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Hematology and OncologyITE ReviewBleeding disordersHemostasis is a balance between excessive bleeding and thrombosisFour components of hemostasisVascular integrityPlatelet functionCoagulation factorsFibrinolysisCoagulation studiesProthrombin timeAffected by extrinsic (and common) pathwaysPT >2 seconds more than control is abnormalIncreased PT: Vitamin K deficiency, warfarin use, liver diseaseInternational normalized ratio (INR)PT ratio that would be obtained if WHO’s thromboplastin has been usedINR of 1 is normal; 2-3 therapeutic; 2.5-3.5 for valvesPartial thromboplastin time (PTT)Affected by intrinsic (and common) pathwaysPTT >8-10 seconds above normal is significantIncreased PTT: Factor VIII, IX, XI, XII deficiency, heparin therapyIncreased PT and PTTHeparin overdose, warfarin overdose, Vitamin K deficiency and severe liver disease, DIC, massive transfusion, thrombolytic therapyVitamin K dependent factorsII, VII, IX, IPlatelet vs coagulation disordersPlatelet disordersPetechiae, purpura (don’t blanch), epistaxis, gum/mucosal bleeding, GIB, menorrhagiaWomen; often acquiredCoagulation disordersDeep muscle or joint bleeding (rarely epistaxis, menorrhagia, GIB)Men; congenitalPlatelet disordersThrombocytopeniaNormal 150-400KDecreased production- marrow disease (malignant infiltration, myelofibrosis, aplastic anemia), drugs (chemo, alcohol, thiazides), vitamin B12 or folate deficiencyIncreased destruction- ITP, TTP, HUS, HELLP, sepsis, viral (HIV, mumps, varicella, EBV), SLE, drugs (PCN, sulfa, quinine, Lasix, heparin, ASA)Splenic sequestration- hypersplenism, cirrhosis, heme malignancyDilution- massive transfusionPlatelet transfusionSix pack increases platelet count approx. 50KIndications- platelet count <10-20K, life threatening bleedingIdiopathic thrombocytopenic purpura (ITP)Acute ITPAntiplatelet antibody IgG (both acute and chronic)Kids 2-6 yrsFollows viral infectionSelf limited; resolves spontaneouslyTx supportive unless severe bleeding (plt <50K) or plt <20KPrednisone 1 mg/kgIVIGPlatelet transfusion only for life-threatening hemorrhageChronic ITPWomen 20-50 yrsRemission rareUnderlying autoimmune, collagen vascular, or malignant diseaseSteroidsIVIG, immunosuppressives, splenectomyPlatelet transfusion only for life-threatening hemorrhageThrombotic thrombocytopenic purpura (TTP)Subset of thrombotic microangiopathiesSubendothelial and intraluminal deposits of fibrin and platelet aggregationFemales; 80% mortality if untreatedInfection, autoimmune disease, immunosuppressives, chemoTreatment- steroids, plasmapheresis, dialysis, FFPAvoid platelet transfusionsFAT RNFeverAnemia- MAHA; schistocytes on peripheral smearThrombocytopeniaRenal NeurologicHemolytic uremic syndrome (HUS)Thrombotic microangiopathyThrombocytopenia, hemolytic anemia, fever, neurologic, renalLess mental status change and more renal dysfunction than TTPOften kidsBacterial gastroenteritis (E coli O157:H7, Shigella)ASA/NSAIDs block cyclooxygenase, which decreases thromboxane formation decreased platelet aggregationASA effect irreversibleNSAID effect reversibleDisseminated intravascular coagulation (DIC)Platelet, coagulation, fibrinolytic disorderDiffuse bleeding from multiple sitesAcrocyanosis, thrombosis, pregangrenous changes of fingers, toes, genitalia, nsoe (purpura fulminans)Trauma, burns, pregnancy, sepsis, transfusion, carcinoma, acute leukemia, liver disease, snake bites, heat strokeTreat underlying causeIf hemorrhageblood productsIf thrombosis low dose heparinMore commonly seen with Gram (-) sepsis in pregnancy, retained fetus, chronic DIC, purpura fulminansFindingsIncreased PT/INRIncreased PTTDecreased plateletsDecreased fibrinogenIncreased FSP (fibrin split products)Increased D-dimerSchistocytesHeparin induced thrombocytopenia (HIT)Antibodies to heparin/platelet factor 4 complex platelet activation and clot formationOccurs 5-10 days after exposureHeparin > LMWHThrombocytopenia <150K or drop of 50% from baselineArterial or venous thrombosisStop the heparin!Avoid platelet transfusions, lower limb dopplers (high incidence of DVT), test for HIT antibodiesVon Willebrand’s diseaseMost common genetic bleeding disorderVon Willebrand factor functionsFacilitates platelet adhesionLinks platelet to endotheliumPlasma carrier for factor VIIIAutosomal dominantDeficiency or dysfunction of vWF and mild factor VIII defectType I- decreased vWF (most common)Type II- abnormal or dysfunctional vWFType III- no vWFMucocutaneous bleeding (epistaxis, menorrhagia, GIB)Abnormal platelet function studies, increased bleeding time, normal platelet count, normal PT/PTTTreatment- DDAVP (desmopressin), factor VIII concentrates, cryoprecipitateCoagulation disordersHemophiliasDelayed/protracted bleeding after mild trauma or dental extractionSpontaneous hematuriaHemarthrosis and muscle hematomas Most common in ankle in kids; knee in adultsIntracranial hemorrhageProloned PTT; normal PT and plateletsHemophilia AX-linked recessive deficiency of Factor VIIIMild (hematuria, deep lac)- 20 U/kgModerate (oral lac, dental, minor surgery, late hemarthrosis)- 25 U/kgSevere (CNS/GI/abd, major trauma)- 50 U/kg1 U/kg increases activity level by 2%Cryoprecipitate, DDAVP, FFPHemophilia BAka Christmas DiseaseX-linked recessive deficiency of Factor IXFactor IX concentrateProthrombin Complex Concentrates (PCC), FFP, NOT