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Emergency Medicine Module 3 > ENT > Flashcards

Flashcards in ENT Deck (47):
1

maxillofacial trauma

•Often impressive appearance

•ABC’s - airway risk?

•C-spine a priority

•Facial trauma = head trauma

•Vital signs resolving?

•EtOH common

•Other injuries

2

Maxillofacial trauma - history

  • What happened and when
    • Fall? (why fell?), MVA? Assault?
  • LOC? Vomiting? Can’t walk?
  • Visual symptoms?
  • Facial anesthesia/paresthesia?
  • Condition of teeth, bite, blown nose?
    • Blown nose – they blew their nose and their face puffed up -  air now in sinus

  • PMH, meds, tetanus
  • Police report made?
  • Domestic Violence? Child abuse?

3

Maxillofacial trauma - physical exam

  • Look from above/below/side for asymmetry
  • Whistle, smile, wrinkle forehead
  • Eyes
    • Visual acuity (Rosenbaum card)
    • Periorbital - edema, crepitus, lacerations
    • EOM’s
    • Pupils, conjunctiva and anterior chamber
      • Symmetry, subconjunctival hemorrhage, hyphema
  • Mouth
    • Full, gloved exam
    • Lips - lacs, hematoma, thru/thru, vermillion
    • Trismus or can’t close?
    • Teeth present and intact? Where are they?
    • Alveolar ridge, frenulum attachment (put index finger on hard palate and just gently pull to see if there is wiggle)
    • Bleeding in mouth?
    • Tongue - lacs?
  • Nose
    • Locate, control bleeding
    • Nasoseptal hematoma?
    • Palpate medial canthus for mobility
  • Ears
    • Drainage (blood, CSF?)
    • Ear lac?
    • Auricular hematoma, Battle sign
    • TM’s - hemoptypanum, rupture
  • Palpation
    • Palpate entire face, both hands
    • Look for tenderness, bony crepitus, subcutaneous air, flattening, anesthesia
    • Palpate entire orbital rim
    • Check if anterior maxillary arch is stable - if it moves at all, stop
  • Intraoral palpation of zygomatic arch
  • Tongue blade test for mandible Fx- bite down, twist
    • If can hold on, likely no Fx
    • Tongue blade when you suspect mandible fracture – have them bite down and try to pull the blade out. If you pull it right out and they cant hold it, suspect mandible fracture

4

Managment

  • ABC’s first - suction
  • Consider IV - pain control, Abx; tetanus
  • Pain control
    • IM/IV or topical (eyes, nose) - avoid po’s
  • Imaging - CT preferred over plain film
    • Panorex for mandible
  • Make a diagnosis before calling a consultant
    • Oral Maxillofacial surgeon (OMFS)
    • Ophthalmologist

5

Frontal sinus/bone fracture

  • Significant mechanism
  • Step-off, forehead lacs
  • High risk for intracrainial injury, dura tear
  • Bony crepitus, deformity, subcutaneous air, limited upward gaze, ptosis, sensory deficit forehead
  • CT, Abx, OMFS, admit

6

Pediatric considerations

  • Frontal bone injury more common - check those lacs carefully
  • Higher incidence of intracrainial trauma with frontal bone Fx - consider CT head
  • Upper cervical spine injury more common than lower in kids
  • Non-accidental facial trauma - ?abuse
  • Development, cosmetic deformities

7

Nasoethmoidal-orbital fx's

  • Small NEO Fx’s easy to miss
  • Trauma to bridge, medial orbits
  • Associated with lacrimal injury and dural tears
  • Pain at medial bridge, w/ EOM’s
  • Maybe crepitus, telecanthus
  • CT, Abx, OMFS, admit

8

Orbital floor - blow out fx

  • Orbital floor fx
  • Fat, blood into maxillary sinus
  • Entrapment of ocular muscles possible (inferior rectus gets stuck)
    • Diplopia on upward gaze
    • Upward gaze deficit on EOM’s
    • 30% have globe rupture
  • Management
    • CT maxillo-facial and orbits (head?)
    • Check eye: vision, hyphema, pressures, subconjunctival hemorrhage, subcutaneous emphysema
    • Check infraorbital anesthesia
    • OMFS, ophtho consult
    • Pain control, tetanus; admit?
  • You can have a blow out fracture without entrapment
  • Entrapment is when the muscle of the eye is trapped and cant work - you will get double vision when you look up if there is entraptment

