242. Complications of Airway Devices

Diseases/Disorders

Tube Change: Do not try to change if < 7 days old due to possible false passage creation. Do not need to rush the procedure. Stable patient can easily breath through the stoma. Use an obturator to minimize soft tissue damage though when placed, quickly remove the obturator. Lay patient supine when doing procedure. Can consider using suction catheter as a sort of bougie if needed. Inner cannula is in place (usually not on pediatric patients) to allow clearance of secretions. Cuffed tubes used if patient is usually placed on ventilator.

Tube Obstruction: suction within inner cannula. If unable to, remove inner cannula checking for secretions and suction through outer cannula. If still having difficulty, use sterile saline with suction. Always try to preoxygenate before doing so.

Tracheostomy Site Bleeding: could be due to granulation tissue, thyroid vessel erosion, the trachea wall, or the innominate artery. Slow local bleeding can be controlled with silver nitrate. If heavy bleeding, place cuffed tube below site of bleeding.

Tracheoinnominate artery fistula: due to pressure against artery causing erosion or from overinflation of the cuff. Usually in first 3 weeks of trach (peak at 1-2nd week). 50% will present with sentinel arterial bleed or hemoptysis. If massive bleeding, need to hyperinflate the cuff. If that doesn’t work, consider passing ETT past area of bleeding and then holding direct digital pressure against manubrium of the sternum until able to take to OR.

Tracheal Stenosis: usually due to scarring. can be seen on xray. temporizing treatment includes humidified oxygen, racemic epi, steroids. ENT consult for rigid bronch and laser excision may be required.

Passy-Muir valve: one-way valve that fits over uncuffed trach tube and allows forced exhalation to obstruct trach causing air to go up to vocal cords. If having a problem with it, just remove the valve.

Tracheoesophageal prosthetic valve: placed valve in fistula created between trachea and esophagus so with forced exhalation can allow speaking. If opening is too large, can place foley temporarily. At increased risk for aspiration if fistula is too large.

References

Tintinalli, Seventh Edition, Chapter 242: Complications of Airway Devices

242. Complications of Airway Devices

241. Infections and Disorders of the Neck and Upper Airway

Diseases/Disorders

Viral pharyngitis: petechial patches, rhinorrhea; usually does not have tonsillar exudate or adenopathy. Usually rhinovirus. Consider influenza, mononucleosis or acute retroviral syndrome. Mono: caused by EBV, 25% will have false negative monospot. Tx with amoxicillin/ampicillin causes maculopapular rash. CMV/HSV6 can cause similiar presentation. Acute retroviral syndrome occurs in 90% for HIV patients – looks alot like mono.

Group A Streptococcus: headache, nausea, vomiting are common. Center criteria: tonsillar exudates, tender anterior cervical adenopathy, no cough, hx/o fever. Consider abx use if has 3-4 or 2-4 and + test. If only 1 factor, no further testing needed. Tx: IM 1.2million PCN G or 500mg PO BID/TID x 10 days. Macrolide resistance coming up on 10%. Single dose dexamethasone decreased pain and shorter duration of pain in moderate/severe cases. Group C and G Strep don’t cause rheumatic fever and if patient clinically is improving, no need to tx. Tx helps reduce risk of RF and PTA, not for glomerulonephritis.

Peritonsillar Abscess: polymicrobial. Fluid between tonsillar capsule and superior constrictor and palatopharyngeus muscles. Fever, sore throat, trismus, muffled voice, uveal deviation. Tx: I&D or needle aspiration. 90% will be successful treated with simple I&D. 18g needle no more than inserted 1 cm midway between base of uvula and maxillary alveolar ridge just lateral of tonsil. Antibiotics: Augmentin 875mg BID, PCK 500mg QID + Flagyl 500mg QID, or clindamycin 150mg QID. Single dose steroid (Solumedrol 125mg) improved pain and severity. Need 24hr f/u after aspiration.

Epiglottis: use to be H.flu, though with vaccines, now most common causes are strep, staph, virus, fungi. 25% still H.flu type b. 3 Ds: drooling, dysphagia, and distress less common now. Inspiratory stridor. Lateral cervical xrays can help with the ‘thumbprint sign” – swollen epiglottis. Vallecula sign: on lateral neck xray with pt’s mouth closed, trace tongue down to hyoid level, locate epiglottis and airpocket extending nearly to the hyoid – vallecula should be deep and roughly parallel to pharynotracheal air column. Tx: ENT consult and prepare to emergent airway. Humidified oxygen helps decrease risk of sudden airway blockage. Consider cric if needed. Abx: ceftriaxone 2g IV or Ampicillin-sulbactam, cefoxtaxime, piperacillin-tazobactam. Steroid help decrease edema (solumedrol 125mg).

Retropharyngeal Abscess: in kids related to abscessed lymph node. In adults, usually extension of something like Ludwig’s angina so usually extends into mediastinum. Strep viridans/pyogenes, though usually PMN/anaerobes. Sore throat, fever, torticollis (twisting neck) and dysphagia, neck extended. CT soft tissue neck imaging study of choice. Lateral cervical xray (deep inspiration with neck extended) will show thickening/protrusion of retropharyngeal wall (should be <7mm at C2, <22mm at C6 in adults and < 14mm in kids). Tx: ENT consult (usually requiring surgery) and IV abx (clindamycin 600-900mg, cefoxitin 2g, Unasyn or Zosyn.

Lemierre’s Syndrome: oropharynx infection, + blood cx/bacteremia, IJ thrombosis and 1 metastatic infection. Tonsillitis that turns septic. Diagnosis by phlebitis of internal jugular vein. Caused by Fusobacterium necrophorum. Tenderness in sternocleidomastoid region of neck. Pulmonary involvement in 80% of cases.

Ludwig Angina: rapid cellulitis/infection of the submental, sublingal and submandibular spaces bilaterally. Usually due to dental infection. Upper neck/floor of the mouth swelling. Usually requires definitive airway since systemic abx can sometimes take a week to fully resolve the swelling. Ask patient to extend tongue past vermillon border of upper lip – if able to do this, unlikely sublingual space involved.

