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    Copyright:

    © All Rights Reserved
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    Download as pdf
    10 views7 pages

    First Call As An Otolaryngologist

    Uploaded by

    Bill
    First call as an otolaryngologist

    Copyright:

    © All Rights Reserved
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    Your First Call Night as an Otolaryngologist George Brinson, MD UNC OTO-HNS ‘Note: The statements that follow are not always based on the literature, but they have stood the test of time for me and many of my colleagues, Please use them as a guideline if you wish. Severe Acute Tonsilli An anonymous ENT once said “I’ve never had to admit a case of acute tonsilltis” People come tothe ER for tosilits when they cant drink. They are admitted tothe hospital because they can’t Arink. ‘The tonsils can become so enlarged tat they obstruct the airway, but this is exceedingly rare and is only really seen with MONO or malignaney. As you know, we see children with kissing tonsils inthe eini everyday. Therefore, the goal of therapy is symptom reduction to prevent hospitalization, You don't necessarily need t0 see these patients in the ER. Give the ER doc the following advice, and have them call you back ifthe patient is not improved enough to go home, You will rarely get a second cal How to treat: 2 liters TV fluids (invariably they are dehydrated) IV or po pain medicine (invariably they come to the ER because they hut) IV Steroids: Decadron 10 mg or Solumedrol 125mg IV Abx: Unasyn 3gm Ifmono suspected (avoid amp or amox) or pen allergic: Clindamycin 600 mg, Note: Use of antibiotics in acute tonsilltis is controversial. Antibiotics have been shown to reduce symptoms and. therefore should be used in severe cases to prevent admission (because inadequate po intake results in admission). ‘Some people would argue that you should only treat Strep positive cases to prevent sequelae of strep infection, (i. ‘heumatic fever.). Sanford recommends Penicillin as frst line. You make your own decisions. Complete discussion found in Pocket Guide to Antimicrobial Therapy in OTO/H&NS DIC on oral abx and pain meds both in liquid form with close flu. Ifreliable, OK to make appt in 2 weeks, with ‘caveat that they call or return if not improved. If mono is suspected, get a CBC with diff to look for >50% monos. Menospot is based on the presence of antibodies that don’t usually appear until at least two weeks after onset of illness. 50% are positive at 2 weeks, 90% at weeks, Order EBV titers if you're real suspicious for Mono. Not sure when these show up. Peritonsillar Celluliti ‘This is presumably the precursor to peritonsillar abscess and can mimic PTA clinically. Presents usually with unilateral pain and peritonsillar erythema, but no pus, and overall ess severe than PTA. Treat the same as Acute severe tonsllitis, but I would advise using broad spectrum or “stronger” abx like Unasyn or clinda unless you want this to develop into a PTA, PTA ‘Atleast 75% of the time (maybe more) that you get called fora PTA, the patient will not have a PTA. Almost invariably, patients with PTA have trismus, drooling (although if they are tough, they may beable to handle seretions) inability to take po, hot potato voice, and submandibular tendemess (Iympadenopathy). You can usually tell from across the room if they have a PTA. these folks look sik The intreoral exam is not subtle. Large erythematous bulge in pertonslla space with uvula deviation. Run your finger along the cheek over the RMT repion and palpate the tonsil and peritonsillar space. This helps you tell a tinfateraly enlarged toni from a PTA. You may fel futuance, bu Ifyou have pus under pressure, it may just feel firm, ‘The key is that this swelling is separate from the tonsil itself. ‘Treat with 18D: ‘When first called, ask the nurse or ER doc to start the appropriate meds: ‘Abx: Unasyn or Clinda Steroids TV fluids If these people don’t have a PTA, this alone will make them better, if they have pus, they will likely still be pretty miserable. Getting the meds in early helps withthe trismus, which makes the drainage easier. ng thing you do all Mainstay of treatment is 1&D to provide prompt relief (and it does, this will be the most gr day) and prevent extension of the abscess, ultimately towards the chest. ‘Things vou need: Hurricane spray Scalpel #15 or #11 Tonsil clamp or curved hemostat Lido with Epi 1/100,000 3 ce syringe with 1.5 inch 25 gauge needle for injection 10 ce syringe for aspiration 19 gauge needle for aspiration and to draw up local tongue blade or sweetheart retractor