EENT EM

what must we do on an eye exam in the ER

must document visual acuity in both eyes and test w the contacts/glasses pt normally wears (2 lines below pts normal corrected vision in the affected eye = higher chance of eye emergency). if pt cant see chart test for fingers, motion, and light/dark

check pupillary reaction (look for symmetry in direct and indirect and consensual reflec, check for afferent pupillary defect. check for severe pain/photophobia and see if that pain is w direct or indirect stimulation)

check extraocular movements, visual fields

check fundoscopic exam (red light reflex, anterior chamber depth, optic disc, retinal circulation (is it pale/bleeding/has venous congestion), macula. opacities in the media look like black silhouettes aka floaters, lid eversion to see foreign bodies, flourescein stain, intra-occular pressure testing bc if you cant check pressure you cant r/o acute glaucoma, anterior chamber depth

causes and sx of conjunctivitis

can be viral (most common), bacterial, or allergic

not as much painful as it is irritated/itchy feeling w possible pus/crusties

purulent discharge in ONE eye = more likely bacterial

conjunctivitis tx

anti-histamines, lubricants, abx as needed, no contacts till healed

herpes simplex keratitis sx and tx

severe eye pain and FB sensation, can see corneal dendrite w fluorescein uptake. often w trigeminal involvement (nose = hutchinson sign, pre-auricular, forehead)

tx w antivirals, call optho and no contact use till healed

corneal ulcer sx and tx

eye pain and FB sensation, eye is super super red, most common w contact lens use, often has visible opaque ulcer can be seen w fluorescein uptake and sometimes w/o

call optho, requires compounded drops given every hour, no contact use till healed

acute angle glaucoma cause and sx

pupil dilates → tightens contact of lens and iris → stopping outflow of aqueous humor → self evolving as pressure inc. can be precipitated by dilating (mydriatic) drops, emotional upset, sympathomimetic and anti-cholinergic drugs (basically anything that makes pupil constrict fast)

deep boring pain thru to brain, HA, NV, photophobia, rainbow colored rings or “halos” around bright lights. dec visual acuity, injected conjunctiva, steamy/cloudy cornea, fixed mid-dilated pupil, intraocular pressure over 30

acute angle glaucoma tx

drops = timolol or pilocarpine to dilate pupil

PO= acetazolamide, osmotic diuretics

iritis and uveitis sx and tx

consensual photophobia (light shining in unaffected eye hurts), red sclera

optho consult and theyll do intraocular steroids

episcleritis sx and tx

sector of eye involved w pain and FB sensation (only part of sclera is bright red)

normally self limiting, lubricating drops and optho consult, (ocular NSAIDS usually only after optho consult)

scleritis sx and tx

eye pain, vasculitis, common in healthy 20-40yo, deeper sector involvement w violaceous hue, bright red sclera w a ton of vascularity, very tender eye w pain during EOM use and painful to touch closed eye. normal vision, no trauma

oral NSAIDS and optho f/u after d/c

sudden mononocular vision loss that has a cherry red spot on fundoscopic exam caused by retinal artery not getting enough blood

central retinal artery occlusion

central retinal artery occlusion tx

rebreathe CO2 for arterial dialtion, gentle eyeball massage, IOP lowering drugs (timolol, acetazolamide), call optho stat (bc retina gets irriversible damage in 90 min)

rapid progression of vision loss that can get really bad super fast. will see blood and thunder fundus on fundoscopic exam bc retina getting too much blood. call optho stat

central retinal vein occlusion

retinal detachment sx (call optho stat, will prob need eye injections/surgery)

painless bright lights, dec visual fields (curtain drops over eyes), visual floaters possible visible on red light test, hazy grey billowing retina on exam

causes of 60-90% of periorbital cellulitis cases

sinusitis spreading into surrounding tissues (can progress to meningitis)

periorbital cellulitis sx

pronounced periorbital edema (usually one sided), NO VISION CHANGES OR PAIN W EXTRAOCULAR MUSCLE USE bc its not affecting muscles/nerves yet (also means we gotta open the eye and check these things to make sure)