9

Retrobulbar hematoma

  • Collection of blood behind globe
  • Trauma, post surgical
  • Proptosis, swelling
  • CT face/orbits, Ultrasound
  • Abx, pain control
  • Ophtho consult, admit
  • Red Flags: vision loss, pupil irregular, papilledema, IOP up, field deficit = optic neuropathy
  • Orbital Compartment Syndrome
    • Swelling with optic neuropathy
    • Lateral canthotomy to relieve pressure and save vision

10

Periorbital, orbital cellulitis

  • Unilateral infection around or around (periorbital) and behind (orbital) orbital structures
  • Fever, red, swelling
  • EOM’s painful
  • Proptosis if orbital
  • CT orbits all, ULS useful
  • Periorbital:
    • Abx, +/- admit
  • Orbital:
    • Serious, vision/life threatening
    • Abx (broad spectrum), Ophtho
    • consult, admit all

11

nasal fx

  • Prior nasal trauma, deformity?
  • Can you breathe thru your nose?
  • Blow nose = face swelling?
  • Clinical Dx – minor = no xray
  • Suspect NEO Fx or other pathology – CT max/face/orbits
  • Check for nasal-septal hematoma
    • If present, must I&D or necrosis of septum ensues à
    • Document if not present
  • “Reduction”- specific cases only
  • ENT f/u 5-7 days after edema subsides

12

zygomatic arch

  • Common; if isolated =less serious
  • Direct blow, swelling
  • Periorbital edema, subconj hemorrhage, flat cheek bone
  • Intraoral exam
  • X-rays- “bucket handle” view - depression?
  • CT common: other fx’s
  • OMFS f/u - cosmesis

13

tripod fracture

  • Significant mechanism, facial swelling
  • Lateral subconjunctival hematoma
  • Infraorbital anesthesia
  • Check eye, lateral canthus pulled downward
  • Trismus
  • Consider head injury
  • CT for Dx, OMFS consult, Ophtho consult, admit

14

maxilla fractures

  • High-energy, midface,  not subtle
  • LeFort Fx’s
    • Fracture patterns often mixed
    • Check hard palate/upper teeth mobility
    • CT, Abx, tetanus
    • OMFS and Optho consult
    • Admit for open reduction and fixation
  • Persistent nose bleed common
  • Intracranial injury common – CT head too

15

mandible anatomy and mandible fxs

  • Open or closed?
    • Multiple fx’s common
    • Tender, swelling, trismus, malocclusion, jaw ecchymosis, bite test
    • Sublingual hematoma is pathognomonic
    • Panorex; then/or CT
    • Open = blood in mouth, gingival lacs, teeth loose separated or uneven
    • Open - OMFS, Abx, tetanus, admit
    • Closed - outpatient f/u

16

TMJ dislocation

  • Jaw stuck open - post trauma, seizure or spontaneous
  • Hx of same?
  • Unilateral - jaw away from side of dislocation. Bilateral - protrudes forward
  • X-rays if traumatic
  • Pain meds, anxiolytics, suction
  • Reduction: Downward pressure, rock and pull forward - from above or from front of patient
  • Liquid diet for 3 days, OMFS f/u

17

hearing loss

  • Sudden or gradual?            
  • Partial or total?
  • Unilateral or bilateral?
  • Trauma, recent infection, meds (bilateral)
    • NSAIDS, aminoglycosides, erythromycin, Lasix, ASA, antimalarials, chemo
  • Associated Sx’s: tinnitus, vertigo, HA, drainage, pain
  • Conductive or Sensorineural?
  • Look in ear first, then look for the tuning fork
    • Conductive loss is common
    • Cerumen (most common), TM perf, OE, SOM, FB
  • Weber test - tuning fork on head
    • Conductive - heard best in affected ear
    • Sensorineural - heard best in good ear
  • Rinne test - mastoid then next to ear
    • Conductive - BC>AC
    • Sensorineural loss - AC>BC or can’t hear it

18

Cerumen Impaction

  • Well appearing pt
  • Fullness, “underwater”
  • Removal:
    • Manual – curette
    • Irrigate:
    • 18g angiocath w/o needle
    • 1part peroxide, 2parts water
    • Irrigate w/ 30cc syringe
    • Immediate relief sx’s
  • Check TM after

19

Malignant otitis externa

  • Osteomyelitis of ear canal
  • Elderly, DM, immunocomp
  • Unresponsive OE, Pseudomonas
  • Painful, especially with movement of tragus
  • Conductive hearing loss +/-
  • Thick, granulation tissue in canal, +/- can’t see TM, facial nerve palsy or paralysis
  • Admit, IV anti-pseudomonals, ENT consult

20

Fungal OE and perichondritis

  • Fungal OE
    • Chronic OE in DM, immunocompromised
    • Painful, white or black fuzzy discharge in canal
    • Suction out canal, antifungal/acetic acid
  • Perichondritis
    • Acute, supprative
    • Auricle tender, warm, swollen - TM normal
    • Check behind the ear! Think mastoiditis
    • IV Abx (pseudomonas),  ENT, consider admit

21

Ransay Hunt Syndrome

  • Herpes zoster of face with involvement of auricle and TM
  • Painful, unilateral
  • Hearing loss, peripheral facial paralysis or sensory loss
  • Acyclovir, steroids, pain meds
  • Check for corneal involvement – Hutchenson’s sign (zoster lesions on tip of the nose)
  • 48hr f/u after ENT consult
  • Just auricle = Herpes Zoster Oticus

22

ear canal problems

  • Furuncle
    • Painful, ear canal abscess
    • Tragal motion tender
    • Staph Aureus
    • Needle aspirate or I&D
    • Abx, pain meds
  • Foreign Body
    • Insect: lidocaine drops - mosquito forceps
      • this gives the insect a heart attack so the 
    • Kids: may need sedation
    • Irrigate if not organic
    • Check TM
    • Tx for otitis externa

23

otitis media

  • Red, bulging TM, decreased mobility
  • Amoxicillin still first-line
  • Serous otitis media
    • “Fullness”, bubbles, TM not red
    • Decongestants
  • Bullous myringitis
    • Painful, clear or red blisters on TM
    • URI common
    • Mycoplasma or viral - Tx with macrolides
    • This is an emergency!

24

TM perforation

  • Post-infection, blunt or penetrating trauma, noise trauma, barotrauma
  • Painful, hearing loss
  • Blood, serous fluid or no discharge
  • Tinnitus, vertigo common
  • Up to 90% heal on own
  • Weber lateralizes to affected side
  • Ear dry, no drops, suspension ok
  • Refer to audiology, ENT

25

Cholesteatoma

  • Squamous epithelium mass behind TM
  • Acquired or congenital
  • Grows, erodes TM and ossicles
  • Hearing loss, pain, d/c; neuro sx’s = red flag
  • Risks: chronic OM, perf’s
  • CT if suspect, then MRI
  • ENT for removal

26

auricular hematoma

  • Post-traumatic, hematoma between skin and cartilage
  • Leads to necrosis if no tx: “cauliflower ear”
  • Incise edge, evacuate clot
  • +/- suture – check with ENT consultant
  • Dressing packed firmly into contours/behind ear
  • Pressure dressing
  • 24hr follow-up - check clot recurrence

27

auricle laceration

  • Block the ear or local anesthesia
  • Suture through skin, not cartilage, to close
  • Non-absorbable
  • 6-0 suture best
  • Attempt to retain shape, contour
  • Do not debride too aggressively

28

mastoiditis

  • Rare, serious, toxic pt
  • Complication of unresolved OM
  • Can be chronic
  • Hearing loss, ear pain, tender fluctuant mastoid, TM red, +/- perf with discharge
  • CT head w/o con
  • IV Abx, ENT consult
  • Kids, toxic = admit

29

nasal furunculosis/cellulitis

  • Infected hair follicle - usually Staph, cover MRSA
  • Remove offending hair
  • Aspirate or I&D if localized, pointing
  • Abx (MRSA), warm compress, 24h f/u
  • Abscess of cartilage, ala, columella cellulitis
    • DM, immunocomp - admit

30

nasal foreign bodies

  • Options:
    • Infants, little kids: parent occludes opposite nostril and blows into mouth
    • Vasoconstrict with Neo-synephrine or Afrin mixed with lidocaine (not w/ Cocaine)
    • Blow after vasoconstriction
    • Alligator forceps, ear curette, Dermabond on end of q-tip or small foley cath passed beyond object – inflate – pull out
  • Organic FB? Irrigate gently - say “eng”
  • Kids may need procedural sedation
  • Check ears too!
  • No luck? ENT

31

Epistaxis

  • Anterior or posterior?
  • Coumadin? Trauma?
  • Anterior: 
    • 90% at Kiesselbach’s plexus - anterior
    • Mild-moderate bleeding
      • Blow nose - get clots out
      • Sit forward/pinch
    • Won’t stop?
      • Gown, glasses, light,   suction
      • Soak several Q-tips in 4% Cocaine or Neo-Synephrine w/ 4% Lido
      • Apply to nostril
    • Silver Nitrate cautery stick
      • Minimum, one side only
      • Abx ointment over site, saline nasal spray
    • Tranexamic acid topical - new
    • Tampon packing
      • Insert along floor of nasal cavity – lube w/ abx oint
      • Moisten after insertion - expands to space
      • 24hr f/u, Abx, saline drops
    • Rhino Rocket - tampon alternative
      • Mesh covered, inflate w/ saline
    • Still bleeding? Nasal balloon + ENT
    • Abx ointment for lube
    • Vitals, monitor, Tetanus
    • 24hr f/u, abx w/ Rhino Rocket
  • Admit if posterior, massive, re-bleed
  • Moisten tampon prior to removal

32

sinusitis

  • Unilateral, face pain, purulent d/c, teeth pain, HA; Sx’s +/- 7days
  • Vast majority viral - Abx if fever, hx chronic
  • Decongestants
  • Not imaged in ED*
    • CT preferred
    • Plain xrays if no CT

33

Dental fractures

  • Ellis I, Class I, etc 
    • Describe what is exposed
    • Enamel only
    • No further Tx
    • Dental referral
  • Ellis II, Class 2, etc
    • Hot/cold/air sensitive
    • See yellow dentin exposed
    • Cover with cement
    • Dental consult
    • 24hr f/u
  • Ellis III, Class 3, etc
    • Pulp exposed - see blood
    • Dental consult now
    • Cover with cement or isolate tooth with moist, sterile gauze
    • 24hr f/u - discuss necrosis, tooth loss

34

Concussion, subluxation, avulsion of teeth

  • Concussion = painful but not loose, no ED Tx, dental f/u
  • Subluxation = loose
    • Push very loose back in - stabilize/splint
    • PCN VK, dental f/u 24hrs
  • Avulsion - totally out
    • <15min – gently clean tooth, socket - push back in
    • 15min - 2hrs - soak tooth, clean socket, replace
    • >2hrs - same with discussion
    • PCN VK, dental f/u 24hrs
    • No tooth? Get a CXR

35

alveolar ridge fracture

  • Subluxed or avulsed teeth
  • Lift lip, check buccal space
  • Hematoma
  • Ridge moves with palpation
  • Panorex; then/or CT
  • IV Abx, pain control
  • OMFS consult

36

dental abscess or infection

  • Facial edema, pain, tender tooth
  • Block tooth locally if possible (bupivicaine)
  • I&D in ED only if clearly pointing or buccal space is full, fluctuant
  • Dental referral 24hrs
  • If fever, trismus, big swelling, face redness: OMFS now
  • PCN/Amox/ Clindamycin pain meds, warm rinses

37

dry socket, necrotizing ulcerative gingivitis (trench mouth)

  • Dry socket
    • Painful necrosis socket, 2-4 days post extraction
    • Block the tooth, irrigate socket with warm NS
    • Gently pack socket with ¼” plain packing gauze soaked in clove oil or dry socket paste
    • Dentist 24hrs
  • Necrotizing Ulcerative Gingivitis (Trench Mouth)
    • Fetid breath, bleeding gums, fever, pain, immunocomp
    • “punched out” interdental papilla
    • Flagyl, Chlorhexidine rinse, dental and PMD  f/u for w/u

