ENT

Question 1

initial considerations when you first see the patient

(can be generalized to any visit)

Answer 1

outpatient vs inpatient vs immediate referral

sick vs not sick

Question 2

•Your patient has a locked jaw, with pain and difficulty swallowing, and malocclusion (poor bite alignment)

what do you do for this patient?

Answer 2

jaw dislocation (clinical Dx)

Anterior Dislocation Most Common
•Imaging only indicated for trauma

you can reduce this

Question 3

what are some methods to reduce an anterior dislocated jaw?

Answer 3

Method discussed in class:

Put the operator’s thumbs (pad your thumb!) over the molar teeth of the patient and push the dislocated jaw downward and backward. This maneuver takes a lot of effort and usually needs sedation.

• failure not uncommon +bite/disease transmission risk
• Method found in PubMed (ID: 17197953): via extraoral route →once the mandible is dislocated anteriorly, the coronoid process and anterior border of the ramus can be palpated easily over the cheek. By applying steady pressure over this prominent part, the anteriorly dislocated mandible can be reduced easily*

Question 4

Your patient shows:

Hx: Pruritus, pain, external ear TTP

Erythema and edema external auditory canal

Pain w/ movement of the pinna/tragus or insertion of the speculum

Likley Diagnosis and appropriate Tx?

Answer 4

This is Otitis Externa (Swimmer’s Ear)

Tx: Topical Antibiotic Drops (Ofloxacin, Cipro/Hydrocortisone) apply using a wick/gauze

Question 5

In which populations would you especially worry about MALIGNANT otitis externa (life threatening)?

Tx is hospital admit with ENT consult and IV Abx

Answer 5

Diagnosed on CT when pain out of proportion to exam or CN involvement seen

Elderly, diabetic, immunocompromised

Question 6

Top 3 organisms causing AOM?

Answer 6

Streptococcus pneumoniae

• Haemophilus influenzae*
• Moraxella catarrhalis*

Question 7

Describe exam findings with AOM.

Answer 7

Hx: otalgia, w/ or w/o fever, pain,

PE: Retracted or bulging TM w/ erythema

Question 8

What is serious complication of AOM that we always need to evaluate for?

Answer 8

Mastoiditis

PE: TTP +/- swelling over mastoid

Dx: CT

Tx: ENT consult, IV abx, +/- surgery

Question 9

Describe (presentation, PE, Tx):

Bullous Myringitis

Answer 9

→infection that causes painful blisters on the eardrum (tympanum)

Sudden onset of pain, Usually NO fever

PE: TM Inflammation w/ blebs

Tx: Analgesics, abx w/ AOM, Macrolides

Question 10

Management for a TM perforation

Answer 10

Trauma ( scuba, blow to ear, improper cleaning)

or infection?

Avoid ototoxic meds - gentamicin, neomycin, and tobramycin

Choose suspension rather than solution (later could enter behind TM and cause more damage)

Keep the ear dry. Refer to ENT for follow up if traumatic/dizziness/not healing in 2 weeks

Question 11

What should you do to prevent this (see picture) from happening in a wrestler who presents with a collection of blood between cartilage and perichondrium on his right pinna?

Answer 11

(auricular hematoma)

Tx: Aspiration or drainage of blood

Compressive dressing

Antibiotics

**. F/U every 48hours in case needs re-draining or dressing changes. Incision may help to continue to drain better than aspiration does

Question 12

Before/ After picture

What considerations in fixing this ear?

Answer 12

Use ear block so they can tolerate cleaning and repair. No EPI for ear.

Need to approximate cartilage well. Still not going to be pretty.

Question 13

What foreign bodies are you likely to find in the ears of adults?

Answer 13

• Cotton
• Hearing Aid
• Insects

Question 14

What foreign bodies are you likely to find in the ears of kids?

Answer 14

Rocks, candy, beads, or anything else that fits

Question 15

When would you not want to try to get a foreign object out of ear by flushing it out?

Answer 15

Organic matter→ may swell w/ liquids

-don’t want to make wet bc then will have to scrape out mush

Question 16

Some helpful hints discussed in class to remove foreign bodies from ear:

Answer 16

May have to swaddle kids, even if toddler to preschool (wrap in blanket so can’t flail arms). Have parents help.

Nasal suction tip works best if round object. Try sucking, flushing, scooping, whatever need to do to get out

Dermabond (superglue in with long Q-tip and let dry on object (2min) so that can withdraw object). **2 min is an eternity to hold child still

Question 17

Two types of nosebleeds (epistaxis) and which is most common, most serious?

