ENT
Oral
Emergencies,
Ear, Nose, and
Upper Airways
Gabriella Minera, PGY-4
Oral Emergencies
•
•
•
•

Pulp: Sensory, makes Dentin
Crown: Covered with Enamel
Root: Covered with Cementum
Innervation:
...
Oral Emergencies
• Nomenclature
• Clockwise from maxillary 3rd molar to
bottom mandibular molars
Oral Emergencies
•

Trauma

•
•

Primary Tooth: No tx required
Secondary Tooth: Reimplant within 20
minutes. Peridontal li...
Oral Emergencies

•

Ellis Classification

•
•

Class I: Enamel injury, Painless
Class II: Dentin and Enamel,
Hot/Cold Sen...
Oral Emergencies
•
•
•

•
•
•

Concussions: injuries that involve tenderness to percussion
but no mobility
Subluxation: tt...
Oral Emergencies
•

Cheek Lacerations: Check for involvement of
salivary ducts and injury to facial nerve

•

Parotid (Ste...
Oral Emergencies
•

Acute Necrotizing Ulcerative Gingivitis
(ANUG)/Vincent’s Angina/Trench Mouth:
overgrowth of normally p...
Oral Emergencies
• Alveolar Osteitis (Dry Socket): sudden
excruciating pain 3-4 days after
extraction caused by displaceme...
Oral Emergencies
• Trigeminal Neuralgia
• High Rate of spontaneous remission
• Tx: Tegretol, also Dilantin, Baclofen,
Sx (...
Oral Emergencies
•

Oral Manifestations of Systemic Disease:

•
•
•
•
•

Heavy Metal: Lead (Gingival “lead line”)
Dilantin...
Ear Emergencies
Ear Emergencies
•

Acute Otitis Media:

•
•
•

Viral > Bacterial
S. pneumo > H. Flu > M. Cat
Most Sensitive Test is mobili...
Ear Emergencies
• Mastoiditis: complication of AOM
when infection spreads to adjacent
mastoid air cells via the aditus ad
...
Ear Emergencies
•

Otitis Externa (Swimmer’s Ear)

•
•
•
•

Pseudomonas (MC etiology)

Aspergillus and Candida are MC fung...
Ear Emergencies
•

•

Herpes Zoster Oticus (Ramsey-Hunt Syndrome)

•
•
•

Triad: vesicles in the auricle/canal, ipsilatera...
Ear Emergencies
•

Trauma

•

Ear Laceration

•

•
•

Skin is vascular but cartilage is avascular and
relies on overlying ...
Nasal Emergencies
Nasal Emergencies
•

Sinusitis

•
•
•

Imaging: CT preferred to plain films (air fluid levels, 4
mm of sinus wall thickeni...
Nasal
Emergencies
• Trauma
• Septal Hematoma: Drainage followed
by anterior packing

• Saddle Nose Deformity
Oral and Upper Airway
Emergencies
•

•

Ludwig’s Angina

•
•

Polymicrobial cellulitis of oral floor
Consider prophylactic...
Oral and Upper Airway
Emergencies
•

•

Peritonsillar Abscess

•
•
•

Hot Potato voice
The abscess is PERItonsillar so the...
Oral and Upper Airway
Emergencies
•

Pharyngitis

•

Bacterial: Group A Strep

•
•
•

•
•

Rapid Strep Test: variable sens...
Oral and Upper Airway
Emergencies
• Epiglottis
•
•

•
•
•

More in Adults now since the H. Flu
vaccine. Vaccination effica...
Oral and Upper
Airway Emergencies
•

Croup (Laryngotracheobronchitis)

•
•
•
•
•
•

•

MCC of upper respiratory obstructio...
Some Extras...
•

•

Chalazion

•
•
•

Chronic Stye, Not infected
Point inside to the lid
Meibomian gland

Hordeolum

•
•
...
Questions
• Ludwig’s Angina is an infection that
most typically originated from which
previous location?

