High Volume Low Risk DON’T GET COMPLACENT · Head EENT -Bell’s Palsy Acute Onset of Unilateral Facial Paralysis ִHyperaccusis, Pain behind ear, Taste change Usually Maximal Symptoms

Copyright E.W. Schaefer

Otorhinolaryngology(HEENT)

Edwin W. Schaefer, ND., RN., C-FNP

Emergency Nurse Practitioner


Objectives

�Recognize warning signs of life threatening HEENT emergencies

�Describe basic pathophysiology and symptomotology of several HEENT problems

�Understand how to stabilize and appropriately disposition several HEENT problems


General

�High Volume

�Low Risk

�DON’T GET COMPLACENT


History

�Chief Complaint

�Onset & Course

�Historical Perspective

�Precipitating & Alleviating Factors

�Level of Activity

�Home Treatment

�Medical History


History - Terminology

�Pharynx

�Pharyngitis

�Larynx

�Bolus

�Uvula

�Epiglottis

�Cricoid Membrane


History - Terminology

�Trismus

�Dysphagia

�Odynophagia

�Otalgia

�Chemosis

�Photophobia

�Exopthalmus

�Enopthalmus

�Hyperacusis

�Diplopia

�Dysphonia

�Tinnitus


HEENT Warning Signs

�Worst Headache

�Visual Changes

�Muffled Voice

�Dysphagia / Drooling

�Hearing Loss / Acute Tinnitus


HEENT - Head


HeadEENT – Anatomy


HeadEENT - Head Injury

Head Injury

Over Two Years Old

Under One Year Old⌧Need Imaging Study

Sport Injury

Players/Coaches Minimize Injury

Return to Sport Recommendation


HeadEENT - Temporal Arteritis

� Over 50 years old 15-30cases/100K

� Systemic panarteritis, targets arteries with a lot of elastin

� Headache; severe, throbbing & frontotemporal

� Associated with Polymyalgia Rheumatica

� Can Cause Blindness

� Diagnose (3/5) Greater 50 y.o.

New-onset Localized HA

TA Tenderness /↓ Pulse

ESR Greater then 50

Abnormal Artery Bx

� Steroids


HeadEENT - Bell’s Palsy

�Acute Onset of Unilateral Facial Paralysis

Hyperaccusis, Pain behind ear, Taste change

�Usually Maximal Symptoms within 5 days

�Consider Lyme’s Disease, Ramsey Hunt Syndrome, HIV and CVA

�Treatment:

Early use of Steroids may help.

Protect eye from drying


HeadEENT - Mandible Dislocation

�Usually non traumaticFollowing yawn, laugh

Previous Hx

Trauma - consider Mandible Fx

�Usually Easy Reduction

�Versed If Needed

�ENT Follow up


HEENT - Eyes


HEyeENT - Anatomy


HEyeENT - Foreign Body

�Pain, Erythema, Tearing, FB Sensation

� Inquire what type; Wood, Metal Mechanism: High Speed

�Remove - Cotton Applicator, Needle, Eye Spud

� If Metal - Look For Rust RingNeeds to be removed

�TreatmentAntibiotic Drops

Slit Lamp Exam

Optho Follow up

Corneal Ulcer



HEyeENT - Hyphema

�Layering of cells in dependent region of the anterior chamber

�Usually Traumatic, can be from Inflammation

�Pain, Photophobia, and Decreased Vision

�TreatmentHOB Up 30-45 degrees

Limit Eye Movement

⌧No ReadingNo ASA or Platelet Inhibiting medications


HEyeENT - Globe Laceration

� Blunt Trauma: Violation usually at Limbus

� Bloody Chemosis over Scleral violation

� Stream of Flourscene Dye surrounded by pool

� Tear Drop Pupil - Points to site of injury.