Answer 17

1. Anterior nosebleeds (90+%)

-Kiesselbach’s Plexus (Nose picking zone). Causes: Trauma, FB, picking, tumor, lack of humidity, oxygen

2. Posterior nosebleeds (serious, needs w/u)

-Blood pouring down throat, not coming out front OR blood pouring out nose but you don’t see any anterior source

Question 18

Management of a nose bleed that isn’t stopping:

Answer 18

Have blow nose very hard (get blood out)→use afrin,→use lidocaine with epi to help vasoconstrict, soak packing material in aminocaproic acid (busts clot), silver nitrate to cauterize anterior plexus

Quick clot is coated to help stop bleeding→may stop bleeding well enough that don’t need to pack nose (RTC precautions and tell not to blow nose)

Pack with “rhino rockets” Moisten with water→tell pt not going to like, but will stop bleeding, expand balloon until pt tells to stop (bc can’t tolerate)→inflate a bit more 5min later. Want to put in straight back (towards ear at slight angle). Longer packing available if posterior bleed.

Don’t have balloons small enough for kids

Question 19

W/U for posterior epistaxis:

Answer 19

• ABCs
• IV access
• Labs - CBC, Type and Screen, Coags
• Packing
• ENT Consult
• Observation

**admit if would have to pack bilaterally as pt won’t tolerate this

Question 20

How would you treat this?

(nasal Fx)

Answer 20

• Good H &P
• R/o Septal Hematoma
• Imaging not always needed
• Ice, Analgesics
• F/U w/ ENT
• Warn patients about ecchymosis/swelling

►reduce once swelling goes down in a few days

Question 21

What is this and how is it treated?

Answer 21

SEPTAL HEMATOMA

Can affect airway

May cause deformity/damage to the cartilage

Tx - drainage (Let patient decide if wants to numb, or if just wants you to try to do quickly without local anesthesia)

⇒ENT follow up

Question 22

Describe the modified “parent’s kiss” method to remove a foreign body from a child’s nose.

Answer 22

https://www.youtube.com/watch?v=Smr0wcXJnbo

Occlude nostril without FB, put a straw in child’s mouth and have mom/dad blow hard into the straw (item should come shooting out— hopefully.)

Question 23

Describe Sx of sinusitis and complications that need to be ruled out.

Answer 23

Sx: Congestion, facial pain, pressure, nasal discharge, dental pain, +/- fever

Complications (need to R/O):
•Meningitis, cavernous sinus thrombosis, abscess, orbital cellulitis, osteomyelitis.

Question 24

How would you diagnose/ Tx sinusitis?

Answer 24

Clinical Dx.

Tx: Supportive - decongestants - Afrin, Pseudoephendine (get with phenylephrine)
•Abx after 10 days or looks ill

Question 25

What Sx do patients with cerum impaction usually have?

Answer 25

hearing loss, pressure/pain, tinnitus

Question 26

What is a **Le Fort fracture**? What do you need to do if you find this/these?

Answer 26

Fractures of the midface, which collectively involve **separation of all or a portion of the maxilla from the skull base**. This requires **a lot of trauma**, so think about brain bleeds, **CSF leaks**, etc

Question 27

Below are all the places might Fx jaw. When would you treat one of these fractures with Abx?

Answer 27

comminuted mandible fractures ## Footnote *comminuted= A fracture in which a bone is broken, splintered, or crushed into a number of pieces.*

Question 28

What do you need to worry about with someone who got punched in the eye?

Answer 28

**Orbital Fx**→ inferior/medial portion is weakest /most likely to break Consider **globe injury** Document **EOM** →entrapment= tethered extraocular muscle Phone a friend (ENT vs plastics) Abx, Analgesics, Follow up

Question 29

When do you refer to dentist for dental trauma (and how urgently)?

Answer 29

- Enamel Only: refer for outpatient dental follow up - Through dentin: cover with Dycal and f/u within 24 hours - Exposed Pulp: immediate dental referral and start antibiotics *(can be hard to get pt in immediately, so you need to make some phone calls on his/her behalf)*

Question 30

What is a good management option for someone who comes into ED (especially on weekends/evenings) with DENTAL pain?

Answer 30

Offer nerve block (tell pt have something that can instantly take away pain with nerve block)→ if med seeking will say afraid of needles and want dilaudid 2 types of **nerve blocks: infraorbital & menta**l

Question 31

What do you need to do for this oral abscess?

Answer 31

Drain Antibiotics Dental Follow Up

Question 32

What do you need to do for this patient?

Answer 32

1. Decide if is Thrush or leukoplakia * Hx of abx use, or is this 30pack year smoker that worried about oral cancer*? leukoplakia CANNOT be scraped off 2. Treat appropriately: Fungal infection (candida): Antifungal rinses→Nystatin, Lozenges→Clotrimazole leukoplakia: usually benign, but can occur next to cancers, so refer patient to dentist

Question 33

What two (categories) of things commonly cause parotitis?

