Download Slide 1

HEENT Review
October 1, 2008
Nick Genes
the inservice exam
•
•
•
•
Feb 25, 2009
Short term  $$$ (moonlighting, Mets)
Long term  $$$$$$ (licensure, career in EM)
But also: intro to EM practice
• Similar questions to ABEM
• Last year: 207 questions counted
• Physician’s Evaluation and Educational Review VII
• Las Vegas Board Review Course MP3s (2003?)
This lecture series
• Board review: Five months, 20 lectures…
• Different than Dr. Cherkas sessions
•
•
•
•
•
This year:
More engagement than 2005-6
More questions, buzzwords than last year
More repetition
More candy
HEENT
• 21 questions in PEER VII (out of 410, 5%)
• Some overlap in ID, Trauma, Procedures, S&S
• Last year’s inservice: it was 10 out of 207
• CV, GI, Pulm, Trauma each ~20
• Likely emphasis: details that make or break ED
diagnosis or management
HEENT
• Today: H and T, then N, then E, then E.
• No evidence, no nuance.
– I would love to spend 20 minutes talking about
preseptal cellulitis vs. orbital cellulitis
– Sorry
Question 1
A 32-year-old man presents 30 minutes after getting a tooth knocked out in a
fight. On examination, a small clot in the socket is noted. The next step in
management is:
a) Call the patient’s dentist
• They’re too slow
b) Clean the tooth with a brush
• No brush! Worry about the dental ligament
c) Gently irrigate the socket
• To remove the clot to let the tooth reconnect
d) Immediately replace the tooth
• Sure… after clot removed
e) Tell the patient the tooth cannot be reimplanted
• Not true…
Tooth Avulsion
• Tooth completely removed from the socket
• Permanent teeth avulsed for less than 3 hours can be
reimplanted
–
–
–
–
Rinse tooth with Hank’s solution, sterile saline, or milk
Irrigate socket with sterile NS prior to reimplantation
Emergent Dental Consult
Do NOT scrub tooth
Tooth Avulsion
• What if the tooth is missing?
– You need films to rule out aspiration
• What if this is a four year old?
– Primary teeth in children should not be replaced
Tooth Avulsion
• Replant permanent teeth quickly
– 1% loss of survival per minute
– Early, improper reimplantation is better than waiting
for OMFS
• Rinse first, no scrubbing (injures periodontal
ligament). Handle only the crown
• Transport / storage media = saliva, sterile saline,
or milk. Hank’s solution is best
• Only permanent teeth need replantaion
– reimplantation of “baby” teeth can result in bone
fusion and prevent permanent teeth eruption
Tooth Fractures
enamel
dentin
Ellis I
Ellis II
Ellis III
pulp
horizontal fx
• Ellis II and III fractures
require covering of
exposed dentin or pulp
and <24h referral to a
dentist
• “if you see pink, send ‘em”
• May refer Ellis I for
cosmesis
Alveolar Osteitis (dry socket)
• 2-5 days post-extraction
• “The clot got lost, bugs got in”
• Severe pain due to exposed alveolar bone and a
localized osteomyelitis as the result of protective clot
displacement
• Risk factors:
– Females on HRT, pre-existing gum and tooth infections,
traumatic extraction, impacted third molar extractions (2035%)
• Treatment:
– Anesthetize, irrigate socket, pack with iodoform gauze +
eugenol, Antibiotics, early referral
Dental Abscesses
• I don’t think there’s testable material here… no gamechanging tricks in management
Periapical Abscess
Question 2
A 25-year-old man presents with mouth pain and bleeding gums.
He does not recall any medical problems but says he is homeless.
He is afebrile without systemic symptoms. Which of the following
is an ineffective component of treatment?
a) Acyclovir
• Because this isn’t massive herpes outbreak, no vesicles
b) Chlorhexidine oral rinses
c) Debridement
d) Diet rich in proteins and vitamins
e) Metronidazole
Q2 -- Trench Mouth (ANUG)
Diagnosis is based on three
symptoms/signs:
• Pain
• ulcerations between teeth
• gingival bleeding
• Also smell, loose teeth, fever.
• Poor hygiene, HIV.
• Anaerobes.
•
Treat with chlorhexidine oral rinses, metronidazole.
