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107 title slides This one’s a real bitch 1. 2. 3. 4. 5. Nose bleed anatomy Indications for antibiotics in sinus infections Symptoms of rhinitis medicamentosa Treatment options for perennial rhinitis Treatment for orbital cellulitis 1. Nose bleed anatomy Anatomy/Physiology of Epistaxis Anatomy Vascular organ Nasal cavity heating Vascular supply humidification Physiology Vascular nature Mucosa Vasculature runs just under mucosa (not squamous) Arterial to venous anastomoses ICA and ECA blood flow External Carotid Artery Internal Carotid Artery Sphenopalatine artery Anterior Ethmoid artery Greater palatine artery Posterior Ethmoid artery Ascending pharyngeal artery Posterior nasal artery Superior Labial artery Anterior vs. Posterior Maxillary sinus ostium Anterior: younger, usually septal vs. anterior ethmoid, most common (>90%), typically less severe Posterior: older population, usually from Woodruff’s plexus, more serious. Kesselbach’s Plexus/Little’s Area: Anterior Ethmoid (Opth) Superior Labial A (Facial) Sphenopalatine A (IMAX) Greater Palatine (IMAX) Woodruff’s Plexus: Pharyngeal & Post. Nasal AA of Sphenopalatine A (IMAX) 2. Indications for antibiotics in sinus infections Acute Rhinosinusitis … sinus infection Facts: Viral sinusitis - 1 billion viral URIs per year Bacterial sinusitis – only 0.5% - 2% secondary bacterial infection of the sinuses.1,2 Indication for use of antibiotics Symptoms have not resolved after 10 days or worsen after 5 to 7 days (see chart on next slide) 1. Gwaltney Clin Infect Dis 1996;23:1209 2. Berg et al. Rhinology 1986;24:223-5 3. Symptoms of rhinitis medicamentosa 4. Treatment options for perennial rhinitis 1st line therapy Avoid the offending allergen Therapeutic options: Decongestants Mucolytic treatment Intranasal steroids Antihistamines Saline irrigation Leukotriene antagonists Intravenous immune globulin http://www.medscape.com/viewarticle/560619 Adjunctive Therapy Decongestants no good controlled studies Mucolytic treatment Wawrose et al. Laryngoscope 1992;102:1225 1 double blinded study ○ 2400 mg of guaifenesin or placebo with chronic sinusitis ○ improvement in congestion and thick secretions Topical steroids ○ Cochrane Database Syst Rev. 2013. Intranasal steroids for acute sinusitis. Zalmanovici Trestioreanu A, Yaphe J. Adjunctive Therapy Antihistamines may play a role in allergic rhinitis patients with sinusitis Saline irrigation may help mucociliary clearance mild vasoconstrictor of nasal blood flow excessive use can remove beneficial mucus Leukotriene antagonists … allergies Useful in patients with CRS with nasal polyps Intravenous immune globulin … infectious disease docs indicated in patients with impaired humoral immunity 5. Treatment for orbital cellulitis http://emedicine.medscape.com/article/12178 58-treatment Medical Therapy: Immediate hospitalization Broad-spectrum IV antibiotics – start immediately Identify pathogen – start narrow spectrum IV antibiotics IV antibiotics continued up to 1-2 weeks and then followed by Oral antibiotics for an additional 2-3 weeks. Oral antibiotics (eg, ampicillin, cefpodoxime, cefuroxime, cefprozil) for aerobic infections or to metronidazole for anaerobic infections Surgery: Surgical drainage indications: If the response to appropriate antibiotic therapy has been poor within 48-72 hours or if the CT scan shows the sinuses to be completely opacified. Ocular symptoms progress: 1) decreased vision, 2) development of afferent pupillary defect develops, 3) progression of proptosis 1. 2. 3. 4. 