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Flashcards in ENT Deck (131):
1

priority imaging in maxillofacial trauma

C-spine a priority

2

history with facial issues

1. What happened and when
a. Fall? (why fell?), MVA? Assault?

2. LOC? Vomiting? Can’t walk?

3. Visual symptoms?
--> IS THE EYE DAMAGED

4. Facial anesthesia/paresthesia?
--> The amt of nerves in your face are no joke

5. Condition of teeth, bite, blown nose?

6. PMH, meds (on Coumadin?), tetanus

7. Police report made?

8. Domestic Violence? Child abuse?

3

PE for facial injury -ORAL

1. -Full, gloved exam
2. -Lips - lacs, hematoma,
3. Thru/thru, vermillion
4. -Trismus or can’t close?
5. -Teeth present and intact?
6. Where are they?

7. -Alveolar ridge, frenulum attachment
--> need to see if this is stable b/c it is differnt than a maxilla fracture
if that is moving get a CT
8. -Bleeding in mouth?
9. -Tongue - lacs? Bleed A LOT!!

4

PE-Eyes

• Look from above/below/side for asymmetry
• Whistle, smile, wrinkle forehead
• Eyes
Visual acuity (Rosenbaum card – near card; if they can stand do Snellan)
Periorbital - edema, crepitus, lacerations
EOM’s
Pupils, conjunctiva and anterior chamber
Symmetry, subconjunctival hemorrhage (blood vessel breaks between conjunctiva and sclera, hyphema (blood in ant. Chamber)

5

PE-nose

1. -Locate, control bleeding

2. -Nasoseptal hematoma?

3. -Palpate medial canthus for mobility (worried about sinuses)

6

PE- ears

1. Drainage (blood, CSF?)
2. Ear lac?
3. Auricular hematoma, Battle sign (ecchymosis behind the ear – basal skull fx)
4. TM’s - hemoptypanum, rupture

7

what do you need to palpate in facial trauma

how to assess for mandible fracture

how to check maxillary arch

Palpate entire face, both hands
Look for tenderness, bony crepitus, subcutaneous air, flattening, anesthesia
Palpate entire orbital rim

check if anterior maxillary arch is stable - if it moves at all, stop
• Intraoral palpation of zygomatic arch

• Tongue blade test for mandible Fx- bite down, twist
If can hold on, likely no Fx

8

systems you should not forget in ENT assessment

1. Scalp, Neck, Neuro exam, CN exam, Chest wall, lungs, heart, abdomen, extremities, pelvis

9

what should be done

what needs to be administered
what should you avoid

What imaging do you need for the mandible

1. ABC’s first - suction
2. Consider IV - pain control, Abx; TETANUS

3. Pain control

a. IM/IV or topical (eyes, nose) - AVOId po’s

4.Imaging - CT preferred over plain film
a. Panorex for mandible

before you call a surgeon have a dx

10

MOA of frontal sinus fx

right above the eyebrows you will have penetration into the brain

1. Significant mechanism-MVA
a. Common prior to seat belts


may have forhead lacs
high risk for intracranial injury and bleeding in the brain

11

sxs with frontal sinus fx

Bony crepitus, deformity, subcutaneous air, limited upward gaze, ptosis, sensory deficit forehead

need to het the bony windows in a CT

12

frontal bone injury is common in what do we worry about in these populations

children

much higher incidence of intracranial truama

Higher incidence of intracrainial trauma with frontal bone Fx - consider CT head

Frontal bone trauma – worry about the kid’s neck

Upper cervical spine injury more common than lower in kids

worry about to abuse

13

Nasoethmoidal-orbital fractures occurs form trauma to this

associated with these type of injuries


Small NEO Fx’s easy to miss
Trauma to bridge, medial orbits


Associated with lacrimal injury and dural tears (encephalities or brain infection)

14

sxs asscoaited with nasoethmoidal-orbital fractures

4. Pain at medial bridge, w/ EOM’s
5. Maybe crepitus, telecanthus

15

mnmgnt of Nasoethmoidal-orbital fractures

(if eyes are further apart than they should be)
6. CT, Abx, OMFS, admit

16

Orbital Floor – Blow out fx

what do you need to document

you can have this without entrapment but if you have entrapment of this muscle it needs to be repaired
this is when the muscle of the eye does not work

you say look up and one moves and the otherone does not (tethered and stuck)

IS THERE DBL vision on upward gaze*

17

Orbital Floor – Blow out fx how many have globe rupture

c. 30% have globe rupture

18

mngmt of orbital floor fx PE and imaging

CT maxillo-facial and orbits (head? If LOC)

Check eye: vision, hyphema, pressures, subconjunctival hemorrhage, subcutaneous emphysema (air b/c maxillary sinus has ruptured and the air escapes)

19

who do you call and what do you do for orbital floor fx

c. Check infraorbital anesthesia
d. OMFS, ophtho (since there is entrapment) consult
e. Pain control, tetanus; admit?