Neck Masses: Squamous cell carcinoma is most common cause of cancer in the neck – RF include smoking/alcohol use. Mucoceles and mucus retention cysts can form. Ranula: sublingual mucus retention cyst. Plunging ranula occurs when it extends into mylohyoid muscles. In adults > 40yo, lateral neck masses that persist > 6 weeks are malignant in 75% of cases. Branchial cleft cyst: painless fluctant masses anterior to anterior border of sternocleidomastoid muscle. Enlarge after sinus infection.

Posttonsillectomy Bleeding: 1-6% after tonsillectomy. Half require surgical intervention. Most bleeding occurs at day 5-10 post-op due to sloughing of fbrinious debris. Higher risk the older you are. Keep head elevated, consider apply gauze pack with soaked thrombin/1% epi. Consider running suture through pack and taping to face to make sure patient doesn’t aspirate the gauze. Can also consider silver nitrate.

Recurrent respiratory papillomatosis: earlier in very young or in your 20s (due to STD). Due to HPV 6/11. Wartlike lesions without ulceration near glottis. Can cause stridor/hoarseness.

Angioedema: 4 types: 1) Hereditary angioedema caused by C1 esterase inhibitor deficiency. AutoDom. Diagnosed by measured C1 esterase inhibitor level. Cinrye, C1 inhibitor approved for use for prophylaxis for known hx. FFP can help though some pts can get more edematous with FFP. ACE inhibtors and estrogens can increase risk of attacks. 2) Angiotensin-converting enzyme inhibitor-induced angioedema: usually within first month of use. More common in blacks. Medication causes increased bradykinin. Other types: immunoglobulin E-mediated type I allergic reaction and idiopathic. Tx: for severe cases, give epi 1:1000 IM 0.3mg max or consider giving racemic epi at same dose. Give every 15-20min. Also give benadryl 25-50mg and high dose steroid (for later rebound swelling). Isolate uvula edema can be early sign of angioedema. If mild, given decadron 4mg IV/PO as single dose.

References

Tintinalli, Seventh Edition, Chapter 241: Infections and Disorders of the Neck and Upper Airway

CrashingPatient.com, Scott Weingart, Ear, Nose, and Throat ENT

 

241. Infections and Disorders of the Neck and Upper Airway

240. Oral and Dental Emergencies

Anatomy

Diseases/Disorders

Teething: either primary or deciduous teeth. Irritability, drooling, decreased oral intake. Fever/diarrhea not necessary associated with it.

Pericoronitis: infection/inflammed operculum (gingiva above erupting third molar/wisdom tooth). Tx like most dental abscess: PCN VK or clindamycin.

Dental caries: enamel breakdown; cold/sweet sensivity. If deep enough into the dentin, can get into pulp and cause irreversible damage. Tx for irreversible pulpitis or pulpal necrosis is root canal or extraction.

Periodonitis: extension of infection into surrounding gingiva/tissue. Can form dental abscesses. Tx: PCN VK 500mg QID/Clindamycin 300mg QID.

Dry Socket: postextraction pain (usually lasts 12-24 hrs with ice/NSAIDs) or postextraction alveolar osteitis – second/third day postoperative day – usually due to clot displacement. Xray may show retained root tip. Tx: irrigate socket, dry area with dry gauze and eugenol ribbon gauze. Should have immediate pain relief. Tx: PCN VK or Clindamycin, daily packing changes.

Postextraction Bleeding: usually just needs firm packing for 20 minutes. If not, apply surgicel or can consider suture to loosely close gingiva. Consider lido/epi or silver nitrate as well.

Periodontal Abscess: infection between tooth and socket. Tx: I&D if necessary, abx, warm saline rinses.

Acute Necrotizing Ulcerative Gingivitis: “Vincent dx/trench mouth”. gingiva ulceration that can lead to bone and tissue destruction. Triad: pain, ulcerated/punched-out papillae, gingiva bleeding. Similiar presentation to herpes gingivostomatitis. Usually anaerobic bacteria. RF: HIV. Tx: chlorhexidine 0.1% oral rinses BID, debridement, metronidazole 500mg TID.

Trigenimal neuralgia: age 30-60yo, primarily women, maxillary branch of CNV. Severe electric shock-like paroxysmal pain, short duration. Unilateral. Can be triggered by touching point. Consider ruling out: acoustic neuroma, cerebral aneurysm, nasopharyngeal carcinoma. Tx: carbamazepine 100mg BID (up to 1200mg daily). Also can receive phenytoin,gabapentin, oxcarbazepine, baclofen. Neurology referral. Surgery for refractory cases.

Trigenimal Nerve

Oral Candidiasis: white pseudomembranous curd-like plaques that can be scraped off to show red base. RF: extremes of age, dentures, antibiotics, AIDS. Tx: nystatin oral suspension 500k units swillow and swallow QID, clotrimazole 10mg troches 5x/daily, or fluconazole 100mg PO daily.

Aphthous Stomatitis: “canker sores”, labial/buccal mucuosa, erythematous macule that ulcerates and forms central fibropurulent eschar. Self-limited, usually resolves in 10-14 days. Major/minor forms – major is deeper. Due to unknown trigger: could be immune, breach to mucosal barrier, allergic reaction. Tx: Fluoconionide 0.05% gel applied topically; can also do betamethasone syrup of 0.01% dexamethasone elixir as mouth risnse. Resistane can require steroid injection.

Herpes Simplex: type 1/2 indistinguishable. Fever/adenopathy a few days before it occurs; burning/tingling can occur as well prior to vesicles erupt.  Painful,  ulcers that rupture over 1-2 days, then heal over 1-2 weeks. Kids: acyclovir 75mg/kg/day divided into 5x daily (max 2g/daily) x 7 days. Adults: acyclovor 400mg TID/5x daily x 5 days or valacyclovir 2g PO daily x 1 day.