CryoHypercoagulabilityFactor V Leiden (most common inherited hyercoagulability disorder)Prothrombin mutationHyperhomocysteinemiaProtein C deficiencyProtein S deficiencyRed blood cell disordersRBC incidesMean corpuscular hemoglobin (MCH)- measure of hemoglobin content within RBCMean corpuscular hemoglobin concentration (MCHC)- measure of concentration of hemoglobin within RBCMean corpuscular volume (MCV)- measure of RBC sizeRBC distribution width- measure of deviation in volume of RBCsMicrocytic anemiasIron deficiency anemiaHypochromic (decreased MCHC), decreased retics, decreased iron, increased TIBC, increased RDWLead poisoningHypochromic, basophilic stipplingLead lines- hyperdense lines at metaphyses (knee and wrist)ThalassemiaMediterranean, African, AsianHypochromicSpherocytosisHyperchromic (increased MCHC)Macrocytic anemiasVitamin B12 deficiency (pernicious anemia), folate deficiency (alcoholism)- large, oval RBCs, hypersegmented neutrophilsLiver disease, hypothyroidismHemolytic anemiasFindings in hemolysis- decreased hemoglobin, decreased haptoglobin, increased LDH, increased unconjugated bilirubin, schistocytes on peripheral smearG6PD deficiencyX-linked nonimmune hemolytic anemiaCoombs test negativeProtects against malariaStressors- infection, fava beans, medications (sulfa, nitrofurantoin, pyridium, antimalarials, dapsone)Heinz bodies on peripheral smearSickle cell diseaseAutosomal recessive abnormal hemoglobin resulting from single amino acid substitutionDeoxygenated HbS results in sickle-shaped, nondeformable rbc that cannot traverse small capillariesSickle cell traitSpontaneous bleeding (hematuria, hyphema)Hyposthenuria (impaired ability to concentrate urine)Vaso-occlusive crises (rare, only extreme hypoxia)Presentation in kidsUnexplained gnawing bone painLUQ pain (splenic infarction)RUQ pain (gallstones)Severe hemolytic anemiaJaundice Painful swelling of hands and/or feet (dactylitis)Increased susceptibility to infectionEncapsulated organisms (S pneumoniae, H influenzae)Salmonella osteomyelitisStressorsGlobal/local hypoxiaHigh altitudeLow temperatureAcidosisRadiographic contrast dyeDiagnostic studiesDecreased hemoglobin, increased WBC, increased plateletsSickled RBCs on peripheral smearIncreased retic countIncreased alkaline phosphatase, increased bilirubin, increased LDHVaso-occlusive (thrombotic) crisisMost commonCBC to exclude aplastic/sequestration; retic count to exclude aplastic crisisTreatment- analgesics, hydration, supportiveHemolytic crisisUsually from infection or drugsJaundice, pallor, increased retic count, decreased hemoglobinSequestration crisisKids 6 mo-6 yrsAbdominal pain, distention, splenomegaly, shock, pallor, hemoglobin very low, high retic countTreatment includes splenectomyAplastic crisisPrecipitated by infection (parvovirus B19)Hemoglobin very low, retic count very low (pathognomonic)ComplicationsInfectionsDue to functional asplenia, poorly migrating neutrophilsEncapsulated organismsBroad spectrum antibiotics if suspectedAcute chest syndromePulmonary infiltrate on CXR with fever, chest pain, cough, wheezing, tachypneaCan be from infection, fat embolism, rib infarction, thromboemboli, reactive airway disease, fluid overload, atelectasisBroad spectrum antibiotics, ICU, exchange transfusionPriapism- 10-40%Cerebrovascular accident- thrombotic or hemorrhagicImmediate exchange transfusionRenal papillary necrosisCongestive heart failurePulmonary hypertensionLeg ulcersRetinal infarction/detachmentAvascular necrosis (digits in children, femoral head in young adults)Pigmented gallstonesProliferative disordersPolycythemia veraMarkedly increased hemoglobinAbnormal proliferation of all 3 cell linesJAK2 mutationHypertension, plethora, headache, hepatosplenomegaly, epistaxis, engorged retinal veins, erythromelalgiaSludging, thrombosis, infarction in peripheral circulationItching after hot showers- histamine release from increased basophil and mast cell productionTreatment- phlebotomyHyperviscosity syndromeBlurred vision, headache, fatigue, somnolence, stroke, mesenteric ischemiaCausesWaldenstrom macroglobulinemia (IgM)- most commonMultiple myeloma (IgG or IgA)Leukemia with blast formationPolycythemia veraManagementPhlebotomy for polycythemiaPlasmapheresis for dysproteinemiasLeukapheresis for blast transformationsMultiple myelomaProliferation of plasma cells causing a monoclonal immunoglobulinExtensive skeletal destruction and osteolytic lesions on imaging “punched out”Bone pain, anemia, hypercalcemia, renal insufficiency, hyperviscosityRouleaux on peripheral smearBence Jones protein on urine protein electrophoresisM spike on serum protein electrophoresisTransfusion reactionsTRALI (transfusion related acute lung injury)Presents acutely within 4-6 hoursNoncardiogenic pulmonary edemaHypotensionLooks like ARDSStop transfusion immediatelyTACO (transfusion associated circulatory overload)Presents within several hours of transfusionCardiogenic pulmonary edemaHypertensionMassive transfusionTransfusion of volume of blood equivalent to patient’s entire blood volume within 24 hour period ORTransfusion of the equivalent of one-half of patient’s blood volume at one timeCoagulopathy- dilution of clotting factors, platelet destruction, DICHypothermiaMicroembolization- degeneration products of platelets, leukocytes, fibrinARDSMicropore filtration decreasesHypocalcemia- citrate toxicityCyanosis