20

telecanthus means

if eyes are further apart than they should be)

21

lateral canthomotomy -when would this be indicated and what is it

Orbital Compartment Syndrome

need to cut the lateral canthus to allow more room for the globe

this can be a site saving procedure

22

RF with retrobulbar hematoma

vision loss, pupil irregular, papilledema, IOP up, field deficit = optic neuropathy

23

limbus in retrobulbar hematoma

Limbus – where the conjunctiva ends (around the pupil)

24

what does periorbital, Orbital Cellulitis entail

1. Unilateral infection around or around and behind orbital structures

25

sxs of periorbital, Orbital Cellulitis

2. Fever, red, swelling
3. EOM’s painful
4. Proptosis if orbital

26

tx of orbital and periorbital

Periorbital:
a. Abx, +/- admit


Orbital Cellulitis-vision and life threatening need to admit

27

imaging for periorbital cellulitis

CT orbits all, ULS useful

28

questions you want to ask with nasal fx

Prior nasal trauma, deformity?
2. -Can you breathe thru your nose?
3. -Blow nose = face swelling?

29

nasal fx secret

What do you NEED in your chart

Check for nasal-septal hematoma**
a. -If present, must I&D or necrosis of septum ensues


if you see this it is a ENT emergency that needs to be drained or else you will have necrosis of the septum

LOOK UP IN THERE

30

ENT f/u with nasal trauma

-“Reduction”- specific cases only
8. -ENT f/u 5-7 days after edema subsides

31

imaging for nasal fx

X-rays- “bucket handle” view - depression?

CT common: other fx’s

32

tripod fxs involve ....

1. Involve the maxilla, the orbit, and the zygomatic arch

significant mechanism

33

suspected maxillary fx with swelling indicated imaging

8. CT for Dx, OMFS consult, Ophtho consult, admit

34

maxillary fxs are

Common; if isolated =less serious
2. Direct blow, swelling
3. Periorbital edema, subconj hemorrhage, flat cheek bone
4. Intraoral exam

35

what do we see associated with a tripod fx

Lateral subconjunctival hematoma

Infraorbital anesthesia

Check eye, lateral canthus pulled downward

often seen with Trismus

36

High-energy, midface, not subtle

LeFort

37

mnmgt and workup of LeFort

Fracture patterns often mixed
b. Check hard palate/upper teeth mobility
c. CT, Abx, tetanus
d. OMFS and Optho consult
e. Admit for open reduction and fixation

38

LeFort classifications

I- mustach
II-nose involvement
III-eyes down

39

big thing you need to assess this on mandible fx

Open or closed?

look at the cortex

open- gingival lacs with tooth disruption

OPEN-extends through the alveolar ridge gumline

40

sxs with mandible fx

Tender, swelling, trismus, malocclusion, jaw ecchymosis, bite test

unusual to fx in one spot

look for multiple

OPEN= blood in mouth, gingival lacs, teeth loose separated or uneven

41

pathognomonic signs for open fx

Sublingual hematoma is pathognomonic

and bruising beneath the jaw

42

tx for mandible fx
open

Open - OMFS, Abx, tetanus, admit

43

tx for mandible fx closed-

Closed - outpatient f/u

44

post trauma, seizure or spontaneous with jaw open suspect

TMJ Dislocation

45

TMJ dislocation can be

Can be bilateral or unilateral – taking a big bite

46

tx and reduction of the jaw

X-rays if traumatic
-Pain meds, anxiolytics, suction


Downward pressure on the jaw, rock and pull forward - from above or from front of patient

47

post reduction management of jaw dislocation

-Liquid diet for 3 days, OMFS f/u

48

differentiating unilateral from bilateral TMJ dislo

jaw away from side of dislocation. Bilateral - protrudes forward

49

Hearing Loss initial management

• Sudden or gradual?
• Partial or total?
• Unilateral or bilateral
• Associated Sx’s: tinnitus, vertigo, HA, drainage, pain
• Conductive or Sensorineural?
• Look in ear first, then look for the tuning fork
• Weber test - tuning fork on head
• Rinne test - mastoid then next to ear

50

what are important questions you want to be asking with hearing loss

(usually intracranial issue)?