•
Debridement may be necessary
•
Diet rich in proteins and vitamins will prevent
Question 3
A 50-year-old man presents with fever and pain on
swallowing. Examination reveals a nontoxic man with neck
swelling, tongue elevation, and trismus. The most likely
diagnosis is:
a)
b)
c)
d)
e)
Epiglottitis
• 2-3d of throat pain, fever, can’t see it
Exudative pharyngitis
• can see it, also cervical LA
Ludwig angina
• bilateral tongue base infection, swelling… deadly
Peritonsillar abscess
• assymmetry, hot potato voice
Pharyngeal tumor
PEER VII Q223
• no fever
Q3 -- Ludwig’s Angina
• Bilateral cellulitis of the submandibular space
• Painful edema of submandibular area
• Involves connective tissue, fascia and muscle
• Dental source most common (abscess, trauma, recent
extraction). Mixed aerobic / anaerobic
• Contrast CT is diagnostic, aids surgical mgmt
• Can progress to restricted neck motion, trismus,
dysphonia, posterior tongue displacement, airway
compromise (drooling, stridor suggest doom)
• May need fiberoptic for airway control
• If that fails, cricothyroidotomy
Ludwig Angina
Epiglottitis
•
•
•
•
Now more common in adults than children
Severe sore throat with normal oropharynx exam
Pain on moving thyroid cartilage, out of proportion
X-ray: “thumb shaped” epiglottis
• Stridor / airway obstruction / rapid onset / leaning
forward / drooling.
• Notify ENT, anesthesia, operating room early
• Safest in OR: fiberoptic examination, intubation or
tracheostomy
• Admit (ie, don’t send them home)
• Cefuroxime or Unasyn
• Humidified oxygen, airway control / cric tray
Peritonsillar Abscess
• Clinical Features
– Fever, malaise, sore throat
– Odynophagia, Dysphagia
– “Hot potato voice”
– Trismus
– Can spread, compromise airway
• Most common deep neck
infection
• Rare in children under 12y
• Usually Strep
• 3-33% recur
Peritonsillar Abscess
• Clinical Features
– Fever, malaise, sore throat
– Odynophagia, Dysphagia
– “Hot potato voice”
– Trismus
– Can spread, compromise airway
• ED Care
– Aspiration with 18- or 20- gauge
• Diagnostic and Therapeutic
• Try to avoid puncturing Internal
Carotid Artery located 2.5cm
behind and lateral to the tonsil
•
Antibiotic therapy with
Penicillin
Retropharyngeal Abscess
• Young children: suppurative lymph node (primary
infection elsewhere)
• Adults: direct extension of infection, extension to
mediastinum more likely
• Fever / neck pain / difficulty talking, swallowing
and breathing / torticollis
• “Cri du canard” = duck-like voice
• Intraoral exam shows anterior displacement of
the posterior pharyngeal wall
• IV Abx (Clinda or Unasyn), surgical drainage
Retropharyngeal Abscess
X-ray may show soft
tissue displacement
anterior to vertebral
bodies
However, expiration and
neck flexion may give
false-positive X-ray
findings
CT is the gold standard
Other
Pharyngeal / Laryngeal / Tracheal
Infections
• Pharyngitis?
• Croup?
• Diphtheria?
• Tracheitis?
Question 4
Which of the following conditions is an unlikely complication of
sinusitis?
a) Cavernous sinus thrombosis
• extension from paranasal sinus
b) Dental abscess
c) Periorbital cellulitis
• extension from ethmoid sinusitis
d) Pott’s puffy tumor
• extension from forehead anteriorly  doughy, edematous
e) Subdural empyema
• extension from forehead posteriorly  empyema or meningitis or
brain abscess
PEER VII Q76
Q 4 Answer
Bacterial sinusitis: more than 7-10 days, fever, hyposmia,
unilateral, pus, tender. If it persists, it can extend… to Pott’s puffy
tumor, cavernous sinus, or brain…
What to do?
• Nasal Decongestant Sprays
• Antibiotics (14-21 day regimens):
• Levaquin, Augmentin, Bactrim
For complications: CT or MRI, IV Abx, surgery eval, admit.