Varicella-Zoster: unilateral, can present as headache/toothache. 15-20% shingles present as trigenimal distribution. Ophthalmic branch requires urgent optho consult.

Herpangina: coxsackievirus group A; usually summer/fall, presents with fever, sore throat, headache, fatigue and oral vesicles in back of mouth sparing the tongue, bucca, gingiva. Lasts 10 days.

Pyogenic granuloma: increase in granulation tissue usually due to trauma/irritation. Can occur in pregnancy and usually resolves post-partum.

Gingival hyperplasia: medication reaction, well known to phenytoin. Also: cyclosporine, CCB. Can bleed easily if inflamed. Worse with poor hygiene.

 Benign Migratory Glossitis: “geographic tongue”, affects 1-3% of population, usually females. Multiple, well demarcated zones of erythema on tongue caused by atrophy. Benign, self-limited. Usually asymptomatic, can be related to stress/menses.

Oral cancer: 90% squamous cell cancer. RF: tobacco use, alcohol use, sunlight. MC site posterolateral border of tongue. Floor of the mouth is 35%. Usually painless. Fixed, adenopathy.

Dental fractures: Ellis classification (most dentists don’t use): I: enamel portion only, no tx necessary. II: dentin involved, requires intervention. 70% of fractures. Patients usually have hot/cold stimuli – look for exposed dentin – creamy yellow color. If not treated, can lead to pulp necrosis. Needs dental cement. Can also consider using dermabond. III: pulp exposure – blood present. Tx: cover pulp with calcium hydroxide base and then cover with dental cement. Most unless very small will require endodontic or root canal therapy. Root fractures – place in splint and refer.

Tooth concussion: tenderness with percussion. No stabilization needed.

Tooth luxation: subluxation is mobility without any displacement. Luxation is displacement requiring splinting. Splinting: firm, gentle pressure will reposition tooth. Flexible wire splint or temporarily splint with noneugenol zinc oxide peridontal dressing (Coe-Pak, ZONE periopak). Need to see dentist or oral surgeon within 24 hours.

Tooth avulsion: Permanent teeth need to be reimplanted ASAP (within 2-3 hrs). Rinse with sterile water, replace into socket. If need to transport, place in Hank’s solution, sterile saline, milk, or saliva. Consider looking for aspirated tooth that was swallowed. Do not scrub the tooth. Prepare socket by removing clot and irrigating. Local anesthesia usually required. All patients need abx: doxycycline 100mg PO or PCN VK. Do not reimplant avulsed primary tooth in kids.

Tongue lacerations: approximate wound edges on the dorsum of the tongue very precisely – may result in epithelial cleft and bifid appearance.

Lip lacerations: through lip border need to have vermillion border sutured first. Sutures usually removed in 5 days.

Frenulum lacerations: maxillary labial frenulum or lingual frenulum do not require sutures.

References

Tintinalli, Seventh Edition, Chapter 240: Oral and Dental Emergencies

Crashingpatient.com, Scott Weingart, Oral Medicine and Denistry

240. Oral and Dental Emergencies

239. Nasal Disorders

Diseases/Disorders

Epistaxis: Kisselbach plexus is series of arteries joined to form anterior nasal septum blood supply, 90% of nose bleeds. Most posterior nose bleeds are splenopalatine artery. Causes: trauma, nasal septum, chemical irritants (intranasal steroids, nasal cannula), rhinosinusitis, blood thinners. Some authors think severe acute elevated BP can prolong hemorrhage, though its recommend to not tx BP until hemorrhage controlled. Diagnosis for posterior hemorrhage determined once anterior bleeding treatment has failed.

Treatment Options:

Direct Pressure: have patient blow out clot to allow topical vasoconstriction to reach mucosa. Instill oxymetazoline or phenylephrine and then hold direct pressure – hold for 10-15 minutes.

Chemical Cauterization: need to have direct visualization of bleeding vessel. Apply silver nitrate sticks just proximal to bleeding source in anterior nasal septum. Needs to be bloodless field. Never do chemical cautery to both sides of septum.

Thrombogenic Foams/Gels: Before packing, consider placing Gelfoam or Surgicel – bioabsorbable, no removal necessary. Floseal is similiar, but is a syringe mixed with thrombin that you inject in to create foam.

Anterior Packing: Balloons (Rapid Rhino) are more comfortable than layered strip gauze/sponges. Soak with water first, then slowly inflate until bleeds stops or patient becomes very uncomfortable. Inflate with air only.

Nasal Tampons/Sponges: expand with hydration, apply abx ointment first, then apply. If it does not expand, instill 5mL NS.

Posterior Packing: can do bilateral packing or do balloon/sponge that is longer in length. Posterior packing is generally only temporary measure while waiting on ENT support. Rhino Rocket has a anterior and posterior balloon that can be inflated. Can also just use a 12-14F foley catheter with 30cc balloon (place until you can see it in the posterior oropharynx, inflate 7cc and retract until lodged in posterior nasopharynx. Add another 5-7cc and then secure to patient’s cheek. Do not inflate the whole way to prevent pressure necrosis.)

Disposition: If any packing placed, send home with staph coverage (Augmentin). ENT f/u in 2-3 days. If posterior packing required, needs admission for further treatment and monitoring.

Nasal Fractures: usually clinical diagnosis. Xrays are terrible. CTs should only be ordered if concerned about other intracranial injury or facial fracture. Periorbital ecchymosis with rest of orbit unremarkable likely related to nasal fx. Tx: If not much swelling, can consider closed reduction at bedside, though likely better for elective closed reduction within 6-10 days (though not much later than this due to possible fibrous connective tissue development). Reduction: anesthesia with infraorbital block, then intranasal mucosa anesthesia, then use surgical elevator to life depressed nasal bone anteriorly and laterally in one motion. Measure how far you should apply elevator by measuring tip of nose laterally to midline of the eye and then apply 1 cm less than that mesurement). Apply external splint afterward and consider nasal packing as well. Children nasal fractures best left to ENT f/u within 4 days.

