Emergency Medicine > Lecture 2: EENT > Flashcards

Lecture 2: EENT Flashcards

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1
Q

What are the 3 CNs that control eye movement and their corresponding muscles?

A
  • CN3 (Oculomotor): Superior, Medial, Inferior, Inferior oblique
  • CN4 (Trochlear): Superior oblique
  • CN6 (Abducens): Lateral

Superior oblique: Down and out
Inferior oblique: Up and out

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2
Q

What can chronic use of ophthalmic drops result in?

A
  • Chemical conjunctivitis
  • Inflammatory changes to cornea
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3
Q

What oral medications increase the risk for glaucoma?

A
  • Dilating eye drops
  • TCAs
  • MAOIs
  • Antihistamines
  • Antiparkinsonian drugs
  • Antipsychotics
  • Antispasmolytics
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4
Q

What kind of eye injury requires intervention prior to PE?

A

Chemical injury

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5
Q

What is the ideal way to assess VA?

A

With corrective lenses.

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6
Q

When is finger counting or hand motion perception used for VA?

A

VA worse than 20/200.

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7
Q

What test assesses for afferent pupillary defect?

A

Swinging light test

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8
Q

What is normal IOP? When should you NOT check IOP via tonopen?

A
  • 10-20 mmHg
  • CI if globe rupture from trauma
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9
Q

How do you differentiate preseptal cellulitis from orbital cellulitis?

A

Presence of inflammatory proptosis of the eye = orbital.

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10
Q

What recent infections may suggest possible orbital cellulitis?

A
  • Ethmoid sinusitis
  • Maxillary sinusitis
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11
Q

What are the red flags for orbital involvement of an infection?

A
  • Pain with EOM
  • Chemosis
  • Proptosis
  • Increased IOP
  • VA changes
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12
Q

If we suspect orbital cellulitis in a young child who is difficult to examine, what is the ideal imaging?

A

Orbital CT w/ con

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13
Q

Management for periorbital cellulitis OP for older child and up

A
  • Augmentin or cephalexin (clinda for PCN allergy)
  • Hot compresses
  • f/u in 24-48h with oph to make sure it improves
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14
Q

Management of periorbital cellulitis for young children/severe presentation

A
  • Admit
  • IV rocephin OR (unasyn + vanco)
  • PCN allergy: FQ + metro/clinda
  • Oph consult
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15
Q

Management of orbital cellulitis

A
  • Immediate consult
  • IV abx: Rocephin or (unasyn + vanco) or (FQ + metro/clinda)
  • Topical nasal decongestant
  • Lateral canthotomy for increased IOP or optic neuropathy
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16
Q

Describe a hordeolum.

A
  • Stye
  • Acute infection of follicle or meibomian gland
  • Redness
  • Tender
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17
Q

Describe a chalazion.

A
  • Swelling d/t obstructed meibomian gland
  • Hard, non-tender
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18
Q

What are the S/S of both a hordeolum and chalazion?

A
  • Pain
  • Erythema
  • Swelling
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19
Q

How do you treat a hordeolum or chalazion?

A
  • Warm, moist compresses QID
  • Erythromycin ointment
  • Do not manipulate lesion
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20
Q

What diagnostics are indicated in bacterial conjunctivitis?

A
  • Fluorescein exam to r/o herpes, ulcers, abrasions
  • C&S if severe purulence
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21
Q

Management for bacterial conjunctivitis

A
  • Topical abx of TMP-polymyxin B
  • FQ or tobramycin for contact lens d/t pseudomonas
  • Admit for infants < 30d or hyperacute onsets.
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22
Q

What PE finding would suggest viral rather than bacterial conjunctivitis?

A

Watery discharge

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23
Q

Management of viral conjunctivitis

A
  • Cool compresses
  • Topical antihistamine/decongestant
  • Artificial tears

Much less dangerous

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24
Q

What PE findings suggest allergic conjunctivitis primarily over other etiologies?