• Mandibular odo...
Questions
•

A 48 year-old man with no previous medical history
presents with dizziness and hearing loss. He reports
recur...
•

Meniere’s Disease:

•

•
•
•

•

Recurrent but also progressive hearing loss, tinnitus
and vertigo.

Etiology thought t...
Questions
•

A 22-month-old girl is brought in parents for concern of an ear infection.
She was recently seen for an ear i...
Questions
•

•
•

While imaging of the temporal bone is indicated in this
patient, this patient is not stable for radiogra...
Questions
•

A homeless patient presents complaining of a white film to
the surface of his tongue and burning pain. What f...
Questions
•
•

Oral candidiasis and oral hairy leukoplakia both occur in
HIV positive and immunocompromised patients.
Oral...
Questions
•

A 5-year-old previously healthy boy is brought in by mom for
fever and decreased appetite for 2 days. Mom has...
Questions
•
•

Herpes gingivostomatitis is the likely causative agent in
this case scenario.
While both herpes gingivostom...
ENT
• The END
• Questions?
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ENT Board Review 2013 Gabriella Minera

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ENT Board Review 2013 Gabriella Minera

  1. 1. ENT Oral Emergencies, Ear, Nose, and Upper Airways Gabriella Minera, PGY-4
  2. 2. Oral Emergencies • • • • Pulp: Sensory, makes Dentin Crown: Covered with Enamel Root: Covered with Cementum Innervation: • • Maxillary Teeth by Superior Alveolar Nerves (branch from CN V2) Mandibular Teeth by Inferior Alveolar Nerve (branch from CV V3)
  3. 3. Oral Emergencies • Nomenclature • Clockwise from maxillary 3rd molar to bottom mandibular molars
  4. 4. Oral Emergencies • Trauma • • Primary Tooth: No tx required Secondary Tooth: Reimplant within 20 minutes. Peridontal ligaments die >60 minutes. Rinse with water, milk or Hank Solution. Do not Scrub. Grasp tooth by crown. • • Brace with zinc oxide paste (Coe-Pak) Abx: Pcn VK or Erythromycin
  5. 5. Oral Emergencies • Ellis Classification • • Class I: Enamel injury, Painless Class II: Dentin and Enamel, Hot/Cold Sensitivity, Yellow Dentin exposed • • Tx: Calcium Hydroxide, Urgent referral Class III: Enamel, Dentin, Pulp, Pain/painless (NV supply dependent), Pink tinge indicates exposed pulp • Tx: Emergent/Immediate OMFS, Abx
  6. 6. Oral Emergencies • • • • • • Concussions: injuries that involve tenderness to percussion but no mobility Subluxation: ttp, mobility, without evidence of dislogement • Tx: NSAIDs, soft diet, referral to dentist Extrusive Luxation: tooth is partially avulsed from alveolar bone • Tx: reposition the tooth, splint with zinc oxide Lateral Luxation: lateral displacement with fracture of alveolar bone Intrusive Luxation: tooth is forced below the gingiva, poor outcome Avulsion: tooth has been completely removed from its socket.
  7. 7. Oral Emergencies • Cheek Lacerations: Check for involvement of salivary ducts and injury to facial nerve • Parotid (Stensen) and Submandibular (Wharton) MC injured • • ENT consult if duct injury Perioral Electrical Burns: Full-Thickness Burn at Lip Commissure • • • Delayed Bleeding from Labial Artery 5-21 days postinjury Anticipate bleeding/Apply direct pressure Involve plastics/ENT as outpatient
  8. 8. Oral Emergencies • Acute Necrotizing Ulcerative Gingivitis (ANUG)/Vincent’s Angina/Trench Mouth: overgrowth of normally present bacteria which invade nonnecrotic tissue • • Pseudomembrane, Metallic Taste, Friable Periapical Abscess: Infection of root apex, usually confined to alveolar bone, facial edema • Tx: Pcn VK, Clinda, referral, +/- I+D