5. Indications for tonsillectomy Evaluation of hoarseness Cord cysts vs. polyps vs. nodules vs. edema Evaluation of airway foreign bodies Tonsillectomy #1 indication Pearls … straight from lecture 27, slide 91 Tonsils hypertrophy due to acute and chronic infections SDB (sleep disorder breathing) most common reason for tonsillectomy Paradise criteria for recurrent tonsillitis Foreign body symptoms based on location Vocal cord paralysis: malignancy or surgical trauma Hoarseness 2 weeks or more needs evaluation Etiology of hoarseness usually benign Best test for voice- videostroboscopy 1. Indications for tonsillectomy When is surgery appropriate? Sleep disordered breathing (#1) – most common Airway compromise (unresponsive to medical Tx) Recurrent infections (#2) Chronic tonsillitis (#3) Peritonsillar abscess, recurrent Risk of malignancy Paradise Criteria for Tonsillectomy Paradise JL, Bluestone CD, Bachman RZ, et al. Efficacy of tonsillectomy for recurrent throat infection in severely affected children: results of parallel randomized and nonrandomized clinical trials. N Engl J Med. 1984;310:674-683. Baugh R F et al. Otolaryngology -- Head and Neck Surgery 2010;144:S1-S30 Copyright © by American Academy of Otolaryngology- Head and Neck Surgery 2. Evaluation of hoarseness When to pursue workup? “Any patient with hoarseness of two weeks duration or longer must undergo visualization of the vocal cords” Hoarseness Considered a symptom of a disease. Definition: Rough, abnormal harsh quality Rough or noisy quality of voice Perception of voice with breathy quality Abnormal quality Evaluation of Hoarseness: HISTORY Hoarseness persisting for more than two weeks requires evaluation occupation or livelihood depends on the normal use of the voice need earlier and more aggressive intervention often require more specialized care. exception: upper respiratory tract infection history of tobacco use ○ head and neck cancer is the first diagnosis to consider, as hoarseness is often the only presenting symptom. Voice use pattern Nature and timing of the dysphonia Associated symptoms pain, dysphagia, cough or shortness of breath amount and style of voice use gastroesophageal reflux recent voice use (such as screaming at a baseball game) vocal environment (where the patient uses his or her voice—such as talking while wearing earmuffs on an assembly line) history of hearing loss in the patient or in a family member Professional voice user sinonasal diseases (allergic rhinitis or chronic sinusitis) Medications that dry the upper airway mucosa Tobacco and ethanol use must be determined Other irritant exposure Surgery on the head and neck Intubation. Physical Exam Head and neck exam Cranial nerve exam Tongue Incisions Hearing acuity Visualization of larynx http://youtu.be/ajbcJiYhFKY?t =9s Mirror Laryngoscopy Videostroboscopy ○ Best test for diagnosis EMG Drs. Zeitels (left) and Hillman (middle) examine a voice patient (seated) using digital videoendoscopy with stroboscopy 3. Cord cysts vs. polyps vs. nodules vs. edema Benign growth on vocal cords Nodules – callous Cyst Polyps - blister Varices Granulomas Papillomas Laryngocele Polypoid Corditis/ Reinke’s edema Granular cell tumor http://fauquierent.blogspot.com/2011/10/how-do-vocalcord-cysts-polyps-and.html 3a. Cord cysts Cyst http://www.ghorayeb.com/VocalCordCyst.html Epithelial lining covering cyst Results from misuse or overuse Midcord Found in the lamina propria, Reinke’s space May cause fibrosis to contralateral cord Cyst Treatment: Medical - modified voice use, vocal hygiene, steroid taper, anti-reflux Surgical - vocal cysts typically do not respond to conservative therapy ○ Goal is preservation of the mucosal cover with minimal disruption of underlying tissue Lateral vs. medial flap Triamcinolone acetate at the end 3b. polyps Polyp … 3rd most common “Blister” Sessile or pedunculated Fibrotic, vascular or mixed Not uncommon to find contralateral prenodule Not symmetric Polyp Treatment can be different based on type of polyp Sessile – microflap and resect Pedunculated – may retract, small flap and amputate http://youtu.be/wrsHxE9bRzA 3c. nodules Nodules “calluses” overuse/misuse hard glottal attacks females and children free edge anterior & middle third bilateral and symmetric hourglass wave on strob Nodules