N60-NAS_i420_L

Nasal Septal Hematoma: can occur with nasal fractures. Need urgent I&D to prevent nasal septal necrosis – leading to saddle deformity. Can also develop abscess. I&D with packing and then need to apply bilateral nasal packing to prevent reaccumulation. Needs 24hr f/u.

Nasal Foreign Bodies: Use vasoconstrictor such as 0.05% oxymetazoline, then consider 2-4% nebulized lidocaine. If able to visualize edges, use alligator or Takahashi forceps.

Sinusitis: 6 sinuses: two maxillary, two frontal and single ethmoid and frontal sinus. Paranasal sinuses not fully develop until 12yo. Acute inflammation leads to obstruction resulting in negative pressure in sinuses. Acute is usually viral. If bacterial, usually H. flu and Strep pneumonaie. Chronic due to anaerobes, GN bacteria, staph, occasional fungi in immunocompromised. Symptoms: nasal congestion, facial pain/pressure, diminshed smell, nasal drainage for < 12 weeks, sinus pressure with bending forward, changing head positions, fever. Chronic or recurrent acute can get CT sinuses to r/o invasive infection or neoplasm. Tx: supportive, nasal saline irrigation + decongestant. Oxymetazoline for 3 days to avoid rebound congestion/edema (rhinitis medicamentosa). Topical steroids can shorten duration as well. Abx can help shorten symptoms if symptoms have been ongoing for > 7 days. If goint the abx route, use amoxicillin or zpack/bactrim in PCN allergy. If received abx already, consider fluoroquinoline or high dose augmentin. If chronic sinusitis, consider ENT consult for functional endoscopic sinus surgery which can relieve obstruction.

References

Tintinalli, Seventh Edition, Chapter 239: Epistaxis, Nasal Fractures, and Rhinosinusitis

239. Nasal Disorders

238. Face and Jaw Emergencies

Diseases/Disorders

Facial Cellulitis: Staph/strep. Redness/warmth/edema/pain. CT can help r/o deep infection/extension. Tx first line with oral abx generally 7-10 days. Tx failure generally due to not covering MRSA (augmentin, keflex, etc) or not covering strep (clindamycin/bactrim).

Erysipelas: usually in lower extremities, due to strep pyogenes. Bullous erysipelas (more severe form) due to MRSA. Red, raised area with sharply demarcated, shiny. Progressives rapidly. Tx: oral abx initially, can be PCN in 100% convinced its strep, though more than likely to trat with augmentin/keflex.

Impetigo: amber crusts or fluid filled vesicles. Usually staph, strep common as well. Well localized. Tx: topical sufficient for uncomplicated cases (mupirocin, retapamulin in resisistant cases). If needing oral abx, erythromycin or cloxacillin.

Viral Parotitis: Mumps, caused by paramyxovirus, though rare with vaccination. Was common in children under 15yo. Usually URI symptoms and then swelling starts. Generally turns into bilateral swelling. Tx: supportive, contagious for 9 days after onset of parotid swelling.

Suppurative Parotitis: bacteria infx of parotid gland. Gland ducts (Stensen’s duct) exit at 2nd upper molar region. RF: recent anesthesia, dehydration, trachesostomy. Drugs: diuretics, antihistamines, TCAs, phenothiazines, beta blockers, barbiturates. Usually staph, sometimes anaerobes. Rapid, tender/red, fever, trismus (jaw pain, hard to open mouth). Tx: hydration, heating pad, sialagogues like lemon drops. Oral abx augmentin, clindamycin, or keflex + metronidazole.

Sialolithiasis: calcium carbonate/phosphate stones in the salivary ducts. 80% in the submandibular gland. Very similiar to parotiditis in clinical presentation and treatment. Can milk the stone out digitally.

Masticator Space Infection: 4 potential spaces connected together by mastication muscles. Bacteria usually from dental, trauma, injection. Strep, peptostrep, bacteroides, prevotella, etc. Typicall polymicrobial and anaerobic. Facial swelling/pain/redness/trismus. CT scan to confirm. Usually no airway involvement. IV abx usually since its a deep infection – Clindamycin; consider Unasyn, cefoxitin, PCN + metro. Erythromycin no longer recommended. ENT consult.

Temporomandibular Joint Dysfunction: pain with chewing with one or both TMJs. Masseter muscle most typically painful muscle. Tx: NSAIDs, soft foots, OMFS referral.

Mandible Dislocation: anterior dislocation MC. Usually bilateral. Promenient lower jaw, preauricular depression, pain with jaw movement. If posterior dislocation, look in ear canal. Can be clinically diagnosed, though panoramic view xray or CT scan confirm. Tx: can inject lidocaine into preauricular depression anterior to tragus and inject 2mL 2% lidocaine. Reduction Techniques: patient’s head against wall/gurney; place layers of gauze over gloved thumbs and place thumbs over occlusal surfaces of mandibular molars, place rest of your fingers wrapping around outside mandible, apply pressure downward and backward. Also can do wrist-pivot method with thumbs placed on mentum, applying upward force to rock the mandible back into place. If dislocation is open, superior, associated with fracture, nerve injury, or irreducible, OMFS consult. Dispo: discharge, soft diet, hold off against opening mouth > 2cm for 2 weeks. OMFS consult.

References

Tintinalli, Seventh Edition, Chapter 238: Face and Jaw Emergencies

Questions

Q. Whats the difference between facial cellulitis vs erysipelas? A. Erysipelas is demarcated, usually strep. Wrong answers: Impetigo symptoms, MRSA blistering, autoimmune rash with steroid tx.

238. Face and Jaw Emergencies

237. Ear Disorders

Disorders/Diseases

Tinnitus: perception of sound without sound. ‘auditory hallucination.’ Possible due to damaged cochlear hair cells. 10% due to drugs: aspirin, NSAIDs, antibiotics (aminoglycosides), loop diuretics, topical agents. Referral to ENT. Antidepressants help somewhat with idiopathic tinnitus.