Trauma, recent infection, meds (bilateral)

NSAIDS,
aminoglycosides,
erythromycin,
Lasix, ASA, antimalarials, chemo

51

evaluation of sensorineural vs conductive

Conductive - BC>AC
Sensorineural loss - AC>BC or can’t hear it

52

describtion of Cerumen Impaction

1. Well appearing pt
2. Fullness, “underwater”
3. Have to document that the TM look good after removal

53

mangement of conductive cerumen impaction

a. Manual – curette
b. Irrigate:
i. 18g angiocath w/o needle
ii. 1part peroxide, 2parts water
iii. Irrigate w/ 30cc syringe
iv. Immediate relief sx’s

54

Malignant Otitis Externa

2. Elderly, DM, immunocomp
3. Unresponsive OE, Pseudomonas

55

presentation of OME

4. Painful, especially with movement of tragus
5. Conductive hearing loss +/-
6. Thick, granulation tissue in canal, +/- can’t see TM, facial nerve palsy or paralysis

56

tx of OME

Admit, IV anti-pseudomonals, ENT consult

57

appearance and management of fungal OE

Chronic OE in DM, immunocompromised

Painful, white or black fuzzy discharge in canal

Suction out canal, antifungal/acetic acid

58

Perichondritis presentation

Auricle/pinna is infected

Acute, supprative


Auricle tender, warm, swollen - TM normal

Check behind the ear! Think mastoiditis

59

Perichondritis tx

IV Abx (pseudomonas),

ENT

consider admit

60

Herpes zoster of face with involvement of auricle and TM

ramsey hunt

61

Ramsay Hunt Syndrome sxs need to check for

Painful, unilateral

Hearing loss, peripheral facial paralysis or sensory loss

Acyclovir, steroids, pain meds

Check for corneal involvement –

Hutchenson’s sign (zoster lesions on tip of the nose)

62

Herpes Zoster Oticus


48hr f/u after ENT consult

Just auricle (NOT the TM)= Herpes

Zoster Oticus

63

Painful, ear canal abscess

Furuncle

64

furuncle in the ear mngmt

Exquisitely tender

Hair gets infected and you get a zit in your ear canal

Tragal motion tender

Staph Aureus
d. Needle aspirate or I&D


Abx, pain meds

65

mngmt of FB

Insect: lidocaine drops - mosquito forceps

Kids: may need sedation

Irrigate if not organic

Check TM

Tx for otitis externa

66

OM sxs and tx

Red, bulging TM, decreased mobility

Amoxicillin still first-line
3. Serous otitis media
a. “Fullness”, bubbles, TM not red
b. Decongestants

67

Painful, clear or red blisters on TM suspect


Painful, clear or red blisters on TM

URI common

68

Bullous myringitis tx

Mycoplasma or viral - Tx with macrolides (erythromycin or azithromycin)

69

painful hearing loss and tinnitius suspect


TM Perforation

Post-infection, blunt or penetrating trauma, noise trauma, barotrauma

Painful, hearing loss

Blood, serous fluid or no discharge
Tinnitus, vertigo common
Up to 90% heal on own

70

TM Perforation will see webber will lateralize to

Weber lateralizes to affected side

71

TM Perforation tx

Ear dry, no drops, suspension ok

Refer to audiology, ENT

72

Cholesteatoma what is it exactly

Squamous epithelium mass behind TM

Acquired or congenital
3. Grows, erodes TM, ossicles

73

why do we care about Cholesteatoma

Grows, erodes TM, ossicles

will lose hearing

74

big red flag with Cholesteatoma

neuro symptoms

75

mngmt of Cholesteatoma

CT if suspect, then MRI

ENT for removal

76

Auricular Hematoma we are worried about

Leads to necrosis if no tx: “cauliflower ear

77

tx of auricular hematoma

Incise edge, evacuate clot

+/- suture – check with ENT consultant

Dressing packed firmly into contours/behind ear

Pressure dressing

24hr follow-up - check clot recurrence

78

ear lac mngmgt

1. Block the ear or local anesthesia


Suture through skin, not cartilage, to close
Non-absorbable

4. 6-0 suture best
5. Attempt to retain shape, contour
6. Do not debride too aggressively

79

Mastoiditis mngmt and sxs


Rare, serious, toxic pt

. Complication of unresolved OM

Can be chronic

Hearing loss, ear pain, tender fluctuant mastoid, TM red, +/- perf with discharge

CT head w/o con

IV Abx, ENT consult

Kids, toxic = admit

80

Nasal Furunculosis/Cellulitis mngmt

Infected hair follicle - usually Staph, cover MRSA

2. Remove offending hair

81

TX OF nasal Furunculosis/Cellulitis mngmt

Abscess of cartilage, ala, columella cellulitis

know this anatomy!


