EMed - EENT and Dental Emergencies

1) place the dark orange fluorescein dye onto the outer surface of pt's eye

2) shine the cobalt-blue light onto the eye (slit-lamp or ophthalmoscope)

3) have pt blink several times (spreads dye over cornea surface)

How does a provider use fluorescein dye to stain the cornea in the ED?

1) lacrimal system

2) levator muscle

3) optic nerve

What are the most commonly damaged areas from an eyelid laceration?

extraocular muscle entrapment

(leads to periorbital edema and ecchymosis)

What is a common thing that happens d/t an orbital fracture?

Dagnini-Aschner phenomenon

What is the potentially life-threatening consequence of EOM entrapment?

bradycardia or asystole caused by the oculocardiac reflex

What is the Dagnini-Aschner phenomenon?

a triad of...

1) bradycardia

2) syncope

3) nausea

What is the oculocardiac reflex?

CT scans

Specific orgital or maxillofacial ________________ are recommended for patients with orbital fracture and muscle entrapment.

ABX eye drops or ointment

*erythromycin ointment

*ciprofloxacin drops

*moxifloxacin drops

What pharm therapy can be used for corneal abrasions?

corneal foreign bodies

penetrating cause disruption of outer coats of eye without interrupting anatomic continuity

yes

Should you get a CT scan for a patient with a corneal foreign body?

do NOT let them eat/drink anything

(make sure to PROHIBIT oral intake)

What should you make sure your patient with a corneal foreign body does NOT do until examined by ophthalmologist?

PARENTERAL ABX against gram (-) and gram (+)

* PO FQs (after ophthalmology consult) or

* IV vancomycin or ceftazidime

What antibiotics would you want to give a patient that has a corneal foreign body?

ruptured globe

sudden eye pain & vision loss after a potentially penetrating injury

equatorial sclera

What is one of the most common eye laceration location areas?

get a CT scan!!

*MRI is CI w/ suspected ferromagnetic FBs

*US is (relatively) CI - don't need to put direct pressure on globe

What imaging should be done for a patient that has a ruptured globe?

ruptured globe

Patients with a ___________________ should be treated with antiemetics, pain control, and bed rest with elevation of the HOB @ 30°. They also should be NPO because they are going to need surgery.

enucleation

the removal of the entire globe, with separation of all connections from the orbit, including optic nerve transection

trauma and malignant tumors

What are the leading causes of enucleation-evisceration?

traumatic enucleation

What is this the management for?:

- globe subluxation - eye prolapsed out onto cheek

- recline pt

- do NOT squeeze subluxated eye or squint uninvolved eye

- as pt looks up at ceiling, use fingers to spread pts lids around the front of the globe or use cotton swab to roll lids back

- gently push globe back into place

(bacterial) corneal ulcers

Your patient has whitish-yellowish infiltration of the cornea, and a hypopyon appears to be present. You fear that your patient will have serious, rapid perforation of the cornea and loss of the aqueous humor. What is the suspected diagnosis?

orbital cellulitis

Your patient presents complaining of a fever with swelling, pain, and redness around the eye. He is having pain with extraocular movements, and his visual acuity is reduced. He says he recently had a "sinus thing." On PE, you note rapidly progressive exophthalmos. What is the most likely diagnosis?

ceftriaxone 1-2g IV + vancomycin 1g IV

OR

piperacillin/tazobactam 3.375 g IV

What broad-spectrum IV ABX should be administered to a patient with orbital cellulitis?

False

- The eye will NOT be red

True or false:

- A patient with a vitreous hemorrhage will present with sudden, painless loss of vision with the appearance of "floaters," and the eye will often be extremely red.

* Eye

* Red reflex

* retina, optic nerve

* vitrectomy

* 25mg tPA

Vitreous hemorrhage

* _______ is NOT red

* ________________ of fundus is hazy, faint, or black

* Details of the _________ and _________ are obscured by cloudy vitreous.