Acute Otitis Externa: swimmer’s ear – pruritis, pain, tenderness over external auditory canal. Can spread to tragus and auricle. RF: frequent contact from swimming or bathing in hot tubs, pools, freshwater lakes; trauma due to scratching or disimpaction frequently. MC organism Pseudomonas, enterobacteriaceae, and proteus. Tx: nonototoxic abx such as ofloxacin and cipro have antistaph and antipseudomonas activity. Ofloxacin approved for open middle ear as well and children/infants. Instill medication with ear facing superiorly for 3 minutes. If significant edema, may need to add wick into canal. Oral abx for fever or periauricular extension.

Malignant Otitis Externa: involving pinna and soft tissues extending into skull base. 90% of the time caused by pseudomonas. RF: DM and immunosuppression. 3-4 drug therapy OE concerning for MOE. CNVII involvement first nerve to be involved if CN affected. Tx: Imipenem in children, cephalosporin or quinolone in adults. Mild cases can be managed orally while advanced stages managed with IV abx and surgical debridement.

Otitis Media: 70% of all OM were viral. MC bacteria strep pneumoniae, H. influenzae, and moraxella catarrhalis. Chronic OM due to Staph and pseudomonas. Ear pain with/without fever. TM retracted or bulging, red in color or yellow/white due to fluid. Tx: If >2yo and afebrile without severe ear pain, consider analgesia only and wait 48 hours. High dose amoxicillin is effective. Adult dose 500-875mg q12hrs x 7-10 days. If ineffective, switch to cefuroxime or augmentin. Topical analgesia (antipyrine/benzocaine) helps with pain. OM with effusion may require extended course of abx (3 weeks). Complications: perforation usually in pars tensa portion of TM – causes otorrhea. Healing occurs in 1 week though chronic perforation can occur. Hearing loss can occur, though usually resolves once fluid resorbs. Meningitis/brain abscesses can occur, due to strep and H.flu.

Acute Mastoiditis: infection spread from middle ear to mastoid cells. Ear pain and fever along with postauricular redness, swelling and tenderness with protrusion of auricle. Doesn’t necessary require CT scan for confirmation. Tx: Admission for IV abx (Vancomycin or nafcillin), tympanocentesis, and myringotomy (incision into TM).

Bullous Myringitis: bulla (blood filled blisters) on TM and deep canal. Usually supportive care only. Usually viral in origin – does not need abx most of the time.

bullousmyringitis

Ear burns: mild second degree – keep clean, apply non-sulfa containing antimicrobial (not sulfadiazine). Osteochrondritis is difiguring complication of otic burns.

Hematoma: due to lack of subcutaneous fat, perichondrium is torn from underlying cartilage and adjoining blood vessels. A subperichondrial hematoma can result in stimulation of overlying perichondrium, resulting in asymmetric formation of new cartilage growth – ‘cauliflower ear.’ Tx: remove fluid collection and maintain pressure to prevent reaccumulation. Xeroform inside pinna with dry gauze to back and front on ear with ace wrap.

Foreign Bodies: Live objects drowned with 2% lidocaine or viscous lidocaine. Use alligator forceps.

Cerumen Impaction: Can use cerumen loops/scoops, consider half-strength hydrogen peroxide, mineral oil or debrox (carbamide peroxide). Leave in place for 30 minutes to soften cerumen. If irrigation is necessary, 18g catheter with butterfly tubing and syringe – irrigate along superior portion of canal – direct toward wall of canal and not TM.

Tympanic Membrane Perforation: due to OM or barotrauma, sometimes lightning strikes. Sometimes associated vertigo or tinnitus. Heal spontaneously. Do not allow water in canal, no need for topical or systemic abx unless contamination present (ofloxacin 0.3% otic).

References

Tintinalli, Seventh Edition, Chapter 237: Common Disorders of the External, Middle, and Inner Ear

Questions

Q. Most common region of TM that is perforated? A. Pars tensa. Wrong answers: pars flaccida, malleolar folds.

Q. Picture of Bullous Myringitis. A. Wrong answers: malignant OE, mastoiditis, perforation, tinnitus.

Q. Clinical history for mastoiditis. Tx? A. Admission/IV abx. Wrong answers: topical abx, topical analgesia, oral abx, reassurance, bedside I&D.

Q. Which medication is not commonly associated with tinnitus? A. Wrong answers: furosemide, aminoglycosides, aspirin.

237. Ear Disorders

236. Eye Disorders

Anatomy

Ethmoid sinus (lamina papyracea) is medial surface of orbit. Most likely sinus wall to break with blunt eye trauma. Look for subcutaneous emphysema.

Ophthalmic artery is first major branch of intracranial portion of internal carotid artery. Ophthalmic veins communicate with cavernous sinus which don’t have valves as well.

Conjunctiva: outermost layer, thin, transparent mucous membrane. Episclera is deep to conjunctiva; contains blood vessels. Sclera is collagenous protective coating of the eye.

Physical Exam

Visual Acuity: check with eyes corrected (glasses or contacts). If unavailable, get notecard with 18g pin-hole in it (only parallel light rays to fall on macula and estimates corrected vision).

Snellen chart: 20 feet away and acuity is measured as 20/? with denominator is distance with a normal person could see those same letters. Determined by smallest line someone can read with one half of the letters correct. Rosenbaum chart can be used as near card (14 in from the patient).

Optokinectic nystagmus: involuntary horizontal nystagmus that occurs to exclude blindness in otherwise normal exam. (iPhone App; Youtube)

Visual Fields: Check 4 quadrants. If lesion is on the same side (left or right) on each eye, lesion is proximal to the optical chiasm. Bitemporal hemianopia can occur in pituitary adenoma.

Mobility: Extraocular muscles innervated by CNIII, CNIV, and VI. IV (Trochlear): innervates superiof obliquie – pulls toward the nose (inferomedially). VI (Abducens): innervates lateral rectus – pulls eye laterally. All others innervated by III (oculomotor). Diplopia is usually worse when looking in same direction as malfunctioning muscle. Monocular diplopia is usually a lens or corneal irregularity (or just malingering).

