Emergency Medicine—Eye, Ear, Nose, and Oral



Emergency Medicine—Eye, Ear, Nose, and Oral

EYE

Examination

1) Visual acuity

2) Pupillary function

3) Extraocular motility

4) Visual fields

5) Slit lamp

6) Intraocular pressure

7) Fundoscopy

Corneal Abrasion

Corneal abrasion is a superficial disruption of the cornea resulting from trauma. The cornea is round, avascular, and clear over the anterior eye. It refracts light and protects the eye

Clinical Presentation

1) History – ocular pain, sensation of foreign body, blurred vision, photophobia

2) PE – conjunctival injection, visual acuity defects

3) Contact lens users are prone to ulceration due to Pseudomonas aeruginosa

Diagnosis

1) Visual acuity – blurred vision if near central vision

2) Upper eyelid eversion – foreign body

3) Fluorescein staining

Treatment

1) Topical anesthetics to facilitate exam – proparacaine. Always use anesthesia!

2) Cycloplegic eyedrops – dilate the pupil. Reduce ciliary body spasm, reducing pain. Use in caution in patients with narrow-angle glaucoma. Common side effect is photophobia

3) Irrigation with NS to remove foreign bodies

4) Discharge with broad spectrum antibiotics – Emycin or Polysporin

5) Aminoglycoside/fluoroquinolone for contact lens patients due to P. aeruginosa

6) Oral analgesics

7) Follow-up in 24 hours

Corneal and Conjunctival Foreign Body

Clinical Presentation

1) Pain

2) Sensation of foreign body

3) Rust ring – evidence of metal piece inside eye

Diagnosed

1) Fluorescein

2) R/O intraocular foreign bodies – use soft tissue x-ray or CT scan. Do not use MRI if suspect metal foreign body

Treatment

1) Remove object with moist cotton swabs

2) Use proparacaine

3) Antibiotic ointment

Acute Angle Closure Glaucoma

Acute Angle Closure Glaucoma is an increase in IOP. Untreated can result in blindness. Aqueous humor is a clear fluid substance that bathes the lens and cornea. It is produced by the ciliary process and drains into the episcleral veins by canal of Schlemm.

Clinical Presentation

1) History – sudden eye pain, blurred vision, headache, n/v, halos around lights

2) PE – visual acuity defects, conjunctival injection, cloudy cornea, midway positioned or dilated

3) Slow or sluggish response to light

4) Elevated IOP

Management

1) Improve aqueous humor flow – Pilocarpine 2% eyedrops, laser iridectomy

2) Inhibiting aqueous humor production – Timolol .5% eyedrops

3) Reducing aqueous or vitreous humor volume – Mannitol IV draws water into the circulation and out of the eye

Central Retinal Artery Occlusion

Central retinal artery occlusion causes retinal ischemia and painless vision loss. Eye emergency. Can lead to retinal infarction if not treated within 90 minutes. Risk factors include HTN, a-fib, collagen vascular disease, sickle cell disease, acute glaucoma, and orbital hemorrhage

Clinical Manifestations

1) History – acute, painless monocular vision loss with risk factors

2) PE –macula is cherry red due to retinal thinning, unresponsive pupils, edematous retina, and increased IOP

Management

1) Reestablish central retinal artery blood flow and retinal perfusion – Global ocular massage

2) Anterior chamber paracentesis –

3) Acetazolamide IV

Disposition

1) Hospitalization for treatment by ophthalmologist

Orbital Cellulitis

Periorbital cellulitis does not enter the orbit. Orbital cellulitis is infection posterior to the orbital septum within the orbit. It is a deeper infection and is more emergent. Both should be treated aggressively to avoid extension into meninges and brain via cavernous sinus.

Clinical Manifestations

Periorbital Cellulitis

1) Erythema and swelling

2) No pain with EOM

3) No proptosis

4) No diplopia

Orbital Cellulitis

1) Conjunctival injection

2) Fever

3) Edematous erythematous periorbital soft tissue

4) Tenderness with EOM

5) Elevated IOP

6) Impaired visual acuity

7) Sensation can be impaired

Diagnosis

1) CT soft tissue orbital infiltration

2) Cultures

Management

1) Admit with broad spectrum antibiotics such as Clindamycin and ceftazidime

2) Orbital cellulitis – fever, toxicity, periorbital swelling should be hospitalized with IV antibiotics