and methemoglobinemiaCyanosis>5 g/dL reduced unsaturated hgb, 0.5 g/dL sulfhemoglobin, 1.5 g/dL methemoglobinCentral- decreased arterial oxygen saturationDecreased atmospheric pressure (high altitude)Impaired pulmonary function- hypoventilation, V/Q mismatch, impaired O2 diffusionAnatomic shunts- congenital heart disease, pulmonary AV fistulas, multiple small intrapulmonary shuntsHgb abnormalities- methemoglobinemia, sulfhemoglobinemiaPeripheral- normally saturated arterial blood with increased O2 extractionCHF, cold exposure, shock states, peripheral vascular diseaseMethemoglobinemiaCyanosis when concentration >15%Pulse ox 85% regardless of O2 satBlood is dark brown-purplePrecipitated by meds- nipride, nitroglycerin, local anesthetics (lidocaine, benzocaine), quinolonesTreatment is methylene blueOncologic emergenciesCardiac tamponadeCarcinoma of lung and breast, lymphoma (Hodgkin’s and NHL), leukemia, malignant melanomaSVC syndromeCarcinoma of lung, lymphomaSlow, progressive tumor developmentSymptoms occur in early morningEdema/venous distention of face and upper extremities, SOB, headache, feeling of fullness in head, facial plethora, telangiestasia, papilledemaTreatment- radiation, chemo, elevate HOB; steroids or diuresis if laryngeal or cerebral edemaInfectionsNeutropenia- absolute neutrophil count (ANC) <500Nadir occurs 5-10 days after chemoBacterial, viral, or fungalMost common Gram negative in neutropenic fever- PseudomonasIsolate, broad spectrum antibioticsSpinal cord compressionLung (most common), breast, prostate, multiple myeloma, lymphomaBack pain, motor loss, paresthesias, incontinenceTreatment- steroids, radiation, surgeryHypercalcemiaStones- kidney stonesBones- pain, pathological fx, osteoporosis, osteomalacia, arthritisGroans- constipation, indigestion, N/V, PUD, pancreatitisMoans- lethargy, fatigue, depression, memory loss, psychosis, delirium, comaCarcinoma of lung, breast prostate; multiple myeloma; parathyroid hormone like substance (SCC lung); osteoclast activating factor (NHL, Adult T-cell lymphoma-leukemia)Check ionized calcium levelShortened QT intervalTreatment- IV hydration, Lasix diuresis, bisphosphonatesAcute tumor lysis syndrome1-5 days after chemo for hematologic malignancy (leukemia, lymphoma)Also with SCLC, high tumor burden, highly chemosensitive tumorsMore likely if underlying renal dysfunctionHyperuricemia (DNA breakdown)Hyperkalemia (cytosol breakdown)Hyperphosphatemia (protein breakdown)Hypocalcemia (secondary to hyperphosphatemia)AKI, dysrhythmias (K, Ca), neuromuscular instability (Ca)Treatment- Hydration, allopurinolDialysis if K >6Uric acid >10Cr >10Phos >10Volume overloadSymptomatic hypocalcemiaENT ITE ReviewEARSudden hearing lossConductive loss: lesions of external auditory canal, TM, middle ear, ossiclesCerumen impaction (most common)Canal obstruction (FB)Otitis externaMiddle ear effusionTM perforationSclerosis of TM or ossiclesSensorineural loss: lesions of cochlea, auditory nerve, brainstem auditory pathwaysBilateralototoxic drugs (antibiotics-AG, emycin, vanco, antimalarials, NSAIDs, loops, antineoplastics-cisplatin, nitrogen mustard) exposure to loud noiseUnilateral viral neuritis (cochlear branch of CN VIII)Acoustic neuromaMeniere’s diseaseTemporal bone fractureHearing loss testsRinne test (rinne rings right next to the ear)Tuning fork on mastoid, then next to earNormal: air conduction better than bone (still hear vibrations next to ear)Conductive loss: bone > air conduction (vibration not heard next to ear)Sensorineural loss: test is normalWeber (Weber wrinkles forehead)Tuning fork on forehead (normally sounds equally loud in both ears)Conductive loss: heard better in affected earSensorineural loss: heard better in unaffected earWith bilateral sensorineural hearing loss, both tests are normal but there is decrease in hearing acuityVertigoA sensation of movement of oneself (subjective vertigo) or the environment (objective vertigo)Peripheral (85-90%) vs central (10-15%) vertigoPERIPHERALCENTRALOnsetSuddenSlowSeverityIntense spinningLess intense, ill-definedPatternIntermittentConstantWorse on movementYesNoNausea/sweatingFrequentInfrequentNystagmusHorizontal, rotatory (NEVER verticalMulti-directional, horizontal, rotatory, or verticalFatiguesYesNoHearing loss/tinnitusMay occurNoAbnormal TMMay occurNoCNS symptomsAbsentUsually present (headache, diplopia, dysarthria, dysphagia, ataxia, facial numbness, hemiparesis)Peripheral vertigo causesBenign paroxysmal positional vertigo (BPPV): most common causeCaused by canalolithiasis; delayed unilateral activation of posterior semicircular canal because of impaired endolymph flow caused by clumped otolithsDix-Hallpike to help dxNo hearing problems or tinnitusTx: particle repositioning, sedative, antihistaminesVestibular neuronitisAcute onset, viral etiology??; lasts days to weeksSymptoms limited to vestibular system (balance)LaybrinthitisInfection of labyrinth (concurrent/recent URI) or result of ototoxic drugsUsually viral, rarely bacterial; look for OM/mastoiditis as causeVestibular and hearing symptomsMeniere’s diseaseUnilateral or bilateral excess production of endolymphTriad: tinnitus, vertigo, sensorineural hearing loss; also N/VAges 40-60; spells last hours but can have long symptom free intervals b/t attacksOtotoxicityAG, emycin, minocycline, quinolones, NSAIDs (ASA), loops, cytostatic