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Diagnosis At A Glance Harry Kopolovich 31 y/o female presents with tooth pain and a swollen neck Ludwig's Angina - Submandibular space is primary site of infection - Subdivided by mylohyloid muscle - Sublingual space superiorly - Submandibular space inferiorly - Odontogenic source in >90% cases - Others include: Trauma, tongue piercing, sialedenitis, neoplasm, other parapharnygeal infections - Definitive Airway Management is Key • Direct vs. fiber optic visualization • No blind nasotracheal attempts – May rupture abscess - Empiric antibiotics • Primary flora: Strep, Staph, Bacteroides • 3rd Generation Cephalosporins plus clindamycin • No definite role of steroids - Definitive management is surgical - Prior to antibiotics: Mortality >50% - Currently: Antibiotics + Surgery Mortality 8% 75 y/o white man presents with 5 days of rash and pain to forehead Herpes Zoster Opthalmicus VZV causative agent Reactivation produces typical dermatomal distribution Dissemination occurs in immunocompromised patients Anterior horn cells Muscular weakness, diaphragmatic paralysis, colon pseudo obstruction Spinal cord GBS like syndrome, Transverse myelitis Phases of Presentation Three phases Pre-eruptive Eruptive Pain or dysesthesia occurs 48-72 hours prior Heralded by emergence of skin lesion Erythematous macules Vesicles Ruptured Vesicles Ulcers Crusted lesions Lesions can last 10-15 days Not considered healed until lesion are crusted Considered a TORCH infection Post-Eruptive Post-herpetic neuralgia is pain lasting or recurring >30 days Most t frequent complication: Occurs in 9-45% of cases Higher incidence in elderly males Herpes Zoster Opthalmicus Reactivation of VZV in trigeminal nerve CN V Usually V1 affected Hutchinson’s Sign Lesion on tip of nose Indicates higher likelihood of ocular involvement (76% vs. 34%) Pseudo-dendrites Peripherally located, poorly stain with fluorescein Partial thickness (can be wiped clean as compared to dendrites in herpes keratitis which are full thickness and cannot be wiped clean) Ophthalmology Consult Complications Post-herpetic neuralgia Corneal Anesthesia or hypoesthesia Secondary Infection Treatment Anti-virals Proven benefit when instituted within 48-72 hours Reduces viral shedding and accelerated resolution of symptoms Corticosteroids Controversial at best Two studies conducted using steroids + acyclovir only Current indications Only in moderate to severe pain Or in severe CNS symptoms or paralysis exist Use of steroid contraindicated in isolation Concern exists for promotion of viral replication Optimal Duration uncertain Should not exceed duration of anti-viral agent 24 year old man presents with pain to nose after being hit in the head with a soccer ball Examination reveals the following Nasal Septal Hematoma Uncommon complication following direct nasal trauma Associate with fracture of septal cartilage Nasal septum composed of a thin cartilaginous plate with a closely adherent perichondrirum and mucosa Septal Hematoma Occurs as perichondrium separated from septum Accumulation of blood results Avascular necrosis Septal perforation, saddle nose deformity Abscess Possible meningitis, encephalitis, cavernous sinus thrombosis Make sure to examine nostril on all patients with facial trauma Visual inspection with otoscope or nasal speculum Nasal septum 2-4mm thick (possible bilateral hematomas) Digital inspection Treatment is I & D 70 year old Asian woman present with headache, nausea and eye pain while watching a movie at a local movie theater Acute Angle Closure Glaucoma Aqueous humor produced in ciliary body in the posterior chamber It diffuses through the pupil into the anterior chamber Drains into the vascular system through the canal of Schlemm Acute Angle Closure Glaucoma (AACG) Defined by the presence of 2 of the following symptoms Ocular pain, nausea/vomiting, hx of intermittent blurring of vision with halos And 3 of the following signs IOP >21mmHg (Usually >50), conjunctival injection, corneal epithelial edema, mid-dilated non-reactive pupil, shallow anterior chamber End result is sustained production of aqueous humor which is unable to pass from posterior to anterior chamber, resulting in an increased IOP, culminating ultimately in retinal damage, and visual loss Risk Factors Older age, female, Asian descent, shallow anterior angle, excessive sympathetic tone, thin iris, darkened environment Essentially, any condition which