Pupils: APD (afferent pupillary defect, Marcus-Gunn pupil) usually indicated optic nerve problem. Swinging flashlight test – shine light on pupil, then shine light on opposite pupil. The opposite pupil will dilate because light is not getting thru to the CNS. Can also occur with severe vitreous hemorrhage, retinal pathology. (Youtube)

Hypopyon: WBCs in the anterior chamber. Hyphema: RBCs in the anterior chamber. Flare: headlights in the fog. Usually caused by increased protein in the chamber, usually due to inflammation (iritis).

Seidel test: streaming of fluorescein-tinged aqueous humor seen in full thickness laceration of cornea. Can be negative with small or spontaneously sealed corneal laceration.

Intraocular Pressures: Do not measure if concerned about globe rupture. Normal pressure 10-20mmHg.

Ocular Infections

Preseptal Cellulitis: infection of eyelids and periocular tisues anterior to orbital septum. Associated with URIs, paranasal sinusitis. Staph aureus, staph epidermidis, strep. Full painless ocular motility is intact. Nontoxic pts can be treated with Augmentin or Keflex, though consider in more severe cases MRSA/3rd generation cephalosporins.

Postseptal or Orbital Cellulitis: usually due to paranasal sinusitis. S. aureus, strep pneumoniae, and anaerobes MCC. Pain with moving the eyes. If muscles involved, consider cavernous sinus thrombosis. Requires hospitalization and IV abx (Unasyn, carbapenems, 3rd gen cephalosporins). Consider lateral canthotomy if IOPs are elevated. Complications include CVT, osteomyelitis, empyema, meningitis.

Stye: external hordeolum – folliculitis on eyelid (usually staph). Located on lash line and looks like pimple. Tx: warm compresses and erythromycin ointment x 1 week.

Chalazion: acute/chronic inflammation of eyelid secondary to blocked duct. Painless lump. Tx is the same as stye. Hard to differente chalazion from internal hordeolum.

Blepharitis: eyelash follicle inflammation. Overgrowth of staph epidermitis. Tx usually just cleaning in the morning, sometimes requires abx drop/ointment.

Conjunctivitis: usually viral which is benign, self-limited. Bacterial: unilateral, though can be bilateral, mucopurulent discharge adherence of eyelids in the morning. Preauricular lymphadenopathy absent. Usually staph/strep. Need to do fluorescein staining to look for ulcer/abrasion/dendrite. Tx: topical abx 4x daily x 1 week. Polytrim fine, cipro/ofloxacin for contact wearers. Viral: adenovirus (pink eye): preceded by URI, watery discharge. Usually both eyes over the course of a few days. Preauricular adenopathy present. Look for follicles on inferior palpebral conjunctiva.Conjunctival Follicles

Tx with ocular decongestant (Naphcon-A) one drop TID with cool compresses and artificial tears – can take 1-3 weeks. Allergic conjunctivitis: itching, similiar to viral. Tx: cool compresses 4x daily, topical antihistamine/decongestant.

Herpes Zoster Ophthalmicus: shingles of first division of trigeminal nerve. Involves upper eyelid. Can involve tip of nose as well (Hutchinson sign). Cornea will have pseudodendrite where as HSV will have dendrite (stains better).Dendrite

Tx: With skin involvement, tx with oral antiviral fo 7-10d. Ayclovir 800mg 5x daily, famciclovir 500mg TID or Valacyclovir 1g TID. Tx corneal involvement with bacterial ointment to prevent bacterial secondary infection.

Corneal Ulcer: serious infection involving multiple layers of cornea. Caused by desquamation, trauma or direct microbial invasion. Pseudomonas can be culprit in contact wearers. Exam reveals white, hazy base ulcer. Tx: close f/u with ophtho, fluoroquinoline (Cipro or ofloxacin) drops qhr. Do not patch the eye. Complications including scarring, perforation, glaucoma, cataracts.

Uveitis/Iritis: anterior chamber inflammation. Conjunctival injection, photophobia, decreased vision. No drainage. Perilimbal flushing (injection greatest around limbus). Consensual photophobia (pain with light shine on unaffected eye). Pupil usually miotic poorly reactive. Flare and cells in anterior chamber. Tx: blocking pupillary sphincter and ciliary body with long acting cyclopegic agent (homatropine for 2-4 days and tropicamide with decrease pain. Need to see ophtho in 1-2 days.

Endopththalmitis: inflammation of aqueous or vitreous humor that can lead to loss of vision. Most frequent cause is postsurgical followed by penetrating ocular trauma. Erythema and swelling of eyelids, sclera injection, chemosis, hypopyon, and uveitis. Tx emergent intravitreal abx and steroids + systemic abx.

Vitreous Hemorrhage: sudden painless vision loss, sudden black spots/cob webs/haziness. Can be caused by diabetic retinopathy, posterior vitreous detachement in elderly, ocular trauma in shaken baby. Consider retinal detachment.

Subconjunctival Hemorrhage: rupture from trauma, increased venous pressure related to valsalva, spontaneous as well. Exam normal outside of hemorrhage. Resolves in 2 weeks spontaneously. Bloody chemosis is raised, bullous appearance.

Conjunctival Abrasion/Laceration: conjunctiva not innervated as much as cornea so not as painful. Rule out globe rupture with Seidel test (fluorescein should not flow out of laceration) though rupture can still occur if small or already closed.

Corneal Abrasion: highly innervated so can be extremely painful. Foreign body sensation, photophobia, tearing. Relief to pain with topical anesthesia is virtually diagnostic for abrasion. Iritis can occur if abrasion large or > 24 hours since injury. If there are several linear abrasions, consider looking for FB still stuck in the eyelid. Tx: cycloplegics (cyclopentolate 1% or homatropine 5% one drop q6-8hrs) relive some of the spasm and decrease secondary iritis. Topical NSAIDs like ketorolac and diclofenac give some relief and dont decrease healing time. Some recommend against giving topical anethetics to go home with.