* Partial or total ________________ may be considered later

* Injection of ________________ may be considered.

dx: central retinal artery occlusion

SE: permanent vision loss in as little as 90 minutes

Peggy has a history of atrial fibrillation and has had several DVTs within the past 10 years. She presents with sudden, complete, painless vision loss in her right eye. On ophthalmoscopic examination, her right pupil is sluggish to react to light. You also note pallor of the disc, retinal edema, a cherry-red fovea, and a "boxcar" appearance of the retinal veins. What is the most likely diagnosis? What is the most serious associated side effect?

central retinal vein occlusion

Steve is a 88-year-old male who presented to the ED today with painless vision loss in his left eye. PMHx is positive for glaucoma and hypertension. On PE, there are multiple widespread retinal hemorrhages with dilated tortuous veins, retinal and macular edema, and attenuated arterioles. What is the most likely diagnosis?

dx: optic neuritis

management: routine eye exam, ophthalmoscopy, MRI

tx: steroid meds IV to reduce inflammation in optic nerve

Mr. Jobs presents today for eye pain that is mainly just a "dull ache behind the eye." He said that he has slowly been having vision loss (visual field loss, lack of color vision, flashing lights, etc). You ask him to move his eye and he says "OWWWW." How are you going to manage this diagnosis?

IOP should be NL or low

dx: retinal detachment

You are performing a direct ophthalmoscopic exam and note a gray retina with white folds and globular bullae. To confirm the diagnosis, you do an indirect ophthalmoscopic exam and then see round holes or horseshoe-shaped tears (rips).

You measure the intraocular pressure. What do you expect the IOP to be, and what is the most likely dx?

- acute angle-closure glaucoma

- probable endophthalmitis or uveitis

What diagnoses can cause a red/painful eye AND loss of vision?

sudden onset blurry vision followed by severe pain, HALOS AROUND LIGHTS, photophobia, frontal HA, n/v

also: red eye with FIXED OR SLUGGISH MID-DILATED PUPIL, shallow anterior chamber, hazy cornea, IOP > 30 mmHg

What are the hallmark sxs of acute angle closure glaucoma?

1) hearing loss that is sensorineural in nature

2) hearing loss ≥30 dB over at least 3 consecutive test frequencies

3) occurs within a 72hr period

What are the 3 clinical criteria for SSNHL?

cranial nerve exam, inspection of external ear, otoscopic exam

What physical exam should be done on someone with SSNHL?

audiometry (confirms dx) within 14 days of sx onset

MRI w/ contrast within 3 months

What diagnostic testing should be done on someone with SSNHL?

corticosteroids for 2-6 wks

How do you treat pts w/ SSNHL?

bullous myringitis (infectious myringitis)

most often in children, children often tug or pull ears (may seem irritable, more likely if middle ear infxn), usually a viral etiology, blisters on the TM, VERY painful

amoxicillin or clarithromycin

How do you manage bullous myringitis (infectious myringitis)?

Ludwig's angina

rapidly progressive gangrenous cellulitis of soft tissues

submandibular space

What is the primary site of Ludwig's angina?

odontogenic infxn

What is the main etiology of Ludwig's angina?

airway obstruction, elevation and posterior displacement of tongue

What is the primary concern w/ Ludwig's angina?

high-dose IV PCN

What is the best choice for empiric tx of a peritonsillar abscess?

parapharyngeal abscess

What type of throat abscess presents with high fever (possible rigor), a poorly defined deep neck infxn, neck swelling down the hyoid, trismus in the anterior space, and swelling in the posterior pharyngeal wall that may involve structures within the carotid sheath (bacteremia, neurologic deficits, massive hemorrhage caused by carotid artery rupture)?

erosion into carotid artery; septic thrombophlebitis of IJV (Lemierre syndrome)

What are the main adverse events that can occur from a parapharyngeal abscess?

retropharyngeal abscess

The following are red flags of obstruction associated with what type of pharyngeal abscess?:

voice change (hot potato), intolerant of oral secretions, cervical LAD, refusal to extend neck (pain), CP (into mediastinum), trismus, dysphagia, odynophagia, neck stiffness/swelling, torticollis, respiratory distress (stridor, tachypnea, retractions)

lateral neck x-ray

What is the best initial imaging test for a suspected retropharyngeal abscess?

CT of the neck w/ contrast

What is the best imaging study to evaluate retropharyngeal abscess?

must cover Gram (+) (including B-lactamase producing) and anaerobes (so treat with empiric vanc)

What is the best tx for retropharyngeal abscess?

Kiesselbach's plexus

What is the m/c site of anterior epistaxis?