Three Stages Inflammatory phase increased vascularity and protein accumulation (SP involved early) Localized swelling on the edge of the vocal cord that appears as grayish, translucent thickening Replacement of thickening by fibrotic tissue Nodules Treatment: Voice rest Speech therapy Surgery (secondarily and rare) 3d. edema Reinke's edema Polypoid degeneration smoking, chronic irritation, hormones VC (Varices) – Reinke’s Edema Treatment Smoking cessation Speech Therapy Antireflux medication Surgery ○ Epithelial microflap (lateral/Hirano flap) elevation with SLP contouring and reduction using either cold instruments, Microspot CO2 laser, or both 4. Evaluation of airway foreign bodies Foreign Bodies Children Safety pins Coins Food ○ nuts ○ seeds ○ carrot ○ beans ○ sunflower seeds ○ watermelon seeds Disc Batteries Toys School supplies Adults Food ○ Meat ○ Vegetable matter See a ring - Must R/O a disc battery - Medical emergency – eats through whatever it touches http://www.aaemrsa.org/communication/modernre sident/2011/aug-sept.php Presentation If patient was coughing like crazy, Not any more coughing … BE WORRIED Initial phase choking and gasping, coughing, or airway obstruction Asymptomatic phase … DANGER ZONE relaxation of reflexes, acute inflammation reduces results in a reduction or cessation of symptoms lasting hours to weeks Complications phase erosion or obstruction leading to pneumonia, atelectasis, or abscess Symptoms based on location Esophagus drooling, dysphagia, odynophagia, retching, refusing po, fussy 10 percent have airway symptoms Larynx airway obstruction, hoarseness, aphonia Trachea similar to laryngeal foreign bodies but without hoarseness or aphonia wheezing similar to asthma Bronchus cough, unilateral wheezing, and decreased breath sounds 65% of patients present with this classic triad. If FB in esophagus (cricopharyngeus), it pushes forward on trachea UNILATERAL PNEUMONIA (decrease breathe sounds, wheezing) Location of Ingested Foreign Body Cricopharyngeus 15-17 cm (C6) Aorta 22-24 cm Left mainstem bronchus 28-30 cm Gastroesophageal junction 40 cm (T11) Intrinsic narrowing stricture, tumor Extrinsic tumor Histology for Pathologists, 3rd Edition, 2007 Lippincott Williams & Wilkins Workup at Hospital Chest X-ray AP & lateral Inspiration and expiration **Most important primary test Flouroscopy CT scan virtual bronchoscopy Bronchoscopy – definitive after Rigid vs flexible Foreign Bodies in the Chest: How Come They Are Seen in Adults? Kim TJ, Goo JM, Moon MH, Im JG, Kim MY - Korean J Radiol (2001 Apr-Jun) 5. Tonsillectomy #1 indication When is surgery appropriate? Sleep disordered breathing (#1) – most common Airway compromise (unresponsive to medical Tx) Recurrent infections (#2) Chronic tonsillitis (#3) Peritonsillar abscess, recurrent Risk of malignancy 1. 2. Symptoms, timing of symptoms and treatment of croup Micro of epiglottitis 1. Symptoms, timing of symptoms and treatment of croup 1a. Symptoms of croup Larygotracheobronchitis AKA “Croup” • “steeple sign” on x-ray The most common cause of stridor outside the neonatal period • Peak incidence is ages 6mo – 3yrs • Seasonal distribution: fall & early winter months • Viral: parainfluenza, RSV, rhinovirus, and human bocavirus Classifying Croup by symptoms • • • Mild: occasional barking cough, no stridor, mild to no retractions, no agitation or distress Moderate: frequent barking cough, easily audible stridor at rest, +chest wall retractions at rest, little agitation or distress Severe: frequent barking cough, prominent inspiratory stridor and occasional expiratory stridor, marked sternal retractions, +agitation and distress CLINICAL JUDGEMENT / ASSESSMENT SKILLS! 