DM, immunocomp - admit

82

Nasal Foreign Bodies tx

Infants, little kids: parent occludes opposite nostril and blows into mouth

vasoconstrict with Neo-synephrine or Afrin mixed with lidocaine (not w/ Cocaine)

Blow after vasoconstriction

Alligator forceps, ear curette, Dermabond on end of q-tip or small foley cath passed beyond object – inflate – pull out

no luck--> call ENT

83

Organic FB

Organic FB? Irrigate gently - say “eng”


eeeengg

84

BIG epistaxis mangement

nterior (90%) or posterior (serious bleed)?

85

90% of nosebleeds occur here

Coumadin? Trauma?

-90% at Kiesselbach’s plexus (anterior bleed)

86

anterior bleed

Blow nose gently--> - get clots out
b. -Sit forward/pinch

87

if it won't stop bleeding

Gown, glasses, light, suction

Soak several Q-tips in 4% Cocaine or Neo-Synephrine w/ 4% Lido

-Apply to nostril

Tranexamic acid topical - new

88

Silver Nitrate cautery stick mngmt

-Silver Nitrate cautery stick
a. -Minimum, one side only
b. Don’t cauterize the septum

-Abx ointment over site, saline nasal spray

89

inserting a nasal tampon

Tampon packing (start with tampon, then rhino rocket if that doesn’t work)

straight and down

Insert along floor of nasal cavity – lube w/ abx oint

Moisten after insertion - expands to space

24hr f/u, Abx, saline drops

90

alternative to nasal tampon

Rhino Rocket - tampon alternative
i. Mesh covered, inflate w/ saline
c. Still bleeding? Nasal balloon + ENT

91

management of sinusitis

1. Unilateral, face pain, purulent d/c, teeth pain, HA; Sx’s +/- 7days
2. Vast majority viral - Abx if fever, hx chronic
3. Decongestants
4. Not imaged in ED*
a. CT preferred
b. Plain xrays if no CT

92

dental fx described by

Describe what is exposed
a. Enamel only
b. No further Tx
c. Dental referral
d. Ellis I, Class I, etc

93

what is a ELLIS II

See yellow dentin exposed

b. Cover with cement
c. Dental consult
d. 24hr f/u
e. Ellis II, Class 2, e

94

Ellis III management

Dental consult now

b. Cover with cement or isolate tooth with moist, sterile gauze
c. 24hr f/u - discuss necrosis, tooth loss

95

Concussion what is the mngmt

painful but not loose, no ED Tx, dental f/u

96

Subluxation what is it and what is the mngmt

loose

a. Push very loose back in - stabilize/splint
b. PCN VK, dental f/u 24hrs

97

tooth avulsion

totally out

<15min – gently clean tooth, socket - push back in


15min - 2hrs - soak tooth in milk, clean socket, replace

c. >2hrs - same with discussion
d. PCN VK, dental f/u 24hrs
e. No tooth? Get a CXR

98

Alveolar Ridge Fracture need to


Subluxed or avulsed teeth
-->Lift lip, check buccal space. Hematoma

99

Alveolar Ridge Fracture signs and tx

Ridge moves with palpation

Panorex; then/or CT

IV Abx, pain control

OMFS consult

100

Dental Abscess or Infection mngmt

Facial edema, pain, tender tooth

Block tooth locally if possible (bupivicaine)

I&D in ED only if clearly pointing or buccal space is full, fluctuant

Dental referral 24hrs

101

RF in dental pain

If fever, trismus, big swelling, face redness:

OMFS now

102

rx for dental abscess

PCN/Amox/ Clindamycin pain meds, warm rinses

Definitive tx is pulling the tooth

103

dry socket mangmenet

Block the tooth, irrigate socket with warm NS

Gently pack socket with ¼” plain packing gauze soaked in clove oil or dry socket paste

Dentist 24hrs

104

Painful necrosis socket, 2-4 days post extraction

dry socket

105

Necrotizing Ulcerative Gingivitis (Trench Mouth)

what does this look like

Fetid breath (can’t even get near them, it’s smells horrible), bleeding gums, fever, pain, immunocomp

Punched out” interdental papilla

106

rx of trench mouth


Flagyl, Chlorhexidine rinse, dental and PMD f/u for w/u

107

most important consideration with lip lac

Cross vermillion?