A
  • Intense itching
  • Papillae on inferior conjunctiva
  • Watery discharge
  • Cobblestoning
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25
What diagnostic is appropriate for allergic conjunctivitis?
Fluorescein to r/o herpetic lesions
26
Management of allergic conjunctivitis
* **Cool compresses** * Antihistamine/decongestants * Artificial tears * Refer if severe or resistant | **Pretty much same as viral**
27
How does anterior uveitis/iritis present?
* Unilateral/bilateral **pain** * **Photophobia with consensual photophobia** HALLMARK * **Conjunctival injection/ciliary flush** * Miosis with poor reactivity * Diminished VAs
28
What diagnostics are appropriate for anterior uveitis?
* Slit-lamp: **keratic precipitates** (Inflammatory cells), **aqueous flares** (protein) * Hypopyon check * Fluorescein stain * IOP measurement (usually normal)
29
Management of anterior uveitis/iritis
* Cycloplegics (**dilate pupil** to keep iris from lens) * **Topical prednisolone** * Refer to oph ## Footnote Cyclogyl or cyclopentolate or **homatropine** (DOC) for cycloplegic
30
When are topical steroids NOT indicated for anterior uveitis?
* Corneal abrasion * Infectious * Elevated IOP
31
S/S of a corneal ulcer
* Pain * Redness * Tearing * **Photophobia** * **Blurry vision**
32
Diagnostics for corneal ulcer and expected findings
* Fluorescein: staining defect with **white hazy infiltrate**, iritis, and/or hypopyon * Culture ulcer
33
Management of corneal ulcer
* **Ophthalmic FQ** (ofloxacin or cipro or tobramycin) * Topical cycloplegic * **AVOID eye patching** * Consult oph for immunocompromised * **AVOID TOPICAL STEROIDS**
34
S/S of HSV keratoconjunctivitis
* Unilateral photophobia * Pain, redness * VA loss * **Preauricular LAN** * **Vesicular eruption around eye**
35
Diagnostics for HSV keratoconjunctivitis and expected finding
Fluorescein stain with **dendritic lesion uptake or geographic ulcer**
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Management of HSV keratoconjunctivitis
* Eyelid involvement: **oral antiviral** * **Conjunctival involvement: topical trifluridine** with erythromycin ointment * Corneal involvement: urgent oph consult * **AVOID topical steroids** | **If < 30d old, admit**
37
What is HZV ophthalmicus?
HZV infection of V1 of trigeminal | Ramsay Hunt syndrome ## Footnote I think of shingles entering nerves to differentiate between HSV vs HZV
38
S/S of HZV ophthalmicus
* **Painful** vesicular rash on erythematous vase involving upper eyelid and tip of nose **hutchinson sign** * Fever, malaise, HA * Red eye, blurred vision, eye pain/photophobia * Keratitis, uveitis * Elevated IOP ## Footnote Hunt at the zoo, so you know its zoster and not simplex
39
Diagnostics for HZV ophthalmicus and expected findings
Fluorescein stain showing **pseudodendrites.** | Small, no **central ulceration, no terminal bulbs,** no central stain.
40
Management of HZV ophthalmicus
* Consult * If severe: admit for IV acyclovir * Skin involvement: **Cool compresses, oral antivirals for short-term rash, topical abx** (bacitracin/erythromycin) * Ocular involvement: erythromycin ointment, **cycloplegics, opioids, cool compresses** * If anterior uveitis present: topical steroids via oph * **If occurring in patient < 40y, work up for immunocompromised state**
41
S/S of subconjunctival hemorrhage
* Bright red blood under bulbar conjunctiva * Hx of trauma by **sneeze, cough, valsalva, HTN**
42
Management of subconjunctival hemorrhage
Reassurance | 2-3 weeks to self-resolve
43
S/S of UV keratitis
* Slow onset of FB sensation and mild photophobia * **Blepharospasm**, tearing, conjunctival injection ## Footnote Foreign body
44