1b. Timing of croup symptoms Larygotracheobronchitis AKA “Croup” • The most common cause of stridor outside the neonatal period • Peak incidence is ages 6mo – 3yrs • Seasonal distribution: fall & early winter months • Viral: parainfluenza, RSV, rhinovirus, and human bocavirus 1c. Treatment of croup Treating Croup RACEMIC EPINEPHRINE For moderate to severe croup Do not use Albuterol as β-agonists cause vasodilatation and can increase airway edema Observe for approx 3hrs Studies have shown that approx 38% of patients with Croup refractory to treatment expressed this in the 2nd-3rd hours of observation Treating Croup CORTICOSTEROIDS Dexamethasone 0.6mg/kg IM or PO Reduces severity & duration of symptoms HELIOX (mix of 70%helium & 30%oxygen): may improve laminar gas flow / ventilation but not definitively proven The majority of children w/ Croup are readily managed with Dexamethasone and anti-pyretics / cough & cold preparations. 2. Micro of epiglottitis Epiglottitis • • • “thumbprint sign” on x-ray An ACUTE inflammatory process of the epiglottis which can lead to a life-threatening airway obstruction Primary causative agent is H.influenzae type B; which, has been largely eradicated due to immunization Other potential causative agents: Staph & Strep, Candida (immunocomp.), thermal injury/burns, direct trauma 1. 2. 3. Rash causes after amoxicillin Symptoms of peritonsillar abscess Retropharygeal vs. peritonsillar vs. Ludwigs 1. Rash causes after amoxicillin If a patient is placed on antibiotic (PCN) for a presumed pharyngitis and a scattered, faint, morbilliform rash occurs….what is another possible diagnosis? Amoxicillin rash, differential dx 1. 2. PCN Allergy Infectious mononucleosis secondary to EBV 2. Symptoms of peritonsillar abscess Retropharyngeal Abscess (RPA) • • Believed to be due to suppuration of lymph nodes found within/between the anatomical space between the post. pharyngeal wall & prevertebral fascia These nodes tend to regress by age 4; hence, increased potential in children <4yo Also can be due to trauma/penetration into the space • Symptoms: • • Lack of or very mild URI • Neck pain & swelling • Increased drooling • Tripoding RPA • Pleuritic chest pain (ominous sign of extension into the thoracic cavity/mediastinum) “tripoding” 3. Retropharygeal vs. peritonsillar vs. Ludwigs 3a. Retropharygeal Abscess (RPA) Retropharyngeal Abscess (RPA) • • • • Believed to be due to suppuration of lymph nodes found within/between the anatomical space between the post. pharyngeal wall & prevertebral fascia These nodes tend to regress by age 4; hence, increased potential in children <4yo Also can be due to trauma/penetration into the space Symptoms: lack of or very mild URI, neck pain & swelling, increased drooling, tripoding, pleuritic chest pain is an ominous sign of extension into the thoracic cavity/mediastinum RPA Anatomically speaking RPA Diagnosis • Lateral neck X-ray Retropharyngeal space at C2 is 2x diameter of the vertebral body width OR > ½ width of C4 vertebral body CT scan is near 100% sensitive • Need to be clinically astute as this can cause severe airway compromise – be prepared, airway equipment, steroids to reduce inflammation RPA on X-Ray (L) normal (R) abnormal RPA on CT RPA Treatment • • • • Airway management! ENT consultation for possible Incision & Drainage Often mixed flora: S.aureus, S.pyogenes, S.viridans, gram-negative rods, oral anaerobes Ampicillin/sulbactam or Clindamycin 3b. Peritonsillar Abscess Peritonsillar Abscess (PTA) • • • • Deep OROPHARYNGEAL infection/abscess Can occur at ANY age; however, most common in adolescents & young adults Typically is the propagation of a superficial infection that progresses to an accumulation of pus between the tonsillar capsule the superior constrictor muscle Most are UNI-lateral (<10% BI-lateral) Trismus – cannot open mouth d/t pain PTA Diagnosis & Treatment • • • • • Sore throat, fever / chills, trismus, voice change (“hot potato”), increased salivation Exam reveals UNI-lateral peritonsillar edema, deviation of the uvula away from the side of infection Abscess vs. Cellulitis can often be difficult to discern: more ill appearing = ?PTA, CT scan can identify Antibiotic