drugs, antimalarialsVertigo is uncommon with these because the damage they cause is bilateral and vertigo requires an imbalance of sensory input between the vestibular mechanismsVIII nerve lesionsInvolving VIII directly: meningioma, acoustic schwannoma; gradual onset of mild vertigo and unsteadinessTumors of cerebellopontine angle: neuromas, meningiomas, dermoids; deafness, ataxia, ipsilateral facial weakness, cerebellar signsHerpes zoster oticus (Ramsay Hunt syndrome): deafness, vertigo, facial palsy; grouped vesicles on erythematous base inside the ear canalCentral vertigo causesCerebellar or brainstem hemorrhage, infarction or tumorVertebrobasilar insufficiencyMultiple sclerosis: due to demyelination; look for other signs of MSMigraine related dizziness and vertigo: basilar migraine aura—vertigo, decreased hearing, visual disturbances, dysarthria, diplopia, decreased LOCOtitis externaPruritis, pain, tenderness of external canal, sense of ear fullness, white/cheesy/green discharge, pulling on ear or pressing tragus causes pain, erythema/edema of external canalPrecipitated by excessive moisture (swimmer’s ear) or traumaCauses: Pseudomonas aeruginosa, Staph aureus (also Proteus, Enterobacteriaceae, strep)TreatmentMild, nonpurulent: 2% acetic acid solution with hydrocortisone 1%Edema and discharge: polymyxin B, neomycin, hydrocortisone (Cortisporin) suspension or solution; use suspension if TM perforation present b/c less toxic to middle earAvoid water for 2-3 weeksMalignant otitis externaExtension of otitis externa into the mastoid or temporal boneSeen in adult diabetics and debilitated and immunocompromisedCaused by Pseudomonas aeruginosaMortality up to 50%Fever, excruciating pain, friable granulation tissue in external canal, edema/erythema of pinna and periauricular tissue; +/- CN palsies and trismusAdmit, IV abx, ENT consultAcute otitis media (AOM)Epidemiology: kids 6-36 months; winter and spring; often with viral URI; viral > bacterialEustachian tube dysfunctionretention of secretionscolonizationPathogens: S. pneumo (most common), H. flu, M. catarrhalis, S. pyogenes; S. aureus, group B strep and gram-negative enterics may be seen in neonatal periodHx: irritability, poor feeding ear-pulling, otalgia hearing loss, URI sxExam: TM red/opaque and may be bulging, otorrhea, loss of light reflex, decreased mobility of TM on pneumatic otoscopy (most reliable)Tx: WASP (Wait and see prescription): ask parents not to fill rx for 48 hours and only if kid is worse or no betterAmoxicillin (high dose): 80-90 mg/kg/dayOthers: augmentin, clindamycin, cefuroxime, macrolides, erythromycinBeware of infants less than 2 months, especially if fever or toxic; need septic workup and broad spectrum coverage b/c more likely to be infected by coliforms, GBS, S. aureusComplications: TM perforation, hearing loss, mastoiditis, labyrinthitis, meningitis, brain abscess, cavernous sinus thrombosis, facial nerve palsyBullous myringitisAOM with clear or hemorrhagic blisters within the layers of TM; ear pain and mild hearing lossEtiology: viral or bacterial (same organisms as AOM); not really Mycoplasma pneumonia as previously thoughtMastoiditisComplication of untreated or inadequately treated AOM; also complication of leukemia, mono, sarcoma of temporal bone, Kawasaki diseaseS. pneumo (most frequent), H. flu, S. pyogenes, S. aureusOtalgia, otorrhea, fever, headache, hearing loss, outward and downward displacement of pinna, posterior auricular (mastoid) tenderness, abnormal TMComplications: osteitis, labyrinthitis, meningitis, encephalitis, brain abscess, damage to CN VIIDx with CT temporal boneAdmit, IV abx (ceftriaxone, unasyn), ENT consult, +/- myringotomy with tubes or mastoidectomyTM perforationPenetrating object, loud noise, infection (AOM, myringitis), blast injury (explosion, slap, lightning), rapid pressure change (airplane, scuba), cerumen irrigation complicationSudden hearing loss, severe otalgia, vertigoIf acute, see irregular borders with blood on edges or in canal; if chronic, smooth margins and no bloodMost common area to perforate is pars tensa because most anterior and thinnestIf complete hearing loss, nausea, vomiting, vertigo, facial palsyimmediate ENT because might have concurrent injury to ossicles, labyrinth or temporal boneTx: no water in ear, reassurance, analgesia, ENT referral; consider abx if due to infection or forceful water entry (water skiing) or polluted water; if coexisting otitis externa, topical antibiotic suspension (not solution) should be usedEar FB: if live bug in ear, instill lidocaine to kill it prior to removalAuricular hematomaMust I&D and place protective pressure dressing to prevent formation of “cauliflower ear”Reassess in 24 hours for blood reaccumulation; may require repeat drainageNOSEEpistaxisAnterior (Kiesselbach’s plexus on anteroinferior nasal septum)-90%; posterior (sphenopalatine artery)-10%Posterior bleeds usually in elderly, hypertensive pts with atherosclerosisCausesTrauma (look for septal hematoma)Foreign bodyNose picking (most common)Dry nasal mucosa (winter)AllergiesNasal irritants (cocaine, nasal sprays)AnticoagulantsPregnancyChange in atmospheric pressureInfection (rhinitis, sinusitis)Osler-Weber-Rendu (telangiectasias, visceral lesions, family hx)Jury is out on whether hypertension causes nosebleedsTreatmentDirect pressure for 10 minutesBlow nose to clear clotsCouple squirts