UMEM Educational Pearls - ENT

Epistaxis can be a difficult thing to control in the ED, but there are several techniques you can learn that will make your life easier.

The majority of epistaxis cases are from kiesselbach's plexus therefore you can control it with:

Direct Pressure: Can be held with two fingers pinching the nares, or you can tape 4 tongue blades together and make your own "clothes pin" that can then be used to pinch the nares.

Vasoconstrictor and Anesthesia: A 1:1 mixture of topical lidocaine 4% and oxymetazoline can often be mixed together in the same oxymetazoline spray container enabling you to just spray it into the nares. This will often slow or stop the bleeding and provides anesthesia in case you need to cauterize the bleeding site.  Some IV/IM narcotic pain medication will also help increase patient cooperation.

Visualize the bleeding site: Use a HEAD LAMP with an appropriate sized nasal speculum. You may look like Marcus Welby, MD but nothing works as well to see into the nose.

Cauterization It is best to cauterize circumferential around the bleeding site prior to directly cauterizing the actual site. Be careful with electrical cautery so has not to perforate the septum.

Nasal Packing: Instead of using surgilube to lubricate the packing; use Muprion, Bactroban or Bacitracin ointment to lubricate the packing. This will reduce the chance of Toxic Shock Syndrome.

Manibular Dislocations:

• Mandibular dislocations can be extremely difficult to reduce at times.
• The classic method of reducing a mandible dislocation is for the provider to wrap his thumbs in guaze (to prevent them from being bitten), and while placing his thumbs bilateraly as far posterior on the mandible as possible, he applies downward, and then posterior pressure to reduce the dislocation.
• Significant muscle spasms can result from the dislocation, requiring procedural sedation, but even with sedation it can be very difficult if not impossible to reduce the mandible.
• Dr. Cheng's article, referenced below, describes a new technique, where the provider use both of his thumbs to press down on a single side of the mandible posterior until the side reduces.
  • For a bilateral dislocation, the technique would be to reduce one side and then the other.

Some authors also recommend using rolled guaze to hold the patient's mouth shut so that they do not inadvertantly dislocate their jaw a second time if they happen to yawn while awakening from their sedation.

Show References

Patient with iritis will typically present with a painful red eye and it can sometimes be difficult to tell if it is due to conjunctivitis or a corneal abrasion.  Some tips that can help differentiate iritis from other causes of painful red are:

1. When pain reduction was used as a diagnostic tool, it had a sensitivity of 80% and a specificity of 86% in determining whether a simple corneal injury was present. In iritis, the pain will NOT be relieved with topical anesthetic.
2. In iritis, injection will be localized predominantly around the iris and not diffusely over the conjunctiva.
3. The consensual light reflex can be used to make the diagnosis. Of course, shining a light in the affected eye will cause pain, but in iritis shining a light in the normal, unaffected eye (by causing consensual movement of the other affected iris) will cause pain if iritis is present.

Finally, ensure you document:

1. Visual Acuity corrected in both eyes.  Use a pinhole if they forgot their glasses.
2. That you flipped their eyelids to make sure that no foreign bodies are lurking under the lids
3. Stain their eyes with flouriscen to ensure there are no corneal abrasions in addition to the iritis.

Show References

Conjunctivitis:

Patient presenting to the Emergency Department complaining of "Pink Eye" is very common but how can you be sure that they do not have a bacterial conjunctivitis and absolutely need antibiotics or are they just suffering from a viral or allergic conjunctivitis.

• Bacterial conjunctivitis will typically have  a mucopurulent discharge and the patients will complain that their lids are matted shut in the morning. Though this can occur in allergic or viral conjunctivitis, those with bacterial conjunctivitis typically have a wet, sticky mucopurulent material matted to their lids where viral/allergic conjunctivitis typically have crusting on their lids and lashes due to dried tears and serous secretions.  Bacterial conjunctiviits is also an uncommon condition due to the defense systems of the eye. So most patients can be treated with support care (ie: Warm Compresses).
• Allergic conjunctivitis should affect both eyes.  It would be odd for only one eye to be allergic, so if only one eye is infected that diagnosis is most likely viral or bacterial conjunctivitis.
• When treating allergic conjunctivitis go with the drops.  Several studies have now shown that topical therapy is better than systemic (ie: benadryl, zyrtec, allegra, or claritin) in the resolution of symptoms.

Otitis Externa:

Infections of the external ear canal are common and can typically be treated with topical antibiotic solutions (Cortisporin Otic, Cipro Otic, etc...) or antibiotic solutions mixed with topical steroids (Cortisporin HC Otic, Cipro HC Otic, etc...).  Most patients should not require PO or IV antibiotics.

However, you need to always be on the look out for malginant otitis externa (MOE) which is a more deep seated infeciton extending into the temporal bone and can have a mortality rate as high as 50%.  Patients that are diabetic, immunospressed, or have had radiation therapy to the base of the skull are at increased risk.  Patients with MOE typically have pain out of proportion to clinical findings and granulation tissue may be present in the ear canal.  Suspect this diagnosis in patients that have cellulitis or extreme tenderness over the mastoid process.

If you suspect MOE the patient should be started on antibiotics that cover pseudomonas. Consider obtaining a CT scan with temporal bone cuts and an Otolaryngology consultation.

