HEENT Review

1
HEENT Review

• October 1, 2008
• Nick Genes

2
the inservice exam

• Feb 25, 2009
• Short term ? (moonlighting, Mets)
• Long term ? (licensure, career in EM)
• But also intro to EM practice
• Similar questions to ABEM
• Last year 207 questions counted
• Physicians Evaluation and Educational Review VII
• Las Vegas Board Review Course MP3s (2003?)

3
This lecture series

• Board review Five months, 20 lectures
• Different than Dr. Cherkas sessions
• This year
• More engagement than 2005-6
• More questions, buzzwords than last year
• More repetition
• More candy

4
HEENT

• 21 questions in PEER VII (out of 410, 5)
• Some overlap in ID, Trauma, Procedures, SS
• Last years inservice it was 10 out of 207
• CV, GI, Pulm, Trauma each 20
• Likely emphasis details that make or break ED
  diagnosis or management

5
HEENT

• Today H and T, then N, then E, then E.
• No evidence, no nuance.
• I would love to spend 20 minutes talking about
  preseptal cellulitis vs. orbital cellulitis
• Sorry

6
Question 1
A 32-year-old man presents 30 minutes after
getting a tooth knocked out in a fight. On
examination, a small clot in the socket is noted.
The next step in management is

• Call the patients dentist
• Theyre too slow
• Clean the tooth with a brush
• No brush! Worry about the dental ligament
• Gently irrigate the socket
• To remove the clot to let the tooth reconnect
• Immediately replace the tooth
• Sure after clot removed
• Tell the patient the tooth cannot be
  reimplanted
• Not true

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Tooth Avulsion

• Tooth completely removed from the socket
• Permanent teeth avulsed for less than 3 hours can
  be reimplanted
• Rinse tooth with Hanks solution, sterile saline,
  or milk
• Irrigate socket with sterile NS prior to
  reimplantation
• Emergent Dental Consult
• Do NOT scrub tooth

8
Tooth Avulsion

• What if the tooth is missing?
• You need films to rule out aspiration
• What if this is a four year old?
• Primary teeth in children should not be replaced

9
Tooth Avulsion

• Replant permanent teeth quickly
• 1 loss of survival per minute
• Early, improper reimplantation is better than
  waiting for OMFS
• Rinse first, no scrubbing (injures periodontal
  ligament). Handle only the crown
• Transport / storage media saliva, sterile
  saline, or milk. Hanks solution is best
• Only permanent teeth need replantaion
• reimplantation of baby teeth can result in bone
  fusion and prevent permanent teeth eruption

10
Tooth Fractures

• Ellis II and III fractures require covering of
  exposed dentin or pulp and lt24h referral to a
  dentist
• if you see pink, send em
• May refer Ellis I for cosmesis

Ellis I Ellis II Ellis III horizontal fx
enamel dentin pulp
11
Alveolar Osteitis (dry socket)

• 2-5 days post-extraction
• The clot got lost, bugs got in
• Severe pain due to exposed alveolar bone and a
  localized osteomyelitis as the result of
  protective clot displacement
• Risk factors
• Females on HRT, pre-existing gum and tooth
  infections, traumatic extraction, impacted third
  molar extractions (20-35)
• Treatment
• Anesthetize, irrigate socket, pack with iodoform
  gauze eugenol, Antibiotics, early referral

12
Dental Abscesses

• I dont think theres testable material here no
  game-changing tricks in management

Periapical Abscess
13
Question 2
A 25-year-old man presents with mouth pain and
bleeding gums. He does not recall any medical
problems but says he is homeless. He is afebrile
without systemic symptoms. Which of the following
is an ineffective component of treatment?

• Acyclovir
• Because this isnt massive herpes outbreak, no
  vesicles
• Chlorhexidine oral rinses
• Debridement
• Diet rich in proteins and vitamins
• Metronidazole

14
Q2 -- Trench Mouth (ANUG)

• Diagnosis is based on three symptoms/signs
• Pain
• ulcerations between teeth
• gingival bleeding
• Also smell, loose teeth, fever.
• Poor hygiene, HIV.
• Anaerobes.