  9. 9. Oral Emergencies • Alveolar Osteitis (Dry Socket): sudden excruciating pain 3-4 days after extraction caused by displacement of clot from socket and local osteomyelitis • Tx: Pack with iodoform gauze (Euginol) • Abx: usually not required
  10. 10. Oral Emergencies • Trigeminal Neuralgia • High Rate of spontaneous remission • Tx: Tegretol, also Dilantin, Baclofen, Sx (relief of vascular compression) • Often seen with Multiple Sclerosis
  11. 11. Oral Emergencies • Oral Manifestations of Systemic Disease: • • • • • Heavy Metal: Lead (Gingival “lead line”) Dilantin: Gingival Hyperplasia in 40% Coxsackie (Hand-foot-mouth syndrome): Vesicles spare buccal mucosa, gingiva, and tongue. Hairy Leukoplakia: EBV, white patches on side of tongue that cannot be removed with tongue blade. Tx: Acyclovir Kaposi Sarcoma: malignant cancer of lymphatic endothelium, HHV8, AIDS defining, MC on hard palate
  12. 12. Ear Emergencies
  13. 13. Ear Emergencies • Acute Otitis Media: • • • Viral > Bacterial S. pneumo > H. Flu > M. Cat Most Sensitive Test is mobility of TM with pneumatic ototscopy • Treatment: • • • • • <6 months: tx even if uncertain 6 months- 2 years: observe if unsure > 2years: tx only if certain and illness severe Abx: Amoxicillin (80 mg/kg/day x 10 days), if fails, give second course with Augmentin x 3 days Complications: Hearing Loss, Cholesteotoma (accumulation of keratin-producing squamous epithelium in middle ear, destructive epidermoid cyst)
  14. 14. Ear Emergencies • Mastoiditis: complication of AOM when infection spreads to adjacent mastoid air cells via the aditus ad antrum • MCC: S. pneumo • High risk of meningitis, need admission for IV abx and possible surgical drainage
  15. 15. Ear Emergencies • Otitis Externa (Swimmer’s Ear) • • • • Pseudomonas (MC etiology) Aspergillus and Candida are MC fungal pathogens. Pain with movement of pinna or tragus Tx: • • Keep Canal Dry Abx: FQs • • • • Cipro Otic: Children > 6 months of age Use suspension if TM perforated: Cortisporin Otic suspension (Neomycin, Polymyxin B, hydrocortisone). Aminoglycosides avoided because of ototoxicity*** Steroids: topical hydrocortisone reduces symptoms but not time to clinical resolution Necrotizing (Malignant) Otitis Externa: through the periauricular tissue and into the temporal bone. Tx with systemic abx.
  16. 16. Ear Emergencies • • Herpes Zoster Oticus (Ramsey-Hunt Syndrome) • • • Triad: vesicles in the auricle/canal, ipsilateral facial paralysis, ear pain CN V, VII, IX, and X Tx: Acyclovir, referral Bullous Myringitis • • • Viral: Mycoplasma Hemorrhagic or clear blisters on TM Tx: Macrolide
  17. 17. Ear Emergencies • Trauma • Ear Laceration • • • Skin is vascular but cartilage is avascular and relies on overlying tissue All exposed cartilage must be completely covered suture through skin and perichondrium with 6-0 nylon Subperichondral Hematoma • Aspiration vs. I +D, pressure x 48-72 hrs. Complications - Cauliflower Ear
  18. 18. Nasal Emergencies
  19. 19. Nasal Emergencies • Sinusitis • • • Imaging: CT preferred to plain films (air fluid levels, 4 mm of sinus wall thickening) For purulant discharge, symptoms > 1week: Augmentin x 10 days, another option: Azithromycin or Levaquin x 3 days Complications: • • Frontal Bone Osteomyelitis (Pott puffy tumor) Acute Sphenoid Sinusitis (Most posterior of sinuses). Cavernous Sinuses located laterally (Internal carotids, CN II, III, IV, V3, VI). Sx drainage if no improve x 24 hrs.
  20. 20. Nasal Emergencies • Trauma • Septal Hematoma: Drainage followed by anterior packing • Saddle Nose Deformity