Risk factors for UV keratitis
* Welding * Tanning * Prolonged sun exposure
45
Dx of UV keratitis
* Slit lamp showing **diffuse, punctate corneal edema** * Fluorescein showing **punctate corneal abrasions**
46
Management of UV keratitis
* +/- eye patching * Cycloplegic, oral analgesics, topical abx
47
S/S of corneal abrasion
* Tearing, photophobia, pain * Blepharospasm * Often need topical anesthetic
48
Dx of corneal abrasion
* Look for any ocular FBs * Fluorescein
49
Management of corneal abrasion
* Ketorolac drops * Erythromycin ointment * **FQ/tobramycin for contact lens** * **DO NOT RX topical anesthetics**
50
What may occur if a FB persists in an eye > 24 hrs?
WBC ring forms in anterior corneal chamber
51
Presence of what suggests globe perforation due to corneal FB?
Hyphema or microhyphema | Do seidel test if suspected. (cobalt blue light) ## Footnote Hyphemas present with pain, subconjunctival is often painless
52
When would a CT orbit be added for suspected corneal FB?
If we think its intraocular or globe rupture
53
Management of corneal FB
* Consult **if hyphema present** * Remove FB (unless pt uncooperative or drunk) * F/u with **oph in 24h if rust ring, central FB, or deep** * f/u with oph in 48h if symptoms persist * Update tetanus
54
When would a consult for lid laceration be warranted?
* Lid margin involvement * **Within 6-8mm of medial canthus** * Lacrimal duct or sac involvement * Inner surface of lid * **Ptosis** * Tarsal plate invovement * Levator palpebrae muscle involvement (horizontal lac with ptosis)
55
Management of lid lac
* No sutures of lid margin < 1mm * Soft, absorbable/nonabsorbable 6/7-0 sutures (SMALL) * **Oral keflex** and erythromycin ointment * Cold compresses * Discharge with oph f/u in 24h
56
What usually precipitates a globe rupture?
History of high spd FB or penetrating injury
57
PE findings associated with globe rupture
* Severe subconjunctival hemorrhage * **TEAR DROP pupil** * Limited EOM * Extrusion of globe content * Seidel test (if wound is unsealed)
58
Dx of globe rupture
CT scan of orbit
59
Management of globe rupture
* **Eye shield**, NPO, upright * **Vanco + ceftazidime + zofran** (avoid IOP increases) * Emergent oph consult | zo van dime globe
60
Why should you not use fingers to examine blunt eye trauma?
It will worsen IOP
61
Complications associated with blunt eye trauma
* Ruptured globe * Postseptal hemorrhage * Hyphema * Orbital blowout fx
62
Features of orbital blowout fx
* Fx of inferior/medial orbital wall * Entrapment of **inferior rectus muscle** * **Restricted upward/lateral gaze** * Bruising around the eye
63
Dx of blunt eye trauma
CT facial bones without contrast
64
Management of blunt eye trauma
* Discharge home if normal VA and normal anatomy * **Traumatic iritis**: tx with **prednisolone acetate and cycloplegic** * Emergent Oph consult if rupture, postseptal hemorrhage, hyphema, orbital blowout, or intraocular FB
65
Approach to chemical ocular injury
1. Eye irrigation 2. Physical
66
Management of chemical ocular injury
* Cycloplegic * Opioids * Emergent oph consult: increased IOP, chemosis, conjunctival blanching, epithelial defect, corneal edema, opacification, exposure to HCl, lye or concrete
67
Which glaucoma type is acute?
Narrow angle/closed angle/acute angle closure
68
What part of the eye does glaucoma involve?
Trabecular meshwork: draining aqueous humor via anterior chamber
69
What makes aqueous humor?
Ciliary body
70
What is the characteristic finding of glaucoma on fundoscopic exam?
Cupping of the optic disk
71
Define glaucoma
Eye diseases characterized by **neuropathy to optic nerve, with or without IOP elevation**
72