• Treat with chlorhexidine oral rinses,
  metronidazole.
• Debridement may be necessary
• Diet rich in proteins and vitamins will prevent

15
Question 3
A 50-year-old man presents with fever and pain on
swallowing. Examination reveals a nontoxic man
with neck swelling, tongue elevation, and
trismus. The most likely diagnosis is

• Epiglottitis
• 2-3d of throat pain, fever, cant see it
• Exudative pharyngitis
• can see it, also cervical LA
• Ludwig angina
• bilateral tongue base infection, swelling deadly
• Peritonsillar abscess
• assymmetry, hot potato voice
• Pharyngeal tumor
• no fever

PEER VII Q223
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Q3 -- Ludwigs Angina

• Bilateral cellulitis of the submandibular space
• Painful edema of submandibular area
• Involves connective tissue, fascia and muscle
• Dental source most common (abscess, trauma,
  recent extraction). Mixed aerobic / anaerobic
• Contrast CT is diagnostic, aids surgical mgmt
• Can progress to restricted neck motion, trismus,
  dysphonia, posterior tongue displacement, airway
  compromise (drooling, stridor suggest doom)
• May need fiberoptic for airway control
• If that fails, cricothyroidotomy

18
Ludwig Angina
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Epiglottitis

• Now more common in adults than children
• Severe sore throat with normal oropharynx exam
• Pain on moving thyroid cartilage, out of
  proportion
• X-ray thumb shaped epiglottis
• Stridor / airway obstruction / rapid onset /
  leaning forward / drooling.
• Notify ENT, anesthesia, operating room early
• Safest in OR fiberoptic examination, intubation
  or tracheostomy
• Admit (ie, dont send them home)
• Cefuroxime or Unasyn
• Humidified oxygen, airway control / cric tray

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Peritonsillar Abscess

• Clinical Features
• Fever, malaise, sore throat
• Odynophagia, Dysphagia
• Hot potato voice
• Trismus
• Can spread, compromise airway
• Most common deep neck infection
• Rare in children under 12y
• Usually Strep
• 3-33 recur

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Peritonsillar Abscess

• Clinical Features
• Fever, malaise, sore throat
• Odynophagia, Dysphagia
• Hot potato voice
• Trismus
• Can spread, compromise airway
• ED Care
• Aspiration with 18- or 20- gauge
• Diagnostic and Therapeutic
• Try to avoid puncturing Internal Carotid Artery
  located 2.5cm behind and lateral to the tonsil
• Antibiotic therapy with Penicillin

24
Retropharyngeal Abscess

• Young children suppurative lymph node (primary
  infection elsewhere)
• Adults direct extension of infection, extension
  to mediastinum more likely
• Fever / neck pain / difficulty talking,
  swallowing and breathing / torticollis
• Cri du canard duck-like voice
• Intraoral exam shows anterior displacement of the
  posterior pharyngeal wall
• IV Abx (Clinda or Unasyn), surgical drainage

25
Retropharyngeal Abscess
X-ray may show soft tissue displacement
anterior to vertebral bodies However,
expiration and neck flexion may
give false-positive X-ray findings CT is the
gold standard
26
Other Pharyngeal / Laryngeal / Tracheal
Infections

• Pharyngitis?
• Croup?
• Diphtheria?
• Tracheitis?

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Question 4
Which of the following conditions is an unlikely
complication of sinusitis?

• Cavernous sinus thrombosis
• extension from paranasal sinus
• Dental abscess
• Periorbital cellulitis
• extension from ethmoid sinusitis
• Potts puffy tumor
• extension from forehead anteriorly ? doughy,
  edematous
• Subdural empyema
• extension from forehead posteriorly ? empyema or
  meningitis or brain abscess

PEER VII Q76
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Q 4 Answer
Bacterial sinusitis more than 7-10 days, fever,
hyposmia, unilateral, pus, tender. If it
persists, it can extend to Potts puffy tumor,
cavernous sinus, or brain

• What to do?
• Nasal Decongestant Sprays
• Antibiotics (14-21 day regimens)
• Levaquin, Augmentin, Bactrim
• For complications CT or MRI, IV Abx, surgery
  eval, admit.