PEER VII Q76
Cavernous Sinus Thrombosis
• Complications of facial infections with extension
• Veins of face, oral cavity, middle ear, and mastoid
drain to cavernous sinus
– dental extraction / sinusitis / periorbital cellulitis /
furuncle
– high fever, toxic appearance
– eyelid edema / proptosis / conjunctival edema
(chemosis), facial edema
– III and VI nerve palsies and possibly contralateral facial
nerve deficit
– Pupillary dysfunction
Head/neck infection + venous
• MRI, dynamic CT
obstruction + cranial nerve
dysfunction
Question 5
A 57-year-old man is transferred form a skilled nursing facility
because his tracheostomy tube cuff is not inflating. The
tracheostomy was done 5 days earlier for repeated pneumonia
and is still in place. The patient has no active bleeding and is in no
distress. The most likely complication of replacing the tube is:
a)
b)
c)
d)
e)
Air Trapping
• only if they’re really laboring and you leave in the obturator
Creating a false passage
• still immature
Significant bleeding
• not unless eroding through to vessel
Tracheostomy site closing
• If it’s out for several hours, it’s a possibility
Tube directed upwards
• bad idea to let this happen
Tracheostomy
• Within the first 7 days post-op,
the opening is not mature, and
manipulating the tube can lead
to false passage in the soft
tissues of the neck.
– Necessary to have ENT change
tube within 7 days post-op
• If tube is out for several hours,
there is a risk of a closed stoma
and dilation may be required.
Tracheostomy
• If no distress, use an obturator
to solidify the tube for
maneuvering (this increases air
trapping)
• Remember: push the tube
downward (caudad).
Question 6
The most common unilateral neck mass in an adult is:
a) Lymphoma
b) Mononucleosis
c) Parotiditis
d) Squamous cell carcinoma
e) Thyroid disorder
Question 6 – Neck Mass Trivia
Young kids: neck masses usually benign:
• thyroglossal cyst, branchial cleft cyst, hemangiomas, reactive
lymphadenopathy.
Young adults: most neck masses are
• from infection (Mono) or neoplasm (Hodgkin, lymphoma)
In adults: 75% of neck masses are neoplastic.
• #1 is Squamous Ca of upper airway/GI with cervical node mets.
• Smoking, drinking is a risk.
Question 7
A 24-year old woman presents with diffuse tongue swelling that began
just prior to arrival. She’s had two prior episodes in the past and her
mother has similar problems. She has not eaten any new foods, denies
new toiletries, clothing, and meds. Which of the following medications
would be most efficacious to treat this condition?
a) Cetirizine
• for IgE-mediated allergic reactions
b) Diphenhydramine
• for IgE-mediated allergic reactions
c) Epinephrine
d) Methylprednisolone
• will take hours to work
e) Solumedrol
• Really, the question was worded like this.
Question 7 – Hereditary Angioedema
• from C1 esterase defect. Autosomal dominant, usual onset in teens.
• Attacks last 2-3 days, may be brought on by airway / GI trauma
• Swelling is nondemarcated, nonpruritic.
• More common in African-Americans.
• aminocaproic acid? FFP?
• ACE-mediated angioedema often starts within a week, but can come
at any time. You never take it again.
• Something about bradykinins
• Treat ACE-mediated angioedema like an allergy
Question 8
A 2-year-old boy presents with a 2-week history of purulent
discharge from the right nostril that has not responded to a 7-day
course of amoxicillin. At this point which of the following
management plans is most appropriate?
a) Change the antibiotic to amoxicillin-clavulanic acid
• no effect if FB
b) Continue amoxicillin for at least 2 more weeks
• come on
c) Examine the nose, looking for a foreign body
• Unilateral purulent discharge is FB until proven otherwise.
d) Order plain radiographs of the sinuses
• no value for FB, may confuse issue with sinus opacity
e) Start a course of an oral nonsedating antihistamine
• no effect if FB
PEER VII Q301
Nasal Foreign Body
• Unilateral purulent nasal discharge in a preschoolaged child is considered a foreign body until
proven otherwise
• Plain radiographs unlikely to be of value
• Tools for removal include forceps, suction
catheters, hooked probes, balloon-tipped catheter
Question 9
A 67-year old woman is brought to the ED from her skilled nursing
facility for evaluation of fever and right-sided neck swelling. CT scan of
the neck shows inflammatory changes in the right parotid consistent
with parotitis. Which of the following antibiotic is most appropriate?
a) Amoxicillin-clavulanate
b) Ampicillin-sulbactam
c) Cephalexin and metronidazole
d) Clindamycin
e) Vancomycin and metronidazole
Question 9 – Suppurative Parotitis
A 67-year old woman is brought to the ED from her skilled nursing
facility for evaluation of fever and right-sided neck swelling. CT scan of
the neck shows inflammatory changes in the right parotid consistent
with parotitis. Which of the following antibiotic is most appropriate?
