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Transcript of ENT Emergencies C. Rebus R3-EM DrRebus.com .
Acute Pharyngitis (cont)
Life-threatening Epiglottitis, diphtheria, Ludwig’s angina, peritonsillar
abscess, retropharyngeal abscess, gonococcal pharyngitis, infectious mononucleosis (occlusion), and GABHS (...ARF).
Garden Variety Infectious viral pharyngitis, non-GABHS bacterial pharyngitis,
and candidiasis. Non-infectious
Laryngeal/pharyngeal trauma, GERD, persistent cough or post-nasal drainage, thyroiditis, and malignancies.
Acute Pharyngitis
What!? I'm an EMERG DOC! In the top 10 presentations Females: #5 Males: #10
National Health Statistics Reports, Number 7, August 6, 2008 (US data).
http://4.bp.blogspot.com/_uekyjQXowno/SwreRGgnJ6I/AAAAAAAADwU/8VqTb-gSWl4/s1600/dung-beetle1.jpg
Acute Pharyngitis (cont)
Who is worse then MD at DDx Bact vs Viral? No one.
Epid Group A Streptococcal pharyngitis is disease of
youth. 50% of pts 5 – 15 yo. Peak incidence first few years of school. GAS uncommon <3 yo
Acute Pharyngitis (cont)
Dx? Classic Symptoms of GABHS Pharyngeal or tonsillar exudate Swollen anterior cervical LN Hx fever >38*C Absence of cough
If all 4 symptoms: 44% chance they will NOT have GABHS.
Coin 50%.
http://www.afreeman.org/wp-content/uploads/2009/02/nickel.jpg
Acute Pharyngitis (cont)
Rapid Strep test? Not recommended in AB Lacks sensitivity and evidence of improved clinical
outcome. ASOT? Lets use some science please...
Not in Dx or mgmt of acute pharyngitis. Post treatment swab?
Not routinely.
Acute Pharyngitis (cont)
How to diagnose this simple beast? Throat Swab. In pts with >2 classic symptoms. Sensitivity 90 - 95%.
Acute Pharyngitis (cont)
MCC? Viral ~90% Bacterial: MCC: GABHS
GCBHS, GGBHS, N. Gonorrhoeae, arcanobacterium haemolyticum
http://textbookofbacteriology.net/themicrobialworld/pathogenesis.html
Acute Pharyngitis (cont)
Infectious? 2-5 d prior to symptoms During acute illness ~7 d after if untreated
Back to School? 24 hrs after start ABx Unless symptoms don't improve -?Tx failure.
Acute Pharyngitis (cont)
Mgmt Swab and wait.
Rheumatic fever? “I got the stuff they want”
Penicillin (no documented resistance). Allergy? Clindamycin or Erythromycin. Not getting better 48 – 72 hrs? FUGP.
Post-Tonsillectomy
Time Honoured Tradition of Hemostasis Tonsils are supplied by 5 arteries in an area unable
to collapse on itself.
Post-Tonsillectomy (Cont)
This is bad. Move them somewhere besides PLC eyeroom. Trauma bay or get an airway cart. IV x2, CBC,
INR/aPTT, crossmatch. Ask for tonselectomy bleed pack. Let ENT know early.
Post-Tonsillectomy (Cont)
0.5 – 10% depending on Sx. Bleeding
Intraoperative Primary (<24hrs) Secondary (1-10 days)
5 – 7 POD most common
Post-Tonsillectomy (Cont)
Minor Bleeding Seated position in surgical area Suction Look Call ENT – likely reluctant
Post-Tonsillectomy (Cont)
Major Bleeding Back to basics – Pressure. Kelly clamp + epi 2% soaked gauze. ENT. They need OR. Presume stomach is full of blood from ooze. It is a bad airway.
Posterior epistaxis from the left sphenopalatine artery.
http://emedicine.medscape.com/article/863220-media
Epistaxis (cont)
http://chestofbooks.com/health/anatomy/Human-Body-Construction/The-Mouth-And-Throat-Part-2.html
Epistaxis (cont)
Fatal Posterior Nasal Packing? (from a fictitious CMPA call) 'You put what, where?'
Epistaxis, medical history, and the nasopulmonary reflex: what is clinically relevant? Otolaryngol Head Neck Surg. 1994 Apr;110(4):363-9
Jacobs et al. Posterior packs and the nasopulmonary reflex. Laryngoscope. 1981 Feb;91(2):279-84.
Epistaxis (cont)
http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79932-80545-113132.jpg
Epistaxis (cont)
Posterior Nasal Packing *to stabilize the anterior
packing = tamponade Nasostat Rubber Chicken Foley
Roberts: Clinical Procedures in Emergency Medicine, 5th ed.
Epistaxis (cont)
Posterior Nasal Packing – 10F Foley
http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79932-80545-113136.jpg
10-15ml N.S.
Epistaxis (cont)
Show of hands: Rx ABx with packing? I'll tell you, it's Zero. Unless you have structural heart disease.
Concern Staph toxic shock syndrome, sinusitis, and
clinically-evident bacteremia Evidence
3 RCT, 163 pts. Lack power. Incomplete evidence. Polymixin B/oxytetracycline reduced flora on
packing.
Epistaxis (cont)
Why so much about a bloody nose? It is distressing. It is common. Public (and health care) knowledge of 1st aid is
poor. The next bloody nose visit can be a public health
moment (teaching=freedom).