What is the primary and secondary leading causes of blindness?
1. Cataracts 2. Glaucoma
73
What are the usual predisposing events to acute angle closure glaucoma?
* Exposure to dark room * Reading * Dilating agents (anticholinergics) * Cocaine
74
How does acute angle closure glaucoma present?
* **Sudden onset** eye pain * Blurred vision **colored halos around lights**, **N/V** * HA * Fixed midposition pupil * **Hazy cornea** * Increased IOP (firm eye)
75
Gold standard test for acute angle closure glaucoma
Gonioscopy showing iridocorneal angle
76
Management of acute angle closure glaucoma
1. Oph consult 2. **Supine position** 3. Pharmacologic therapy 4. **Definitive**: Laser peripheral iridotomy
77
Pharmacologic tx of acute angle closure glaucoma
1. Topical BB (timolol) and a2-agonist (apraclonidine) (block production) 2. Acetazolamide (block production) 3. **Mannitol (decrease IOP by reducing volume)** 4. Pilocarpine **once IOP < 50** to **increase outflow** | pile out the car (outflow)
78
When should acetazolamide be given IV for acute angle closure glaucoma?
* **IOP > 50** * Severe vision loss * Unable to tolerate PO
79
How does optic neuritis present (ON)?
* **Painless** vision loss * **Color vision usually more commonly affected** * VA should be altered via red desaturation test * Positive afferent pupillary defect * Edematous/swollen optic desk in anterior ON * Normal optic desk in retrobulbar ON
80
How does Central Retinal Artery Occlusion present?
1. Sudden, monocular painless vision loss (Amaurosis fugax) 2. Positive RAPD 3. Infarcted retina, pale, less transparent, and edematous 4. **Cherry red spot on fovea** 5. **Boxcarring**, segmented arterioles
81
Management for CRAO
Emergent oph and neuro consult
82
How does Central retinal vein occlusion present?
* RAPD * Optic disc edema * Diffuse retinal hemorrhages (**Blood and thunder fundus**)
83
Management of CRVO
Oph consult
84
How does retinal detachment present?
* Sudden onset of painless, monocular vision changes * **Floaters**, flashes of light, **dark veil/curtain** * Only PE changes are VA and visual field by confrontation | Bedside US can be helpful
85
Management of retinal detachment
Urgent consult within 24h ophthalmology for dilated eye exam
86
Presentation of AOE
* **Pruritis, otalgia, and tenderness** of external ear * Otorrhea and decreased hearing in severe * Erythema and edema of external auditory canal * Clear/purulent discharge * Severe cases: complete occlusion of auditory canal
87
Management of AOE
* Analgesics: tylenol/motrin * Cleansing of external canal * Otic drops: acetic acid/hydrocortisone * **Ofloxacin or ciprofloxacin drops** * Ear wick for swelling
88
When is acetic acid/hydrocortisone contraindicated in AOE? Ciprofloxacin?
* CI in **perforated TM** * CI if TM can't be seen * Cipro cannot be used in perforated TM either.
89
What red flags suggest malignant otitis externa?
* Elderly * **Diabetic/immunocompromised** * Persistent symptoms despite standard therapy * Severe otalgia/edema * **Granulation tissue on floor of canal**
90
If malignant otitis externa is suspected, what diagnostic imaging should be ordered?
CT head w/ con showing **bone erosion**
91
Management of malignant otitis externa
* ENT consult * IV **(tobramycin + piperacillin)** or **rocephin** or cipro * IV opiate
92
How does AOM present?
* Otalgia * Otorrhea, possible fever, hearing loss * TM erythema * **Retracted/bulging TM**
93
Top 3 causative organisms for AOM?
* **Strep pneumo** * H. flu * M. cat
94
Management for AOM
* **Amoxicillin** (Cefdinir if allergy) * If recent abx use or recurrent OM, augmentin/cefdinir * Analgesics
95
Presentation of acute mastoiditis