Dental Emergency -- Avulsed Tooth

• Never reimpant a primary tooth.  If replaced, primary teeth have a high likelihood of fusing to underlying alveolar bone, which causes dentoalveolar ankylosis and can result in facial deformities
• Never wipe off a tooth, or hold it by the root. The periodontal ligament is easily wiped off and the tooth will not reimplant without it.
• For maximal success, the tooth should be reimplanted within 60 minutes.
• Avoid allowing the periodontal ligament from drying out.  Transport the tooth in (listed in order of preference):
  • Hanks Solution or EMT Tooth Saver
  • Milk
  • Saline
  • Saliva
• Once the tooth is reimplanted it should be held in place with a wire splint or Coe-Pak that bridges the avulsed tooth to the ones on either side of it.
• Place the patient on antibiotics (Penicillin or Clindamycin) in order to prevent any infections.
• If the avulsed tooth can not be found a Chest X-ray should be obtained to ensure that the tooth was not aspirated.

 

 Trigeminal Neuralgia

• A neuropathic disorder of the trigeminal nerve that causes episodes of intense pain.
• Also known as Tic Douloureux
• Many cases are associated with vascular compression and subsequent demyelination of the trigeminal nerve, though other causes include compression by a tumor, and multiple sclerosis.
• Classic Trigeminal Neuralgia is a clinical diagnosis that has the following criteria:
  • Paroxysmal attacks of pain lasting from a fraction of a second to two minutes that affect one or more divisions of the trigeminal nerve
  • Pain has at least one of the following characteristics: intense, sharp, superficial, or stabbing precipitated from trigger areas or by trigger factors
  • Attacks are similar in individual patients
  • No neurological deficit is clinically evident
  • Not attributed to another disorder
• Treatment options include:
  • Medical:
    • Carbamazepine (most common and drug of choice)
    • Gabapentin (lacks evidence in trigeminal neuralgia but widely used for other neuropathic pain)
    • Lamotrigine
    • Baclofen
  • Surgical:
    • Microvascular decompression: posterior fossa is explored and the culprit blood vessel is moved off the trigeminal nerve. Typically the nerve is padded with a teflon sheet in order to provide additional protection. 80-90% successful with little or no facial numbness.
    • Ablative: Attempts are made to just incapacitate the pain fibers but these techniques can result in facial numbness as other sensory fibers can be damaged.  Common methods include:
      • Glycerol or alcohol injection
      • Radiofrequency rhizotomies
      • Stereotactic radiation therapy
      • Complete severing of the nerve.

Show References

How many times a day are you told "I need antibiotics I coughed up some yellow/green stuff" Neither the color nor the consistency of nasal secretions helps to predict whether there is a bacterial infection. One should only consider treating sinus infections with antibiotics if the patient has:

1. Purulent nasal drainage for more than 10 days
2. Or if symptoms less than 10 days and one or more of the following significant facial pain, facial/periorbital swelling, dental pain, or temperature greater than 39'C

Antibiotic of first choice is Amoxicillin for 10-14 days. [Also consider Bactrim, Augmentin or Cipro for recurrent sinus infections]

With more and more ENT specialist resigning their hospital affiliations in favor of outpatient surgical centers it is getting harder and harder to find an oncall ENT to treat an ENT emergency. Peritonsillar abscesses and the need for drainage are a common reason to initiate a transfer. If you are unable to transfer your patient, here are some tips on how to do a needle aspiration safely.

• The carotid artery lies lateral and posterior to the tonsil. Any attempts should be done anteriorly, and medial to the peritonsillar pillar.


• The incision is made superior to the tonsil in the area of the soft palate. The abscess is normally located in the peritonsillar soft tissues of the soft palate.


• Needle aspiration: Needle aspiration can be therapeutic in itself; in some studies, up to 85% of patients were effectively treated with outpatient needle aspiration and oral antibiotics.


• Consider cutting the cap of the needle or scalpel so that once it is replaced only a portion of the needle /scalpel is exposed. This will help prevent you from inadvertently inserting the needle//scalpel to deeply.


• A single high dose of steroid (decadron 10 mg) prior to antibiotic therapy dramatically improves symptoms of patients with PTAs postdrainage.


• Streptococcus pyogenes (group A beta-hemolytic streptococcus) is the most common aerobic organism, and fusobacterium is the most common anaerobic organism. However, most abscesses contain a mixture of aerobic and anaerobic organisms. Consider Penicillin VK, Clindamycin, or Augmentin. If no response to Penicillin VK in 24 hours consider the addition of metronidazole

Disclaimer: Any and all procedures should only be done by properly trained and qualified individuals. These pearls do not meet the standard for proper training and/or qualification.

Direct Pressure: Can be held with two fingers pinching the nares, or you can tape 4 tongue blades together and make your own "clothes pin" that can then be used to pinch the nares. Vasoconstrictor and Anesthesia: Use a 1:1 mixture of topical lidocaine 4% and oxymetazoline can often be mixed together in the same oxymetazoline spray container and then just spray it into the nares. Some IV/IM narcotic pain medication will also help increase patient cooperation. Visualize the bleeding site: Use a HEAD LAMP with an appropriate sized nasal speculum. You may look like Marcus Welby, MD but nothing works as well to see into the nose. Cauterization It is best to cauterize circumferential around the bleeding site prior to directly cauterizing the actual site. Be careful with electrical cautery so has not to perforate the septum. Nasal Packing: Instead of surgilube use Muprion, Bactroban or Bacitracin ointment to lubricate the packing. This will reduce the chance of Toxic Shock Syndrome.