Emergency Medicine EOR: ENOT and Ophthalmology (Smarty PANCE)

What is acute laryngitis and what is the most common cause?

Inflammation of the larynx; most common cause is viral (rhinovirus, influenza, parainfluenza) — bacterial is rare

What are the classic clinical features of acute laryngitis?

Dysphonia/hoarseness, dry cough, throat discomfort, low-grade fever; symptoms last <3 weeks by definition

What is the treatment for acute laryngitis?

Supportive: voice rest, humidified air, hydration, analgesics (NSAIDs); antibiotics NOT indicated for viral etiology

When should you be concerned about laryngitis lasting >3 weeks?

Chronic laryngitis → must rule out malignancy (laryngeal cancer), GERD-related laryngitis, or vocal cord polyps — refer to ENT

What findings on laryngoscopy suggest laryngeal cancer vs. acute laryngitis?

Cancer: fixed vocal cord, irregular/ulcerated lesion, unilateral; Laryngitis: bilateral erythema, edema, no mass

What is the gold standard for diagnosing laryngeal cancer?

Laryngoscopy with biopsy

What is the most common cause of acute otitis media (AOM) by age?

Children: Streptococcus pneumoniae (#1), Haemophilus influenzae, Moraxella catarrhalis; preceded by viral URI

What are the diagnostic criteria for AOM?

Moderate-to-severe bulging of TM OR new-onset otorrhea NOT due to otitis externa PLUS acute onset symptoms (ear pain, fever)

What is first-line treatment for AOM?

Amoxicillin 80-90 mg/kg/day x 5-10 days; PCN-allergic: azithromycin or cefdinir

When is watchful waiting appropriate in AOM?

Children ≥2 years with mild unilateral AOM without otorrhea — observe 48-72 hours before antibiotics

What is the most common complication of recurrent AOM?

Conductive hearing loss from persistent middle ear effusion (otitis media with effusion/OME)

What are indications for tympanostomy tubes?

Recurrent AOM (≥3 in 6 months or ≥4 in 1 year), persistent OME >3 months with hearing loss

What organism is associated with AOM after amoxicillin failure?

Beta-lactamase producing H. influenzae or M. catarrhalis → treat with amoxicillin-clavulanate

What is the most common cause of acute pharyngitis?

Viral (70-80%): rhinovirus, adenovirus, EBV; Bacterial: Group A Strep (GAS/S. pyogenes) = 15-30% of cases

What is the Centor criteria and its use?

Scores 1 point each for: Tonsillar exudates, Tender anterior cervical LAD, Fever, Absence of cough; Score ≥3 → test or treat for GAS

What is the gold standard to diagnose GAS pharyngitis?

Throat culture (90-99% sensitivity); Rapid strep antigen test (RAST) is faster but less sensitive (~70-90%)

What is first-line treatment for GAS pharyngitis?

Penicillin V x 10 days OR amoxicillin x 10 days; PCN-allergic: azithromycin or clindamycin

What is the most feared complication of untreated GAS pharyngitis?

Acute rheumatic fever (ARF) — presents 2-4 weeks later; Jones criteria: carditis, polyarthritis, chorea, erythema marginatum, subcutaneous nodules

What features of pharyngitis suggest mononucleosis (EBV)?

Exudative pharyngitis + posterior cervical LAD + splenomegaly + fatigue; heterophile antibody test (Monospot) positive

Why should amoxicillin be avoided in suspected mono?

Causes diffuse maculopapular rash in ~80% of EBV-infected patients given amoxicillin/ampicillin

What is the most common cause of acute sinusitis?

Viral (rhinovirus, influenza) in 90-98% of cases; bacterial most often S. pneumoniae, H. influenzae, M. catarrhalis

What clinical features distinguish bacterial from viral sinusitis?

Bacterial more likely: symptoms >10 days without improvement, severe symptoms (fever >39°C + facial pain), or worsening after initial improvement ("double sickening")

What is the gold standard imaging for sinusitis complications?

CT sinuses with contrast (preferred); MRI if concern for intracranial extension

What is first-line antibiotic for bacterial acute sinusitis?

Amoxicillin-clavulanate x 5-7 days (adults); PCN-allergic: doxycycline or respiratory fluoroquinolone

What are the serious complications of sinusitis to recognize?

Orbital cellulitis, cavernous sinus thrombosis (proptosis + CN III/IV/VI palsy), meningitis, brain abscess

What is Pott's puffy tumor?

Subperiosteal abscess of frontal bone from frontal sinusitis — presents as doughy forehead swelling; requires urgent surgical drainage

What adjunctive therapies are used for sinusitis?