PEER VII Q76
32
Cavernous Sinus Thrombosis

• Complications of facial infections with extension
• Veins of face, oral cavity, middle ear, and
  mastoid drain to cavernous sinus
• dental extraction / sinusitis / periorbital
  cellulitis / furuncle
• high fever, toxic appearance
• eyelid edema / proptosis / conjunctival edema
  (chemosis), facial edema
• III and VI nerve palsies and possibly
  contralateral facial nerve deficit
• Pupillary dysfunction
• MRI, dynamic CT

Head/neck infection venous obstruction
cranial nerve dysfunction
33
Question 5
A 57-year-old man is transferred form a skilled
nursing facility because his tracheostomy tube
cuff is not inflating. The tracheostomy was done
5 days earlier for repeated pneumonia and is
still in place. The patient has no active
bleeding and is in no distress. The most likely
complication of replacing the tube is

• Air Trapping
• only if theyre really laboring and you leave in
  the obturator
• Creating a false passage
• still immature
• Significant bleeding
• not unless eroding through to vessel
• Tracheostomy site closing
• If its out for several hours, its a possibility
• Tube directed upwards
• bad idea to let this happen

34
Tracheostomy

• Within the first 7 days post-op, the opening is
  not mature, and manipulating the tube can lead to
  false passage in the soft tissues of the neck.
• Necessary to have ENT change tube within 7 days
  post-op
• If tube is out for several hours, there is a risk
  of a closed stoma and dilation may be required.

35
Tracheostomy

• If no distress, use an obturator to solidify the
  tube for maneuvering (this increases air
  trapping)
• Remember push the tube downward (caudad).

36
Question 6
The most common unilateral neck mass in an adult
is

1. Lymphoma
2. Mononucleosis
3. Parotiditis
4. Squamous cell carcinoma
5. Thyroid disorder

37
Question 6 Neck Mass Trivia

• Young kids neck masses usually benign
• thyroglossal cyst, branchial cleft cyst,
  hemangiomas, reactive lymphadenopathy.
• Young adults most neck masses are
• from infection (Mono) or neoplasm (Hodgkin,
  lymphoma)
• In adults 75 of neck masses are neoplastic.
• 1 is Squamous Ca of upper airway/GI with
  cervical node mets.
• Smoking, drinking is a risk.

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Question 7
A 24-year old woman presents with diffuse tongue
swelling that began just prior to arrival. Shes
had two prior episodes in the past and her mother
has similar problems. She has not eaten any new
foods, denies new toiletries, clothing, and meds.
Which of the following medications would be most
efficacious to treat this condition?

• Cetirizine
• for IgE-mediated allergic reactions
• Diphenhydramine
• for IgE-mediated allergic reactions
• Epinephrine
• Methylprednisolone
• will take hours to work
• Solumedrol
• Really, the question was worded like this.

39
Question 7 Hereditary Angioedema

• from C1 esterase defect. Autosomal dominant,
  usual onset in teens.
• Attacks last 2-3 days, may be brought on by
  airway / GI trauma
• Swelling is nondemarcated, nonpruritic.
• More common in African-Americans.
• aminocaproic acid? FFP?
• ACE-mediated angioedema often starts within a
  week, but can come at any time. You never take it
  again.
• Something about bradykinins
• Treat ACE-mediated angioedema like an allergy

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Question 8
A 2-year-old boy presents with a 2-week history
of purulent discharge from the right nostril that
has not responded to a 7-day course of
amoxicillin. At this point which of the
following management plans is most appropriate?

