Wednesday Lectures, 8/26/2015 – ENT

TTHM a3.1 HEENT Day (8/26)

10a ~ Dental (Biondich) ~ 32 teeth, good to know terminology for consultants
Temperature sensitivity often precedes pain in dental caries
Pulpitis ~ infection to pulp chamber can precipitate rapid septicemia
Periapical abscess can be drained to relieve, associated c tooth injury or decay
Different kinds of abscesses… Gingival, Periodontal, Pericoronal (wisdom tooth), Combined…
Dental Blocks helpful for drainage ~ see Roberts & Hedges (or Google/YouTube)
Have suction going… they smell/taste bad & bleed some, don’t torture them.
Rinse well & home with mouthwash, consider Abx, depending on severity & tooth involvement…
Deep space infections ~ periapical infections can spread along maxilla or mandible, especially in immunocompromised hosts.
Ludwigs Angina ~ sublingual infection c tongue elevation ~ dangerous infection! can involve epiglottis, can be associated c trismus.
Vincent’s Disease/”Trench Mouth” ~ Pain to gums/Ulcerated dental papillae/Bleeding of gums, can become septic, not well understood, but opportunistic infxn common in WW1? Mainly anaerobic bacteria
Traumatic Dental injuries ~ 70% are maxillary central incisors: Ellis 1,2,3 & Alveolar Frxs
Ellis Class III should consider oral Abx, especially if capped with dental cement.
Dental box has dental cement, or even consider *dermabond & N95 mask wire splint!
Avulsion ~ tooth is out. Can potentially be reimplanted & splinted to next teeth?
!!! missing teeth can be subluxed into gums or aspirated or swallowed…
Baby teeth mixed from 6-12 yo, don’t reimplant dt risk to permanent teeth.

1030 ~ Acute Vision Loss (Prince)
Good eye exam: Funduscopic exam, Tetracaine & Fluorescein/Woods, Acuity Chart,
Visual Fields!, Slit Lamp, IOP Tonopen, perilimbic sparing?
*Acute Closed Angle Glaucoma ~ Fixed midposition pupil c conjunctival injection, treat c timolol, acetazolamide, pilocarpine… & Ophtho consult! CRAO v CRVO are emergencies ~ Stroke Code. Flashers & floaters c vision loss can be vitreous or retinal detachment (avg age 55)
Vitreous Hemorrhage, GCA/Temporal Arteritis, Venous Sinus Thrombosis, blurry vision occipital tract CVA…

11a ~ Small Groups (Lavoie)
Epistaxis & rhino rockets, LET…

1130 ~ Small Groups 2 (Rodney)
Epiglottitis Cric Case ~ tends to be fulminant
Lateral XR concerns, thumbprint sign, HFlu & SPneumo cover c Abx!
Airway Anticipation!!! Consider Atropine for secretions if using Ketamine…
While watching the airway, also consider the sats & pulse.

1230 ~ ICARE (Vince Calleo)
Review & Remind, keep expectations low & performance high (overshoot not undershoot)

1p ~ Jr/Sr Session (Lavoie)
Ear Hematomas get drained, elliptical, then packed & ENT follow-up
Ear Block is approximate diamond field block. Center is innervated separately by vagus.
Which NOT to fix? lid edge or medial canthus possibly involving canaliculi/ducts. leave the lid?
Risky wounds need Ophtho follow-up & repair… Home c erythromycin.
Parotitis ~ stensons gland, vs submandibular whartons duct… often a stone.
Lemon drops ~ sialogogue. Abx if fever or purulent, for oral flora… Augmentin/Clinda…
PCN great for strep, but not great anaerobic coverage… warm compresses & followup.
Dental Blocks ~ Infraorbital (Maxillary anterior) & Superior Alveolar branches (local, Maxillary posterior), Inferior Alveolar (Mandible) & Mental (Anterior Mandible)
If it goes to the neck, strongly consider imaging!

130 ~ Nose (Lavoie) ~ Epistaxis
Sphenopalatine Artery is potential more brisk posterior source
Posterior bleed avg age ~67 yo.
>90% anterior, Silver nitrate cautery can help but never do both sides at once!
LET & rhino rockets handy.
Surgicel handy for those pts who may be anticoagulated (hemostatic pad).
Take out within 3 days, & consider Abx for extended course dt TSS risk!?!
Foley for posterior packing needs ADM dt risks for complications.

2p ~ Ears (Pipas)
Anatomy: Tragus & Helix
Cerumen Removal ~ Cerumenolytics at home, Irrigation in ED c VasCath, or direct manual removal. potentially c eardrops for after…
Staph > Pseudomonas for Otitis Externa… CiproDex
Malignant Otitis Externa 98% Pseudomonas, mostly in immunocompromised.

230 ~ Eyes (Rodriguez)
DDx Red Eye… many things.
Anatomy & Terms: Blepharitis, Episcleritis, Keratitis, Uveitis, Endophthalmitis…
Vital Sign of the Eye: Visual Acuity
Limbic involvement is concerning for uveal involvement!
EOM important for limitation of movement or pain!
Hypopion = Bad. ~Uveitis
Dacrocystitis ~ Duct obstruction. ~ Abx & warm compresses.
Blepharitis ~ leads to hordoleum, chalazion… inflammation of sebaceous gland of eyelid
Chalazion ~ Chronic, Hordoleum/Stye ~ Acute.
Lid involved in Hordeolum, vs chalazion usually noninfectious, less painful, can become infected.
Viral Conjunctivitis ~ Incubation ~9 days, Infection for 2 weeks…
Bacterial Conjunctivitis ~ best treated c PolyTrim (vs Gent has more side effects). Polymixin actually does have some Pseudomonal coverage.
Cells & Flare ~ as sunlight angled through a window slat courses through dust.
~Dr. Cherrington, class poet
Periorbital Cellulitis usually appear nontoxic, still get Abx for cellulitis.
CT if in doubt for Orbital Cellulitis, which would need IV Abx & ADM.
HSV ~ Vesicles around the eye ~ keratitis c fluorescein ~ dendrites c terminal bulbs
VZV ~ Ramsey Hunt & Hutchinsons ~ pseudodendrites by fluorescein
Topical & Oral Antivirals, cycloplegics, ophtho consult & pain ctrl! …No steroids.
Both can have post herpetic neuralgia!

3p ~ Sinusitis (Rossettie) ~ see my presentation 😉

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