� Decreased Vision, Distortion of Anterior Chamber

Treatment� DO NOT PUT ANY

PRESSURE ON EYEDo Not Do Tonometry

� Place Metal Shield over eye

� NPO, Antiemetics and Antibiotics

� Avoid Succinylcholine for RSI - Increased IOP

� CT Scan for Dx if suspectedNO MRI

� Immediate Optho Consult


HEyeENT - Acute Angle Glaucoma

Acute Angle � Anatomical Problems

� Decreased Flow Posterior to Anterior chamber

� Precipitated by Dark

� NO CYCLOPLEGICs

� Severe Eye Pain, NV, Visual Changes (Halos)

� Hazy Cornea

� Dilated/Poorly Reactive Pupil

� Treatment Miotic Agents (Piolocarpine)

Optho Consult

Open Angle� Insidious Onset

� Increased Cup/Disc Ratio

� Diminished Peripheral Vision

Cup/Disc Ratio

Retinal Detachment



HEyeENT - Orbital Fx w/Muscle Entrapment

� Trauma Related

Object Less then 10cm diameter

Floor thinnest part

Limited movement, Enopthalmos, Diplopia

Treatment

⌧Optho Consult


HEyeENT - Super Glue

�Usually Very Anxious

�Do Not Force lids Open

�Apply Ointment / Patch

�Consult Optho

�Cyanoacrylate exposure

�Not absorbed, does not cause burn

�Protect eye from drying out


HEyeENT - Herpes Infection

�Always consider with conjunctivitis

�Should always do a slit lamp exam to rule out

�Look for Dendrite

�Consider if Herpes Infection of the FaceEspecially if Nose is involved.

�No Steroid Drops

�TreatmentAntivirals Oral and Topical, Start ASAP, within 3 days is

best.

Emergent Optho Consult


HEENT - Ears


HEEarNT - Meniere’s Disease

�Recurrent usually progressive group of symptomsProgressive Deafness

Tinnitus

Dizziness

Fullness in Ears

�TreatmentSymptomatic

⌧ Anticholinergics, antihistamines, sedation

Valium good for acute attacks


HEEarNT - Mastoiditis

� Clinical Deterioration of Otitis Media

� Rare since antibiotic use

� Usually affects Kids

� Symptoms:

Otalgia

Postauricular swelling, erythema, tenderness

Otorrhea, hearing loss

�Treatment: CT Scan, Emergent ENT Consult, Incision & Drainage,

Antibiotics


HEEarNT - Malignant Otitis Externa

�Elderly Diabetics (80-90%), Immunocompromised

�Symptoms: Otalgia, exacerbated with movement of tragus or pinna

Erythema pinna and periauricular tissue

Trissmus, signs of sepsis

�Treatment: Topical and Oral/Parenteral AntibioticsAnti-pseudomonal Beta Lactam, Aminoglycosides (not

topical), Cephalosporins

�Elderly, Toxic Appearing Admitted


HEEarNT - Subperichondrial Injury

�Cauliflower Ear (Hematoma)

Cartilage Vascularized by Osmosis

Incision & Drainage

Pressure Dressing

�LacerationIf cartilage involved needs to

be repaired

Close Skin

Pressure Dressing


HEEarNT - Tympanic Membrane Rupture

�Heal spontaneously

�Hearing loss

�No Fluids in ear

�Treatment

Floxin (Quinolone)

Systemic Antibiotic if contaminated

Follow up with hearing test


HEEarNT - Foreign Body

�Get Description

�TechniquesYankar Suction

Ear Loop

Alligator Forceps

Super Glue

Irrigation

� InsectsVERY Distressing

⌧Movement

Lidocaine Drops

⌧Paralyze Insect

Remove

⌧Direct

⌧Irrigation


HEENT - Nose


HEENoseT - Septal Hematoma

�Need to evaluate for after trauma

�Purple swelling over septum

�Needs to be drained

If small can drain with needle

If larger need I&D

Should pack nose after to prevent reaccumulation

Antibiotic Prophalaxis (PCN)


