam:
• Stains the basement membrane, which is exposed in areas of epithelial defect
• Visualization enhanced with cobalt blue filter and woods lamp

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23
Q

Patients with signs of corneal abrasion and ulceration should receive urgent ophthalmology consult if…

A

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

Impaired visual acuity

Ulceration

Contact lens wearer
• R/o infiltrate or opacity
• Daily opto exam to r/o infiltrate or ulcer until healed

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24
Q

Treatment for corneal abrasion/ulceration

A 
Topical abx
• Erythromycin ointment
• Sulfacetamide 10%
• Polymyxin/trimethoprim
• Ciprofloxacin
• Ofloxacin drops QID x 5 days

Narcotics optional

NO topical anesthetic or steroid

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25
Other ocular injuries may be present in 2/3 of patients with ________
Lid lacerations So if you see a lid laceration, look for other things too - order a CT!
26
What to do if a kid with a lid laceration comes into your ER
2/3 of these patients will have some other ocular injury as well Exclude globe injury Low threshold fro CT of the orbits Don’t attempt complicated lacerations - CONSULT! Know your eye anatomy!
27
How to deal with uncomplicated, superficial lid lacerations
If <25% of lid can heal by secondary intention: • Clean and apply triple abx ointment • Can consider adhesive surgical tape or adhesives If >25%, repair with 6-0 fast absorbable plain gut suture • Simple interrupted or running sutures within 24 hours • If non-absorbable suture used, remove in 5-7 days • Ophtho or plastics will probably do this, not you
28
What type of lid lacerations require a referral to ophthalmology or plastics?
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 *****Keep a high threshold of suspicion for penetrating injury to globe in the setting of all full thickness lid lacerations*****
29
Orbital floor fractures are also called...
“Blowout” fractures
30
Significant findings in orbital floor fractures...
Entrapment of the inferior rectum muscle (untreated can result in ischemia and subsequent loss of muscle function) Enopthalmos (sunken in eyes) - may develop with posterior globe displacement Orbital dystopia (eye is lower) - may occur as entrapped muscle pulls eye downward Injury to infraorbital nerve secondary to fracture - decreased sensation in cheek, upper lip, and upper gingiva
31
What diagnostics do you need for orbital floor fractures?
Thin cut coronal CT of the orbits on patients with: • Evidence of fracture on exam • Limited EOM • Decreased visual acuity • Severe pain • Inadequate exam - swelling/altered mental status
32
Treatment for orbital floor fractures
Surgical evaluation Prophylactic abx to cover sinus pathogens Cold packs for first 48 hours Head of bed raised Avoid blowing nose/sniffling (b/c it puts extra pressure on the area)
33
Open globe ruptures occur following...
Blunt eye injury
34
PE tips for open globe ruptures
Likelihood of open globe injury following blunt eye injury Avoid pressure to the eyeball • Eyelid retraction • IOP measurement
35
How do you diagnose open globe ruptures?
Axial and coronal CT of the eye WITHOUT contrast
36
Treatment for open globe ruptures
``` Initiate abx EMERGENT ophthalmology consult*** Transfer to tertiary trauma center EYE SHIELD (one of the only times you’ll use this)*** Avoid any manipulation Bed rest NPO No solutions in eye IV Antiemetics (ondansetron 4mg)*** Pain meds (avoid NSAIDs)*** Sedation PRN (lorazepam 0.05mg/kg - max 2mg)*** ```
37
What condition may be present as an initial sx of MS?
Optic Neuritis Inflammatory, demyelination condition that causes acute, monocular vision loss (10% bilateral)
38
Sx of Optic Neuritis
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 in the affected eye Dyschromatopsia - loss/reduced color vision
39
DDx for Optic Neuritis
If >50 years: DM, giant cell arteritis, autoimmune Young child: infectious or post infectious cause
40
Clinical diagnosis of optic neuritis is made by...
Hx and ophthalmology exam MS confirmed by MRI brain/orbits with GAD
41
Treatment for optic neuritis
Corticosteroids - IV methylprednisolone DO NOT recommend oral prednisone - doesn’t affect visual outcomes and may increase risk for recurrence
42
Narrowing or closure of the anterior chamber angle of the eye
Acute angle closure glaucoma Normal angle provides aqueous humor drainage
43
Narrowing of the normal anterior chamber angle in acute angle closure glaucoma leads to...
Elevated intraocular pressure (IOP) —> damage to the optic nerve
44
Normal intraocular pressure = ________ mmHg IOP in closed angle glaucoma = ________ mmHg
8-21 mmHg >30 mmHg in CAG
45
Clinical presentation of acute angle closure glaucoma
``` Decreased vision Halos around lights****** Headache Severe eye pain N/V Red eye Corneal edema/cloudiness****** Mid-dilated pupil 4-6 mm that reacts poorly to light*** Shallow anterior chamber ``` Patients with these Sx need emergent opto eval
46
What does the physical exam for acute angle closure glaucoma entail?