Answer 33

**Infections:** Staph, TB, paramyxovirus (mumps), many other viruses (other viruses won't cause epidemics) **Blockage** - stone, mucous plug, lymph node (+/- with infection) →an image can show if parotid gland is blocked by a stone

Question 34

Treatment for Parotitis:

Answer 34

Depends on cause. * supportive care * sialogogues (something to make salivate), * +/- antibiotics, * +/- stone removal

Question 35

**Centor Score:** who to treat based on likelihood of strep infxn **Fever** (+1) **Exudates** (+1) **Cervical LAD** (+1) **Absence of a cough** (+1) **Age \< 15** (+1) **Age \> 44** (+1)

Answer 35

0-1 Points - Nothing (\< 10% GAS) 2-3 Point - Test (15- 30% GAS) \>4 - Treat (\>50% GAS)

Question 36

Potential (rare) consequences of not aggressively treating strep pharyngitis:

Answer 36

rheumatic fever guttate psoriasis post-streptococcal glomerulonephritis

Question 37

Describe presentation and treatment for a peritonsillar abscess.

Answer 37

**Sx**: Severe Sore Throat, Trismus (“lock jaw”), Uvula Deviation, Asymmetric Swelling, Muffled Voice **Tx** - Drainage, antibiotics, steroids, ENT consult/follow up

Question 38

Pearls for draining a peritonsillar abscess:

Answer 38

Use intubating blade to hold tongue down (have pt hold this→ tell him to get as far back as can without gagging) Give Pt sucker, “Mr. thirsty”, so take care of own secretions. Frees up both your hands, keeps pt busy and helping you. Can give med to dry up secretions. Use hurricane (topical spray) and block before aspirating. Measure on CT how far to go in to drain. Use bumper on 18 gauge needle so can’t go too far in and can’t hit carotid. Call ENT→pt with peritonsillar abscess and you have drained it. They will love you for not having to come in emergently→ since drained, can see next day Post-drainage:→give dexamethasone and abx. Usually do not have to re-drain.

Question 39

Presentation of **Ludwig’s Angina:** often in pt's with DM or immunocompromised usually after mouth injury or tooth abscess

Answer 39

* Pain/swelling to floor of mouth, describe "fullness under tongue" * Difficulty with speech * Trismus * Neck Pain/Swelling * Redness * Tongue deviation * Fever/Chills * "sniffing" position **\*\*Tx - IV Abx, admit**, ENT consult

Question 40

Your patient has a "thumbprint" sign on x-ray. ## Footnote He also has: Drooling, dysphagia, +/- fever, stridor - Muffled, HOT POTATO VOICE - Sore throat, rapid progression - SICK appearance **What SHOULD you do and what should you NOT do?**

Answer 40

***Epiglottitis**, caused by Haemophilus influenzae type B* Things you DO: **ENT/Anesthesia consult**→possible intubation, **keep patient calm**, turn off lights to help relax, IV fluids (nothing orally) What NOT to do: **do NOT put anything down throat** or do anything to further compromise airway

Question 41

Your 2yo patient has a "**bark-like**" **cough**, stridor, hoarseness. What is viral agent has most likely caused his **croup/laryngotracheitis**?

Answer 41

parainfluenza virus

Question 42

Describe the pathophys and Tx of croup.

Answer 42

**Pathophys**: Swelling of larynx, trachea, bronchi. Upper airway obstruction causes stridor. Because children have small airways, they are most susceptible to having more marked symptoms with croup, particularly children **younger than three years old**. usually lasts 3-5 days **Tx**: Dexamethasone, Epi, Observation, Follow up *(home or admit depends on how sick child is)*

Question 43

What **respiratory** condition, common in kids **under 2yo**, especially in **winter**, involves **coughing, wheezing, congestion, and fever** but we can only offer supportive care (nasal suctioning)?

Answer 43

bronchiolitis \*\*do admit if O₂ sats dropping during sleep \*\*can do a chest x-ray if suspcision of PNA \*\*RSV/influenza testing okay if widely circulating

Question 44

What is the most appropriate initial management for an acute peritonsillar abscess?

Answer 44

incision and drainage

Question 45

A 6 month old child in daycare is found to have an elevated temperature (38.1 C). Physical examination reveals an erythematous tympanic membrane with decreased mobility. She has significant pain. Which of the following is the best recommendation?

Answer 45

oral amoxicillin

Question 46

During a busy Saturday night shift at your local ED, a 24 y/o intoxicated male presents after being involved in an altercation with 2 other individuals. On examination you notice that the patient has difficulty looking up and is complaining of blurred vision. What do you expect to see on a facial CT?

Answer 46

Inferior orbital wall fracture

Question 47

The majority of nosebleeds originate from where?

Answer 47

Kiesselbach's plexus

Question 48

Which of the following is incorrect regarding acute sinusitis management? 1. Most patient do not require antibiotics. 2. Afrin/oxymetazoline for 3 days can be recommended for initial management. 3. Presents with facial pain, congestion, dental pain 4. CT is required to make the diagnosis.

Answer 48

CT is required to make the diagnosis. (Is FALSE for sinusitis)