• Vancomycin and metronidazole
• SP caused by retrograde movement of oral flora into salivary gland.
• Usually staph or strep, but also see anaerobes.
• Risk group: Chronically ill, dry mouth, post-op or sialoliths
• If stable, taking PO, can manage as outpatient on augmentin
• In a nursing home patient, must cover HA-MRSA.
Question 10
For the repair of a complex ear laceration, which of the following
nerve blocks is most likely to provide anesthesia?
a) Auriculotemporal
• branch of the mandibular nerve. Inject anterior and posterior to tragus.
b) Inferior Alveolar
• mandibular teeth, lip, chin. May hit VII, paralyze
c) Infraorbital
• cheek, nose, upper lip. May hit eye.
d) Mental
• lower lip
e) Supraorbital
• forehead
Question 11
A 20 year old woman presents with a painful right ear. She has no
history of ear problems but swims several times a week.
Examination reveals erythema of the external auditory canal with
some purulent discharge and a perforation in the tympanic
membrane. The treatment option most likely to damage her ear is:
a)
b)
c)
d)
e)
Ciprofloxacin otic and hydrocortisone otic suspension
• Suspension penetrates less than solution, no acid
Hydrocortisone and acetic acid otic solution
• At pH 3.0, can destroy your middle ear structures, nerves
Neomycin/polymyxn/hydrocortisone otic suspension
• neomycin has theoretical ototoxic risk
Ofloxacin otic solution
• this is the only FDA-approved treatment for OE with perf
Penicillinase-resistant penicillin
• ?
Otitis Externa
Otitis Externa
• Inflammatory process involving the auricle,
external auditory canal, and surface of the TM
• Pain on movement of auricle, purulent drainage
• Caused by gram-negative organisms, Staph
aureus, Pseudonomas, or fungi
• Peak age 9 -19 years
• Erythema, edema of EAC, white exudates on EAC
and TM
• Pain with motion of tragus or auricle
Otitis Externa (continued)
• Treatment
– Fluoroquinolone otic drops
– Oral antibiotics if auricular cellulitis is present or
TM is perforated (Quinolones, Cephalosporins, or
penicillinase-resistant pcn)
• Hydrocortisone and acetic acid otic solution
have a pH 3.0 which can be toxic to the middle
ear in perforations
TM Perforation Causes
• Otic Barotrauma
– Unequal pressures on either side of the TM
– Blocked eustachian tubes (or external canal)
• Increased altitude: gas expands in middle ear
• Diving injury: increased external pressure on TM
• Trauma (slap/blunt, penetrating, acoustic)
• Noise (blast injury) / lightning injury
• Infection: otitis externa, otitis media, myringitis
• Decreased hearing (conductive loss), pain, bleeding
TM perforations
involving the
Pars Tensa
TM Perforation
• Generally involves pars tensa (largest area),
usually anteriorly or inferiorly
• 90% heal spontaneously
• Early referral (<24hrs) for penetrating trauma or
posterior perforation (higher risk of ossicle
damage)
• Later referral is OK for blunt trauma / barotrauma
• Avoid water in ear
• Antibiotics (topical or systemic) only for:
– obvious infection or forceful water entry (water skiing)
Otitis Media
• Infants and Young Children (peaks at 6 to 18 months)
• 1/3 are viral
• Strep pneumoniae most prevalent bacterial cause,
also H. flu, M. catarrhalis
• Signs include dull, bulging, immobile TM
– Light reflex is of no diagnostic value
• Serous Otitis media = OM with effusion
– painless, fluid behind TM, decreased hearing
– affects learning / speech (refer, abx for 3wks)
• Treatment
– Amoxicillin 80 mg/kg/day PO divided q8 – q12 for 10 days
(High-dose amox therapy)
Otitis Media
Acute Otitis Media
•Bulging TM
•Loss of Light Reflex
•Retraction
•Decreased movement on
insufflation
Question 12
A 75-year-old man presents with fever and ear pain. He has had
the earache for several weeks and has been treating it at home
with warm mineral oil. On further questioning, he says he is
diabetic and that his sugars are running higher than normal.