• Change the antibiotic to amoxicillin-clavulanic
  acid
• no effect if FB
• Continue amoxicillin for at least 2 more weeks
• come on
• Examine the nose, looking for a foreign body
• Unilateral purulent discharge is FB until proven
  otherwise.
• Order plain radiographs of the sinuses
• no value for FB, may confuse issue with sinus
  opacity
• Start a course of an oral nonsedating
  antihistamine
• no effect if FB

PEER VII Q301
42
Nasal Foreign Body

• Unilateral purulent nasal discharge in a
  preschool-aged child is considered a foreign body
  until proven otherwise
• Plain radiographs unlikely to be of value
• Tools for removal include forceps, suction
  catheters, hooked probes, balloon-tipped catheter

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Question 9
A 67-year old woman is brought to the ED from her
skilled nursing facility for evaluation of fever
and right-sided neck swelling. CT scan of the
neck shows inflammatory changes in the right
parotid consistent with parotitis. Which of the
following antibiotic is most appropriate?

1. Amoxicillin-clavulanate
2. Ampicillin-sulbactam
3. Cephalexin and metronidazole
4. Clindamycin
5. Vancomycin and metronidazole

44
Question 9 Suppurative Parotitis
A 67-year old woman is brought to the ED from her
skilled nursing facility for evaluation of fever
and right-sided neck swelling. CT scan of the
neck shows inflammatory changes in the right
parotid consistent with parotitis. Which of the
following antibiotic is most appropriate?

• Vancomycin and metronidazole

• SP caused by retrograde movement of oral flora
  into salivary gland.
• Usually staph or strep, but also see anaerobes.
• Risk group Chronically ill, dry mouth, post-op
  or sialoliths
• If stable, taking PO, can manage as outpatient
  on augmentin
• In a nursing home patient, must cover HA-MRSA.

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Question 10
For the repair of a complex ear laceration, which
of the following nerve blocks is most likely to
provide anesthesia?

• Auriculotemporal
• branch of the mandibular nerve. Inject anterior
  and posterior to tragus.
• Inferior Alveolar
• mandibular teeth, lip, chin. May hit VII,
  paralyze
• Infraorbital
• cheek, nose, upper lip. May hit eye.
• Mental
• lower lip
• Supraorbital
• forehead

47
Question 11
A 20 year old woman presents with a painful right
ear. She has no history of ear problems but
swims several times a week. Examination reveals
erythema of the external auditory canal with some
purulent discharge and a perforation in the
tympanic membrane. The treatment option most
likely to damage her ear is

• Ciprofloxacin otic and hydrocortisone otic
  suspension
• Suspension penetrates less than solution, no acid
• Hydrocortisone and acetic acid otic solution
• At pH 3.0, can destroy your middle ear
  structures, nerves
• Neomycin/polymyxn/hydrocortisone otic
  suspension
• neomycin has theoretical ototoxic risk
• Ofloxacin otic solution
• this is the only FDA-approved treatment for OE
  with perf
• Penicillinase-resistant penicillin
• ?

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Otitis Externa
49
Otitis Externa

• Inflammatory process involving the auricle,
  external auditory canal, and surface of the TM
• Pain on movement of auricle, purulent drainage
• Caused by gram-negative organisms, Staph aureus,
  Pseudonomas, or fungi
• Peak age 9 -19 years
• Erythema, edema of EAC, white exudates on EAC and
  TM
• Pain with motion of tragus or auricle

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Otitis Externa (continued)

• Treatment
• Fluoroquinolone otic drops
• Oral antibiotics if auricular cellulitis is
  present or TM is perforated (Quinolones,
  Cephalosporins, or penicillinase-resistant pcn)
• Hydrocortisone and acetic acid otic solution have
  a pH 3.0 which can be toxic to the middle ear in
  perforations

51
TM Perforation Causes

• Otic Barotrauma
• Unequal pressures on either side of the TM
• Blocked eustachian tubes (or external canal)
• Increased altitude gas expands in middle ear
• Diving injury increased external pressure on TM
• Trauma (slap/blunt, penetrating, acoustic)
• Noise (blast injury) / lightning injury
• Infection otitis externa, otitis media,
  myringitis
• Decreased hearing (conductive loss), pain,
  bleeding