of neosynephrineControl focal anterior epistaxis with silver nitrate (only helpful when bleeding minimal; hold for 5-10 sec and on one side of septum-cauterizing both sides of septum can perforate)Hemostatic materials-Surgicel, GelfoamAnterior nasal packingLeave in place 1-3 daysDischarge on antistaph abx (Keflex) to prevent sinusitis, toxic shock syndromeIf posterior bleed, needs posterior packing, admission, ENT consult, supplemental O2ComplicationsRebleeding/severe bleeding (may require transfusion)Sinusitis, otitis media-due to obstruction of sinus ostia and Eustachian tubes by packingToxic shock syndromePressure necrosis of septumNasopulmonary reflex-with posterior packs; promotes bronchoconstriction and increases vascular resistancehypoxia, hypercarbiaFatal airway obstruction with dislodgement of posterior packingBradycardia, dysrhythmias, coronary ischemia with posterior packingNasal fracturesMost commonly fractured facial boneDiagnose on exam; imaging not required unless other facial fractures suspectedIf no deformity, need only analgesia and nasal decongestantRefer to ENT in 2-7 days (when swelling has subsided) for reductionGross angulation can be reduced in EDIf fracture associated with laceration of nasal mucosa or skin, anti-staph abx neededNasal septal hematomaBluish-purple, grapelike swelling of nasal septumNeed to vertically incise and drain, pack nasal cavity, anti-staph abx, ENT in 24-48 hrsFailure to drainavascular necrosis of nasal septum-“saddle nose” deformityCSF rhinorrheaFracture of cribriform plate of ethmoid boneMay not develop for days to weeksClear nasal discharge following trauma; may have hyposmia/anosmia and headacheUsually unilateral and increased by leaning forward or compression of jugular veinDx: CT (most reliable); ring sign (filter paper on bed sheet—2 rings=CSF); dipstick CSF glucose >30 mg/dlTx: place patient in upright position, neurosurgery consult, avoid coughing/sneezing/blowing/nasal packingNasal FBMost common in kids 2-3 yearsMay present only with unilateral foul smelling nasal discharge, persistent unilateral epistaxis, foul body odorRemoval: topical vasoconstrictor and anesthetic facilitates exam and therapy; positive pressure techniques (have parent blow puff of air into child’s mouth while occluding uninvolved nostril), suction catheter, forceps, etcFACESinusitisInfection of paranasal sinuses (ethmoid, maxillary, frontal, sphenoid); maxillary most commonResults from occlusion of sinus ostia, most commonly caused by local mucosal swelling secondary to viral URI (also allergic rhinitis, trauma, mechanical obstruction from tumors/FB/abnormal anatomy)Less than 3 weeks-acute; greater than 3 months-chronicPurulent nasal discharge, upper tooth/facial pain, maxillary sinus tenderness, headache, percussion tenderness, swollen nasal mucosa, opacification on transillumination, nasal congestionAcute: same bugs as AOM (S. pneumo, H. flu, S. pyogenes, M. catarrhalis, S. aureus)Chronic: anaerobesUsually doesn’t require imaging for initial dxWater’s view—sinus opacification, air-fluid levels, >6mm mucosal thickeningCT—most sensitive/gold standard—sinus opacification, air-fluid levels, >4mm mucosal thickening, sinus wall displacementCT not specific—40% asx and 87% pts with recent URI have abnormal findingsTx: most resolve spontaneouslyDecongestants –topical and oralConsider abx if sx >7 days—amoxicillin, Bactrim, augmentin, doxy, azithromycin for 10-14 daysComplicationsOrbital cellulitis (ethmoid)Skull osteomyelitis-Pott’s puffy tumor (frontal)—doughy-feeling tender mass Meningitis, epidural abscess, subdural empyema, brain abscess (frontal)Cavernous sinus thrombosis (sphenoid or ethmoid)Also caused by central face infectionVeins of face, oral cavity, middle ear, mastoid drain to cavernous sinusHigh fever, toxic, eyelid edema, proptosis, chemosis, facial edema, altered mental status, headache, cranial nerve palsies (III, IV, V1, V2, VI); VI most commonly affected-lateral gaze palsyParotitis/sialolithiasisParamyxovirus (mumps)Kids 5-15; winterTender bilateral parotid swelling, low grade fever, headache, malaise, clear saliva from Stensen’s ductCan affect gonads (epididymitis, orchitis), meninges (meningoencephalitis), pancreas (pancreatitis)Other complications—transverse myelitis, Guillain-Barre, myocarditis, deafnessSuppurativeElderly, debilitated, postop, decreased salivary flow (dehydration, drugs, irradiation)S. aureusUnilateral parotid swelling, trismus, purulent discharge from Stensen’s duct, feverTx: heat, massage, abx, sialogoguesSialolithiasisUsually submandibularDry mouth, pain, worse at meal times90% seen on xraysCan get secondary staph infectionsTx-massage, analgesics, sialogogues, warm compresses, milking, sometimes surgeryParotid duct/facial nerve proximityA vertically oriented laceration posterior to the corner of the eye and bisecting a line drawn from the tragus of the ear to the center of the upper lip and involve both the facial nerve and the parotid ductENT should repair theseFacial fracturesLe Fort fracturesRarely occur in pure form; usually in combinationBeware of airway and concurrent C-spine injury!!!Avoid NG tube to avoid intracranial passageCheck for CSF rhinorrheaLe Fort I: horizontal fracture of maxilla at level of nasal floorUpper dental arch mobileLe Fort II: fractures through maxilla, nasal bones, and infraorbital rimUpper dental