Intranasal saline irrigation, intranasal corticosteroids (decongestant effect), analgesics; oral decongestants may help symptoms

What is the pathophysiology of allergic rhinitis?

IgE-mediated Type I hypersensitivity — allergen cross-links IgE on mast cells → histamine, leukotrienes → sneezing, rhinorrhea, congestion

What distinguishes allergic rhinitis from other rhinitis types clinically?

Allergic: clear rhinorrhea, sneezing, nasal itching, pale/boggy mucosa, nasal polyps, "allergic salute/crease," associated with atopy

What is the first-line pharmacotherapy for moderate-persistent allergic rhinitis?

Intranasal corticosteroids (fluticasone, mometasone) — most effective single therapy for allergic rhinitis

What is the role of antihistamines in allergic rhinitis?

2nd-generation H1 blockers (cetirizine, loratadine, fexofenadine) — preferred (non-sedating); good for sneezing/rhinorrhea, less effective for congestion

What is the gold standard for identifying specific allergens?

Allergy skin prick testing (SPT); serum-specific IgE (RAST/ImmunoCAP) is alternative

What is the definitive treatment for allergic rhinitis?

Allergen immunotherapy (subcutaneous or sublingual) — only disease-modifying treatment

What is barotrauma and what are common scenarios?

Tissue injury from failure to equalize pressure between body cavities and environment; common in divers, air travel, mechanical ventilation

What is the most common form of barotrauma?

Middle ear barotrauma (ear squeeze) — eustachian tube dysfunction prevents equalization; presents with ear pain, hearing loss, TM rupture

What is the Boyle's law relevance to barotrauma?

P1V1 = P2V2 — as ambient pressure increases (descent), gas-filled spaces compress; failure to equalize → pressure damage

What are signs/symptoms of pulmonary barotrauma in divers?

Pneumothorax, pneumomediastinum, arterial gas embolism (AGE) — most dangerous: neurologic symptoms immediately on surfacing

What is the treatment for arterial gas embolism from barotrauma?

100% O2 → hyperbaric oxygen therapy (HBO) immediately; position supine (not Trendelenburg)

What is "the bends" (decompression sickness) and how does it differ from AGE?

DCS: N2 bubbles form in tissues from too-rapid ascent (joint pain, rash, neurologic sx); AGE: air embolism from lung overexpansion; both treated with HBO

What is the treatment for middle ear barotrauma?

Decongestants, analgesics, autoinflation (Valsalva); TM perforation → dry ear precautions, ENT follow-up

What is blepharitis and how is it classified?

Chronic inflammation of eyelid margins; Anterior (staphylococcal, seborrheic) involves lash follicles; Posterior (meibomian gland dysfunction) involves oil glands

What are clinical features of blepharitis?

Burning/itching eyelids, crusting/flaking at lash base, red lid margins, morning mattering, foreign body sensation

What is the treatment for blepharitis?

Warm compresses + eyelid scrubs (baby shampoo) twice daily — cornerstone of therapy; topical azithromycin or bacitracin for bacterial component

What systemic condition is strongly associated with posterior blepharitis?

Rosacea — meibomian gland dysfunction is common; treat with oral doxycycline for severe/recurrent cases

What is a chalazion vs. hordeolum?

Hordeolum (stye): acute staph infection of eyelid gland (painful, red); Chalazion: chronic granulomatous inflammation of meibomian gland (painless, firm nodule)

What is a blowout fracture and what causes it?

Fracture of the orbital wall (most commonly the medial wall or orbital floor) from blunt trauma increasing intraorbital pressure

What is the classic clinical finding of an orbital floor blowout fracture?

Enophthalmos (sunken eye), infraorbital hypesthesia (infraorbital nerve), diplopia on upward gaze (inferior rectus entrapment)

What imaging is gold standard for blowout fracture?

CT orbits (axial + coronal cuts without contrast) — shows bony defect, prolapsed fat/"teardrop sign," entrapped muscle

What is the "teardrop sign" on CT?

Herniation of orbital fat/inferior rectus through orbital floor fracture into maxillary sinus — indicates floor fracture

What is the indication for surgical repair of blowout fracture?

Persistent diplopia + confirmed muscle entrapment on CT, enophthalmos >2mm, large fracture >50% of orbital floor

What associated injuries must be ruled out with orbital blowout fracture?

Globe rupture, hyphema, retinal detachment, traumatic optic neuropathy — always check visual acuity first

What are the three main types of conjunctivitis and their key distinguishing features?