* Otalgia * Fever * **Postauricular pain** * Postauricular swelling, erythema, and tenderness
96
Dx of acute mastoiditis
* **CT head with contrast** * Mastoid clouding * Loss of bony septae * Destruction/irregularity of mastoid cortex * Perisoteal thickening
97
Management of acute mastoiditis
IV vanco + rocephin | rocking the van's mast
98
Presentation of bullous myringitis
* Severe otalgia * Intermittent otalgia * **Intact bullae along the TM and EAC** (external auditory canal) * Middle ear infusion
99
Management of bullous myringitis
Same as OM
100
Presentation of auricular hematoma
* Accumulation of blood between skin and cartilage of auricle d/t blunt trauma * Swelling, pain, and ecchymosis of auricle
101
Management of auricular hematoma
* Consult ENT: **immediate I&D** * Compressive dressing after * If left untreated, scarring and cauliflower ear
102
Management of ear FB
* Immobilize live insects with 2% lido * Use forceps or hooked probe or suction * Irrigation with warm water or saline for **non-organic objects**
103
Presentation of TM perforation
* **Hx of barotrauma** * **Sudden onset** of pain and hearing loss * +/- bloody otorrhea, vertigo, tinnitus * Rupture of TM
104
Management of TM perforation
* **Most heal spontaneous** * Uncomplicated = discharge home * Complicated = penetrating TM rupture = 24h f/u with ENT
105
Presentation of anterior epistaxis
* Visualized on external exam * MC at **kiesselbach plexus**
106
Presentation of posterior epistaxis
* Unable to directly visualize bleed * Failure to control bleeding * **MC at sphenopalatine artery** * Use nasal speculum
107
108
Management of epistaxis
* Type and crossmatch blood if hemodynamically unstable, which is **MC in posterior bleed and pts taking AC** * Place in sniffing position * **Direct pressure** application w/ intranasal vasoconstrictor ## Footnote Oxymetazoline or phenylephrine
109
Chemical management of anterior epistaxis
* **Utilize after 2 failed attempts** of direct pressure with **visualized vessel** * Anesthetize with 3 swabs soaked in 1:1 of **oxymetazoline and lidocaine** * Apply **silver nitrate stick** ## Footnote CI in active hemorrhage, bilateral bleeding, recent cauterization
110
If chemical cautery fails for epistaxis tx, what else can we do?
* Thrombogenic foam * Oxidized cellulose * Floseal gelatin matrix * **Nasal packing** via balloon, tampon, or ribbon packing.
111
Among the 3 nasal packing options, which is the **absolute last resort** and why?
**Ribbon gauze**, due to its difficulty in usage and comfort.
112
In posterior epistaxis, chemical cautery cannot be used. What is the alternative to posterior nasal packing?
Catheter with balloon.
113
When are prophylactic abx indicated for nasal packing? What is the abx?
1. Indicated for **packing > 48h** 2. **Augmentin** (cephalosporin or bactrim) | Ideally, ENT removes it in 2 days. ## Footnote Advise pt to not take any **NSAIDs** for 3-4d Its like txing sinusitis in case
114
Centor criteria symptoms and purpose
1. Age 2. Tonsillar exudate 2. Tender Anterior cervical LAN 3. Absence of cough 4. Fever 5. **Purpose: Whether pharyngitis is due to strep and how to manage.** | Young age is +1, middle is 0, old is -1
115
What specific symptoms suggest **Viral pharyngitis**?
* Cough * Rhinorrhea * Nasal congestion * Vesicular lesions | Viral URI symptoms
116
What specific symptoms suggest **bacterial pharyngitis**?
* Tonsillar exudate * **lack of cough** * Anterior Cervical LAN * Sore throat | MCC: Strep pyogenes (GAS)
117
What centor score should you start to maybe consider a rapid strep?
At least **2 or more** | Optional beginning at 2
118
Tx for viral pharyngitis and bacterial pharyngitis