Examination is normal except for the ear, which has granulation
tissue on the floor of the external auditory canal. The most likely
pathogen causing this infection is:
a)
b)
c)
d)
e)
Aspergillus sp.
Candida sp.
Pseudomonas aeruginosa
Staphylococcus epidermidis
Streptococcus pneumoniae
PEER VII Q231
Malignant Otitis Externa
• Seen in the elderly, diabetic, and
immunocompromised patient
• Failing 2-3 weeks of antibiotic therapy
• Progresses from OE to chondritis to skull
osteomyelitis… potentially lethal
• Most Common Organism = Pseudomonas
aeruginosa
• Physical Exam Findings:
– Otalgia, Otorrhea
– Granulation tissue on floor of EAC
• Treatment:
–
–
–
–
Radiology for staging
Admission
Parenteral antibiotics
Possible surgical debridement
Question 13
A 17-year-old girl presents with a painful
right ear. She has had the pain for 2
weeks but has not had time to see her
family doctor. She is worried because
her boyfriend said her ear was red and
looked funny. On examination, the ear
appears as in the picture, and a
posterior auricular crease is not noted.
The best treatment option is:
PEER VII Q241
Question 13
a) Administer oral antibiotics and
discharge
b) Administer topical antibiotics and
discharge
c) Admit for treatment with parenteral
antibiotics
d) Perform typanocentesis and
discharge
e) Refer to an ENT for follow up care
Mastoiditis is the most serious complication of OM.
Mastoid air cells are blocked, inflammed, spreads to periosteum.
Image with CT, treat with IV Abx like cefuroxime
PEER VII Q241
Mastoiditis
• Infection spreads from the middle ear (otitis media) to the mastoid air
cells
• Clinical Presentation:
– Otalgia
– Fever
– Postauricular erythema, swelling
– tenderness
– Protrusion of the auricle
– Obliteration of the postauricular crease
• Imagining
– CT Scan – assess extent
• Treatment
– Emergent ENT Consultation
– IV Cefuroxime, Admission
– Possible surgical drainage
Question 14
A 20 year old man presents with left eye irritation. He was
walking in a park and accidentally ran into a tree branch. He
believes the branch scratched his eye. Examination reveals a
corneal abrasion. The best treatment option is:
a) Erythromycin ophthalmic ointment, no patch
b) Erythromycin ophthalmic ointment, patch
c) Homatropine, no patch
d) Homatropine, patch
e) Topical anesthetic  Don’t prescribe topical anesthetics
Patching may help with pain but is contraindicated in contact
lenses and “organic” injuries (tree branch).
Homatropine relieves ciliary spasm, thought to help with pain.
PEER VII Q 160
Corneal Abrasions
Corneal Abrasions
• Very Painful
• Fluorescein reveals dye update at abrasion site
• Treatment
– Topical Erythromycin, Tobramycin, or Bacitracin/Polymyxin
– Tetanus updated
– Patching does not facilitate abrasion healing
– Topical anesthetics strictly contraindicated
• Cause corneal breakdown and ulceration
– Cycloplegic agents (homatropine) not recommended
• Recent studies show no benefit (Carley and Carley 2001)
Keratitis
Sxs: Pain, redness, decreased
acuity, FB sensation
PE: perilimbal flush
Causes: Staph, HSV, Zoster, Sjogren’s,
exposure, drugs
Keratitis can disrupt the epithelial layers
making the cornea more susceptible
to serious infection
Severe Keratitis
Sxs: Painful, usually causes iritis,
decreased acuity
PE: May see Hypopyon (pus in anterior
chamber)
Causes: central ulcer = GC, peripheral =
Stph
Rx: Gram stain / culture, cycloplegics,
immediate topical and IV abx (genta,
tobra, quinolone), urgent consult
Viral Keratitis Herpes Simplex (HSV)
Dendritic branching pattern
Decreased corneal sensation
Rx: Antivirals, cycloplegics,
Ophtho consult
NO STEROIDS
May be recurrent
Herpes Zoster Opthalmicus
Shingles in trigeminal distribution, commonly with