52
TM perforations involving the Pars Tensa
53
TM Perforation

• Generally involves pars tensa (largest area),
  usually anteriorly or inferiorly
• 90 heal spontaneously
• Early referral (lt24hrs) for penetrating trauma or
  posterior perforation (higher risk of ossicle
  damage)
• Later referral is OK for blunt trauma /
  barotrauma
• Avoid water in ear
• Antibiotics (topical or systemic) only for
• obvious infection or forceful water entry (water
  skiing)

54
Otitis Media

• Infants and Young Children (peaks at 6 to 18
  months)
• 1/3 are viral
• Strep pneumoniae most prevalent bacterial cause,
  also H. flu, M. catarrhalis
• Signs include dull, bulging, immobile TM
• Light reflex is of no diagnostic value
• Serous Otitis media OM with effusion
• painless, fluid behind TM, decreased hearing
• affects learning / speech (refer, abx for 3wks)
• Treatment
• Amoxicillin 80 mg/kg/day PO divided q8 q12 for
  10 days (High-dose amox therapy)

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Otitis Media
57
Acute Otitis Media

• Bulging TM
• Loss of Light Reflex
• Retraction
• Decreased movement on insufflation

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Question 12
A 75-year-old man presents with fever and ear
pain. He has had the earache for several weeks
and has been treating it at home with warm
mineral oil. On further questioning, he says he
is diabetic and that his sugars are running
higher than normal. Examination is normal except
for the ear, which has granulation tissue on the
floor of the external auditory canal. The most
likely pathogen causing this infection is

1. Aspergillus sp.
2. Candida sp.
3. Pseudomonas aeruginosa
4. Staphylococcus epidermidis
5. Streptococcus pneumoniae

PEER VII Q231
59
Malignant Otitis Externa

• Seen in the elderly, diabetic, and
  immunocompromised patient
• Failing 2-3 weeks of antibiotic therapy
• Progresses from OE to chondritis to skull
  osteomyelitis potentially lethal
• Most Common Organism Pseudomonas aeruginosa
• Physical Exam Findings
• Otalgia, Otorrhea
• Granulation tissue on floor of EAC
• Treatment
• Radiology for staging
• Admission
• Parenteral antibiotics
• Possible surgical debridement

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Question 13
A 17-year-old girl presents with a painful right
ear. She has had the pain for 2 weeks but has
not had time to see her family doctor. She is
worried because her boyfriend said her ear was
red and looked funny. On examination, the ear
appears as in the picture, and a posterior
auricular crease is not noted. The best
treatment option is
PEER VII Q241
61
Question 13

1. Administer oral antibiotics and discharge
2. Administer topical antibiotics and discharge
3. Admit for treatment with parenteral antibiotics
4. Perform typanocentesis and discharge
5. Refer to an ENT for follow up care

Mastoiditis is the most serious complication of
OM. Mastoid air cells are blocked, inflammed,
spreads to periosteum. Image with CT, treat
with IV Abx like cefuroxime
PEER VII Q241
62
Mastoiditis

• Infection spreads from the middle ear (otitis
  media) to the mastoid air cells
• Clinical Presentation
• Otalgia
• Fever
• Postauricular erythema, swelling
• tenderness
• Protrusion of the auricle
• Obliteration of the postauricular crease
• Imagining
• CT Scan assess extent
• Treatment
• Emergent ENT Consultation
• IV Cefuroxime, Admission
• Possible surgical drainage

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Question 14
A 20 year old man presents with left eye
irritation. He was walking in a park and
accidentally ran into a tree branch. He believes
the branch scratched his eye. Examination
reveals a corneal abrasion. The best treatment
option is

1. Erythromycin ophthalmic ointment, no patch
2. Erythromycin ophthalmic ointment, patch
3. Homatropine, no patch
4. Homatropine, patch
5. Topical anesthetic