Margin of error is 2mm at MAX!!
a. Approximate first
b. First suture must line up


108

mangemetnt of lip laceration


Irrigate, sew outer part first

Irrigate again, and then sew mucosa



109

anesthesia an stitches of lip lac

Anesthesia: regional block
Infra-orbital nerve (upper) – fantastic

Mental nerve (lower)
4. Absorbable 4-0 for mucosa
5. Non-absorbable 6-0 for lip and skin

110

Oral mucosal lacs: repair

6. Oral mucosal lacs: repair only large or flapping – rest will heal

111

mnmgnt for tongue Lacerations (your own teeth get your tongue)

1. Small, mid-tongue: control bleed, ice, may not need sutures

2. Thru/thru, at edge, w/ flap, large lac: suture

112

anesthesia and sutures for tongue lac

a. Use lidocaine/bupivicaine w/ epi
b. Lingual nerve block for anterior 2/3 tongue – lingual side 2nd lower molar
c. Local as alternative: painful

4. Absorbable 4-0 suture (can use non-absorbable); bury knot
5. Complex – consider layered closure

113

Sialolithiasis MC

Sialolithiasis = Salivary gland stones – obstruction

Most Common: Wharton’s duct

Wharton’s duct is the submandibular duct – floor of the mouth

114

concerns with Sialolithiasis

tx

Sudden edema, pain; possible infection
a. Mouth pain and tongue pain

Abx, lemon drops, analgesia, ENT f/u

115

Sialoadenitis

Mumps

Viral prodrome, mostly involves parotid gland


i. Stenson’s duct is the parotid duct – next to upper 2nd molar
b. Non-immunized kids/adults

116

Bilateral cellulitis of submandibular space

x. Ludwig’s Angina

117

Ludwig’s Angina MC origin

Odontogenic origin common (lower tooth usually in the front with a big abscess)


Fever; painful, tense, red edema under chin; trismus, dysphagia, dysphonia

tongue displaced upward, edema of floor of mouth, edema of submental space

118

big concern and mangement of ludwigs

5. Rapid progression, polymicrobial
6. Airway the big concern
7. CT is test of choice, IV Abx
8. ENT, admit, airway precautions

119

Uvulitis presentation

1. Sore throat, FB sensation

2. Uvula is big, red, angry looking; may touch tongue and cause gag
Position is midline tho if it is JUST the uvula

4. Think allergy, angioedema first

120

ts of uvulitis

Abx for strep, consider steroids

Pain meds, slippery foods, close f/u

121

pharyngitis centor score

NO COUGH

EXUDATE

TENDER LYMPH NODES

SORE THROAT

if you have 4 treat 3?

122

uvula not midline suspect

Peritonsilar Abscess

cellulitis vs abscess

Sore throat, “hot potato” voice, trismus, fever
2. Unilat peritonsilar & soft palate redness, fluctuance
3. Uvula is NOT midline
4. Uvular deviation away from abscess

123

Peritonsilar Abscess mangment

18g needle, 3 puncture sites
Beware “big red”


ULS the swelling for fluid with transvaginal probe
7. Topical anesthesia then inject w/ lido w/ epi

Abx, pain meds, 24hr f/u (abscess can recur)

if you have a dry tap treat for cellulitis

124

tx for cellulitis of uvula

Dry tap? Tx for cellulitis (Clindamycin)

125

2. Neck pain (pain when look up), dysphagia, fever

pain and sx’s out of proportion to exam

xiii. Retropharyngeal Abscess
1. Kids and adults

126

Retropharyngeal Abscess imaging

CT neck is best, diagnostic
6. Airway concerns
7. ENT, IV Abx, admit

127

worse sore throat of my whole life
fever
haven't eaten and doesn't look like a sore throat

RPA or epiglottitis (not immunized)

128

immunization that has really diminished epiglottitis

H.flu vaccine

129

common sxs of epiglottis

Rapid onset, sore throat, fever
Drooling, voice changes, positioning

130

imaging for epiglottitis

Soft tissue neck - portable if worried
6. If has it – IV, monitor, airway equipment
7. Abx, steroids, ENT, admit

131

FB sensation at rest, worse with swallowing

Laryngoscope, fiber optic scope, mirror

Soft tissue neck, CXR
6. Often abrasion only (it isn’t itself there)
7. Pulmonary or GI consult
a. Go fishing