``` Visual acuity Evaluation of the pupils IOP Slit lamp Visual field testing ``` Pupillary dilation should be deferred in cases of suspected angle closure as this may exacerbate the condition
47
Gold standard test for acute angle closure glaucoma?
GONIOSCOPY Special lens for the slit lamp, allows the ophthalmologist to visualize the angle between the iris and cornea in order to diagnose angle-closure
48
Treatment for acute angle closure glaucoma
If ophthalmologist is available within 1 hour, REFER TO THEM***** If >1 hour delay, empirically treat with pressure lowering eye drops • 1 min: 0.5% timolol • 2 min: 1% apraclonidine • 3 min: pilocarpine Oral or IV acetazolamide - check pressures 30-60 min after giving treatment
49
Multilayer of exquisitely organized neurons lining the back of the eye
Retina
50
What is retinal detachment?
Retina separates from the epithelium and choroid Results in ischemia and progressive photoreceptors degeneration
51
Clinical presentation of retinal detachment
Sudden onset of floaters - cobweb Monocular visual field loss Vision loss
52
Treatment for retinal detachment
Emergent eval with ophthalmologist
53
Clinical presentation of external auditory canal FB
Hearing loss Ear pain and (smelly) drainage If children, usually from foreign bodies If adults, usually cerumen plugs
54
How is suspected EAC FB diagnosed and treated?
ID foreign body: • Remove under direct visualization • Neutralize bugs with mineral oil • Do not irrigate organic material - may cause infection Check for otitis externa; if present, treat with Ciprodex or Cipro HC gtts
55
Typical etiology of acute otitis externa
Bacterial - commonly Pseudomonas aeruginosa
56
Clinical presentation of acute otitis externa
Ear “fullness” Drainage Pain - travel motion tenderness
57
Treatment for bacterial acute otitis externa
Debridement Abx drops (Ciprodex or CiproHC) +/- otowick Watch for malignant otitis
58
Etiology of viral acute otitis externa
Ramsey-Hunt (Herpes Zoster virus)
59
Clinical presentation of viral otitis externa
Vesicles in ear canal Facial paralysis Hearing loss Vertigo More serious presentation than bacterial
60
Treatment for viral otitis externa
Antivirals Steroids MRI of brain to rule out skull base tumor
61
Most likely cause of malignant otitis externa
Pseudomonas aeruginosa
62
Who is at high risk for malignant otitis externa?
Elderly Diabetics Immunocompromised
63
Clinical presentation of malignant otitis externa
Sx consisterent with AOE but patient appears acutely ill Ear canal shows granulation tissue Diagnostics: • CBC shows leukocytosis • Cultures • Head CT —> osteomyelitis (skull base)
64
Treatment for malignant otitis externa
ADMIT (severe infection) Debridement (ENT) Parenteral abx • Ciprofloxacin 400mg IV q8h • Change to 750mg PO q12h prior to discharge • Tx prolonged - 6-8 weeks ENT evaluation
65
Complications of malignant otitis externa
``` Cranial neuropathies Brain abscess Meningitis Septicemia Death ```
66
Common causes of TM perforation
Otitis media Closed head trauma Direct ear trauma
67
Clinical presentation of TM perforation
``` Pain Hearing loss N/V Vertigo Otorrhea Tinnitus ```
68
How do you work up a suspected TM perf?
Direct visualization of TM Audiogram Appropriate components if suspected head trauma (CT, check for CSF drainage)
69
Treatment for TM perf
Evaluation by ENT Water precautions 95% resolve w/o treatment (if <25% total surface, within 4 weeks) Abx - ofloxacin otic drops if indicated (infection that led to perf) Tympanoplasty for refractory cases
70
What is the proper name for cauliflower ear?
Auricular hematoma - due to blunt force trauma to the auricle
71
Clinical presentation of auricular hematoma
Collection of blood in the cartilage of the ear
72
Treatment for auricular hematoma
Drain/aspirate ASAP If >7 days, ENT or plastics consult F/U eval q24h for 3-5 days to check for reaccumulation Education • Refrain from contact sports for 7 days • F/U right away with any worsening
73
Acute inflammation and infection of the auricular cartilage
Perichondritis Similar to auricular hematoma but with an infection
74
Typical etiology of perichondritis
Pseudomonas aeruginosa
75
Clinical presentation of perichondritis
Erythema PAIN Abscess formation Systemic symptoms Diagnostics: C&S
76
Treatment for perichondritis
I&D if indicated Empiric abx (ciprofloxacin)
77
When to suspect nasal FB
Hx of FB insertion without symptoms in 88%
78
Clinical presentation of nasal FB
Mucopurulent nasal discharge (copious) Foul odor Epistaxis Nasal obstruction Mouth breathing Exam: • Direct visualization of FB • Make sure lungs are CTAB w/o abnormal breath sounds
79
Do you need diagnostic studies for nasal fb?
Usually not needed if FB fully visible If suspected button battery or magnet order x-ray
80
Treatment for Nasal FB
Child must be adequately restrained Must have good visualization Manually retrieve with alligator forceps or suction Avoid irrigation if FB is organic matter If more than 2 unsuccessful attempts refer to ENT Always re-examine after 1 FB removed to r/o second one... EDUCATION!