? Dont prescribe topical anesthetics
Patching may help with pain but is
contraindicated in contact lenses and organic
injuries (tree branch). Homatropine relieves
ciliary spasm, thought to help with pain.
PEER VII Q 160
65
Corneal Abrasions
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Corneal Abrasions

• Very Painful
• Fluorescein reveals dye update at abrasion site
• Treatment
• Topical Erythromycin, Tobramycin, or
  Bacitracin/Polymyxin
• Tetanus updated
• Patching does not facilitate abrasion healing
• Topical anesthetics strictly contraindicated
• Cause corneal breakdown and ulceration
• Cycloplegic agents (homatropine) not recommended
• Recent studies show no benefit (Carley and Carley
  2001)

67
Keratitis Severe Keratitis

• Sxs Pain, redness, decreased
• acuity, FB sensation
• PE perilimbal flush
• Causes Staph, HSV, Zoster, Sjogrens, exposure,
  drugs
• Keratitis can disrupt the epithelial layers
  making the cornea more susceptible to serious
  infection

Sxs Painful, usually causes iritis, decreased
acuity PE May see Hypopyon (pus in anterior
chamber) Causes central ulcer GC,
peripheral Stph Rx Gram stain / culture,
cycloplegics, immediate topical and IV abx
(genta, tobra, quinolone), urgent consult
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Viral Keratitis - Herpes Simplex (HSV)

• Dendritic branching pattern
• Decreased corneal sensation
• Rx Antivirals, cycloplegics,
• Ophtho consult
• NO STEROIDS
• May be recurrent

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Herpes Zoster Opthalmicus

• Shingles in trigeminal distribution, commonly
  with lid lesions
• Hutchinsons sign zoster at tip of nose,
  increased incidence of ocular zoster
• Rx Acyclovir IV, cyclopelgic, erythromycin,
  ophtho consult
• Steroids if iritis is present (without corneal
  defect)

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Subconjunctival Hemorrhage

• Asymptomatic
• Cause Spontaneous or Traumatic
• Rx none
• Consider Ruptured Globe if
• Associated with trauma
• Circumferential, dense, elevated
• Lateral (then r/o zygoma fracture)

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Corneal Laceration

• Teardrop shape of Iris
• Flat Anterior Chamber
• Black iris pigment may be at the wound edge
• Seidel Test Fluorescein on cornea is washed
  away by leaking aqueous humor corneal
  perforation
• Tonometry is Contraindicated
• Rx Urgent Ophtho Referral

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Once again Corneal Abrasion

• SxsPain, photophobia, FB sensation, injection
• PE r/o retained FB under lids
• Cause Trauma, consider intraocular FB for high
  pressure injury
• Rx Abx Ointment, remove imbedded FBs
• Remove Rust Rings? Not urgent
• Contact lens wearers
• anti-pseudomonal ointment (cipro)

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Question 15
A 55-year-old woman presents complaining of loss
of vision in her right eye that occurred suddenly
and without pain. Examination reveals a pale,
edematous retina with a visible red macula. The
most likely cause of this condition is

• Bells Palsy
• Lid, dryness may affect vision, not eye problem
  in itself
• Cataract
• come on
• Embolus
• classic description pale, edematous, cherry red
  spot
• Glaucoma
• slower, IOP causes nerve damage
• Optic Neuritis
• painful, swollen disc but normal retina

PEER VII Q145
74
Central Retinal Artery Occlusion

• Causes
• Embolus, thrombosis, arteritis
• Sickle Cell Disease
• Trauma
• Clinical Findings
• Painless
• Complete or near-complete vision loss
• Afferent pupillary defect present
• Pale fundus on funduscopy examination
• Cherry-red macula

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CRAO Treatment

• True Ocular Emergency. 90-minute window to
  restore vision
• Goal is to lower IOP to allow emboli to move to
  periphery.
• Gentle globe massage
• Rebreathing into bag -- increase pCO2 to decrease
  blood flow to globe
• IV Carbonic anhydrase inhibitors (acetazolamide)
• Beta blockers (timolol)
• Anterior Chamber paracentesis by Ophtho
• Need to w/u carotid and cardiac disease, consider
  ESR