Corneal Laceration: full thickness can have mishappen iris. Small lacerations though appear very similiar to abrasions and can close spontaneously and be Seidel test negative. Consider CT orbit with id globe anatomy, contour, FB. Sensitivity to detection occult globe perforation is 56-68%. Can convert to endophthalmitis or traumatic cataract.

UV Keratitis: ‘snow blindness,’ ‘welder’s flash,’ exposure to UV light and eyes aren’t protected (welders, suntanners). Symptoms can develop after delay of 12 hours. FB sensation, photophobia. Diffuse punctate corneal edema, punctate corneal abrasions. Tx: cycloplegics, topical abx, double patching of both eyes if pt requests, healing in 24-36 hrs.

Corneal FB: Metal sitting for several hours will form ‘rust rings’ – if longer than 24 hours, can get iritis. Presence of hyphema suggests globe perforation. Seidel test will be positive. Removal: Irrigate with NS first and see if very superficial FB will be irrigated off. Next, try moistened cotton applicator. Full thickness corneal FB should be removed by opthalmologist. Otherwise, 25g needle or sterile FB spud on Alger brush. Rust ring can be cleared by spur, but very often rust forms again the following day which can be toxic to the eye so will need to be seen by optho again the following day, but rust ring do not need to be removed in the ED. Tx: topical abx, cycloplegics, tetanus if needed, f/u with optho next day.

Lid Lacerations: Lacerations involving lid margins, within 6-8mm of medial canthus, involving lacrimal duct/sac, involving inner surface of lid, wounds associated with ptosis, those involving tarsal plate or levator palpebrae muscle (orbital fat present) need specialist repair. Can instill flourescein into eye and see if it appears in the wound to assess for canalicular involvement. Can sometimes be discharged if repair will occur the following day. Small lacerations <1mm at the lid edge do not need sutures and can heal spontaneously. Any laceration > 1mm at the lid edge needs repair by specialist.

Hyphema: blood in anterior chamber. Traumatic or spontaneous (sickle cell). Tx: Elevate head, dilate pupil (prevents further bleeding). Consider lowering IOPs with B-blocker, IV mannitol, topical a-adrenergic agonist (apraclonidine), or oral/topical/IV carbonic anhydrase inhibitors (CAIs) – do not give to sickle cells – will lower pH causing sickling increase risk for clogging ie increased IOP. Rebleeding occurs in 3-5 days. Consider admittting hyphema vs very close followup. If hyphema less than 1/3, can discharge.

Blow-out Fractures: MC site is inferior wall (maxillary sinus, entraps inferior rectus muscle causing restriction of upward gaze and diplopia) and medial wall (ethmoid sinus thru lamina papyracea, subcutaneous emphysema). Isolated blow-out fractures with/out entrapment do not require immediate surgery for repair within 3-10 days. Waters view xray shows cloud maxillary sinus for entrapment. Oral abx recommended. All blow out fractures should be referred for dilated eye exam to rule out retinal tear/detachment.

Ruptured Globe: Can be penetrating or blunt (impact on orbital rim can cause increased IOP to the point of rupture). Look for tear-drop or irregular shaped pupil, AFD, shallow anterior chamber, hyphema, positive Seidel test, lens dislocation. IOPs should not be measured due to possibility of extruding introcular contents. CT orbits to look for FB. If suspected, elevated head, protective metal eye shield, broad spectrum IV, tetanus. Likely need emergent surgery.

Retrobulbar Hematoma: due to blunt trauma. If large, can increase IOP, decrease blood flow to optic nerve and vision loss. Causes proptosis, pain, decreased vision. CT will show hemorrhage. IOP > 40mmHg – needs emergent canthotomy.

Lateral canthotomy: C/I: luxated globe (eyelids not visible) – need to have eye reduced. Equipment: hemostat, suture scissors, pickups, lidocaine with epi.

Numb the lateral portion of the eyelid, your going to crimp it with hemostat to reduce capillary blood flow. Then cut (extend) the skin until you see the inferior ligament and cut that. That usually does it, but you can cut the superior ligament as well. Afterward, IOP decreases, APD resolves, visual acuity improves. Ophthalmologist really doesn’t do anything afterward. Doesn’t need to ‘re-attach’ the ligament or cosmetically fix the previous incisions. Usually heals well afterward.

Chemical Ocular Injury: complications include scarring causing vision loss. Use NS irrigation. Alkali injuries more common than acid. Ammonia and lye found in household cleaners, drain cleaners. Alkali are more serious than acid due to causing liquefaction necrosis (deep penetration into liquids). Acid causes coagulation necrosis preventing deep penetration. Tx: instill topical anesthetic first, then irrigation for 30 minutes. Check pH and continue if pH > 7.4. Irrigation with NS or other isotonic solution via eye irrigating solution via Morgan lens. Usually causes conjunctival injection and chemosis, though severe can cause scleral whitening. Alkaline substances with pH < 12 or >2 should not cause serious injury. If corneal clouding or epithelial defect, should receive prompt optho referral.

Cyanoacrylate: superglue. Rarely permanent damage. Place large amounts of erythromycin ointment on the eye and it should clump together. Do not need to have all of it removed at once. Can have rest removed next day.

Acute Angle-closure Glaucoma: increased IOP due to outflow obstruction. Occurs suddenly usually when pupil dilates (usually the trigger – parasympatholytics, sympathomimetics, dim illumination, emotion upsetting events, causing cornea closure. Cornea becomes edematous and less transparent – foggy vision or halos. Cloudy, dilated eye – conjunctiva injection. Cataracts, farsighted increases risk of acute angle glaucoma. Sudden onset, painful, significant vision loss. Nausea/vomiting as well. Fixed, mid-position pupil and hazy cornea with conjunctival injection at limbus. Eye is rock hard. Normal IOP 10-20, can exceed 60-80 in acute attack. Tx: lowering production of aqueous humor: (topical B-blocker timolol), alpha-adrenergic agonists (apraclonidine) and CAIs (acetazoleamide); faciliting outflow humor (parasympathomimetic miotic agents – pilocarpine); reducing humor volume (mannitol). IV mannitol quickly lowers IOP and should be given if no contraindications. Definitive tx is laser iridectomy.

