Otolaryngologic

  • Ear
    • Foreign Body
    • Cerumen Impaction
    • Mastoiditis
    • Otitis Externa
    • Malignant Otits Externa
    • Otitis Media
    • Perforated Tympanic Membrane
  • Eye
    • External Eye
      • Burn confined to eye
      • Conjunctivitis (viral)
      • Conjunctivitis (bacterial)
      • Conjunctivitis (allergic)
      • Disorders of Lacrimal System
        • Dacrocystitis
        • Dacroadenitis
        • Nasolacrimal Duct Obstruction
        • Canaliculitis
        • Dry Eye Syndrome
      • Keratitis
      • Chemical Exposure
    • Anterior Pole
      • Glaucoma
      • Hyphema
      • Iritis
      • Hypopyon
    • Posterior Pole
      • Optic Neuritis
      • Papilledema
      • Retinal Detachment
      • Retinal Artery Occlusion
      • Retinal Vein Occlusion
      • Vitreous Hemorrhage
    • Orbit
      • Orbital Cellulitis
      • Preseptal Cellulitis
      • Endophthalmitis
  • Nose
  • Oropharynx/Throat
    • Dentalgia
    • Diseases of the Oral Soft Tissue
      • Ludwig Angina
      • Stomatitis
      • Gingival/Periodontal Disorders
        • Acute Necrotizing Ulcerative Gingivitis (ANUG)
        • Gingivitis
        • Periodontitis
      • Odontogenic Infections
        • Periapical Abscess
        • Periodontal Abscess
        • Pericoronal Abscess (Pericoronitis)
    • Diseases of the Salivery Glands
      • Sialolithiasis
      • Suppurative Parotitis
    • Foreign Body
    • Larynx/Trachea
      • Epiglottitis
      • Laryngitis
      • Tracheitis
      • Tracheostomy Complications
    • Oral Candidiasis
    • Pharyngitis/Tonsillitis
    • Retropharyngeal Abscess
    • Temporomandibular Joint Disorders
      • Myofascial Pain Disorder
      • Disc Displacement
      • Temporomandibular Joint Dislocation

Epiglottitis

Rapid Review

  • Background
    • Progressive inflammation of the epiglottitis and surrounding supraglottic structures, potentially leading to airway compromise
    • Typically occurs due to Haemophilus influenzae type B infection in unvaccinated children.
  • Signs/Symptoms
    • Classically “3 D’s” (dysphagia, drooling, respiratory distress)
    • Other symptoms include fever, inspiratory stridor, cough
  • Diagnosis
    • Lateral neck X-ray (will show “thumbprint” sign, indicating enlarged epiglottis)
  • Treatment
    • Airway management (consider early intubation). Consult ENT
    • IV antibiotics (Ceftriaxone +/- MRSA coverage)
  • Disposition
    • All suspected or confirmed cases of epiglottitis should be admitted, typically to the ICU. Consult ENT early.

Pearls

  • Ideally, a definitive airway should be established in the OR. However, always be ready to perform a surgical airway in the ED if needed.
  • Racepmic epinephrine may be useful in adults, but is not recommended for pediatric patients as the increased agitation/anxiety may worsen airway obstruction.
Video Credit: Armando Hasudungan

Epistaxis

Rapid Review

  • Background
    • Nose bleeding; further divided into anterior epistaxis (most common) and posterior epistaxis (most serious). May cause life-threatening hemorrhage
    • Commonly caused by digital manipulation (nose-picking), dryness, cocaine, and hypertension.
  • Signs/Symptoms
    • Mild-severe bleeding, nasal obstruction, respiratory distress
    • Posterior bleeds are more likely to drain from both nares
  • Diagnosis
    • Clinical diagnosis
  • Treatment
    • Direct pressure, lean forward, topical decongestants (oxymetazoline, phenylephrine)
    • Severe bleeds may require cautery, nasal packing, or balloon tamponade
  • Disposition
    • Most patients can be discharged if bleeding is controlled. Patients with nasal packing will require an ENT follow-up in 2 days for removal
    • Admit any patients with uncontrolled bleeding or posterior packing (due to risk of cardiac arrhythmia and hypoxia)

Pearls

  • Consider the possibility of nasal foreign bodies for any unilateral bleeding in pediatric or psychiatric patients.
  • Although hypertension is a risk factor for epistaxis, acute blood pressure reduction in the ED with IV agents is not recommended.
Video Credit: EM:RAP

Peritonsillar Abscess

Rapid Review

  • Background
    • Peritonsillar abscess is the accumulation of a purulent fluid collection in the tonsillar pillar. Typically a complication of strep pharyngitis.
  • Signs/Symptoms
    • Painful swallowing, drooling, fever
    • “Hot potato voice”, (+) uvular deviation, (+) trismus. 
  • Diagnosis
    • Clinical diagnosis
    • Ultrasound can help identify depth of abscess/neck vasculature
  • Treatment
    • I&D or needle aspiration
    • Antibiotics (ex. amoxicillin, clindamycin)
  • Disposition
    • Most patients can be discharged home following abscess drainage
    • Admit any patient with sepsis, inadequate PO intake, or extension of infection beyond peritonsillar space. ICU is needed if any sign of airway compromise.

Pearls

  • Ultrasound can be useful for differentiating peritonsilar abscess from peritonsilar cellulitis. 
  • Use extreme caution during needle aspiration to avoid damaging the internal carotid artery. Safety measures can be taken by cutting the last 1.5 cm off the needle protector and replacing the protector over the needle prior to aspiration.
Video Credit: Larry Mellick

Strep Pharyngitis

Rapid Review

  • Background 
    • Infection and inflammation of the pharynx caused by group A streptococcus. 
    • Typically occurs in children 5-15 years of age
  • Signs/Symptoms
    • Fever, sore throat, cervical lymphadenopathy, absence of cough, tonsillar exudates
  • Diagnosis
    • Rapid strep test (if meet Centor criteria)
    • Gold standard is throat culture
  • Treatment
    • Antibiotics (penicillin, amoxicillin, azithromycin)
  • Disposition
    • Most patients can be discharged as long as there is adequate PO intake and no airway compromise.

Pearls

  • Be vigilant in looking for complications of strep pharyngitis, including lemierre disease, peritonsillar abscess, and retropharyngeal abscess.
  • A single dose of dexamethasone (Adults 10 mg, Pediatrics 0.6 mg/kg) in the ED can reduce the duration of symptoms and provide symptomatic relief. 
Video Credit: Armando Hasudungan

Otitis Media

Rapid Review

  • Background
    • Bacterial or viral infection of the middle ear, usually associated with an upper respiratory infection and/or eustachian tube dysfunction. If bacterial, S. pneumoniae is the most common cause.
    • Most common in children 6-36 months
  • Signs/Symptoms
    • Otalgia +/- systemic symptoms (N/V, diarrhea, fever)
    • Significant erythema and/or bulging of TM
  • Diagnosis
    • Clinical diagnosis based on otoscopy 
  • Treatment
    • Antibiotics (ex. amoxicillin)
    • Recurrent ear infections may require tympanostomy or tympanocentesis
  • Disposition
    • Most patients can be discharged with PCP follow-up
    • Admit patients with systemic illness or inadequate PO intake.

Pearls

  • Many patients with first-time infections will self-resolve and may not need antibiotics immediately.  It is reasonable to take a “WASP” (Wait and See Prescription) approach. 
  • Patients with recurrent infections, cochlear implants, recent hospitalization, or concurrent purulent conjunctivitis require amoxicillin-clavulanate.
Video Credit: JJ Medicine