lid lesions
Hutchinson’s sign = zoster at tip of nose, increased
incidence of ocular zoster
Rx: Acyclovir IV, cyclopelgic, erythromycin, ophtho
consult
Steroids if iritis is present (without corneal defect)
Subconjunctival Hemorrhage
Asymptomatic
Cause: Spontaneous or Traumatic
Rx: none
Consider Ruptured Globe if:
– Associated with trauma
– Circumferential, dense, elevated
– Lateral (then r/o zygoma fracture)
Corneal Laceration
Teardrop shape of Iris
Flat Anterior Chamber
Black iris pigment may be at the wound edge
Seidel Test: Fluorescein on cornea is washed
away by leaking aqueous humor = corneal
perforation
Tonometry is Contraindicated
Rx: Urgent Ophtho Referral
Once again… Corneal Abrasion
Sxs:Pain, photophobia, FB sensation, injection
PE: r/o retained FB under lids
Cause: Trauma, consider intraocular FB for high
pressure injury
Rx: Abx Ointment, remove imbedded FBs
Remove Rust Rings? Not urgent
Contact lens wearers:
anti-pseudomonal ointment (cipro)
Question 15
A 55-year-old woman presents complaining of loss of vision
in her right eye that occurred suddenly and without pain.
Examination reveals a pale, edematous retina with a visible
red macula. The most likely cause of this condition is:
a)
b)
c)
d)
e)
Bell’s Palsy
• Lid, dryness may affect vision, not eye problem in itself
Cataract
• come on
Embolus
• classic description – pale, edematous, cherry red spot
Glaucoma
• slower, IOP causes nerve damage
Optic Neuritis
• painful, swollen disc but normal retina
PEER VII Q145
Central Retinal Artery Occlusion
• Causes
– Embolus, thrombosis, arteritis
– Sickle Cell Disease
– Trauma
• Clinical Findings:
–
–
–
–
–
Painless
Complete or near-complete vision loss
Afferent pupillary defect present
Pale fundus on funduscopy examination
Cherry-red macula
CRAO Treatment
True Ocular Emergency. 90-minute window to restore vision
Goal is to lower IOP to allow emboli to move to periphery.
•
•
•
•
•
Gentle globe massage
Rebreathing into bag -- increase pCO2 to decrease blood flow to globe
IV Carbonic anhydrase inhibitors (acetazolamide)
Beta blockers (timolol)
Anterior Chamber paracentesis by Ophtho
Need to w/u carotid and cardiac disease, consider ESR
Central Retinal Vein Occlusion
Sxs: Slower onset, painLESS, monocular
vision loss
PE: Retinal hemorrhage, cotton wool
spots, macular edema, “blood and
thunder” fundus (dilated venous
system)
Cause: Atherosclerosis, glaucoma
Rx: Urgent ophtho consult, r/o CRAO
consider ASA, no acute treatment
Amaurosis Fugax
Sxs: Transient loss of vision, unilateral,
painless, lasting 5-30 minutes, with
graying/blurring of part or all of visual field
Causes: cholesterol or fibrin-platelet arterial
emboli, sickle cell, temporal arteritis,
collagen-vascular dz, syphillis
Rx: Ophtho / Neuro consult, ASA
Ocular TIA ?Precursor of retinal artery
occlusion
Retinal Detachment
Another cause of painless vision loss
Sxs: “Flashes of light” or “lowering of curtain” in
peripheral visual fields, new prominent floaters or
webs
PE: decreased peripheral vision, retinal / vitreous
hemorrhages, grey retina with folds
Cause: Trauma, Sickle Cell, Diabetes
A tear in the retina allows vitreous fluid to separate
retina from the choroid
Rx: Fundoscopic exam, US, Emergent Ophtho consult.
If tear is inferior, elevate head. If superior, lay flat
Question 16
A 50-year-old man presents with left eye pain, blurred vision, watery
discharge, and photophobia that began 2 days earlier. He has no history
of recent illness or trauma, has quiescent UC. The patient is in moderate
discomfort and is shielding his left eye from the light.
Physical examination findings are depicted in the picture.
Visual acuity is slightly decreased in the left eye and normal in the R eye.
