Flashcards in ENT Deck (131)
priority imaging in maxillofacial trauma
C-spine a priority
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?
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!!
• Look from above/below/side for asymmetry
• Whistle, smile, wrinkle forehead
Visual acuity (Rosenbaum card – near card; if they can stand do Snellan)
Periorbital - edema, crepitus, lacerations
Pupils, conjunctiva and anterior chamber
Symmetry, subconjunctival hemorrhage (blood vessel breaks between conjunctiva and sclera, hyphema (blood in ant. Chamber)
1. -Locate, control bleeding
2. -Nasoseptal hematoma?
3. -Palpate medial canthus for mobility (worried about sinuses)
1. Drainage (blood, CSF?)
2. Ear lac?
3. Auricular hematoma, Battle sign (ecchymosis behind the ear – basal skull fx)
4. TM’s - hemoptypanum, rupture
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
systems you should not forget in ENT assessment
1. Scalp, Neck, Neuro exam, CN exam, Chest wall, lungs, heart, abdomen, extremities, pelvis
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
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
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
frontal bone injury is common in what do we worry about in these populations
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
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)
sxs asscoaited with nasoethmoidal-orbital fractures
4. Pain at medial bridge, w/ EOM’s
5. Maybe crepitus, telecanthus
mnmgnt of Nasoethmoidal-orbital fractures
(if eyes are further apart than they should be)
6. CT, Abx, OMFS, admit
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*
Orbital Floor – Blow out fx how many have globe rupture
c. 30% have globe rupture
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)
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?
if eyes are further apart than they should be)
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
RF with retrobulbar hematoma
vision loss, pupil irregular, papilledema, IOP up, field deficit = optic neuropathy
limbus in retrobulbar hematoma
Limbus – where the conjunctiva ends (around the pupil)
what does periorbital, Orbital Cellulitis entail
1. Unilateral infection around or around and behind orbital structures
sxs of periorbital, Orbital Cellulitis
2. Fever, red, swelling
3. EOM’s painful
4. Proptosis if orbital
tx of orbital and periorbital
a. Abx, +/- admit
Orbital Cellulitis-vision and life threatening need to admit
imaging for periorbital cellulitis
CT orbits all, ULS useful
questions you want to ask with nasal fx
Prior nasal trauma, deformity?
2. -Can you breathe thru your nose?
3. -Blow nose = face swelling?
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