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Flashcards in EENT Emergencies Deck (49)
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Common presenting complaint to EDs
1. Ideally, have patient in a straight up in what position?
2. What does this positioning do?
3. Prevents what?
4. May have to modify if patient appears to be what?

1. (90 °) sitting

2. Decreases nasal arterial pressures

3. aspiration

4. shocky


What is the significance of a Posterior bleed as opposed to an Anterior Bleed?

In posterior the bleeding can continue down the throat without the person knowing. These are more severe

Anterior are more common


Hx questions? 5

1. One nare or both
2. Sensation of blood in the back of the throat
3. History of epistaxis, trauma, head/neck tumor, radiation or head/neck surgery
4. Family history of bleeding disorders
5. Anticoagulants, NSAIDS, or ASA?


Look for underlying cause of epistaxis

1. Nose picking
2. Dryness
3. Trauma
4 .Anticoagulation or ASA therapy
5. Bleeding diathesis
6. Foreign body
7. Allergies-nasal steroid use
8. ASA? & HTN?


Bleeding diathesis that may contribute the epistaxis?

1. Hematologic Disease
2. Polycythemia,
3. TTP,
4. von Willebrand Dz,
5. hemophilia,
6. Aplastic Anemia


Treatment for epistaxis


Step 1: Start with direct pressure

Step 2: If still bleeding after direct pressure

Step 3: Determine site of bleeding

Step 4: Cautery with silver nitrate stick

Step 5: Anterior Packing


tx for epistaxis:
Step 1: Start with direct pressure
1. Compress the nares between where?
2. Hold pressure for how long?
3. Patient to lean forward or sit upright at a ___ degree angle

4. How will this tx affect a posterior bleed?

1. the thumb and index finger or 2 tongue depressors taped together

2. 20 minutes

3. 90

4. This will have no effect on posterior bleeds


Treatment for epistaxis

Step 2: If still bleeding after direct pressure
1. Apply a what? 2
-Commercial preparation like?
-Or make your own by mixing by?

2. Place impregnated cotton balls in the nare X how long?

3. Remove cotton balls and evacuate clot. How? 2

1. topical anesthetic + vasconstrictor
-Afrin and cotton balls soaked in Lidocaine 2%
-2% Lidocaine and 1:1000 epinephrine and soaking cotton balls in this mixture

2. 10 min

3. (blowing or suction)


Treatment for Epistaxis
Step 3: Determine site of bleeding
1. You need what? 5
2. Many times the site is determined by age:
-Older adults?

-good illumination,
-a nasal speculum,
-ENT chair (if available)

-Children – Often in anterior Kiesselbach’s area
-Adults – Generally just posterior to Kiesselbach’s area
-Older adults – Most difficult and often posterior


Treatment for epistaxis
Step 4: Cautery with silver nitrate stick
If still bleeding and can visualize the bleeding area?
3 steps

1. Apply pressure with the silver nitrate for 5-10 seconds
2. Cauterize a small area around the bleeder as well
3. Apply abx ointment to area
If this resolves the bleed then abx ointment X 7 days


Treatment for epistaxis
Step 5: Anterior Packing
Indicated if all measures up to this point have failed
1. Can use what? 2
2. Apply a what to the nare?
3. Apply what to the packing?
4. Insert along the _________ plane to the max depth

Foam polymers may need water to expand, some devices may require inflation

1. nasal tampons or nasal balloon catheters

2. topical anesthetic

3. surgial lubricant

4. horizontal


Treatment for epistaxis
Step 5: Anterior Packing
After Care? 4

After care:
1. Remove packing in 48-72 hours
2. Oral antibiotics required
3. Patient to remain upright (even sleep) for 48 h
4. No lifting and avoid laughing for 24 hours


1. If still bleeding after packing consider this is a what?

2. Then?

3. What so we do with a septal hematoma?

4. What deformity can it cause?

1. posterior bleed
2. Consult ENT emergently

3. We drain it

4. saddle nose


1. What is ineffective?
2. Packing in a posterior pt?
3. What artery?

1. Direct pressure is ineffective

2. Nasal packs are uncomfortable to place
-Posterior packed patients are often admitted for observation

3. Sphenopalatine artery
ENT consult is warranted


Epistaxis: Posterior

1. Difficulty swallowing
2. Otitis media
3. Necrosis of the nasal mucosa


What is the most commonly fractured bone in the face?

Nasal fracture


Nasal fracture
1. Dx based on?
2. Nose will present how? 2
3. Look for? 3
4. Inspection with what is mandatory?
5. Manage how long?

1. Diagnosis usually based on physical exam
2. Nose usually edematous and tender
3. Look for
4. Inspection with a nasal speculum mandatory to rule out septal hematoma
5. Manage (closed reduction) 2-10 days post injury to allow for reduction of swelling


Septal hematomas occur secondary to trauma to the what?

anterior nasal septum


Septal hematomas occur secondary to trauma to the anterior nasal septum
1. Adults suspect one?
2. Children can occur with what?
3. Treatment? 2
4. Cartilage fracture: Formation of what?