periorbital cellulitis tx

CT of orbit and sinuses to r/o orbital cellulitis, must open to examine eye, treat w PO abx and follow closely

spread of infxn into actual orbit

orbital cellulitis

orbital cellulitis sx

edematous lid, proptosis (eye looks pushed out bc infxn behind it pushing), PAINFUL EXTRAOCULAR MUSCLE USE, diplopia, vision LOSS

orbital cellulitis dx and tx

CT scan orbit and sinuses, CBC, cultures, maybe lumbar puncture, must open eye to examine

IV abx and optho consult

corneal abrasion sx and tx

pain and FB sensation, NO vision changes, often can recall moment abrasion occured, abrasion visible w fluorescein uptake

tx w abx drops, no contact use till healed

globe penetration sx

pain and FB sensation, very decreased vision

seidel sign = leaking aqueous humor washes off fluorescein looks like waterfall

globe penetration tx

do NOT put pressure on the eye, do NOT remove the impaled item if its still there, cover both eyes so they dont move (if you remove it youll start leaking aqueous humor)

CT orbits, protect glob and call optho

orbit trauma resulting in orbit fracture entrapping inferior rectus and orbital fat, often from baseball/softball/MVA/fist

blowout fracture

blowout fracture sx and tx

inability to move eye upwards (upward gaze palsy)

CT orbits, optho consult stat, tx like open fx

otitis externa infection that extends into underlying tissues and possible skull persistent otitis externa despite 2-3wks of topical antimicrobial therapy should be suspect for this

malignant otitis externa

malignant otitis externa dx and tx

CT or MRI to confirm (looking for inflammation/infxn)

tx w IV abx (can lead to acute mastoiditis)

otitis media infxn that spreads to mastoid air cells. will have postauricular erythema, swelling, tenderness with protrusion of the auricle adn obliteration of the postauricular crease (ear pushed out)

acute mastoiditis

acute mastoiditis dx and tx

confirmed w CT or MRI

IV abx, myringotomy, and tympanocentesis

caused by trauma to the ear sheering blood vessels from cartilage to skin. must remove the fluid collection and maintain pressure in teh area for several days to prevent reaccumulating of fluid. if fluid not removed will result in permanent cauliflower ear

auricular hematoma

how do we tx an insect in the ear

kill insect by pouring lidocaine into ear canal → attempt to remove w forceps or flush out w saline esp if oyu think TM may be injured → examine canal and TM for damage → abx to prevent infxn from scratches

how do we treat anterior epistaxis (wayyyy more common)

first try afrin (aka oxymetazoline, causes vasoconstriction) → lido w epi covered packing → chemical cautery w silver nitrate → rhino rocket (void if possible bc they have to leave in until they see ENT, possibly days later)

how do we treat posterior epistaxis (way more severe and rare)

often coming out of BOTH nostrils and mouth, can be hard to control adn lead to death due to size of vessels and difficulty to control

can attempt rhino rockets or foley cath to apply posterior pressure (rhino rocket stays in until ENT f/u)

how do we treat a closed nasal fracture

tx as potentially open fx, refer to ent w/i 6-10d. PO abx to possible internal skin injury resulting in open fx that cant be seen

how do we treat a grossly open nasal fx

emergent ENT consult

must be ruled out in all facial and nasal trauma cases. if present must incise adn drain to avoid ischemic necrosis of the nasal septum and f/u w ENT (inject lidocaine then poke w scalpel to drain)

nasal septal hematoma

how do we tx a nasal foreign body

attempt to remove (use forceps, parents blowing into kids mouth w their other nostril covered, may attempt to pass a foley cath past it, inflate, and then pull to remove)

place on abx post removal for organic material thats been there a while

how can we tell if a pt has bacterial sinusitis

purulent nasal secretion and severe sx for 7 days +, or double worsening or unilateral pain (pain was bad → got better → then got really bad bc now its bacterial)