for polymicrobial coverage: Amoxicillin/clavulanic acid or Clindamycin Needle Aspiration PTA Aspiration Complications: Compliance of patient to participate Hemorrhage Puncture of the Carotid artery; needle should not penetrate >1cm as the Carotid lies lateral & posterior Aspiration of purulent material 3c. Ludwig’s Angina Ludwig’s Angina • • • • • • Infection of the submental, sublingual, and submandibular spaces Clinical findings: 1) poor dentition/dental hygiene, 2) dysphagia, odynophagia, 3) trismus, 4) edema of the upper midline neck and floor of the mouth 85% of cases arise from an odontogenic source (abscess) Need to consider in patients with recent dental instrumentation/procedures Rapidly progressing Infection/inflammation cause the posterior displacement of the tongue airway compromise Treatment: airway management, steroids, IV antibiotics, ENT/surgical consultation Ludwig’s Angina Ludwig’s Angina on the Inside Tongue can fall posterior and can block airway 1. 2. 3. 4. 5. Promoter and synergistic agents of head/neck cancers What to do with hoarseness > 2 weeks Sinus cancer presentation Why do supraomohyoid dissection Etiology of sinus cancers Conclusions Head and neck cancer is the 8th leading cause of death worldwide Tobacco use is the most significant risk factor for developing a head and neck cancer Most common sites include Tongue Floor of mouth Tonsil Vocal cord Early detection and smoking cessation lead to the best longterm outcomes Cancer of the nose and sinuses are very rare and require a high index of suspicion for diagnosis Conclusions Status of cervical lymph nodes is an important prognostic indicator The benefit of elective therapy outweighs the risks, if the prevalence of micrometastases is >20% … neck dissection (early removal can prevent mets) Neck dissections are divided into 3 main categories (RND, MRND, SND) Selective neck dissection is based on lymphatic drainage of the primary site Recurrence rates are comparable in appropriately selected patients 1. Promoter and synergistic agents of head/neck cancers Head and Neck Cancer All tobacco products – cigarettes, pipes, cigars, smokeless tobacco, betel quids (nut), reverse smoking, secondhand smoke Tobacco and alcohol are considered the most common factors associated with the development of head and neck cancer This relationship is synergistic Alcohol serves as a promoter for the carcinogenic effects of tobacco Head and Neck Cancer Tobacco 1.9 fold risk for males 3.0 fold risk for females Risk directly proportional to the number of cigarettes smoked and number of years smoked (dose dependant relationship) Alcohol Alone confers a 1.7 fold risk Combination At least 15 fold risk 35 fold risk for 2 pack per day and 4 drinks per day 2. What to do with hoarseness > 2 weeks Hoarseness (side note) Hoarseness lasting >2 weeks with little or no improvement needs laryngeal exam URI is most common cause of hoarseness Often lasts several weeks Rarely lasts 6 weeks Hoarseness lasting >6 weeks in an adult should be considered cancer until proven otherwise Acute Hoarseness in any smoker should be considered cancer until proven otherwise Evaluation (laryngeal exam) Complete history and physical Laryngosocpy Videostroboscopy CT neck with contrast CXR Labs including LFTs FNA neck mass Biopsy / Exam under anesthesia Consultations Head and neck surgeon Radiation oncologist Medical oncologist Internal medicine Dentist / Oral surgeon Speech pathologist Nutritionist Psychologist Tobacco cessation Evaluation Flexible fiberoptic nasopharyngoscope Videostroboscopy 3. Sinus cancer presentation Cancer of the Paranasal Sinuses Very rare: 3% of Head and Neck Cancers Delay in diagnosis due to similarity to benign conditions (i.e. usually present in advanced stages [88% at T3/T4]) Nasal cavity neoplasms ½ benign ½ malignant Paranasal Sinuses Malignant Presentation Oral symptoms: 25-35% Pain, trismus, alveolar ridge fullness, erosion