Bacterial: purulent discharge, bilateral, morning crusting; Viral: watery discharge, preauricular LAD, often unilateral→bilateral; Allergic: itching, clear discharge, bilateral

What is the most common cause of bacterial conjunctivitis in adults?

S. aureus, S. pneumoniae, H. influenzae; in sexually active adults: N. gonorrhoeae (hyperacute), C. trachomatis (chronic)

What features suggest gonococcal conjunctivitis and how is it treated?

Hyperacute copious purulent discharge + chemosis within 12-24 hours; treat with IM/IV ceftriaxone; can cause corneal perforation

What is the treatment for bacterial conjunctivitis?

Topical antibiotics (erythromycin, trimethoprim-polymyxin, fluoroquinolone drops) x 5-7 days; self-limited but treatment shortens course

What is the most common viral conjunctivitis cause?

Adenovirus — highly contagious, follicular conjunctivitis, watery discharge, preauricular LAD; treatment is supportive

What neonatal conjunctivitis organism is most sight-threatening?

N. gonorrhoeae (chemical prophylaxis with erythromycin ointment at birth); C. trachomatis causes conjunctivitis at 5-14 days

What are indications to refer conjunctivitis immediately?

Decreased vision, severe pain, corneal involvement, contact lens wearer with symptoms (risk Pseudomonas), hyperacute purulent discharge

What is a corneal abrasion and how is it diagnosed?

Disruption of corneal epithelium; diagnosed by fluorescein staining under cobalt blue/Wood's lamp — abrasion fluoresces green

What are symptoms of corneal abrasion?

Severe pain, photophobia, foreign body sensation, tearing, blepharospasm, decreased visual acuity

What is the treatment for corneal abrasion?

Topical NSAIDs (ketorolac) for pain; topical antibiotics (erythromycin ointment or fluoroquinolone drops); patch NOT recommended routinely

What is a corneal ulcer and how does it differ from abrasion?

Ulcer: infected corneal defect with stromal involvement — appears as white opacity on slit lamp; more severe, risk of perforation

What organism causes corneal ulcers in contact lens wearers?

Pseudomonas aeruginosa — most common and most aggressive; treat with topical fluoroquinolones (ciprofloxacin or moxifloxacin drops)

What organism causes a dendritic corneal ulcer?

Herpes simplex virus (HSV) — dendritic pattern on fluorescein staining is pathognomonic; treat with topical trifluridine or oral acyclovir

Why should topical steroids be avoided in corneal ulcers?

Can worsen bacterial/viral/fungal infections, mask progression, and lead to corneal perforation

What is dacryoadenitis?

Inflammation of the lacrimal gland (superior lateral orbit); can be acute (infectious) or chronic (inflammatory/granulomatous)

What are clinical features of dacryoadenitis?

Swelling/tenderness lateral upper eyelid, ptosis, S-shaped lid deformity, pain with eye movement, possible fever

What are the infectious causes of acute dacryoadenitis?

Bacterial (S. aureus most common), viral (EBV, mumps, CMV, adenovirus)

What systemic conditions cause chronic dacryoadenitis?

Sarcoidosis, Sjögren syndrome, IgG4-related disease, lymphoma

What is the treatment for acute bacterial dacryoadenitis?

Warm compresses + systemic antibiotics (oral cephalexin or augmentin for mild; IV oxacillin for severe); incision and drainage if abscess forms

What organisms most commonly cause dental abscess?

Polymicrobial: oral anaerobes (Prevotella, Fusobacterium), streptococci; Strep viridans common in periapical abscess

What is the classic presentation of a dental abscess?

Throbbing toothache, tender tooth to percussion, facial swelling, possible fluctuant mass, fever; tooth may be carious or non-vital

What are the two types of dental abscess?

Periapical (apex of tooth root, from pulp necrosis) and Periodontal (from gum disease, lateral pocket)

What is the definitive treatment for dental abscess?

Dental referral for incision/drainage ± root canal or extraction; antibiotics (amoxicillin or amoxicillin-clavulanate) if systemic signs

What are life-threatening complications of dental abscess?

Ludwig's angina (bilateral submandibular space infection → airway compromise), cavernous sinus thrombosis, descending necrotizing mediastinitis

What is Ludwig's angina and how is it managed?

Rapidly spreading cellulitis of submandibular/sublingual spaces; hard board-like floor of mouth, drooling, tripod position; AIRWAY FIRST (early intubation), IV antibiotics, surgical drainage

What are the primary causes of ear pain (otalgia) to consider?