Woodruff's plexus

To identify the bleeding source in the case of epistaxis, the posterior oropharynx should be inspected for blood dripping down the throat. What location (that is less common but more severe) may be the source?

septal hematoma

What is "fluctuant swelling that must be drained to prevent septal necrosis" in a patient with epistaxis?

lean forward to prevent aspiration, apply direct nasal pressure (pinch the soft part of the nose for 10-15 minutes)

What is the initial conservative management in patients with epistaxis?

True

True or false: You should avoid cauterizing both sides of the nasal septum.

posterior nasal cavity (probably the sphenopalatine artery)

Debbie presents with a difficult to control nose bleed that is described as bilateral, brisk, and pulsatile. What is the most likely location?

refractory bleeding despite packing and cautery

suspected posterior epistaxis requiring endoscopic or surgical intervention

hemodynamically unstable pts (e.g., hemorrhagic shock)

pts on anticoagulation w/ ongoing bleeding

What are the indications for hospital admission in patients with epistaxis?

warfarin: check INR, consider reversal w/ vit K if INR is supratherapeutic

DOACs (e.g., apixaban, rivaroxaban): may require reversal agents

aspirin/clopidogrel: often continued unless major bleeding occurs

Your patient with epistaxis is on anticoagulation. How does the management of a pt on the following anticoagulants change?: warfarin, DOACs, aspirin/clopidogrel

anterior

What type of epistaxis?: most common, unilateral, scant blood in OP; kiesselbach area (anteriomedial septum) (anastomoses of 3 septal arteries)

posterior

What type of epistaxis?: arterial source, bilateral bleeding, large amount of fresh blood in the OP w/ little in the anterior nose

1-8 years of age

What is the m/c age for a nasal foreign body obstruction?

nasal obstruction

What is the m/c sx of a septal hematoma?

septal hematoma

What is the expected dx for a patient that presents with asymmetry of the septum with bluish or reddish mucosal swelling that is soft and fluctuant?

posterior, impacted, penetrating or hooked, failed attempt for retrieval

When would you want an ENT referral for a nasal foreign body?

thermosensitivity

What sx is a hallmark of a periapical abscess?

dental abscess

Johnny presents with a severe, constant, throbbing toothache. He said that it occasionally radiates to the jawbone, neck, and ear. His girlfriend is there and says his breath has been atrocious lately. What is the most likely diagnosis?

sudden rush of foul-smelling and foul-tasting, salty fluid in mouth

pain relief

What happens if a dental abscess ruptures?

periapical abscess

What type of dental abscess?: originates in dental pulp; secondary to dental caries; most common in children

periodontal

What type of dental abscess?: supporting structures (periodontal ligaments, alveolar bones); most common in adults

pericoronitis

What type of dental abscess?: infxn of gum flap; partially erupted or impacted 3rd molar

dental fracture

Cassandra was using an ab wheel and wasn't strong enough to push herself back up on her last rep. She fell and smacked her jaw on the floor. Soon after that, she had pain that would come and go, particularly with chewing. She also reports sensitivity to temperature changes and sweet foods. There is swelling around one particular tooth. What is the most likely diagnosis?

class I

What class of dental fracture based on the Ellis Classification Scale?: enamel only - no urgent tx (sanding, cosmetic later)

class II

What class of dental fracture based on the Ellis Classification Scale?: dentin exposed - yellow patch visible, vulnerable to bacteria; needs to be irrigated with sterile saline, dry, cover with calcium hydroxide paste, foil, other dressing; dental f/u within 24 hrs

class III

What class of dental fracture based on the Ellis Classification Scale?: pulp exposed - bloody or pink, VERY painful; need empiric ABX and maybe a nerve block; dental f/u within 24 hrs

class III

With what class of dental fracture should you start initiation of empiric ABX?

tooth is loose in the socket

What is a dental subluxation?

1°: remove if significant to prevent ankylosis to alveolar bone, or aspiration

2°:

- minimal mobility (<2mm) - d/c on soft foods/liquids with dental f/u

- moderate mobility (>2 mm) - socket reseating and splint

How do you treat a 1° versus 2° dental subluxation?

tooth completely out of socket

What is a dental avulsion?

clean tooth in NSS... then do NOT place water or dry it

How do you treat a dental avulsion?