1. Adults
-Suspect significant trauma and nasal fracture

2. Children
-Can occur with simple falls or minor altercations

3. Treatment
-Drain and pack
-Antibiotics (Augmentin) if abscess suspected IV Clindamycin and admission

4. Cartilage fracture
-Formation of bilateral hematomas


Complications that occur from untreated septal hematomas

1. Saddle nose deformity
2. Septal abscess
3. Septal perforation


Common Ear Complaints Encountered in EM

1. Otitis Externa
2. Otitis Media
3. Vertigo


External Otitis
1. AKA?
2. Signs and symptoms?
3. What must you visualize?
4. Whats the positive sign?
5. Tx? 3
6. Have to rule out what?
7. What bug?

External otitis
1. AKA “swimmer’s ear”
-erythema of EAC with +/- exudate
3. MUST see TM (if not make sure you clean out ear so TM is visible)
4. Positive pinna tug
5. Treatment is generally
-application of wick and cortisporin otic;
-local heat,
6. MALIGNANT OE! -need referral to EENT and systemic abx for 6-8 weeks. Whole side of head will be swollen.
7. Pseudomonas
Otitis Media
You know this ad nauseum so just treat it!


Differentiate between a neurologic disorder vs. a disorder of the ear
1. Nystagmus
2. Hearing loss
3. Other neuro symptoms
4. Other symptoms
5. DDx (3 for CNS) (4 for Ear)

1. Usually absent
2. Rare
3. Present
4. Rare
-Drug toxicity
-Cerebellar stroke
-Brain stem stroke

3. Ear
1. Horizontal
2. Usually present
3. Absent
4. N, V, sweating
-Acoustic neuroma


Ménière's disease:
1. What is it?
2. Presentation?
3. Usually what symtpom?
4. Tx?

1. Fluctuating, progressive, sensorineural deafness. Hydrops, FULLNESS in the ear!
-Episodic*** characteristic definitive spells of vertigo lasting 20 minutes to 24 hours**
-no unconsciousness,
-vestibular nystagmus always present.
3. Usually tinnitus


Acute labyrinthitis
1. Recovery takes how long?
2. Describe the acute period?
3. Approximately how long?
4. How long may chronic compensation last?
5. May follow what?

1. Recovery generally takes from one to six weeks
2. An acute period, which may include severe vertigo and vomiting
3. Approximately two weeks of sub-acute symptoms and rapid recovery
4. Chronic compensation, which may last for months or years
5. Upper respiratory infection


1. What is BPV?
2. Tx?

1. Benign paroxysmal positional vertigo (BPPV) is a disorder arising in the inner ear. Its symptoms are repeated episodes of positional vertigo, that is, of a spinning sensation caused by changes in the position of the head. BPPV is the most common cause of the symptoms of vertigo.

2. Tx:
-Epley maneuver
-Antiemetic's (ondansetron-Zofran 4-24mg po/d)/ anticholinergics (meclizine 25mg po 1-4x/d)


Emergencies involving the Pharynx and Hypopharynx

1. Acute tonsillitis
2. Epiglottitis
3. Peritonsilar abscess
4. Croup
5. Ludwig’s Angina


Acute Tonsillitis
1. Signs and symptoms? 3
2. Difficult to differentiate etiology b/w?
3. Bacterial is usually caused by?
4. Rapid strep is helpful how?
5. Watch for atypicals like?
6. First line?

1. Signs and symptoms:
-adenopathy common

2. Difficult to differentiate viral versus Strep

3. Bacterial is usually caused by Strep (group A)

4. Rapid strep is helpful for cases that you suspect may be viral otherwise just treat

5. Watch for atypical, resistant infection (i.e.- GC pharyngitis)

6. Oral PCN
-alt: amoxicillin


1. What is it?
2. Signs? 2
3. Management?
4. What will you see on X-ray?

1. Infection/inflammation of epiglottis and surrounding soft tissue
-Tripod Posture
-Thumb print sign
3. Usually seen in children
If you suspect – STOP – DO NOT EXAMINE; obtain soft-tissue lateral of neck and call ENT/Pediatrics

-Inflamed epiglottis
-swollen aryepiglottic folds


Peritonsillar Abscess
-Signs? 8

1. Severe pain,
2. hoarseness,
3. “hot potato voice”,
4. drooling,
5. dysphagia
6. Cervical lymphadenopathy,
7. fever
8. Soft palate bulging and uvula deviating AWAY

1. CT of neck

-Call ENT to evaluate and take to the OR for an I&D;
-Usually Strep; Start IV antibiotics
-Draining of abscess is the treatment
-After drainage, High dose abx