Nasal findings: 50% Obstruction, epistaxis, rhinorrhea Ocular findings: 25% Epiphora, diplopia, proptosis Facial signs Paresthesias, asymmetry Epidemiology Predominately disease of older males Exposure: Wood working, nickel-refining processes Industrial fumes, leather tanning Cigarette and Alcohol consumption No significant association has been shown HPV may play role in malignant degeneration of inverting papillomas Location Maxillary sinus 70% Ethmoid sinus 20% Sphenoid 3% Frontal 1% Inverted Papilloma UNILATERAL “SINUS INFECTION” - Think inverting papilloma - Will turn into SCC 10% if untreated 4% of sinonasal tumors Site of Origin: lateral nasal wall Unilateral Malignant degeneration in 2-13% (avg 10%) Must rule out IP for any CT showing unilateral sinusitis 4. Why do supraomohyoid dissection Introduction One of the most important prognostic indicators for patients with squamous carcinomas of the upper aerodigestive tract is the status of the cervical lymph nodes Local metastatic disease (spread to cervical lymph nodes) can be managed with surgery, radiation, or both i.e. Goal is to remove cancer that may have spread to the neck Supraomohyoid Type Used for oral cavity cancer: lip, buccal mucosa, upper & lower alveolar ridge, RMT, hard palate, anterior 2/3 tongue, FOM Tumors in this region, especially oral tongue & FOM, metastasize early 20% risk occult disease >90% of occult metastatic disease in oral cavity cancer involves Levels I, II, and III Supraomohyoid Type En bloc removal of node levels I-III Posterior limit: posterior border SCM Inferior limit: superior belly of omohyoid m. where it crosses the IJ 5. Etiology of sinus cancers Epidemiology Predominately disease of older males Exposure: Wood working, nickel-refining processes Industrial fumes, leather tanning Cigarette and Alcohol consumption No significant association has been shown HPV may play role in malignant degeneration of inverting papillomas 1. 2. 3. 4. 5. Injuries with associated internal injuries Clavicle injuries with Surgical repair required When to intubate a trauma Most easily seen injuries on plain x-ray Define flail chest 1. Injuries with associated internal injuries Blunt Chest Trauma Chest Wall Injuries ○ Rib, clavicle, sternal fractures ○ Chest wall contusions Cardiac Injuries ○ Cardiac Tamponade* ○ Myocardial Contusions* Pulmonary Injuries ○ Pulmonary contusion ○ Pneumothorax*/Hemothorax* ○ Flail Chest Vascular Injuries ○ Aortic Rupture* Esophageal Rupture* Tracheal/Bronchial Injuries* Diaphragmatic Rupture* 2. Clavicle injuries with Surgical repair required Clavicle Fractures Most common newborn/childhood fracture Mechanisms Force directly to clavicle or to outer end Most pts have history of direct fall onto shoulder Football, bike accidents, wrestling, hockey, MVC Classification of fractures Based on dividing clavicle into thirds Proximal (5%), Middle (80%), Distal (15%) Presentations swelling, loss of normal contour, skin tenting, head turned towards affected side, open fx possible Complications Brachial plexus injury, pneumothorax, non-union (0.1-15%) Vascular Injury: subclavian artery/vein, internal jugular, axillary artery Lateral (Distal) Third Fractures 15% of clavicle fractures Mechanism – direct blow to top of shoulder Fracture lateral to the coracoclavicular ligament Integrity of CC Ligament Fx Displaced? Treatment Type I Intact No Non-operative: sling, ice, pain control, early ROM exercise Type II Torn YES Medial fragment pulled superiorly Ortho consult within 72 hrs -possible surgical repair Risk of non-union Type III Intact What type of fracture is this? No Fx through articular surface of AC joint Non-operative: sling, ice, pain control, early ROM exercise Risk of OA of joint 3. When to intubate a trauma Pulmonary Contusion Treatment Maintenance of adequate oxygenation & ventilation ○ Endotracheal intubation may be necessary Pain control, encourage deep breaths, incentive spirometry