Pain with a consensual light reflex is present. Flare is noted on slit-lamp
examination, and the intraocular pressure is within normal limits. What
is the most likely diagnosis?
Question 16
A 50-year-old man presents with left eye pain, blurred vision, watery
discharge, and photophobia that began 2 days earlier. He has no history
of recent illness or trauma, has quiescent UC. Flare is noted on slit-lamp
examination, and the intraocular pressure is within normal limits. What
is the most likely diagnosis?
a)
Acute narrow-angle glaucoma
• corneal clouding, high IOP, mid-dilated pupil
b) Corneal abrasion
• FB sensation, watery discharge, defect on staining
c) Iritis
• uvea inflammation and ciliary spasm, with flare, ciliary flush
d) Orbital cellulitis
• pain with eye movement, exophthalmosis
e) Scleritis
• often bilateral, with nodules, systemic disease
The Red Eye
•
•
•
•
•
Conjunctivitis
Foreign Body
Uveitis / Iritis
Narrow angle glaucoma
Keratitis
C FUNK
Iritis / Uveitis
• Consensual Light Response eliciting pain in the red eye is
highly suggestive of iritis.
• Inflammation of the anterior uvea and spasm of the ciliary
body results in symptoms
–
–
–
–
Eye Pain
Blurred, decreased vision
“Cells” (WBCs)
“Flare” (headlights in a fog)
• Treatment:
–
–
–
–
Anticholinergic Preparations
Cylcoplegics
Topical Steroids
Oral Analgesics
• Ophtho Consultation
Question 17
A 35-year-old woman presents with a painful right eye. She has
had the pain for 1 day and some blurred vision as well.
Ophthalmoscope examination reveals a swollen optic disc. She
has never experienced this and has no medical problems. The
best treatment options is:
a) Admit for MRI
• Maybe later as part of MS workup… not Tx
b) Admit for treatment with methylprednisolone
• This is optic neuritis. Start IV steroids in the ED.
c) Begin treatment with oral prednisone
• Oral steroids actually worse than placebo
d) Perform lumbar puncture
• ? Relief for pseudotumor
e) Obtain CBC
• Not tx…
Optic Neuritis
• Inflammation of Optic Nerve
– Caused by:
• Infection
• Demyelination
• Autoimmune Disorders
• Clinical Presentation:
–
–
–
–
–
–
Reduction of vision
Pain with extraocular movement
Visual field cuts
Afferent pupillary defect
Swelling of Optic Disc
Color vision affected more than visual acuity
• ED Care
– IV Steroids lower risk of MS in 2 years (oral steroids actually did worse than
placebo).
– Admission / consult neuro, ophthalmology
Optic Neuritis
Sxs: decreased vision over hours to days, pain
increased by EOM, unilateral (70%)
PE: dilated pupil, may have APD, field defect
common especially central scotoma (blind spot),
red desaturation test (dullness of color), minimal
disc elevation
Causes: Multiple Sclerosis common (25%), sarcoid,
leukemia, viruses, TB, heavy metal ingestion
Rx: ED mgmt is controversial, Ophtho consult
Acute Angle Closure Glaucoma
• Clinical Presentation:
–
–
–
–
–
Eye Pain
Headache, N/V
steamy hazy cornea
Fixed, mid-dilated pupil
Increased intraocular pressure of 40 to 70 mm Hg (10-20)
Acute Angle Closure Glaucoma
• ED Care
–
–
–
–
–
Decrease intraocular pressure
Timolol
Apraclonidine
Acetazolamide IV for pressures > 50mm Hg
If pressure does not decrease in 1 hour, give IV Mannitol
Question 18
Which of the following physical examination findings most strongly
indicates that an eye infection is only a preseptal cellulitis?