Primary (ear pathology): AOM, otitis externa, TM perforation, mastoiditis; Referred (CN V, VII, IX, X): dental, TMJ, cervical spine, pharyngeal

What nerve mediates referred otalgia from pharyngeal/tonsillar pathology?

Glossopharyngeal nerve (CN IX) — Jacobson's nerve branch; explains ear pain with tonsillitis/PTA

What is the most common cause of ear pain in adults without otoscopic findings?

TMJ dysfunction — pain with jaw movement, clicking, tender masseter/TMJ

What exam findings point to AOM vs. otitis externa as cause of ear pain?

AOM: TM erythema/bulging, no tragal tenderness; OE: tragal tenderness, canal edema/discharge, TM usually normal

What is epiglottitis and what is the classic presentation?

Life-threatening supraglottic inflammation; classic presentation: "4 D's" — Dysphagia, Drooling, Distress, Dysphonia (muffled "hot potato" voice) + fever, tripod/sniffing position

What organism was the classic cause of epiglottitis and what changed?

Haemophilus influenzae type B (Hib) — dramatic decrease since Hib vaccine; now more often Strep, Staph, or viral in vaccinated children; adults increasingly affected

What is the most important first step in managing suspected epiglottitis?

DO NOT disturb the patient — no throat exam, no lying flat; call anesthesia/ENT immediately, prepare for emergent airway (OR preferred)

What is the "thumbprint sign"?

Classic finding on lateral neck X-ray — swollen epiglottis resembles a thumb; CT neck can confirm but airway management should never be delayed for imaging

What is the treatment for epiglottitis?

Secure airway first → IV antibiotics: ceftriaxone ± vancomycin (MRSA coverage); corticosteroids may reduce inflammation

What age group is most commonly affected by epiglottitis today?

Adults (30-50 years old) in the post-Hib vaccine era; children now less commonly affected

What are the two categories of epistaxis and their differences?

Anterior (90%): Kiesselbach's plexus, Little's area, usually self-limited; Posterior (10%): sphenopalatine artery, often severe, higher risk complications

What is Kiesselbach's plexus?

Anastomotic network of vessels on anteroinferior nasal septum (Little's area) — site of 90% of anterior epistaxis; supplied by branches of ICA and ECA

What is first-line management for anterior epistaxis?

Direct pressure (pinch nose) x 10-15 min with head forward; can use oxymetazoline-soaked cotton for vasoconstriction; silver nitrate cautery if localized

When is posterior nasal packing indicated?

Anterior packing fails or posterior bleed suspected (blood flowing down throat, bilateral bleeding); use Foley catheter or posterior pack

What medications/conditions predispose to epistaxis?

Anticoagulants, NSAIDs, hypertension, hereditary hemorrhagic telangiectasia (HHT/Osler-Weber-Rendu), cocaine use, nasal trauma

What is HHT (Osler-Weber-Rendu) and how does it present?

Autosomal dominant; telangiectasias on lips/tongue/fingers + recurrent epistaxis; treat with laser coagulation

When should you be concerned about a neoplastic cause of epistaxis?

Unilateral nasal obstruction + epistaxis + cranial nerve deficits → rule out nasopharyngeal carcinoma (especially in Asian males) or juvenile nasopharyngeal angiofibroma

What is the approach to a foreign body in the ear?

Visualization with otoscope; removal with suction, forceps, or irrigation (NOT irrigation for organic material/batteries — swell); batteries require urgent removal

Why is urgent removal of button batteries in the ear/nose critical?

Generates hydroxide ions via electrolysis → liquefactive necrosis within hours; can cause septal perforation (nose) or ossicular damage (ear)

What is the approach for a nasal foreign body?

"Mother's kiss" technique (occlude unaffected nostril, parent blows into child's mouth); positive pressure, or forceps/suction; watch for aspiration

What is the approach for a corneal/conjunctival foreign body?

Slit lamp exam; remove with moistened cotton swab or 25-gauge needle at slit lamp; rust ring from metallic FB → ophthalmology for burr removal

What are signs of a retained intraocular foreign body?

Seidel sign (fluorescein streaming from puncture wound), peaked pupil, low IOP; get CT orbits (not MRI if metallic)

What is acute angle-closure glaucoma (AACG) and what causes it?

Sudden obstruction of aqueous outflow through trabecular meshwork due to forward displacement of iris occluding angle; IOP rises acutely (>21 mmHg, often >40)

What are the classic symptoms and signs of AACG?

Sudden severe eye pain, headache/nausea/vomiting, halos around lights, fixed mid-dilated pupil, rock-hard eye, corneal clouding/steamy