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Central Retinal Vein Occlusion

• Sxs Slower onset, painLESS, monocular vision
  loss
• PE Retinal hemorrhage, cotton wool spots,
  macular edema, blood and thunder fundus
  (dilated venous system)
• Cause Atherosclerosis, glaucoma
• Rx Urgent ophtho consult, r/o CRAO
• consider ASA, no acute treatment

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Amaurosis Fugax

• Sxs Transient loss of vision, unilateral,
  painless, lasting 5-30 minutes, with
  graying/blurring of part or all of visual field
• Causes cholesterol or fibrin-platelet arterial
  emboli, sickle cell, temporal arteritis,
  collagen-vascular dz, syphillis
• Rx Ophtho / Neuro consult, ASA
• Ocular TIA ?Precursor of retinal artery occlusion

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Retinal Detachment

• Another cause of painless vision loss
• Sxs Flashes of light or lowering of curtain
  in peripheral visual fields, new prominent
  floaters or webs
• PE decreased peripheral vision, retinal /
  vitreous hemorrhages, grey retina with folds
• Cause Trauma, Sickle Cell, Diabetes
• A tear in the retina allows vitreous fluid to
  separate retina from the choroid
• Rx Fundoscopic exam, US, Emergent Ophtho
  consult. If tear is inferior, elevate head. If
  superior, lay flat

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Question 16
A 50-year-old man presents with left eye pain,
blurred vision, watery discharge, and photophobia
that began 2 days earlier. He has no history of
recent illness or trauma, has quiescent UC. The
patient is in moderate discomfort and is
shielding his left eye from the light.
Physical examination findings are depicted in
the picture. Visual acuity is slightly
decreased in the left eye and normal in the R
eye. Pain with a consensual light reflex is
present. Flare is noted on slit-lamp
examination, and the intraocular pressure is
within normal limits. What is the most likely
diagnosis?
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Question 16
A 50-year-old man presents with left eye pain,
blurred vision, watery discharge, and photophobia
that began 2 days earlier. He has no history of
recent illness or trauma, has quiescent UC. Flare
is noted on slit-lamp examination, and the
intraocular pressure is within normal limits.
What is the most likely diagnosis?

• Acute narrow-angle glaucoma
• corneal clouding, high IOP, mid-dilated pupil
• Corneal abrasion
• FB sensation, watery discharge, defect on
  staining
• Iritis
• uvea inflammation and ciliary spasm, with flare,
  ciliary flush
• Orbital cellulitis
• pain with eye movement, exophthalmosis
• Scleritis
• often bilateral, with nodules, systemic disease

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The Red Eye
C FUNK

• Conjunctivitis
• Foreign Body
• Uveitis / Iritis
• Narrow angle glaucoma
• Keratitis

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Iritis / Uveitis

• Consensual Light Response eliciting pain in the
  red eye is highly suggestive of iritis.
• Inflammation of the anterior uvea and spasm of
  the ciliary body results in symptoms
• Eye Pain
• Blurred, decreased vision
• Cells (WBCs)
• Flare (headlights in a fog)
• Treatment
• Anticholinergic Preparations
• Cylcoplegics
• Topical Steroids
• Oral Analgesics
• Ophtho Consultation

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Question 17
A 35-year-old woman presents with a painful right
eye. She has had the pain for 1 day and some
blurred vision as well. Ophthalmoscope
examination reveals a swollen optic disc. She
has never experienced this and has no medical
problems. The best treatment options is

• Admit for MRI
• Maybe later as part of MS workup not Tx
• Admit for treatment with methylprednisolone
• This is optic neuritis. Start IV steroids in the
  ED.
• Begin treatment with oral prednisone
• Oral steroids actually worse than placebo
• Perform lumbar puncture
• ? Relief for pseudotumor
• Obtain CBC
• Not tx

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Optic Neuritis

• Inflammation of Optic Nerve
• Caused by
• Infection
• Demyelination
• Autoimmune Disorders
• Clinical Presentation
• