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Unit 2 Emerg/Surg > L6: ENT Emergencies > Flashcards

L6: ENT Emergencies Flashcards

(101 cards)

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1
Q

Dendritic lesions on slit lamp with fluorscein

A

HSV-1 Keratitis

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2
Q

Herpes Simplex Keratitis presentation

A

Acute onset: eye pain, photophobia, blurred/decreased vision, tearing

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3
Q

Herpes Simplex Keratitis management

A 
Urgent ophthalmology referral
General measures
Topical or oral antivirals
Trifluridine 1% (topical)
Ganciclovir 0.15% gel (topical)
Acyclovir (oral)
NO TOPICAL GLUCOCORTICOIDS
Severe scarring or perforation→ Corneal transplant
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4
Q

Trifluridine

A

Topical antiviral (HSV-1 keratitis)

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5
Q

UV keratitis aka

A

photokeratitis

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6
Q

How long does it take for photokeratitis onset after sun exposure?

A

6-12 hours

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7
Q

UV keratitis presentation

A 
Bilateral intense eye pain 
Can’t open eyes
Photophobia
Foreign body sensation
Distraught, pacing, rocking secondary to severe pain
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8
Q

Photokeratitis on exam

A

Penlight→ tearing, generalized injection and chemosis of the bulbar conjunctiva

Cornea→ may be mildly hazy

Fluorescein→ superficial punctate staining of the cornea

+/- miosis

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9
Q

UV keratitis treatment

A

Supportive→ resolves in 24-72 hrs

Mild oral opioid: Oxycodone 5-10mg Q 4-6 hrs X 24 hrs

Lubricant antibiotic ointment

F/U in 1-2 days

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10
Q

Preseptal or orbital cellulitis presentation

A

Unilateral periorbital edema with erythema, warmth,
tenderness

+/- Complication of:
Sinusitis
Extension of infection from adjacent structure
Local disruption of skin

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11
Q

Preseptal cellulitis exam

A

Tissues anterior to the orbital septum

Swelling of eyelids, upper cheek

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12
Q

Orbital cellulitis exam

A

Structures deep to the orbital septum

Vision loss, impaired EOMs, diplopia

+/- proptosis, chemosis, fever (common)

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13
Q

Preseptal or orbital cellulitis diagnostic studies

A

CT scan orbits and sinuses with contrast

+/- Leukocytosis

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14
Q

Preseptal cellulitis treatment

A

Mild/No systemic symptoms→ discharge home
Oral antibiotics
Follow up within 24-48 hrs

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15
Q

Orbital cellulitis treatment (or if preseptal cellulitis is “concerning”

A

A true emergency
Admit to hospital, IV abx
Consult ophthalmology and ENT

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16
Q

Corneal injuries can result from

A

eye trauma
foreign bodies
improper contact lens use

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17
Q

Corneal abrasian

A

Thin protective coating of anterior ocular epithelium

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18
Q

Corneal ulceration

A

Break in the epithelium exposing the underlying corneal stroma

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19
Q

Corneal abrasian/ulceration presentation

A

Severe eye pain
Foreign body sensation
Can lead to impaired vision secondary to scarring

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20
Q

Corneal abrasion/ulceration exam

A

Penlight→ before to fluorescein stain:
Anterior chamber - clear, deep and normal contour
Pupil round, Clear tears
Mild conjunctival injection if > 2 hrs
Ciliary flush if several hrs old
Visual Acuity
EOMs
Fundoscopic Exam→ confirm red reflex
Fluorescein exam:
Stains the basement membrane→ exposed in areas of epithelial defect
Visualization enhanced with cobalt blue filter: Woods lamp

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21
Q

Corneal abrasion/ulceration needs to be urgently referred to ophthalmology if

A

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

Impaired visual acuity, Ulceration

Contact lens wearer:
to r/o infiltrate or opacity, daily to r/o infiltrate or ulcer until healed

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22
Q

Corneal abrasion treatment

A 
1. Topical Antibiotics: 
Erythromycin ointment
Sulfacetamide 10%
Polymyxin/trimethoprim
Ciprofloxacin
Ofloxacin drops QID x 5 days
2. +/- Narcotics
NO topical anesthetic or steroid
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23
Q

The only time steroids are indicated in the HEENT lecture

A 
Otitis externa with viral cause
Optic neuritis (IV, oral doesn't help)

Don’t be putting topical steroids in the eye pls

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24
Q

If your patient has a lid laceration

A

They probably have an associated ocular injury

High threshold of suspicion for penetrating injury to globe in the setting of all full thickness lid lacerations

Don’t attempt complicated lacerations, refer em

“Low threshold for CT”= just CT the orbits

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25
When to refer a lid laceration to ophthalmologist or surgeon (plastic or oromaxillofacial)
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
26
How do you treat an UNcomplicated lid laceration?
< 25% of lid can heal by secondary intention, clean and apply triple antibiotic ointment +/- adhesive surgical tape or adhesives >25% repair with 6-0 fast absorbable plain gut suture Simple interrupted or running sutures within 24 hrs Non absorbable suture used→ remove in 5-7 days
27
What's an UNcomplicated lid laceration
Superficial lacerations, horizontal, follow skin lines
28
Orbital floor fracture aka
"Blowout fracture"
29
Significant findings in an orbital floor fracture
Entrapment of the inferior rectus muscle → ischemia→ loss of muscle function Enophthalmos→ +/- develop with posterior globe displacement ``` Orbital dystopia (eye is lower) Entrapped muscle pulls eye downward ``` Injury to infraorbital nerve secondary to fracture→ decreased sensation: cheek, upper lip, upper gingiva
30
On exam, an orbital floor fracture has...
Limitation of EOM Decreased visual acuity Severe pain Inadequate exam→ swelling/altered mental status
31
Special imaging for an orbital floor fracture
Thin cut coronal CT of the orbits
32
Orbital floor fracture management
``` Surgical evaluation Prophylactic antibiotics→ cover sinus pathogens Cold packs→ first 48 hrs Head of bed raised Avoid blowing nose/sniffing ```
33
When do you get an open globe rupture?
Occurs following blunt eye injury
34
During exam of open globe rupture
Avoid pressure to eyeball in eyelid retraction Avoid IOP measurement
35
Open globe rupture management
``` Abx, NPO Emergent ophthalmology consult Transfer to tertiary trauma center Eye shield Bed rest IV antiemetics – (ondansetron 4mg) Pain medication Sedation prn (lorazepam .05mg/kg – max 2mg) Avoid: manipulation, solutions in eye, NSAIDS ```
36
Ondansetron
IV antiemetic
37
What is an inflammatory, demyelinating condition→ acute, monocular vision loss (10% bilateral) High association with multiple sclerosis (MS)
Optic neuritis
38
Optic neuritis presentation
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 Dyschromatopsia → loss/reduced color vision
39
DDx for optic neuritis by age
>50 years old: DM, giant cell arteritis, autoimmune | Young child: infectious or post infectious cause
40
If MS is confirmed, then a suspected optic neuritis case gets
MRI brain/orbits with gadolinium | but it's a "clinical diagnosis"
41
Optic neuritis treatment
IV methylprednisolone | No oral prednisone→ Doesn’t affect visual outcomes +/- increase risk for recurrence
42
Acute angle closure glaucoma
Narrowing or closure of the anterior chamber angle→ inadequate drainage of aquous humor--> elevated intraocular pressure (IOP) → damage to the optic nerve
43
Acute angle closure glaucoma presentation
``` Decreased vision Halos around lights HA, N/V Severe eye pain Red eye Corneal edema/ cloudiness ```
44
Wha't a gonioscope? What's it used for?
A special lens for the slit lamp lens→ visualize angle between the iris and cornea for acute angle closure glaucoma
45
multilayer of exquisitely organized neurons lining the back of the eye
the retina
46
How could the retina detach?
separates from the epithelium and choroid→ ischemia and progressive photoreceptor degeneration
47
A patient with retinal detachment will complain of...
Sudden onset of floaters, cobwebs Monocular visual field loss Vision loss
48
Imaging for retinal detachment
Ultrasound
49
Retinal detachment management
emergent opthalmologist eval
50
What do adults who don't go around sticking stuff in their ears like toddlers, get "foreign bodies" of?
Cerumen plugs
51
Ear foreign body presentation
Hearing loss, ear pain and drainage
52
Foreign body management
Identify foreign body→ remove under direct visualization Neutralize bugs with mineral oil Do not irrigate organic material→ may cause infection Check for otitis externa Ciprodex or CiproHC gtts
53
Otitis externa causes:
Bacterial: pseudomonas aeruginosa Viral: Herpes Zoster Virus
54
Otitis externa presentation: | Bacterial vs Viral
Bacterial: Ear fullness, drainage Tragal motion tenderness/ pain ``` Viral: Vesicles in ear canal Facial paralysis Hearing loss Vertigo ```
55
Viral otitis externa needs
MRI brain→ rule out skull base tumor
56
Malignant otitis externa is caused by
pseudomonas aeruginosa
57
High risk for malignant otitis externa
Elderly, DM, immunocompromised Otitis externa + acutely ill patient, ear canal granulation tissue
58
Diagnostics for otitis externa
CBC→ leukocytosis Cultures Head CT→ osteomyelitis skull base
59
Malignant otitis externa treatment
Admit, Debridement, ENT eval Parenteral abx: Cipro 400mg IV Q8 hrs→ change to 750mg PO Q 12 hrs prior to discharge x 6-8 weeks
60
Complications from malignant otitis externa
Cranial neuropathies, Brain abscess, Meningitis, Septicemia, Death
61
What can cause tympanic membrane perforation?
otitis media closed head injury direct ear trauma
62
Tympanic membrane perforation presentation
Pain, Hearing loss N/V Vertigo, Otorrhea, Tinnitus
63
Exam for tympanic membrane perforation includes....
Direct visualization of TM | Audiogram
64
If you suspect head trauma caused a tympanic membrane perforation
CT and check drainage for CSF
65
Tympanic membrane perforation management
+/- Evaluation by otolaryngology Water precautions 95% resolve without treatment <25% total surface in 4 weeks Ofloxacin otic drops Tympanoplasty→ Refractory cases
66
Cauliflower ear aka
Auricular hematoma caused by blunt force trauma to auricle
67
Collection of blood in the cartilage
Auricular hematoma
68
Auricular hematoma management
Drain/aspirate ASAP > 7 days→ Otolaryngologist or plastic surgeon Follow eval Q 24 hrs for 3-5 days, or ASAP if worsening Refrain from sports for 7 days
69
What is acute inflammation and infection of auricular cartilage caused by Pseudomonas aeruginosa
Perichondritis
70
Perichondritis presentation
Erythema Pain Abscess formation, pus Systemic symptoms
71
Perichondritis management
Culture + Sensitivity +/- Incision + Drainage Empiric abx→ ciprofloxacin
72
Nosal foreign body presentation
``` Asymptomatic, history of insertion (most) +/- Mucopurulent nasal discharge Foul odor Epistaxis Nasal obstruction→ mouth breathing ```
73
Exam and diagnostics for nasal foreign body
Direct visualization of FB Check lungs CTAB without abnormal breath sounds Imaging not needed Xray: suspected button battery or magnet
74
Nasal foreign body management
``` Child must be adequately restrained Good visualization Manually retrieve with alligator forceps or suction→ re-examine to rule out second FB Avoid irrigation if FB is organic matter >2 unsuccessful attempts→ refer to ENT ```
75
Which type of epistaxis is more common, anterior or posterior?
Anterior
76
Anterior epistaxis comes from
Kiesselbach’s Plexus (90%): anastomosis: 1. Septal branch of the anterior ethmoidal artery 2. Lateral nasal branch of the sphenopalatine artery 3. Septal branch of the superior labial branch of the facial artery
77
Posterior epistaxis comes from
1. Posterolateral branches of sphenopalatine artery | 2. Carotid artery (rare)
78
Epistaxis is caused by
``` Nose picking Low moisture Hyperemia secondary to allergic rhinitis FB Drug use Trauma ```
79
Stepwise fashion for epistaxis management
Conservative treatment Cautery Nasal packing Antistaph Abx
80
Conservative management of epistaxis
Oxymetazoline (Afrin) – 2 sprays Direct pressure of the alae tight against septum X 10 minutes No further bleeding→ nasal hydration
81
Cautery of epistaxis
If source easily identified Avoid large areas Remove excess silver nitrate with cotton tip applicator Risks: Ulceration, septal perforation
82
Nasal packing for epistaxis
3 days, 5 days if anticoagulated
83
Meds for epistaxis
Antistap Abx→ Keflex, Augmentin
84
Nasal trauma possible complications
Early complications→ Hematoma, Abscess, Uncontrolled epistaxis, CSF rhinorrhea Late complications→ Nasal deformity, Obstruction, Perforation
85
Nasal trauma exam shows....
``` Epistaxis CSF rhinorrhea Impaired EOMs Orbital edema/ecchymosis Lacerations Septal hematoma ```
86
Imaging for nasal trauma
CT maxillofacial without contrast | to rule out other facial fractures
87
Who is septal hematoma more common in?
Peds
88
Inflammation and/or infection of the mastoid air cells
Mastoiditis
89
Septal hematoma can be caused by
Trauma Septal surgery Bleeding disorders
90
Septal hematoma management
``` Incision and drainage→ prevent avascular necrosis of the septum Pack nose, Antibiotics Outpatient ENT referral • Remove packing in 24 hrs • Recheck • Re-pack ```
91
"soft, tender swelling around septum"
septal hematoma
92
Mastoiditis presentation
+/- Asymptomatic Ear pain Drainage Tenderness, erythema and edema over the mastoid process
93
Diagnostics for mastoiditis
CT head | Infection→ Culture
94
Mastoiditis management
Refer to ENT Immunocompetent→ start empiric abx Recalcitrant disease or immunocompromised→ mastoidectomy +/- IV abx
95
Periodontal abscess imaging
Panoramic radiograph or CT for bone involvement
96
Periodontal abscess presentation
Fever, Pain | Red, fluctuant swelling of the gingiva, Tenderness to palpation
97
Periodontal abscess management
Pain management, I+D, F/U with dentist Oral antibiotics if limited infection Augmentin or Clindamycin x 7-14 days
98
Dental avulsion presentation
Avulsion of permanent tooth→ True dental emergency Pain Tooth completely displaced from the alveolar ridge Periodontal ligament severed
99
Dental avulsion management
Unable to re-implant immediately→ store tooth: balanced saline solution, cold milk, container of patient’s saliva→ urgent dental consult Reinsert: Maintain periodontal ligament, handle tooth by crown→ gently rinse in saline→ insert into the empty socket→ hold in place with gauze Success of re-implantation: 85-97% at 5 min Nearly 0% at 1 hour Tetanus prophylaxis and antibiotic therapy
100
Tongue laceration
Related to injury that involves the teeth | Oral cavity and tongue are very vascular→ potential for increased bleeding
101
Tongue laceration management
Not considered for repair < 1 cm, Non-gaping, minor in the clinical judgment of the examiner Consideration for repair Large (>1cm), Extend into the muscular layer or completely through the tongue Deep on the lateral border Large flaps or gaps, Significant hemorrhage Possible dysfunction with improper healing Use absorbable suture material→ 3-0 or 4-0 chromic gut or vicryl Antibiotics

Unit 2 Emerg/Surg (8 decks)

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