EAR

Ear Pain

History Questions

1) History of trauma, surgery, recent infection

2) Specific symptoms

3) Pain quality

4) Exact location of the pain

Physical Exam

1) Palpate area surrounding ear to identify lymph nodes

2) Pain, swelling and erythema at mastoid process

3) If pain in canal look for discharge from canal

4) View canal, TM

5) If ear exam is normal, examine teeth

Acute Mastoiditis

Acute Mastoiditis can be an extension of AOM. Etiology is s. pneumoniae, s. pyogenes, and s. aureus

Clinical Manifestations

1) Fever

2) Pain

3) Swelling and erythema at mastoid

4) Canal with no erythema or discharge

5) Possibly findings of AOM

Treatment

1) ENT consult

2) Admission

3) IV antibiotics – Cefotaxime

Foreign Body

Clinical Manifestations

1) Insect noted on canal or on TM

Treatment

1) Removal by Frazier suction, alligator forceps, or curette

2) For insect, instill lidocaine in canal and flush out insect

3) If secondary canal trauma, treat for otitis externa

4) Do not flush the ear with water if the foreign body is an organic substance

Otitis Externa

Otitis externa is caused by p. aeruginosa, s. aureus, or fungal infection. Caused by excessive moisture which removes cerumen and causes the pH of the ear to elevate. Commonly seen in swimmers

Clinical Manifestations

1) Ear pain and itching

2) Otorrhea

3) Erythematous canal

4) Pain with pinna movement

5) Faulty hearing if canal is occluded

Treatment

1) Wick through obstructed canal for antibiotic administration

2) Treat with topical steroid and antibiotic preparations such as hydrocortisone-polymyxinneomycin or ciproHC

3) Analgesics

4) Consider malignant otitis in diabetics, immunocompromised, or elderly – treat with anti-pseudomonal and hospitalization

Acute Otitis Media

Acute otitis media is caused by s. pneumonia and h. influenzae.

Clinical Manifestations

1) TM erythematous

2) Dull light reflex

3) Limited motility

4) Landmarks may not be visible

5) Ear pain

6) Conductive hearing loss

7) History of URI

Treatment

1) Amoxicillin for 10 days

2) Augmentin if recent treatment failure

3) Bactrim

Perforation of TM

Etiology is blunt or penetrating trauma

Clinical Manifestations

1) Pain

2) Otorrhea

3) Tinnitus

4) Retraction of TM

Treatment

1) Most need no intervention

2) No antibiotics unless infection present

NOSE

Epistaxis

Most episodes of epistaxis are without life threatening blood loss. Typical site of bleeding is Kiesselbach’s area of anteriomedial nostril. Anterior nosebleeds are usually caused by digital trauma. Posterior nosebleeds are usually caused by HTN.

History Questions

1) Picking your nose?

2) Dry air?

3) Pregnancy?

4) History of anticoagulant therapy?

Physical Exam

1) Both nostrils should be examined for bleeding and the integrity of the septum

2) Observe posterior pharynx for blood dripping – posterior

3) Bright red blood – anterior

4) Dark red blood – posterior

Management

Anterior

1) Pinch nostrils and lean forward

2) Silver nitrate for cautery – only if the bleeding can be localized

3) Anterior packing if bleeding persists – Merocel

4) If nasal packing, give prophylactic Augmentin

Posterior

1) Arterial site – use vasoconstrictive agents

2) Foley catheter or nasal balloon devise

3) Admit for airway observation, prophylactic antibiotics and ENT consultation

Nasal Obstruction

Clinical Manifestations

1) Object might be visible

2) Purulent discharge from one nostril

Treatment

1) Puff technique – have mother blow into child’s mouth, holding unaffected nostril closed with finger. Should dislodge object

2) Remove object with forceps

3) Insert small Foley catheter past object, inflate balloon and pull out to remove object

Nasal Fracture

Diagnosis

1) Suggested by mechanism of injury, swelling, tenderness, crepitance, gross deformity, periorbital ecchymosis

2) Look for septal hematoma – applies pressure to the septum. Can lead to necrosis due to pressure

Treatment

1) Ice/analgesics

2) OTC decongestants

3) Follow up in 2-5 days for re-examination

4) Treatment of septal hematoma is incision and drainage with anterior nasal packing

ORAL AND DENTAL EMERGENCIES

Dental Fractures

Ellis Classification

1) Type I – enamel

2) Type II – dentin

3) Type III – pulp and presents as a red blush of dentin

Clinical Manifestations

1) Air and temperature sensitivities

Treatment

1) Dry dentin and cover with zinc oxide/eugenol paste

2) See dentist within 24 hours

Concussion

Concussion is no abnormal loosening.