suction setup with Yankauer headlight and lightsource facemask with shield or other eye protection ‘Technique: Have patient spray self with hurricane immediately. You may administer 1V pain meds, but you need them awake and cooperative. Drape patient to prevent soiling clothes. Allow patient to control suction. This frees your hands and keeps them from aspirating and swallowing pus and blood, Anesthetize over anterior tonsil pillar, ‘op to bottom, and deep...aspirate prior to injecting. Do not inject carotid artery. Use syringe with 19 guage needle {or aspiration to localize pus (optional step). Incise MUCOSA ONLY with scalpel. Spread with clamp in peritonsillar space, (not into tonsil itself). Open widely from superior to inferior and as posterior as you can. Expect ‘some bleeding, it will usually stop. Suction pus and into cavity itself. Don’t bother culturing pus, usually will grow ‘multiple organisms, S. Pyogenes, or no growth. DIC home when taking po with abx and pain meds. F/U in 1-3 days. “There are some people who think that a needle aspiration is adequate to treat a PTA. This was studied and showed that 90% of people showed resolution after 2 repeat aspirations (the second was sometimes needed for reacculmulation of pus ata clinic visit). The other 10% eventually needed to be opened. If you think this is acceptable and if you think that a needle aspiration is acceptable treatment for any abscess, go ahead, but you will certainly be in the minority, and I hope none of your patients develop mediastinitis. Note: If the patient presents with symptoms similar to any ofthe above illnesses (mainly odynophagia), and ‘examination oftheir pharynx is unimpressive, scope them to r/o causes you can’t see. Also if you are at all ‘concerned about the airway, scope ‘em. This is a common call from the peds ED, and the difference isnot subtle. The main question is: Are they more tender on the tragus or the mastoid, It would be very unusual to have an otitis externa and mastoidits. Acute rmastoiditis is very, very rare. Patients with mastoidits are pretty sick, patients with otitis extema are miserable, but not sick. Otitis externa has circumferential canal wall swelling and erythema, sometimes extending to the auricle . and onto the face. Mastoiditis can have posterior canal wall erythema and edema, but most notably should have ‘tendemess over the mastoid and a concurrent otitis media, elevated WBC, fever, etc. Detailed description found in texts Angioedema Most often from ACE inhibitors. ‘This can occur at any time the patient is taking the ACEI, because it isnot an allergy to the ACEI. The pathophysiology is complex, but basicaly, by taking an ACEI, your body loses its ability to keep an allergic reaction in check (something about bradykinin, I'm sure nitric oxide is involved). Therefore the inciting agent is some allergen that may normally produce a mild, even asymptomatic reaction, but because the person is taking an ACEI, the reaction is severe Ruz Assure airway stability by examining the airway with a scope. ‘Administer steroids, H1 blockers (benadryl), and H2 blockers (axid). Epi if severe or progressing, Humidified Oxygen Elevate head of bed Usually resolves quickly in ER, but requires admission to ICU if there is a question of airway stability. Itis debated which medicine, really makes this better. Who cares, the medicines are all pretty innocuous and this is nota time to hold back, Severe cases have resulted in intubation and emergent trach or cricothyrodomy. Lacerations ‘You are on call for complicated lacs and if'a patient requests plastic surgeon. All lacs not involving the lip and vvermillion border, nose, eyelid, and ear can (and should) be closed by ER docs. In general: ‘Anesthetize with Lidocaine with Epi (for hemostasis to prevent the sitch-dab-stitch-dab phenomenon) some textbooks say avoid Epi with ears and noses, but we do it ll the time. Just be aware that the risk of ischemia may exist. Irrigate thoroughly with normal saline Remove any foreign bodies, including tatooing (may require OR) ‘Approximate like with like, put everything back together like a puzzle, take tension off skin Deep tissues (approximate muscle to retain form and function) “use PDS or Vieryl 3/0 on sealp and other tension areas (rarely on face itself) suse 4/0 and 5/0 otherwise Skit use 610 Ethilon or Prolene on face 5/0 prolene in areas of more tension (neck or scalp) “use 5/0 oF 6/0 mild chromic or fast absorbing gut if you don’t want to have to remove them: kids that won't tolerate removal in clinic -around the eye “delicate skin flaps you don’t want to disrupt when removing suture -use fine silk if suture tags willbe irtating comea ‘Mucosa: use chromic gut or viery! 