arch and nose mobileLook for injury to infraorbital nerveLe Fort III: fractures through zygomaticofrontal suture or zygoma and frontal bone above noseEntire face is mobile; “dish pan” faceBasilar skull fractureSkull base involves floor or anterior/middle/posterior cranial fossaBattle’s sign, raccoon eyes, hemotympanum, CSF rhinorrheaMay take hours to develop signsMandible fractureSecond most commonly fractured facial boneRing structure—look for second fracture (>50%)Jaw deviates TO the side of fracture, difficulty with mouth opening, decreased ROM, malocclusion (most sensitive)—tongue blade testBadly fx mandible can result in airway compromise (tongue support is compromised)Dx with panorex, CTAny fracture in tooth-bearing region considered open because periodontal ligament communicates with oral cavity—antibioticsTeeth that are angulated and sometimes avulsed—alveolar fracturesLateral crossbite—unilateral condylar fracturesDisplacement of lower incisors, interruption of arch continuity—symphysis fracturesEcchymosis or hematoma of floor of mouth—suspicious for mandibular fxAnesthesia of lower lip—injury of inferior alveolar or mental nerve secondary to fxAdmit for airway compromise, excessive bleeding, severely displaced, grossly infected, comorbid diseaseMandible dislocationCan result from trauma, yawning, laughingJaw locked open (condyle locked anterior to articular eminence), difficulty talking/swallowingBilateral—anterior open biteUnilateral—jaw displaced AWAY from dislocationManual reduction with downward pressure applied to posterior teeth to dislodge condyle; chin then pressed posteriorly so condyle returns to fossa. Protect your thumbs!!Tripod fractures (zygomatic-maxillary complex)Blow to cheek results in fx of zygomatic arch, zygomaticofrontal suture, infraorbital foramen. Also, fx of lateral wall of maxillary sinus and orbital floorFlattening of cheek, periorbital swelling/ecchymosis, diplopia, step-off deformity of inferior orbital rim, anesthesia of cheek/upper teeth/lip/gumOrbital floor fractures (“blowout” fx)Orbital fat, bone, extraocular muscles may protrude into maxillary sinus and become entrappedDiplopia, enophthalmos, upward gaze palsy, hypesthesia of infraorbital nerveCT, abx if sinus involvement, surgery if persistent enophthalmos, visual changes, muscle entrapmentMOUTHNumbering the teethAdults: start from upper right third molar (#1) and around to upper left third molar (#16). Then down to lower left third molar (#17) and around to lower right third molar (#32)Kids: lettered starting on upper right second molar (A) and around to upper left second molar (J). Then down to lower left second molar (K) and around to lower right second molar (T)Nerve blocksSupraorbital nerve block: forehead/scalpPosterior superior alveolar nerve block: maxillary molars (except portion of first molar)Infraorbital nerve block: midface, maxillary incisors, premolars, lower eyelid, upper lip, side of nose, portion of first molarInferior alveolar nerve block: mandibular teeth, lower lip, chinTooth emergenciesTooth fracturesEllis I: fracture of enamel only; no hot/cold sensitivity; tx electiveEllis II: fracture of enamel and dentin; hot/cold sensitivity; see yellow dentin on exam; tx with calcium hydroxide paste and see a dentist w/in 24 hrsEllis III: fracture of enamel, dentin, pulp; severe pain; see pink dot on exam; moist cotton or calcium hydroxide paste and see dentist ASAPAlveolar osteitis “dry socket”Loss of clot with localized osteomyelitis2-5 days postextraction (most often 3rd molar)Tx: pain meds not that great, nerve block, irrigate socket, pack with iodoform gauze dampened with eugenol, antibiotics, dentist ASAPDental painReversible pulpitis with caries: sharp intermittent tooth pain subsides quickly, worse with cold temps; tx with fillingIrreversible pulpitis with caries: dull, continuous pain persists minutes to hours, worse with hot temps; tx with PCN, pain meds, root canalPericoronitis: gum inflammation due to food impaction around crowded, malerupted or impacted third molars; tx with irrigation and abx if surrounding cellulitisPeriapical abscess: most common cause of severe tooth pain. Inflammation, infection, necrosis of apical portion of tooth; can erode into abscess through cortical bone. Suspect if tooth severely painful on percussion. Parulis: abscess draining externally on gums. Tx=abx, extractionPeriodontal abscess: gum disease is MCC of tooth loss; gum inflammation, calculus, infection, abscess; tx with I&D, clinda, flagylAvulsed teethDo not reimplant primary teeth—risk of alveolar ankylosisReimplant quickly--1% loss of survival per minuteRinse gently with saline; do not brush or will remove periodontal ligamentTransport medium: saliva, milk, Hank’s solution (best)Prophylactic PCN, soft diet, TdElectrical burns to lipWorry about delayed hemorrhage from labial artery 3-14 days laterAcute necrotizing ulcerative gingivostomatitis (“trench mouth”)Infection of gingiva precipitated by psychological stress, smoking, poor oral hygieneOnly periodontal lesion in which bacterial actually invade nonnecrotic tissueFusobacterium, spirochetesPt c/o pain, metallic taste, foul breath, fever, malaise, lymphadenopathyGingivae swollen, fiery red; interdental papillae swollen, ulcerated, “punched out” and covered with grayish pseudomembraneWarm saline irrigation, hexadine rinse, abx (PCN, clinda, flagyl)Other conditions with gingival hyperplasia: phenytoin, diabetes, nifedipine, acute leukemiaAphthous ulcer vs herpetic lesionsAphthous ulcers: single circular ulcer <1cm with central yellow area surrounded by prominent band of erythema. Can occur anywhere in oral cavity EXCEPT lips, hard palate, attached gingiva. Tx with abx, topical steroids, anesthetic rinsesHerpetic lesions: clusters of small vesicles that coalesce. Occurs exclusively on the lips, hard palate, attached gingiva. Tx with topical acyclovirCandidiasis vs hairy leukoplakiaCandidiasis: painless, white, curd-like plaques on erythematous base that SCRAPE off with tongue blade. Risk: extremes of age, abx, dentures, diabetes, steroids, HIV, chemotherapyHairy leukoplakia: asymptomatic white patches with hair-like projections, often on lateral tongue, that CANNOT be scraped off with tongue blade. Caused by EBV; 80% develop AIDS within 3 yearsLudwig’s anginaProgressive cellulitis of floor of mouth; submandibular, sublingual, submaxillary spaces involved bilaterallyAirway obstruction occurs in 33%Precipitated by abscess to posterior mandibular molars (most commonly 2nd)Anaerobes (Bacteroides) and aerobes (staph, strep)Dysphagia, odynophagia, dysphonia, trismus, drooling, neck/sublingual pain, massive brawny edema of floor of mouth/anterior neck, fever, elevated tongueTx—keep sitting up, airway/airway/airway, ENT, abx (PCN+flagyl, cefoxitin, clinda, unasyn), ICUComplications—Airway compromise is #1; extension to deeper layers of neck or chestmediastinitis, mediastinal abscessMasticator space infectionBounded by muscles of mastication (masseter and internal pterygoid muscles)From extension of anterior space infection (buccal, sublingual, submandibular space) or infection of third molarStrep and anaerobesLateral facial swelling, pain, fever, trismusTx—abx (PCN, clinda), ENT, admissionNECK/THROATCroup (laryngotracheobronchitis)Most common cause of upper respiratory obstruction in childhoodUsually 6 mo-3yrs, male>female; caused by virus (parainfluenza); fall and winterAffects glottis and sublottic tissuesPreceding viral URI for 2-3 days, gradually increasing cough; insidious onset, nontoxic appearingBarking cough (worse at night), hoarse voice, respiratory distress (tachypnea, dyspnea, retractions, stridor), nasal discharge, low-grade feverCXR—subglottic narrowing of tracheal air column-“steeple sign”Tx--cool mist, O2, hydration, racemic epi if stridor at rest (observe for rebound), steroids (decadron 0.15-0.6 mg/kg IM), no antibioticsAdmit—persistent stridor at rest, unable to tolerate po, unreliable social, incomplete response to racemic epi, multiple doses of racemic epi, severe presentationEpiglottitisAdults >children since Hib vaccine; peak incidence 20-40 yrs; nonseasonalS. pneumo (also GABHS, toxic fumes, superheated steam, gasoline ingestion, angioedema)Affects supraglottic tissues (epiglottis, aryepiglottic folds, arytenoids in kids; can extend to prevertebral soft tissues, valleculae, base of tongue, soft palate in adults)Usually no prodome in kids; adults have 1-2 day URI; progression is rapid (adults can be insidious)Toxic appearance, tripod position, “hot potato” voice, sore throat, dysphagia, drooling, respiratory distress (tachypnea, dyspnea, inspiratory stridor), restlessness, tachycardia out of proportion to fever; can be less impressive in adultsUnremarkable oropharynx exam (if it is done)Diagnosis ideally in OR—cherry red epiglottis; do not disturb a child for exam and radiographs; notify ENT, anesthesiaIf less severe, lateral xrayenlarged “thumbprint” epiglottisTx—ceftriaxone, ENT, ICUBacterial tracheitis (membranous laryngotracheobronchitis)Bacterial infection of subglottic region with copious tracheal secretions; superimposed upon viral URIHas features of both croup and epiglottitisAges 3 mo -10 yrs (usually <3 yrs); nonseasonalS. aureus (also H. flu, S. pyogenes, M. catarrhalis)Prodrome of URI or croup then rapid progression, toxic appearance, barking cough, respiratory distress (stridor and retractions), high feverDirect visualization confirms dx; should be done by ENT in OR; see pseudomembranes and purulent secretionsTx—O2, ENT/anesthesia, abx (-cillin plus ceftriaxone), ICUParapharyngeal abscessSpace lateral to pharynx and medial to masticator space; extends from base of skull to hyoid bonePrecipitated by dental, pharyngeal, tonsillar infectionAnaerobes and aerobesNeck pain, sore throat, dysphagia, odynophagia, unilateral swelling of neck/angle of mandible, restricted neck movement, torticollis, pharyngitis, bulging of pharyngeal wall, drooling, cervical adenopathy, feverTx—airway, IV abx, ENT, steroids, ICUComplications—airway obstruction, spread (CN IX-XII neuropathies, carotid artery extension, septic thrombosis of internal jugular vein)Peritonsillar abscessMost common deep head/neck infectionBetween tonsillar capsule and superior constrictor muscle; complication of untreated or partially treated suppurative tonsillitis, also mucosal trauma, odontogenic spreadTeenagers/young adults; rare in kids <12; males>femalesCan occur after tonsillectomyPolymicrobial (GABHS, strep, H. flu, staph, bacteroides, fusobacterium)Unilateral sore throat, dysphagia, odynophagia, drooling, “hot potato” voice, inferior and medial displacement of tonsil, deviation of uvula to opposite side, ear pain, trismus, fever, tender cervical