a) Decreased visual acuity
• suggests orbital cellulitis
b) Fever
• nonspecific
c) Pain with blinking
• Nonspecific, maybe suggests orbital
d) Recent abrasion on the eyelid
• Hard to go from here to orbital cellulitis
e) Swelling around the eye
• nonspecific
PEER VII Q260
Periorbital (Preseptal) Cellulitis
• History:
– Trauma, otitis
• Clinical Presentation:
–
–
–
–
–
Warm, indurated, erythematous eyelids
No restriction of ocular motility
No Proptosis
No painful eye movement
No impairment of pupillary function
• ED Care:
– Oral Abx – Augmentin (staph, h. flu)
– Need to admit:
• Under 5 years-old
• Toxic Appearing
• Start on IV Abx – Vanco and Ceftriaxone
• History:
Orbital Cellulitis
– Sinus infection
• Clinical Presentation:
– Warm, indurated, erythematous
eyelids
– Fever
– Toxicity
– Restriction of ocular motility
– Proptosis
– Painful eye movement
• Diagnosis:
– Orbital and Sinus CT scan w/ and
w/out contrast
• ED Care:
– IV Abx – Cefuroxime or Vanc
– Ophtho Consult
– Admit
Question 19
A 23-year-old man with sickle cell disease presents with blurred
vision after being poked in the eye. He has a hyphema. Intraocular
pressure is 30. Which of the following drugs might worsen his
condition?
a) Carbonic anhydrase inhibitor
• Contraindicated in sicklers because lower IO pH, stiffer RBC
b) Mannitol
c) Optic ciprofloxacin
d) Topical alpha-adrenergic agonist
e) Topical beta-blocker
Question 20
Question 20
A 23-year-old man presents holding both hands over his left eye.
He was playing basketball when another player hit him in the
eye. He is able to cooperate with the examination and reports
decreased vision. The definitive treatment option in the
emergency department is?
a) Carbonic anhydrase inhibitor
• Useful in glaucoma-mediated elevated IOP
b) Gentle pressure to reduce the eye
• Would make things worse (this isn’t CRAO)
c) Lateral canthotomy
• Because retrobulbar hemorrhage raises IOP, can compromise retina
d) Observation pending ophthalmology consultation
• This is a true emergency, can’t wait
e) Thyroid-stimulating hormone level measurement
• Maybe useful in nontraumatic exophalptosis
PEER VII Q6
Retrobulbar Hemorrhage
Retinal Circulation Compromised
Clinical Findings:
•Proptosis
•Vision Loss
•Decrease Ocular Movement
•Increased Intraocular Pressure
Immediate decompression is Key
Lateral Canthotomy is the Best Option
Lateral Canthotomy
• emergent procedure to relieve orbital compartment pressures
• release of lateral canthal tendon
Cantholysis
•
•
•
•
adjunctive procedure to canthotomy
can further reduce orbital compartment pressures
release of inferior crus of lateral canthus
if necessary, may also release superior crus but should
avoid if possible as lacrimal gland and artery are in the area
Indications
• proptosis
• decreased visual acuity
• increased intraocular pressure
>40mm Hg, resistance on ballotment
Purpose
• temporizing measure
• relieves orbital compartment pressures
• prevents further neurovascular damage
Contraindications
• globe rupture
Question 21
A 6-year-old boy presents complaining of severe eye pain and blurred
vision. He had tipped over a cup of plaster, and some of it splashed in
his eye. What is the proper order of management?
a) Document visual acuity, irrigate, perform slit lamp exam, measure pH
b) Document visual acuity, measure pH, irrigate, perform slit lamp exam
c) Irrigate, measure pH, document visual acuity, perform slit lamp exam
• Time is vision! No justification for delaying irrigation. Talk to triage nurse.
d) Measure pH, irrigate, document visual acuity, perform slit lamp exam
e) Perform slit lamp exam, document visual acuity, measure pH, irrigate
PEER VII Q328
Chemical Ocular Injury
• Acid and Alkali burns are managed in similar manner
– Time is Vision
– Flush eye immediately
• Normal Saline or Ringer’s Lactate – 1-2 Liters (any drinkable fluid…)
• Morgan Lens – topical anesthesia may help
– Continue to flush until pH is normal (7.0-7.5)
– Recheck pH in 20-30 minutes to ensure no additional corrosive is
leaching out of tissue
– Document Visual Acuity
– Rx:
• Cycloplegic
• Erythromycin Ointment
• Narcotic pain medications
– Tetanus updated
– Ophtho Consultation
Chemical Ocular Injury
• Acid and Alkali burns are managed in similar manner
– What’s worse?
Chemical Burn
Alkali substances (worse than acids):
– Liquefaction Necrosis
– Damage is related to initial pH
– Tear gas and mace are similar
Acid:
– Coaguation Necrosis
– Penetration is not as deep as with
alkali
– Chlorine, sulfur
The end