3/0 to 5/0 -vieryl takes longer to absorb, but isa litle softer Spx considerations: Scalp Lacs always close the galea with 3/0 vieryl some people think staples are acceptable behind the hairline, and they are usually adequate. However, remember that hairlines recede over time and hair gets thinner, scars jast forever. Some men wear their haar very short and widened scars are easily visible Shaving a small amount of hair around the lac makes the wound much easier to close and makes sutures ‘much easier to remove. Hair grows back. As an alternative, Vaseline or bacitracin ointment can be used to slick the bair off to the side. Lip Ines -always approximate the vermillion border precisely (should usually be 1* stitch) Close through and through lacs in 3 layers- mucosa, muscle, and skin -always approximate the orbiculars oris to prevent notching leave stitches in for 7-10 days because this area is under tension Eyelid lacs use tetracaine to anesthetize the comea -Isnasolacrimal duct involved? Call upper level may require OR for good closure usually OK to close skin and not orbicularis, since this is usually one thin layer -Teapproximate tarsal plate, levator/septum complex. Ear lacs cover all cartilage -reapproximate cartilage with viryl or PDS if i isnot held together well with skin sutures -the ear is amazingly resilient even totally avulsed segments will often live -stick a small trimmed meroce! in the EAC to prevent stenosis if required -ABX drops for EAC lacs -fashion bolster if'skin significantly raised off cartilage Bites -Abx of choice: Augmentin alone or clinda with flouroquinolone if Pen allergic -bites on ear may require TV abx Abx -for skin, Keflex -anything with an intraoral component probably needs augmentin or clinda for anaerobic coverage opinions on this vary, but wound infections on the face are unsightly antibiotic ointment, clean wound with peroxide, avoid sunlight, bid massage of scar after 3 weeks to soften Facial nerve -Isit intact? Classical teaching mandates immediate repair if lateral to line from lateral canthus to oral Parotid Duet explore wound to see if intact, repair over stent Foreign Bor Ears: can wait until moming if convenient for you, viscous lidocaine will kill bugs Nose: should probably be done that night to avoid aspiration -tell them to give Otrivin or similar decongesant on the phone, with lidocaine if possible (you probably should bring this yourself) useful tools for ears and noses: alligator forceps (various sizes, otoscope with operating head, wax currte, suction) Airway and esophageal FB: obviously call the senior resident tell ER to make patient NPO Lchoked on a fishbone (substitute porkchop bone, etc.) and its still there”: Needs to be evaluated that: retained fishbones can cause life threatening complications -intraoral exam and flexible fiberoptic exam -plain films see fishbones less than 50% of time -CT scan is elose to 100% to ro fishbone (but rarely indicated) -ifscope is normal and patient improving send home with close fu -if scope shows abrasion and no FB, send home -if scope shows edema and erythema in an area that you can’t see thoroughly, a FB could be hiding History is very helpful: Ifthe patient is getting beter and taking some po, then there is probably no FB, if they are not geting beter overtime and certainly if they are getting worse, this probably needs eval in OR Mandible Abx (Unasyn or Clinda), panorex (or facial CT), have ER call you when its done, NPO “we typically admit these folks with IV Abx and repair ASAP, sometimes that night, bt not typically Orbital floor ~Optho eval (ER doc can make that call) ‘entrapped or change in visual acuity, you should see that night, otherwise, ' in einie in 2-3 days ~antibiotes to cover sinus bugs for prophylaxis (amoxicillin) no nose blowing Midface fractures and nasal fractures fi in clinic when swelling has subsided (3-5 days) -abx if blood in sinus -Is there a septal hematoma? (probably not) Frontal sinus anterior table can flu in elinie, repair for cosmetic deformity “posterior table, probably need to evaluate in ER, r/o pneumocephalus or other intracranial pathology, will need obliteration or close fu to prevent mucocele Temporal Bone -Is facial nerve intact? “CSF leak? audiogram when stable Bell’s Palsy Prednisone | mg/kg tapered over 2-3 weeks, 7day course antiherpetic meds (Acyclovir, Famvir)=> use dose for Zoster -lacrilube, artificial tear, tape eye shut at night if won't close “fi in clinic one week or sooner has ER ruled out other causes of facial paralysis? Sudden Sensorineural