Clinical Manifestations

1) Tenderness to percussion

Management

1) NSAIDs

2) Soft diet

3) Dental referral

Subluxation

Subluxation is a loose tooth

Management

1) NSAIDs

2) Soft diet

3) Dental referral

Extrusive Luxation

Extrusive luxation is when the tooth is coming downward.

Treatment

1) Reposition tooth and splint with zinc oxide

2) Evaluate in 24 hours

Lateral Luxation

Lateral luxation is when the tooth is laterally displaced

Treatment

1) Splinting

Intrusive Luxation

Intrusive luxation is when the tooth is forced below the gingival line

Dental Avulsion

In dental avulsion, secondary teeth must be replaced within 3 hours. Handle avulsed tooth by crown only, rinse with water and have replanted immediately. Root must be moist. If not soak in citric acid, then stannous fluoride and then doxycycline

Tongue Lacerations

Tongue lacerations that actively bleed require suturing. Smaller lacerations will heal on their own. Use 4 0 absorbable sutures and approximate as closely as possible.

Lip Lacerations

Lip lacerations may possibly involve the transition between lip tissue and skin of the face. Use infraorbital nerve block for upper lip and mental nerve for lower lip. If oral laceration, prophylaxis with Penicillin or Clindamycin for 5 days

Tooth Eruption

Tooth eruption is the emergence of secondary teeth.

Treatment

1) Cold compress and acetaminophen

Wisdom Teeth in Adults

Treatment

1) Penicillin, ibuprofen, clindamycin, and warm saline mouth rinses

2) Oral surgeon if necessary

Tooth Decay

Tooth decay is the most common cause of toothache. It is periapical pathology.

Clinical Manifestations

1) Pain localized to one tooth

2) Pain can radiate to head, neck, ear

3) Decayed tooth

4) Percuss teeth with metal object will elicit pain

Treatment

1) Penicillin or Clindamycin, ibuprofen, oxycodone

2) I/D if abscess present

Pulpitis

Pulpitis is inflammation of the pulp. The pulp is exposed through the center of tooth. Presents as deep throbbing pain on exposure to hot or cold.

Periodontal Infection

Periodontal infection is acute bacterial infection of the periodontal tissues localized to gingival or mucosa adjacent to the involved tooth.

Treatment

1) Antibiotics

Periodontal Abscess

Periodontal abscess results from plaque and debris entrapped between the tooth and gingiva.

Treatment

1) Oral antibiotics – Penicillin or clindamycin

2) Analgesics

3) Chlorhexidine mouth rinses

4) Large abscess need I/D by dentist

5) Dental referral

Acute Necrotizing Ulcerative Gingivitis

Acute necrotizing ulcerative gingivitis is found mainly in patients with lowered resistance due to HIV, malnourishment, stress, and alcoholics.

Clinical Manifestations

1) Pain

2) Ulcerated Interdental papillae

3) Gingival bleeding

4) Fever

5) Malaise

6) Extremely foul breath odor

Treatment

1) Metronidazole

2) Chlorhexidine mouth rinses

Oral Candidiasis

Oral candidiasis is a.k.a. oral thrush. Risk factors include elderly, young, and immunocompromised patients. It is an opportunistic infection.

Clinical Manifestations

1) Removable white curd-like plaques on an erythematous mucosal base causes bleeding

Treatment

1) Oral antifungal agents such as clotrimazole troches, Nystatin, and fluconazole

Aphthous Stomatitis

Aphthous stomatitis is a.k.a. canker sores. It is an intraoral ulceration triggered by cell-mediated immunity (HSV type VI).

Clinical Manifestations

1) Painful small round ulcerations with yellow-gray centers surrounded by red halos

2) Found on buccal and labial mucosa

Treatment

1) Usually self-limiting – 7-10 days

2) Give topical steroid mouth rinse for pain

Herpetic Stomatitis

Herpetic stomatitis presents as burning followed by small vesicles, which form scabs. Symptoms can be severe in immunocompromised patients.

Management

1) Antiviral therapy

HSV Type I

HSV type I presents as labial vesicles that rupture and crust and intraoral vesicles that ulcerate. Found on lip and oral mucosa.

Management

1) Antivirals

2) Look for secondary infection

Coxsackievirus

Coxsackievirus is transmitted through fecal/oral or airborne route

Types

1) Type A – found on oropharynx. Associated with herpangina

2) Type B – associated with pneumonia and bronchitis

Clinical Manifestations

1) Presents as vesicles and ulcers on the tonsilar pillars, uvula, soft palate, posterior pharyngeal wall

2) Also associated fever, sore throat, headache, and dysphagia

Treatment

1) Self-limiting – lasts 5-10 days

2) Supportive

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