cause the iris to heap up, and become closer to pupil, thus preventing egress of aqueous humor Or any condition that disrupts the egress of aqueous from the anterior chamber Diagnosis Clinical suspicion: Anyone with headache and eye pain, make sure to examine eye Tono pen If not working or stolen, use your finger Treatment Lie patient flat: May cause separation of Iris from lens Analgesia Topical β- blockers or α- agonists Decreases aqueous humor production (Timolol 0.5% 1 drop) Topical Steroids Reduce inflammation (Prednisolone 1 drop Q15min Hyperosmotic agents Decrease fluid volume in eye (Mannitol 1-2 g/kg IV over 30-60min) Topical Miotics Pulls the iris back away from pupil (Pilocarpine ½% 1 drop Q6hr) Will not work unless IOP <40mmg 50 year old female presents with headache and blurry vision CN III Palsy Anatomy Originates in the brainstem continues within sub-arachnoid space traverses the cavernous sinus terminates within the orbit after exiting the superior orbital ridge Contains voluntary muscle fibers and parasympathetic control Responsible for majority of EOM Pupillary Constriction Raises eyebrow (Levator palpebrae superiorus has dual innervation) Presentation Typically down and out pupil, which doesn't’t constrict or accommodate Ptosis Why is the anatomy important? Disposition Because of the origin and course CN III, deficits can indicate PCA Aneurysm Uncal Herniation Compressive Neoplasms Inflammatory Conditions Trauma Cavernous sinus neoplasm Cavernous sinus thrombosis Carotid-Cavernous fistula MRI/MRA Imaging and neurology consult strongly recommended It is possible to have isolated CNIII deficits affecting primarily the EOM and rarely the pupil Adjunct indicator for micro vascular disease in HTN and DM Usually a painful condition Low threshold for neurology involvement 20 year old wrestler presents with ear pain Auricular Hematoma Develop when the ear sustains blunt trauma Causing auricular perichondrium to separate from underlying cartilage Tearing of the perichondrial blood vessels results in subsequent hematoma Chronic presence of blood stimulates new cartilage deposition and subsequent cauliflower ear Auricular Hematoma Treatment >7 days <7 days Referral to ENT I&D Needle aspiration no longer recommended as hematoma tends to reaccumulate Pressure dressing Follow-up in 24 hours Most pressure dressing are inadequate, tend to allow hematoma to reaccumulate 18 year old woman presents with ear pain and fever Examination reveals a tender, erythematous bulge posterior to ear Mastoiditis Mastoid bone is directly contiguous to and is an extension of the middle ear cleft Mastoidits is the result of an extension of purulent otitis media Medial wall erosion can result in Cavernous sinus thrombosis, CN VII palsy, Meningitis, Brain abscess Treatment Flora is similar to causes of AOM Strep Pneumo most common Risk Factors Likely multifactorial Invasive species vs. host anatomy (Eg. Congenitally narrow mastoid antrum) Disposition Broad spectrum antibiotics: Semi-synthetic PCN’s, 3rd generation cephalosporins, Vanco Imaging Admission Surgery in refractory cases 20 year old man presents with eye pain and fever after being scratched by his cats claws 2 days ago Orbital Cellulitis Orbital septum is a fascial layer which extends vertically from the periosteum of the orbital rim to the inferior border of the tarsal plate in the lower eyelid Orbital cellulitis is an infection posterior to the septum Etiology 1) Extension of an infection from the periorbital structures Usually ethmoid sinusitis 2) Direct inoculation from trauma or surgery 3) Hematogenous spread from bacteremia Veins in this region are valveless allowing retrograde and anterograde flow Presentation Pain, fever, chemosis Important findings are proptosis, painful EOM’s Disposition Imaging: CT with contrast Broad spectrum abx (MRSA becoming common) Admission Complications Visual Loss Cavernous sinus thrombosis Meningitis Abscess Osteomyelitis 7 year old boy is brought in by mom for evaluation of a bump next to his eye Dacrocystitis Lacrimal excretory system Drain tears from the medial aspect of the eye through a series of canal which ultimately terminate in the nose Prone to infection as system is contiguous with conjunctiva proximally and nasal mucosa distally Infection usually develops when stagnation occurs secondary to obstructed lacrimal sac Microbiology Usual nasal and skin flora Management Most case are self limited Warm compresses, massage