lymphadenopathy, foul breathAbx (PCN, unasyn, clinda, cefoxitin, emycin), decadron, needle aspiration (not deeper than 1 cm and stay medial to avoid laterally located carotid artery)Retropharyngeal abscessAnterior to prevertebral fascia and posterior to pharynxKids 6 mo-3yrs (b/c large retropharyngeal nodes prone to infection; these involute w age)S. aureus, GABHS, anaerobesUsually follows URI, pharyngitis, OM, wound infection s/p penetrating injury to posterior pharynx (popsicle)Sore throat, dysphagia, labored respirations, stridor, muffled voice, fever, unilateral bulging of posterior pharyngeal wall, tender cervical adenopathy, toxic, sit with neck in extensionSoft tissue neck xray done in sniffing position—neck in extension and during inspirationnormal retropharyngeal space <1/2 width of adjacent vertebral body; RPA will be thickenedTx—airway, abx (-cillin + flagyl, clinda, cefoxitin, unasyn), ENT, ICUComplications—airway obstruction, aspiration, spread (mediastinum, vessels), sepsisPrevertebral infectionSpace between prevertebral fascia and cervical spineUsually from cervical osteomyelitis (staph, TB)Bilateral bulging of pharynx, tenderness of C-spineXray—retropharyngeal swelling or osteo of spineTx—abx, neurosurgeryInfectious mononucleosisCaused by Epstein-Barr virus (human herpes virus 4)10-25 yrsSore throat, fever, malaise, fatigue, exudative pharyngitis, tender POSTERIOR cervical adenopathy, splenomegaly, Kehr’s sign (left shoulder pain), atypical lymphocytosis, elevated transaminasesMonospot helpful if positiveIf given ampicillin, 95% get EBV-induced antibodies to it and a rashCare regarding potential splenic rupture is appropriateSteroids if: airway obstruction, severe hemolytic anemia, thrombocytopenia, neurologic (encephalitis, GBS)DiphtheriaSecondary to noncompliance with DPT immunization; spread by contact with respiratory secretions; incubation one weekCorynebacterium diphtheria=club-shaped Gram + bacillusInfectious invasiontissue necrosis produces pseudomembrane in posterior pharynx; can lead to airway obstructionToxinCV (myocarditis/AV block/endocarditis); nephritis; hepatitis; neuro (eyes-strabismus, ptosis; palate-first muscles affected; limb paralysis; loss of DTRs)Sore throat, fever, malaise, toxic, tachycardia, hoarse/muffled/absent voice, exudative pharyngitis, white/gray adherent pseudomembrane, marked cervical adenopathy (“bull neck”), fetid breath (“dirty mouse”)Culture on Loeffler’s or tellurite mediaTx—Abx (PCN, emycin), diphtheria antitoxinAsymptomatic, immunized contacts—Td boosterAsymptomatic, partially immunized or unimmunized—one dose IM PCN and begin immunization seriesGroup A beta-hemolytic strep (GABHS)Late winter, crowded conditions; <20 yrs; rare in <3 yrsCentor criteria: fever, tender cervical adenopathy, exudative tonsillitis, no coughAbdominal pain, vomiting, headache common in kidsStrep screen helpful if positiveTx—10 days PCN or single IM benzathine PCN; cephalosporins and azithro usually reserved for recurrent; steroidsComplicationsSuppurative: PTA, OM, sinusitis, necrotizing, fasciitis, bacteremia, meningitis, brain abscess; abx decrease incidenceNonsuppurativeStrep toxic shock syndromeGlomerulonephritis-abx do not decrease incidenceRheumatic fever-abx within 9 days prevent thisJones criteria for diagnosis (need 2 major or 1 major and 2 minor PLUS evidence of recent strep infectionMajor criteriaJ (Joints): migratory polyarthritis of large joints, usually starting in legs and migrating upO-imagine a heart (carditis): CHF, pericarditis, new murmur (mitral valve damage)N (nodules): subcutaneous-painless, firm collections on back of wrist, outside elbow, front of kneesE (erythema marginatum): begins on trunk or arms as macules and spreads outward to form snakelike ring while clearing in middle. Never starts on face; worse with heatS (Syndenham’s chorea): St. Vitus’ dance; rapid movements of face and armsMinor criteriaFeverArthralgiasLabs-ESR, CRP, leukocytosisEKG-prolonged PR intervalPrevious rheumatic fever or rheumatic heart diseaseEvidence of Group A Strep infectionPositive throat culture, elevated or rising ASO or DNAase titer, recent scarlet feverAirway obstructionLabored respirations: tachypnea, retractions, nasal flaringStridorInspiratory: (supraglottic or glottic) indicates obstruction above or at the larynx, ex. epiglottisBiphasic: (subglottic) indicates obstruction below the larynx, ex. croupExpiratory: indicates bronchial or lower tracheal obstructionHoarseness, dysphagia, coughing, cyanosisForeign body aspirationKids 1-4 yrs; males>femalesPeanuts most common agent; hot dogs most common cause of fatal aspirationNarrowest part of airway is where FB get lodgedAdults—vocal cordsKids—cricoid cartilagePresenting signsAphonia: complete upper airway obstructionStridor: incomplete upper airway obstructionWheezing: incomplete lower airway obstructionCoughing: incomplete obstruction at larynx or distal airwaysIs the coin in the esophagus or airway???Esophageal FB: lies in frontal/coronal plane and will be round in PA viewTracheal FB: lies in sagittal plane and will be round in lateral view (on edge in PA view)Partially obstructing FBSeen best on expiratory films“ball valve” effect: hyperinflation of obstructed lung due to air trapping, shift of mediastinum away from affected side ................
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