* Viral: Supportive * Bacterial: **Single dose of PCN G or amoxicillin** 500mg 10d BID (keflex/cefdinir)
119
Patient education for pharyngitis
* Change toothbrush * **Not contagious after 24h of tx** * Self-resolving in 2-3 weeks but will remain contagious without tx.
120
What S/S suggest peritonsillar abscess?
* **Hot potato voice** * Odynophagia/dysphagia * **Contralateral deflection of uvula** * Drooling * Unilateral tonsillar enlargement * Fever
121
Dx of peritonsillar abscess
* **Clinical**, but if needed: * Intraoral U/S to differentiate cellulitis from abscess * CT con of the neck (Not C-spine)
122
Management of peritonsillar abscess
* Needle aspiration or I&D * Non-toxic: **PCN VK + metro** for 10d if PO tolerable. (clinda/metro) * **Toxic: sepsis w/u with Zosyn** | Mouth + anaerobe coverage
123
S/S of a retropharyngeal abscess
* **Muffled voice** * **Cervical adenopathy** * **Respiratory distress** key differentiating factor from peritonsillar abscess * Stridor * Neck pain/torticollis
124
Dx of retropharyngeal abscess
* Neck XR: Thickening and protrusion of retropharyngeal wall * **GOLD STANDARD TEST: CT NECK w/ con**
125
Findings seen for retropharyngeal abscess via CT Neck w/ con
* Early: nonsuppurative edema, mild fat stranding, linear fluid, minimal mass effect. * Later: **Necrotic nodes**, **low attenuation, ring enhancement**
126
Management for retropharyngeal abscess
* **Prep for airway placement** * IVF + NPO * IV **clinda/cefoxitin** (zosyn or unasyn)
127
S/S of epiglottitis
* Progressive dysphagia, odynophagia, dyspnea * **Tripoding** * **Anterior neck tenderness** (larynx/upper trachea) * **Tachycardic**
128
Dx of epiglottitis
* Neck XR: **thumbprint sign** * **transnasal fiberoptic laryngoscopy is gold standard**
129
Management of epiglottitis
* Prep for airway * Humdified O2, IVF * IV **cefotaxime + vanco** (respiratory FQ) * IV methylprednisolone 125mg | Tax the meth van with 3 wheels (tripoding) ## Footnote Bacterial etiology
130
Etiology of odontogenic abscess
Extension of dental abscess into retro or parapharyngeal spaces or floor of mouth.
131
S/S of odontogenic abscess
* **Hx of dental pain/abscess** * Erythema/edema of labia/buccal gingiva or intraoral (tooth abscess) * Ludwig's angina (trismus, fever, edema of floor, displacement of tongue) * Retro-parapharyngeal abscess: sore throat, dysphagia, dyspnea
132
Dx of odontogenic abscess
* Beside US if superficial * CT Neck w/ con if deep
133
Two main complications of odontogenic abscess
* **Ludwig's angina**: cellulitis of sublingual/mandibular space = **verify airway** * Necrotizing infection: **toxic appearance w/ hemodynamic instability** = **surgical fasciotomy** ASAP.
134
Management of odontogenic abscess
* Non-toxic & superficial: **Oral PCN VK or amoxicillin** 500mg TID x10d (clinda) * Toxic, deep or complication: IVF, NPO, **unasyn + clinda + cipro**
135
MC food lodged in esophagus
Meat
136
Dx of swallowed FB
* "foreign body film" for radiopaque * CT w/o con for non-radiopaque
137
What object features make obstruction risky if it gets past the pylorus?
* Irregular/sharp * Wider than 2.5cm * Longer than 6cm
138
Management of swallowed FB in distal esophagus
**IV glucagon** to relax LES and hopefully allow it to pass | Provided no red flags for obstruction
139
Management of food impaction, coins, or sharp objects swallowed
* Emergent endoscopy * Consult sx
140
Management of swallowed battery
1. **If in esophagus, REMOVE ASAP** 2. If in stomach, f/u in 24h 3. Takes 48-72 hrs to pass
141
Management of swallowed narcotics
1. **NO endoscopy** 2. Admit for obs until it reaches rectum
Emergency Medicine
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