hearing Loss “Steroid taper (1 mg/kg tapered over 2-3 weeks) Acyclovir (controversial) “audiogram after taper or in AM-should be able to diagnose this by Px Exam with tuning fork, therefore, should be able to start steroid taper that night or weekend ‘Traumatic TM perfs drops if filled with pond water or dirty or real bloody “fu one month Otitis externa drops and oral abx (cipro-but notin kids) if diabetic or evidence of cell debridement every I-2 days in ENT clinic -wick if EAC occluded by swelling can usually wait until morning to be seen by ENT Epistaxis ‘You will lear to hate it if you don't already. Develop a systematic approach that you are comfortable with and ‘most will be routine, When called: Isthe patient currently hypertensive? If so, normalize the BP, this makes a big difference a y Isthe patient coagulopathic? CBC and PT, PTT shouldbe obtained on all but the most minor nosebleeds epistaxis is often a presenting sign of coagulopathy “These may stop the bleeding or allow time forthe bleeding to stop on its own: Tee pack and pressre to nose, otrivn or other decongestant. Most nosebleeds aris fom the anterior septum, and direct Pressure can ‘easily be applied, Have the patient lean slightly forward so they can spit the blood out or let it run out the nose. Examine patient: Is airway stable? Is patient hemodynamically stable? Localize site of bleeding if possible wth anterior rhinoscopy and nasal endoscopy if needed. This isnot always possible, particularly in profuse bleeding, but is immensely helpful in developing plan. . Ifsiteis identified attempt cauterization with silver nitrate or electrocautery. Use electrocautery cautiously on the septum and avoid bilateral cauterization to prevent septal perforations. You can blaze through the septum very easily with electrocautery, If bleeding does not stop with the above measures, then some form of packing is probably necessary. ‘There are two major categories of nasal packs: absorbable and nonabsorbable Absorbable packs: Gelfoam, Avitene, surgicel, flowseal, etc “Useful in patients with coagulapathies because you don’t have to remove because they cannot be secured. these probably don’t stop bleeding as well as nonabsorbable packs that actually apply pressure, but this is debatable since every nosebleed is different -can be used in conjunction with nonabsorbable packs them, There isa risk of aspiration Nonabsorbable packs: Merocels, thinorocket,fingercots, gauze, foley catheters ‘The classical steps in packing the nose are as follows: 1. Metocel or absorbable anterior packs 2. If bleeding persists pack the anterior nose with a formal gauze pack vthis step is often skipped, since usually the bleeding is coming from behind the pack rather than from the anterior nose, and a posterior bleed may be suspected 3, Ifbleeding persists posteriorly, remove anterior pack and place a 14 gauge Foley catheter (any gauge nt the smaller tubing allows more room to place an anterior pack). Most balloons are rated for S ce, Ifyou can find one with a bigger balloon, you may want to use it, but you won't be able to find one. A See balloon will hold more saline and most people will put up to 10 cc in the balloon. But beware, these balloons will burst ifunder too much pressure. It is acceptable to place unilateral packs, either anterior or posterior, but often bilateral packs are necessary, particularly posteriorly to occlude the choana Foley will work, b Special considerations with posterior packs: Mere exists (although some would question its existence) a phenomenon called something like the naso-respiratory reflex, where people ean become apneic when the nasopharynx is stimulated. Therefore anyone with a posterior pack should be on continuous pulse ox and a cardiac monitor. Consider ICU for closer airway monitoring Posterior packs are very uncomfortable when done correctly, These people should be on strong pain meds (usually MSO4) and probably benzos, but watch for respiratory depression, “You can also fashion posterior packs out of gauze and suture- refer to outdated textbooks for diagrams ‘While packs are in place: -all patients with nasal packing should have the packing secured in some fashion (not possible with absorbable. ‘This can be done either by taping merocels tothe face with steristrips, tying merocels across the columella (not too tight! Very loose), or tying a folded 4x4 gauze to the merocel that will prevent posterior displacement (not ‘commonly done, but acceptable), Foley catheters should be secured with umbilical cord clamps or hemostas if a clamp is not readily available.

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