Generally require admission – contusions tend to worsen over 24 hrs Avoid excessive IV fluid - may worsen contusions May lead to ARDS, pneumonia, respiratory failure http://www.trauma.org/index.php/main/image/1002/ Flail Chest Management Oxygenation, ventilation, pain control Manual stabilization initially Detection & treatment of underlying injuries ○ CT scan indicated ○ Chest tube if PTX of hemothorax Positive pressure ventilation - endotracheal intubation often required ○ Provides splinting Pain Control - IV narcotics, regional nerve blocks, epidural anesthesia If no hypotension, hypovolemia, blood loss limit IV fluids 4. Most easily seen injuries on plain x-ray Hemothorax Pneumothorax Pulmonary contusion Vascular injury 5. Define flail chest Flail Chest Three or more adjacent ribs, each fractured in 2 or more places Chest wall unstable & segment lacks continuity with rest of thoracic cage Paradoxical motion of chest wall Segment moves IN during Inspiration & OUT during Exhalation May not be obvious initially (splinting, muscle spasm) 1. 2. 3. Secondary pneumothorax causes Symptoms (it’s not shortness of breath),Tx and imaging of simple PNX Treatment of tension PNX Summary Points - PTX Primary ptx occurs in pts without lung disease Pain, not dyspnea may be the chief complaint in primary ptx Secondary ptx occurs in pts with underlying lung disease - COPD most common Tension pneumothorax is an immediate life threat and if suspected must be treated emergently before x-ray confirmation. A CXR is the initial test to detect ptx in a stable patient. An open ptx must be sealed and then a chest tube placed A needle decompression may be performed in an emergent situation as a temporizing measure in suspected tension pneumothorax. A chest tube must be placed following needle decompression. 1. Secondary pneumothorax causes Secondary Pneumothorax PTX in setting of underlying lung disease 1/3 – 1/2 of all spontaneous ptx (o) Most common risk factor? COPD Peak age is 60-65 years; male to female 3:1 More likely to present with dyspnea & more severe symptoms . Why? Much higher mortality than PSP Don’t Memorize! Other diseases associated with SSP HIV Other Airway Disease – asthma; CF Infections - necrotizing bacterialpneumonia/ abscess; TB Interstitial lung disease – sarcoidosis; idiopathic pulmonary fibrosis Neoplasms - primary lung ca; pulmonary/pleural metastasis Miscellaneous - connective tissue dx; pulmonary infarction 2. Symptoms (it’s not shortness of breath),Tx and imaging of simple PNX Simple pneumothorax is a non-expanding collection of air around the lung. The lung is collapsed, to a variable extent. Diagnosis on physical examination may be very difficult. 2a Symptoms (it’s not shortness of breath) simple PNX Primary Pneumothorax Clinical Manifestations - Chest pain & dyspnea Chest pain ○ Acute onset, ipsilateral ○ Often pleuritic Symptoms often mild – rarely life threatening (l) Why? Physical Exam Findings Vital signs often normal (l) Most common physical finding - tachycardia (o) Ipsilateral Chest findings ○ \/ movement with respiratory cycle ○ Hyperresonant to percussion ○ \/ Breath sounds ○ \/ fremitus Chest exam findings may be absent in small ptx Symptoms of PTX Sudden onset of ipsilateral chest or shoulder pain Dyspnea - variable Cough Reduced air entry Resonance to percussion are often difficult or impossible to appreciate. Careful palpation of the chest wall and apices may reveal Subcutaneous emphysema Rib fractures as the only sign of an underlying pneumothorax. Signs of PTX Mild resting tachycardia Tachypnea Unilateral \/ breath sounds ○ Caution: Often normal with small ptx Other possible findings ○ Hyperresonance to percussion ○ Unilateral enlargement of hemithorax ○ \/ chest excursion with respiration 2b. Tx simple PNX Observation Oxygen 2c. Imaging of simple PNX Summary Points - PTX Primary ptx occurs in pts without lung disease Pain, not dyspnea may be the chief complaint in primary ptx Secondary ptx occurs in pts with underlying lung disease - COPD most common Tension pneumothorax is an immediate life threat and if suspected must be treated emergently before x-ray confirmation. A CXR is the initial test to detect ptx in a stable patient. An open ptx must be sealed and then a chest tube placed A needle decompression may be performed in an emergent situation as a temporizing measure in suspected tension pneumothorax. A chest tube must be placed following needle decompression. 