Optic Neuritis: idiopathic or MS. acute onset of vision loss. Not very painful, but can be painful with eye movements. Vision loss occurs over days, sometimes over hours. Usually unilateral. Color vision affected more than complete vision – red desaturation. APD common as well. Will have swollen/edematous optic disk (papillitis). Tx: consult neurology – ONTT trial supported IV steroids, not oral steroids.

Central Retinal Artery Occlusion: first branch off internal carotid artery is ophthalmic artery – if occluded, inner retina infarcts – causing pale, less transparent, edematous retina. macula still present – looks like cherry red spot. Sudden (over seconds) painless monocular loss of vision – preceded by amaurosis fugax. Exam has APD, pale retina (yellow/white), cherry red macula, box-carring (cattle-trucking) of arterioles. Non-evidence tx with digital massage, IOP lowering drugs, breathing into bag to increase PaCO2. No exact treatment placed at this time. HBO can be an option.

Central Retinal Vein Occlusion: CRAO. Sudden painless vision loss. Occlusion of retinal vein causes stasis, edema and hemorrhage. Loss of vision varies. RF: DM, HTN, CVA, CV, hypercoaguable, vasculitis, no idea. Diffuse retinal hemorrhages in all 4 quadrants – ‘blood and thunder’ fundus. No specific tx. Consult neuro/optho.

Flashing Lights/Floaters/Retinal Detachment: Always unilateral (bilateral usually means intracranial process such as opthalmic migraine). Vitreous gel shrinks over time causing it to separate from posterior wall. Average age of onset if 55yo. If gel separates successfully, floaters occur. If pull causes tear in retina, fluid can disperse into space and peel retina off called retinal detachement – dark veil or curtain in the field of vision. Most tears occur in peripheral retina. If tear involves macula, repair should occur within a few days. If not, should occur with 10 days. Ophtho consult for dilated indirect exam within 24 hours.

Giant Cell Arteritis: temporal arteritis. systemic artertitis involving medium sized arteries in carotid circulation. causes painless ischemic optic neuropathy. Generally >50yo, hx/o polymyalgia rheumatica. Headache, jaw claudication, fatigue, fever, anorexia, temporal artery tenderness. 1/3 have stroke symptoms. Severe vision loss with contralateral side involved if not treated. APD present. ESR usually range 70-110. Tx: IV steroids f/u by oral steroids. Biopsy will be positive for a week after starting therapy.

Bell’s Palsy: cranial nerve VII palsy. Usually viral in origin. Ipsalateral upper and lower face – orbicular muscles involved – incomplete closure of eyelids. Need eyedrops to prevent keratitis. Tx always changing over steroids vs antivirals + steroids. Check extraocular movements – Genu VII Bell’s palsy is stroke involving CNVI + CNVII – will have paralysis of abduct of ipsalateral eye (CNVI palsy).

CNIII palsy: diabetic related usually with pupil spared. Unable to medial gaze, upward gaze and downward gaze as well as some ptosis. Lateral gaze will be preserved. diplopia worse with pt looking to contralateral side. If ipsalateral pupillary dilation noted, it is a posterior communicating artery aneurysm until proven otherwise.

CNVI palsy: (Abducens) Lateral gaze will be diminished. Need to check for intracranial lesion.

Horner’s syndrome: ipsalateral ptosis (drooping eyelid), miosis (pinpoint pupil), anhydrosis (no sweating). blocked sympathetic nerve. Recommend looking for possible blockage along path – CXR, CT brain/cervical region, CTA head/neck for carotid dissection. Causes: CVA, tumor, dissection, zoster, trauma in adults. In kids, neuroblastoma, lyphoma, metastasis.

Papilledema: bilateral edema of head of optic nerve due to increased ICP. Causes: malignant HTN, pseudotumor cerebri, intracranial tumors, hydrocephalus. Papillitis is unilateral, papilledema is bilateral. Optic disk is blurred, cup is diminished/absent, flamed shaped hemorrhages seen near nerve heard. Prolonged preservation of visual acuity (asymptomatic frequently).

Optic Nerve Sheath Diameter

Do ocular ultrasound with linear probe. Check the diameter of the dense black optic nerve 3mm posterior to the eye.

In an adult, normal ICP is under 5mm. Anything above this correlates with elevated ICP.

Crescent Sign: Echolucent circle within the optic nerve in severely elevated ICP.

Mount Sinai: Optic Nerve Papilledema and Crescent Sign

Sometimes optic nerve sheath can appear dilated with normal ICP. Do the 30 degree test.

30 degree test: check diameter with patient looking straight and then check it again with patient looking 30 degrees in another direction. If increased diameter due to increased ICP, the optic nerve stretches with the change in gaze and the diameter should be lower. If the diameter does not change, likely due to parenchymal infiltration or thickening of the optic nerve. (Emergency Ultrasound, Matthew Lyon and Michael Blaivas, 2008)

Optic Nerve ultrasound for the detection of raised ICP, 2011: Checked optic nerve diameter on neuro ICU patients with EVDs in place to measure their ICP. Noted sensitivity of 96% when using diameter of > 4.8mm.

Pseudotumor Cerebri (Idiopathic Intracranial Hypertension): Increased ICP, papilledema nd normal CXR and normal CT/MRI. Nausea/vomiting/headaches/blurry vision. Can causes CNVI palsy causing horizontal diplopia. Basically need LP – Tx: acetazolamide 500mg PO BID + neurology consult.

Questions

Q. Which eye drop for acute angle glaucoma is NOT used to decrease aqueous humor production? A. Pilocarpine – used to faciliate outflow. Timolol, apraclonidine, and acetazolamide are used to decrease production.

Resources

Tintinalli, Seventh Edition, Chapter 236: Eye Emergencies

2 PK’s: Preemie Delivery / Central Retinal Artery Occlusion, Davut Savaser, eMedHome, AAEM Scientific Assembly 2016

236. Eye Disorders