HEENoseT - Cavernous Sinus Thrombosis

�Usually secondary to Oculonasal Infection

�SymptomOrbital Edema, Chemosis, Venous Congestion, III, IV, V

and VI Nerve Palsy

Fever, Acutely Ill, Headache, NV, Orbital Tenderness, Ophthalmoplegia

� 30% Mortality

�TreatmentEmergent ENT Consult

Admission

Aggressive Antibiotic Therapy


HEENoseT - Epistaxis

�AnteriorKiesselbach’s Plexus

Cocaine Sniffing

Vasoconstriction/ Anesthesia

Packing / Cautery

�PosteriorNasal Packing

Close Follow Up


HEENoseT - Foreign Body

�Usually has history

�Presents with odorous nasal D/C, no history

�If a plant product, early removal is easiest

�If Visible

Yankaur, Metal Ear Loop, Mouth to Mouth

�If Not Visible, consult ENT

Xray may be helpful


HEENT - Throat


HEENThroat - Peritonsilar Abcess

�Usually Teens / Young Adults

�Odynophagia, Dysphagia, Dysphonia, Deviated Uvula, Fever

�TreatmentENT Consult

Needle Aspiration

Antibiotics (PCN, Macrolide)


HEENThroat - Epiglotitis

� Pre HiB VaccinePeak 2-8 & 20-40 years old

� Increased Incidence in African Americans

� 1-2 day URI Prodrome

� Acute Exacerbation

� Dysphagia, Drooling, Inability to swallow, Tri-Pod Position, Tenderness of Thyroid Cartilage

� TreatmentAirway

Antibiotic (Cephalosporin, Unasyn)

Emergency ENT Consult


HEENThroat - Tongue Laceration

�Large gapping lacerations should be closed

�Can lead to increased healing times and morbidity

�Use large absorbable stitches

�Hold Tongue with gauze or suture

�Conscious Sedation

�Not very painful

Mandibular Dislocation



HEENThroat - Tooth Injury/Avulsion

�ClassificationEllis I: Enamel Only

Ellis II: Include Dentin⌧Needs to be sealed

Ellis III: Include Pulp⌧Bleeds from the site

⌧Needs to been seen by DDS

�AvulsionReplace Permanent Tooth

ASAP


HEENThroat - Sialolithiasis

�Salivary Calculi

�Peak 30-60 years and Male

�Pain, swelling of parotid gland, usually unilateral, worse when eating.

�TreatmentLemon Drops

Analgesics

Antibiotics if evidence of infection

ENT follow up (canalization)


HEENT - Neck

�Lymphatic DrainageCan help identify

infectious Region


HEENT - Ludwigs Angina

�Painful Swelling, Erythema - Anterior Neck, Trismus, Dysphonia, Odynophagia, Fever

�TreatmentICU Admission

30% require intubation

Antibiotics (PCN, Flagyl)

�Bilateral Swelling of the Anterior Neck

� Infection of the Submandiular Fascia

�Subsequent to Dental InfectionPosterior Mandibular

Molars

�Males 20-60 years


HEENT - Neck Fracture

�Xray indicated if neck tenderness after trauma

� If patient is alert, not intoxicated, No Paresthesia

�Assess if they have pain with self movement


HEENT - Pearls

�Don’t Get Complacent

�ALWAYS Check Visual Acuity for Eye Problems

�Heed the Warning Signs - Further Investigation

�Assure Good Follow Up


Questions


Nasal Packing


Dendrite - Herpes Infection


Mandible Reduction

Wrap thumbs in gauzePush Down & Back


Acute Angle Glaucoma


Globe Laceration


Globe Enucleation


Hyphema

Documents

High Volume Low Risk DON’T GET COMPLACENT · Head EENT -Bell’s Palsy Acute Onset of Unilateral Facial Paralysis ִHyperaccusis, Pain behind ear, Taste change Usually Maximal Symptoms