can do XT w contrast for abx resistant or very severe infxns

can lead to meningitis, sinus cavernosum infxn, brain abscess, or orbital cellulitis

dental pain followed by local swelling that spreads within facial plane

dental abscesses

dental abscesses dx and tx

xray or CT to ID abscess (panogram to xray whole mouth like how they do at the dentists)

possible regional anesthesia for acute pain, tx w incision f/o w dentist

abx = penicillin Vk or amoxicillin

oral infxn that spreads into bilateral submandibular spaces, crosses midline. will see submandibular space is swollen, red, and indurated (hardened). can turn into airway emergency as the swelling blocks the airway. pt will need IV abx, CT of face/neck w contrast, emergent surgical consult and we gotta prep to intubate

ludwig angina

enamel-dentin dental fractures sx and tx

sensitivity to hot or cold stimuli and air passing over the exposed surface during breathing

if pt cant f/u w dentist w/i 2d, cover w dental sealant to prevent infxn. also do abx prophylaxis (bc this is an open fx) and f/u w dentist

crown-root dental fx tx

stabilize the fx (splint behind and in front of it), dental f/u w/i 24-48hrs is important, splint for minimum 4wks. abx prophylaxis bc its an open fx

how to tx luxation injuries

caused by something hitting mouth, the same forces that cause dental fractures can result in loosening of a tooth from the attachment apparatus.

splint in place a f.u w dentist

how to tx avulsion dental fracture (tooth gone)

dental emergency to save tooth, rinse tooth less than 10 sec w sterile saline or tap water (bc hypotonic saline can damage tooth), replace tooth and splint in place, abx

sx of peritonilar abscess (collection of purulent material in tonsil)

severe sore throat, inferior and medial displacement of infected tonsil(s), contralateral deflection of swolen uvula, tender cervical lymphadenopathy, trismus (pain when opening mouth fully), muffled voice

peritonsilar abscess tx

requires drainage (prep suction, inject local anesthesia, needle aspiration = cut needles plastic sheet at 1cm, put needle into lateral tonsil and dont it the carotid!!, 1 dose IV steroids, abx for 10d)

epiglottitis sx (infection and inflammation of epiglottis leading to possible airway compromise)

3 D’s = drooling, dysphagia, distress

pts often sitting up/leaning forward, mouth open head extended, panting, drooling

epiglottitis dx

often clinical dx!! can confirm w radiographs or transnasal fiberoptic laryngoscopy (lateral cervical soft tissue radiographs shows enlarged epiglottis and thumb sign)

epiglottitis tx

prep to establish definitive airway do NOT leave pt unattended, keep them sitting up

initial tx = supplemental O2, IV hydration

IV abx, IV steroids

when does most post-tonsillectomy bleeding occur (can be fatal and needs prompt intervention w control of airway, must consult ENT immediately and apply direct pressure w tonsillar pack or 4×4 gause on long clamp)

most significant hemorrhage occurs between post op days 5-10

toxic ingestion risk factors

pmhx of depression, suicidal ideation or attempts, missing time in parents hx of events or where kid was found, report of accidental/intentional ingestion

ingestion related esophagitis sx

spectrum of issues based on amount of damage; odynophagia and dysphagia w tissue damage, N/V, abdominal apin and tenderness (if caustic enough to hurt stomach/intestines), hematemesis, coffee ground emesis, hematochezia, melena

possible airway damage adn respiratory difficulty if aspirated (wheezing, cough, SOB, respiratory distress/arrest)

AMS (bc trauma or chemical delerium)

ingestion related esophagitis dx

CXR for ANY resp problems

acute abdominal series xrays (r/o perforation, use for possible battery ingestion, must differentiate coins and batteries and remove batteries)

upper endoscopy to dx initial injury and to determine severity (injury will require repeat endoscopy to follow possible complication)

ingestion related esophagitis tx

emergent airway stabilization as needed

battery removal via endoscopy STAT

caustic liquids= NEVER induce vomiitng and NEVER use neutralizing agents bc can cause exothermic rxn and make it worse