3. Treatment of tension PNX EXAM … Management – Tension Pneumothorax Emergency! Clinical diagnosis – don’t wait for cxr! Immediate needle decompression Must follow w/ chest tube Needle Decompression Temporizing measure Insert 14-16 gauge IV catheter over rib at 2nd ICS, midclavicular line Advance catheter & remove needle Rush of air is confirmatory Tube Thoracostomy 28-36F in Trauma 16-20F for Spontaneous 4th-5th ICS (about nipple level) Mid to anterior axillary line Case – Patient A Resolution Occlusive dressing placed over wound Needle decompression followed by 36 F chest tube Pt dramatically improved after chest tube and was taken to the OR for exploration of his abdomen due to a GSW to the abdomen 1. 2. 3. 4. 5. Dermoid vs. 1st branchial cleft cyst Symptoms of thyroglossal duct cyst Tx of thyroglossal duct cyst Anatomy of 3rd branchial cleft cyst Micro / appearance of scrofula 1. Dermoid vs. 1st branchial cleft cyst 1a. Dermoid 1b. 1st branchial cleft cyst 2. Symptoms of thyroglossal duct cyst 3. Tx of thyroglossal duct cyst 4. Anatomy of 3rd branchial cleft cyst 5. Micro / appearance of scrofula 1. 2. Distinguish metabolic acidosis / alkalosis / respiratory acidosis / alkalosis / gapped Treatment for high CO2 1. Distinguish metabolic acidosis / alkalosis / respiratory acidosis / alkalosis / gapped 1a. metabolic acidosis 1b. alkalosis 1c. respiratory acidosis 1d. alkalosis 1e. gapped 2. Treatment for high CO2 1. 2. 3. 4. 5. Inspiratory cough anatomy Treatment of epiglottitis Diagnosing laryngomalacia Diagnosing croup with imaging Diagnosing vocal cord dysfunction 1. Inspiratory cough anatomy 2. Treatment of epiglottitis 3. Diagnosing laryngomalacia 4. Diagnosing croup with imaging 5. Diagnosing vocal cord dysfunction 1. 2. 3. 4. 5. Etiology of VTE Origin of PE clots EKG findings in PE Definitively diagnosing PE Length of tx for PE 1. Etiology of VTE 2. Origin of PE clots 3. EKG findings in PE 4. Definitively diagnosing PE 5. Length of tx for PE 1. 2. 3. 4. 5. Define pulmonary hypertension pulmonary function tests of pulmonary hypertension treatment plans for pulmonary hypertension diagnose Goodpasture syndrome lab findings of Goodpasture syndrome 1. Define pulmonary hypertension 2. pulmonary function tests of pulmonary hypertension 3. treatment plans for pulmonary hypertension 4. diagnose Goodpasture syndrome 5. lab findings of Goodpasture syndrome 1. 2. 3. 4. Management of CF hemoptysis Differential Newborn with no poop Lab findings in CF Testing for CF 1. Management of CF hemoptysis 2. Differential Newborn with no poop 3. Lab findings in CF 4. Testing for CF 1. 2. 3. 4. 5. 6. Preventing and treating pertussis Micro of bronchiolitis When to hospitalize bronchiolitis Define RDS Etiology of RDS Symptoms of primary ciliary dyskinesia 1. Preventing and treating pertussis 1a. Preventing pertussis 1b. treating pertussis 2. Micro of bronchiolitis 3. When to hospitalize bronchiolitis 4. Define RDS 5. Etiology of RDS 6. Symptoms of primary ciliary dyskinesia 1. 2. 3. Intrinsic vs. Extrinsic causes of restrictive lung PFTs in restrictive dz Asbestosis vs. sarcoid vs. hypersensitivity vs. pneumonia 1. Intrinsic vs. Extrinsic causes of restrictive lung 1a. Intrinsic causes of restrictive lung 1b. Extrinsic causes of restrictive lung 2. PFTs in restrictive dz 3. Asbestosis vs. sarcoid vs. hypersensitivity vs. pneumonia 3a. Asbestosis 3b. sarcoid 3c. hypersensitivity 3d. pneumonia