lacrimal sac, oral anti-biotic (βlactamase resistant) Consider imaging for recurrent causes Obstruction caused by malignancy 25 year old brought to ER screaming. Pain began while yawning when trying to fall asleep TMJ Dislocation Mandibular dislocations occur when the mandibular condyle disarticulates from the articular groove in the temporal bone Dislocations can occur in Anterior (Most common) Superior Posterior Lateral Patients present with an inability to close jaw Treatment aimed at analgesia and reduction 48 year old woman with no past medical history presents with the following midline neck mass She states it is has been present for as long as she can remember, but now wants it removed Thyroglossal Duct Cyst Thyroglossal Duct Cyst Most common form of congenital neck cyst Arises embryologically from the thyroid gland Presence of cysts indicates failure of tract to involute Distinguishing feature Midline Non-tender Moves with swallowing and tongue protrusion due to proximal attachment to hyoid bone Treatment Rarely gets infected Abx Imaging if concern for airway exists ENT referral for excision Send TSH (May contain ectopically located thyroid tissue) 58 year old man with a 2 week history of progressive DOE, neck swelling, decreased appetite and fatigue Quit smoking in 2012 SVC Syndrome Superior vena cava carries blood form the head, arms and upper torso to the heart Carries 1/3 of the bodies circulating volume SVC is pliable and easily compressible Compression leads to retrograde flow into collateral vessels Etiology Carcinoma (90%) Bronchogenic, Lymphoma, Teratoma, Thymoma Infectious TB, Syphilis Thrombus CVP placement Symptoms Limb/facial edema, Headache, Confusion, Dyspnea Treatment Directed at underlying condition Poor prognosis Radiotherapy Palliative stents Tumor debulking EMS brings in a restrained driver who was involved in a frontal collision on I-95 Seat Belt Sign Two and 3 point seat belts, when worn correctly have significantly reduced mortality in MVC Abrasions from seat belts occur in ~20% of MVC Presence of these abrasions increases the likelihood of underlying thoracic injuries four fold and abdominal injury by eight fold Neck abrasion: Carotid artery injury, laryngeal injury, c-spine injury Chest abrasion fracture of sternum, ribs, clavicles; injuries to aorta and heart Abdomen abrasion: mesenteric injury, bowel perforation/hematoma, Chance fracture Presence of seat belt sign should heighten suspicion of potential underlying injury Thorough exam, liberal imaging, frequent re-assessment are cardinal points to remember 50 year old man, was curling 100lb dumbbells at the gym The patient heard a pop, and then felt pain in his right arm Biceps Tendon Rupture Ruptured Biceps Tendon Biceps Anatomy Proximal Biceps: Two heads which attach proximally about the scapula Distal Biceps: Solitary attachment to the radial tuberosity Biceps function to cause forearm flexion and supination Most common location of injury is proximal attachment Long head (90-97%) Most patient describe a pop and simultaneous loss of strength in affected arm Predisposing Factors Repetitive micro trauma Steroid injection Muscle over usage Management X-ray: Rule out concomitant avulsion fracture Sling, NSAIDS Ortho referral 37 year old man presents with pain to left hand after getting it scraped along a brick wall Fight Bite Clenched Fist Injury (Fight Bite) All wound at the MCP joint, especially when on the dominant hand are fight bites until proven otherwise Infections tend to be polymicrobial and aggressive Staph, strep, E. Corrodens, anaerobes Complications Rapidly progressive infections Loss of function Septic Arthritis Flexor Tenosynovitis Amputation Management Irrigation Tendon strength testing Debridement Radiography Prophylactic anti-biotics Splinting & Elevation Close follow-up or admission 42 year old dental assistant presents with painful and swollen finger Herpetic Whitlow Primary or recurrent HSV lesion HSV-1 Seen in children who auto-inoculate their digits with oral secretions Health care workers who are exposed to oral secretions HSV-2 More common in adults due to digital/genital contact May be confused with paronychia Clear vesicles seen early, coalesce and may appear purulent, actually contains necrotic epithelial cells Symptoms Painful and red distal digit Axillary lymphadenopathy Treatment Local wound care Pain control Topical Acyclovir: Decreases Duration of Symptoms Oral anti-virals Do not I & D