38

Lip lacerations

  • Cross vermillion?
    • Approximate first
    • Must line up
  • Thru and thru?
    • Irrigate, sew outer
    • Irrigate again, sew mucosa
  • Anesthesia: regional block
    • Infra-orbital nerve (upper)
    • Mental nerve (lower)
  • Absorbable 4-0 for mucosa
  • Non-absorbable 6-0  for lip and skin
  • Oral mucosal lacs: repair only large or flapping – rest will heal

39

tongue lacerations

  • Small, mid-tongue: control bleed, ice, may not need sutures
  • At edge, w/ flap, large lac: suture
  • Anesthesia:
    • Use lidocaine or bupivicaine w/ epi
    • Lingual nerve block for anterior 2/3 tongue – lingual side 2nd lower molar
    • Local as alternative: painful
  • Absorbable 4-0 suture (can use non-absorbable); bury knot
  • Complex or thru/thru: call OMFS

40

sialolithiasis, sialoadenitis

  • Sialolithiasis = Salivary gland stones – obstruction
  • Common: Wharton’s duct
  • Sudden edema, pain; possible infection
  • See stone? Try to massage it out
  • Abx, lemon drops, analgesia, ENT f/u
  • Sialoadenitis = Mumps
    • Viral prodrome, mostly involves parotid gland
    • Non-immunized kids/adults
  • Wharton’s duct is the submandibular duct – floor of the mouth

  • Stenson’s duct is the parotid duct – next to upper 2nd molar

41

Ludwig's angina

  • Bilateral cellulitis of submandibular space
  • Odontogenic origin common
  • Fever; painful, tense, red edema under chin; trismus, dysphagia, dysphonia
  • Tongue displaced upward, edema of floor of mouth, edema of submental space
  • Rapid progression, polymicrobial
  • Airway the big concern
  • CT is test of choice, IV Abx
  • ENT, admit, airway precautions

42

uvulitis

  • Sore throat, FB sensation
  • Uvula is big, red, angry looking; may touch tongue and cause gag
  • Position is midline tho
  • Think allergy, angioedema first!
  • Abx for strep, consider steroids
  • Pain meds, slippery foods, close f/u

43

pharyngitis, tonsilitis: GRP A strep

  • Modified Centor Score includes age: 3-14yrs = 1pt, 15-44yrs = 0, >45yrs = minus 1pt
  • Used in lieu of throat culture in ED (use rapid strep test if have it)
  • One point each for: fever, tender/swollen anterior cervical nodes, exudate, absence of cough
  • Abx if 4 or greater
  • PCN allergic? 1st Gen Cephalosporin, Clinda or Macrolide

44

Peritonsilar abscess

  • Sore throat, “hot potato” voice, trismus, fever
  • Unilat peritonsilar & soft palate redness, fluctuance. Visual Dx
  • Uvula is NOT midline
  • Uvular deviation away from abscess
  • Cellulitis vs. abscess
  • ULS the swelling for fluid
  • Topical anesthesia then inject w/ lido w/ epi
  • 18g needle, 3 puncture sites
  • Beware “big red”
  • Dry tap? Tx for cellulitis (Clindamycin)
  • Abx, pain meds, 24hr f/u

45

retropharyngeal abscess

  • Kids and adults
  • Neck pain (pain when look up), dysphagia, fever
  • Pharynx looks almost normal – pain and sx’s out of proportion to exam
  • Soft tissue neck less common
  • CT neck is best, diagnostic
  • Airway concerns
  • ENT, IV Abx, admit all

46

epiglottitis

  • No H.flu vaccine
  • Rapid onset, sore throat, fever
  • Drooling, voice changes, positioning
  • Pharynx looks almost normal – pain and sx’s out of proportion to exam
  • Soft tissue neck, get portable if worried
  • CT is best test, if stable
  • If has it – IV, monitor, airway equipment
  • Abx, steroids, ENT, admit

47

swallowed foreign bodies

  • Aspirated vs swallowed
  • The fish bone
  • FB sensation at rest, worse with swallowing
  • Laryngoscope, fiber optic scope, mirror
  • Soft tissue neck, CXR
  • Often abrasion only
  • Pulmonary or GI consult
    • go fishing