Sinusitis
The Forgotten Badboy of the URTI
http://www.topalbertadoctors.org/informed_practice/cpgs/acute_sinusitis.html
Sinusitis
Defn Inflammation of one or more of the paranasal sinus
cavities, the cause of which may be allergic, viral, bacterial, or rarely fungal
Exclusions <6wks, immunocomp, severe underlying dz,
complications of acute bacterial sinusitis, hospital acquired sinusitis.
Sinusitis (cont)
Acute Sinusitis <4 wks.
Recurrent 4+ episodes/yr lasting 10+ days, symptom free b/w.
Chronic >12 wks with/without Rx.
Sinusitis (cont)
Persistent symptoms of URTI without improvement after 10 - 14 days or worsening after 5 days with both:
nasal congestion/purulent nasal discharge and facial pain
+/- fever, maxillary toothache, facial swelling. Physical findings of: swelling and/or erythema, tenderness
on palpation/percussion of paranasal sinuses, periorbital swelling, erythema/swelling of nasal mucosa, post nasal drip
Nasal/nasopharyngeal cultures NOT recommended Transillumination of the sinuses is of limited value in adults
TOP Guidelines, 2008 Update
Sinusitis (cont)
Abx? 1st Line Amoxicillin 500mg PO TID 10d Allergy? Doxycycline 200mg PO once, then 100mg PO BID 10 d TMP/SMX 1 DS PO bid 10d
TOP Guidelines, 2008 Update
Sinusitis (cont)
What!? I'm an EMERG DOC! Progress, in this case, is bad.
http://www.emedmag.com/html/pre/fea/features/061505.asp
Sinusitis (cont)
Preseptal cellulitis Orbital cellulitis * Subperiosteal abscess Orbital abscess.
http://www.emedmag.com/html/pre/fea/features/061505.asp
Sinusitis – CST (cont)
Vague symptoms, vague findings. Dx? CT or *MRI LP
Opening pressures? 450 – 500 mmH2O ~75% CSF – Normal ~75%
CXR? Dispo
Admit
Sinusitis – CST (cont)
Facial Danger Zone
http://resources0.news.com.au/images/2008/07/22/va1237320544789/Tom-Cruise-in-Top-Gun-6158917.jpg
Summary
Pharyngitis – You can make a difference. Post tonsilectomy bleed – It's bad. Epistaxis – Fulfil you urge to put something in
there. Pack. Pack, Pack. Pack, Pack, Pack. Pack, Pack, Pack, Pack.
Sinusitis – If you see it, treat it.
ReferencesBr J Ophthalmol 2003;87:1051 doi:10.1136/bjo.87.8.1051
Janfaza et al. 2001. Surgical anatomy of the head and neck.
Kidermann et al. British Journal of General Practice, March 2005. Adjuvant prednisone therapy in pharyngitis: a randomised controlled trial from general practice.
Middleton, Paul M. Epistaxis. Emergency medicine Australasia (2004) 16, 428-440.
Pofh et al. Burden and Economic Cost of Group A Streptococcal Pharyngitis. PEDIATRICS Vol. 121 No. 2 February 2008, pp. 229-234 (doi:10.1542/peds.2007-0484)
National Health Statistics Reports Number 7 August 6, 2008
Roberts: Clinical Procedures in Emergency Medicine, 5th ed.(via cma.ca)
Tintinalli JE, Kelen GD, Stapczynski JS, Ma OJ, Cline DM: Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 6e: http://www.accessmedicine.com/content.aspx?aID=609033.
Waters Thomas A, Peacock IV W. F, "Chapter 241. Nasal Emergencies and Sinusitis" (Chapter). Tintinalli JE, Kelen GD, Stapczynski JS, Ma OJ, Cline DM:
http://www.bestbets.org/bets/bet.php?id=1412http://www.emedmag.com/html/pre/fea/features/040040035.asphttp://emedicine.medscape.com/article/764304-diagnosis
Images, In order:http://www.boxingscene.com/forums/showthread.php?t=329320http://meded.ucsd.edu/clinicalimg/head_pharyngitis.htmhttp://textbookofbacteriology.net/themicrobialworld/pathogenesis.htmlhttp://www.afreeman.org/wp-content/uploads/2009/02/nickel.jpghttp://www.naze.net/2005/images/2005%200122%20jack%20blood%20in%20sink.jpghttp://www.instantanatomy.net/headneck/areas/phoropharynx.htmlhttp://www.esnr.com/www/case_studies/content/nosebleeds_epistaxis_fig1.htmhttp://www.beerkada.net/images/nosebleed1.jpghttp://chestofbooks.com/health/anatomy/Human-Body-Construction/The-Mouth-And-Throat-Part-2.htmlhttp://drdavidson.ucsd.edu/Portals/0/Pathway/NoseBled.htmhttp://emedicine.medscape.com/article/863220-mediahttp://img.medscape.com/pi/emed/ckb clinical_procedures/79926-79932-80545-113132.jpghttp://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79932-80545-113136.jpghttp://academia.hixie.ch/bath/eye/home.htmlhttp://www.topalbertadoctors.org/informed_practice/cpgs/acute_sinusitis.htmlhttp://www.emedmag.com/html/pre/fea/features/061505.asphttp://travel.webshots.com/photo/1451171186076146350zjzyCYhttp://www.bartleby.com/107/illus571.html