81
Epistaxis can be subclassified as...
Anterior or Posterior
82
Which is more common: Anterior epistaxis or Posterior epistaxis
Anterior Up to 90% of bleeds occur at Kiesselbach’s plexus Can be managed conservatively
83
Common causes of epistaxis
Nose picking**** (Most common) Low moisture Hypermedia secondary to allergic rhinitis FB Drug use or trauma
84
What is Kiesselbach’s Plexus?
Anastomoses of 3 primary vessels: • 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 Most common site of anterior epistaxis
85
Posterior epistaxis most commonly arises from...
The posterolateral branches of the sphenopalatine artery Less common - from the carotid artery
86
Conservative treatment for epistaxis
Oxymetazoline (Afrin) - 2 sprays Direct pressure of the alae tight against septum x 10 min If no further bleeding, nasal hydration
87
Treatment options for epistaxis if conservative measures fail to stop bleeding
Cautery if source is easily identified • Avoid large areas • Remove excess silver nitrate with cotton tipped applicator • Risks: Ulceration, septal perforation Nasal packing • 3 days in normal patient • 5 days for anticoagulated patient Abx if packing • Antistaphylococcal - keflex, augmentin • For entire course of packing (to prevent toxic shock syndrome
88
What history questions do you need to ask when evaluating nasal trauma?
Time frame MOI Direction of force (pattern of fracture) Prior nasal surgery or trauma
89
What do you need to rule out during PE for nasal trauma?
``` Epistaxis CSF rhinorrhea Impaired EOMs Orbital edema/ecchymosis Lacerations SEPTAL HEMATOMA ```
90
What diagnostic studies do you need for nasal trauma?
Maxillofacial CT without contrast (to r/o any additional facial fractures)
91
Early complications of nasal trauma
Hematoma Abscess Uncontrolled epistaxis CSF rhinorrhea
92
Late complications of nasal trauma
``` Nasal deformity (permanent) Obstruction Perforation ```
93
How to treat nasal trauma
Repair skin lacerations immediately (if significant swelling, wait 4-6 weeks until resolved before surgical correction) Attempt a closed reduction immediately (maximizes airway, and improved aesthetics if there is a significant deformity) Elevate head of bed Cold compress Pain management Photos F/U 3-5 days
94
Causes of septal hematomas
Trauma Septal surgery Bleeding disorders More common in pediatrics
95
Clinical presentation of septal hematoma
Nasal obstruction and pain PE shows soft, tender swelling along the septum
96
Treatment of septal hematoma
Incision and drainage • Helps prevent avascular necrosis of septum • Untreated hematomas —> possible septal perforation and/or saddle nose deformity Pack nose Abx Outpatient ENT referral • Remove packing in 24 hours • Recheck and re-pack
97
Inflammation and/or infection of the mastoid air cells, typically following otitis media
Mastoiditis
98
Clinical presentation of mastoiditis
May be asymptomatic with normal exam Ear pain Drainage Tenderness, erythema, and edema over mastoid process
99
What diagnostics do you need for mastoiditis?
CT of head WITHOUT contrast Culture necessary if infection
100
Treatment of mastoiditis
REFER TO ENT May start empiric oral abx if immuno-competent Mastoidectomy and consideration of IV abx if recalcitrant disease or immunocompromised
101
Clinical presentation of periodontal abscess
Fever Pain RED, FLUCTUANT SWELLING of the gingiva TTP Diagnostics: Panoramic radiograph or CT for bone involvement
102
Treatment for periodontal abscess
Pain management I&D Oral abx if limited infection • Augmentin or clindamycin x 7-14 days F/u with dentist
103
Avulsion of a permanent tooth is considered...
A true dental emergency
104
Clinical presentation of dental injury
Pain Tooth is completely displaced from the alveolar ridge Periodontal ligament is severed
105
What to do if you cannot immediately re-implant an avulsed tooth
Store tooth in: • Balanced saline solution • Cold milk • Container of patient’s saliva Store in above until seen by dentist
106
How to treat a dental injury
Maintain the vitality of the periodontal ligament Handle tooth by crown Gently rinse in saline Insert tooth into the empty socket, hold in place with gauze • Success of re-implantation is 85-97% at 5 min but nearly 0% at 1 hour URGENT DENTAL CONSULTATION Tetanus prophylaxis and antibiotic therapy
107
Tongue lacerations are usually related to...
Injury that involves the teeth Oral cavity and tongue are very vascular —> potential for increased bleeding
108
When should you consider repairing a tongue laceration?
``` If Large (>1cm) • Extending into the muscular layer • Completely through the tongue ``` Deep on the lateral border Large flaps or gaps Significant hemorrhage Any that may cause dysfunction with improper healing
109
DON’T consider repairing tongue lacerations if...
<1 cm Non-gaping Assessed to be minor in the clinical judgement of the examiner
110
If you ARE repairing a tongue laceration...
Use absorbable suture material • 3-0 or 4-0 chromic gut or vicryl Antibiotics

EMED Unit II (5 decks)

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