  21. 21. Oral and Upper Airway Emergencies • • Ludwig’s Angina • • Polymicrobial cellulitis of oral floor Consider prophylactic intubation as airway compromise occurs quickly. May not be able to cric. Sialadenitis and Sialolithiasis • • • • Sialadenitis: inflammation of salivary glands (parotid, submandibular, sublingual) Sialolithiasis (stone formation in salivary gland) Submandibular form of both MC Etiology: Viral (Mumps/HIV) and Bacterial (S.aureus). Pus from Wharton’s duct (submandibular) or Stenson’s duct (parotid)
  22. 22. Oral and Upper Airway Emergencies • • Peritonsillar Abscess • • • Hot Potato voice The abscess is PERItonsillar so the needle is not placed into the tonsil Carotid Artery is located 2.5 cm inferior lateral to tonsil Retropharyngeal and prevertebral space abscesses • • • • • MC in children < 6 years (lymph nodes regress in adulthood) Posterior to pharynx/Anterior to vertebral bodies/Carotid sheaths laterally/Inferiorly by mediastinum Duck “quack” (cri du canard) Holds neck extended/ Trismus/Stridor X-ray: Obtain in full extension, inspiration, tissue space should be no wider than vertebral body
  23. 23. Oral and Upper Airway Emergencies • Pharyngitis • Bacterial: Group A Strep • • • • • Rapid Strep Test: variable sensitivity and specificity Culture: 95% sensitive Centor Criteria: All four 55% probability of Strep etiology • • • • 1. Tonsillar exudate 2. Fever 3. Tender cervical LAD 4. Absence of cough Treatment: tx within 9 days to prevent rheumatic fever (Glomerulonephritis not prevented by abx administration). PCN VK (erythro if PCN allergic) Viral (60%): • Enterovirus MC from spring through fall, Adenovirus associated with unilateral conjunctivitis in 50%
  24. 24. Oral and Upper Airway Emergencies • Epiglottis • • • • • More in Adults now since the H. Flu vaccine. Vaccination efficacy decreases with age. Diagnosis initially missed in 33% of cases Etiology: H Flu, S. pneumo, S.aureus Patient sitting in sniffing position, “tripod” Tx: Manage in OR for kids, airway compromise less common in adults (increased ratio of trachea diameter to
  25. 25. Oral and Upper Airway Emergencies • Croup (Laryngotracheobronchitis) • • • • • • • MCC of upper respiratory obstruction in kids Peak Incidence: 2 years old 50% by Parinfluenza virus Tx: Cool mist, racemic epi (observe for 4-6 hours for rebound), Steroids (controversial) Admission Criteria: Hypoxia, respiratory distress/stridor persists, <6 months of age Wesley Croup Score • Mild Croup < 2points, Moderate Croup 2-7 points, Severe Croup >8 points Bacterial Tracheitis • • • • • • Laryngeal/Tracheal/Bronchial inflammation Etiology: Staph Peaks in ages 3-4 y/o Barky cough, inspiratory/expiratory stridor - difficult to differentiate from croup or epiglottis but in BT patients have mucopurulant cough and are toxic appearing X-rays show subglottic narrowing as in croup Tx: OR for intubation, Bronchoscopy may be diagnostic
  26. 26. Some Extras... • • Chalazion • • • Chronic Stye, Not infected Point inside to the lid Meibomian gland Hordeolum • • • Hordeolum is a painful nodule from blocked Zeiss + Moll gland (abscess on lid margin) Points externally Hordeolum is a stye because horders live in a pig stye.
  27. 27. Questions • Ludwig’s Angina is an infection that most typically originated from which previous location? • Mandibular odontogenic infection • Maxillary odontogenic infection • Peritonsilar abscess • Retropharyngeal abscess
  28. 28. Questions • A 48 year-old man with no previous medical history presents with dizziness and hearing loss. He reports recurrent episodes of dizziness with ringing in one ear, severe nausea and vomiting, and feels that his hearing has decreased over time. Which of the following statements is TRUE regarding his condition? • • • • High-frequency hearing loss is commonly observed HCTZ is treatment of choice Perilymphatic fistula is the underlying etiology Vertical nystagmus is observed during an episode
  29. 29. • Meniere’s Disease: • • • • • Recurrent but also progressive hearing loss, tinnitus and vertigo. Etiology thought to be due to excessive endolymphatic fluid and endolymphatic distension. The diagnosis if often made clinically, with horizontal nystagmus seen. Low-frequency sensorineural hearing loss is also seen on audiometry. The treatment is salt restriction and diuretics.
  30. 30. Questions • A 22-month-old girl is brought in parents for concern of an ear infection. She was recently seen for an ear infection 10 days ago and was prescribed high-dose amoxicillin, but continues to have ear pain. On exam, the child appears listless and limp. Vital signs are BP 85/55, P 135, RR 35, T104F (40C), O2Sat 99% room air. ENT exam shows a red and bulging right tympanic membrane with an air-fluid level, and fluctuance and erythema behind the auricle. The remainder of the physical exam is unremarkable, including a grossly intact neurologic exam. Broad-spectrum antibiotics and IV crystalloid fluid bolus resuscitation are initiated. Which of the following is the next best step in managing this patient? • • • • Admit to pediatrics ICU pending culture results Consult ENT for drainage CT head and temporal bones with contrast Lumbar puncture to rule out meningitis
  31. 31. Questions • • • While imaging of the temporal bone is indicated in this patient, this patient is not stable for radiographic studies and ENT should be emergently consulted for drainage, based on high clinical suspicion (given postauricular fluctuance in the setting of an obvious acute otitis media failing outpatient antibiotics). The choice of antimicrobial therapy should be directed to the most common microorganisms involved, which are S. pneumoniae, S. aureus. Antibiotics against pseudomonal species should be considered when there is a history of recurrent otitis media or recent antibiotics use.
  32. 32. Questions • A homeless patient presents complaining of a white film to the surface of his tongue and burning pain. What findings are suggestive of oral candidiasis versus oral hairy leukoplakia? • • • • HIV Positive White plaques can be scraped off with red friable tissue underneath Immunocomprimised Previous viral pharyngitis in an immunocompetent individual
  33. 33. Questions • • Oral candidiasis and oral hairy leukoplakia both occur in HIV positive and immunocompromised patients. Oral candidiasis can be diagnosed as a white film that can be easily scraped off to reveal red friable tissue underneath on the tongue .
  34. 34. Questions • A 5-year-old previously healthy boy is brought in by mom for fever and decreased appetite for 2 days. Mom has not noticed any runny nose or cough, but patient has been complaining of mouth pain. Oropharyngeal exam is shown, with exquisitely painful lesions. Which of the following most accurately describes this condition? • • • • Adenopathy and fever typically precede the appearance of ulcers Antiviral can shorten duration of symptoms and reduce recurrence Coxackievirus is likely the causative agent Throat culture is the gold standard for diagnosis
  35. 35. Questions • • Herpes gingivostomatitis is the likely causative agent in this case scenario. While both herpes gingivostomatitis and herpangina can lead to painful vesicles and ulcers in the oropharynx, herpangina generally spares the buccal mucosa, gingivae and the tongue (unlike herpes gingivostomatitis).
  36. 36. ENT • The END • Questions?
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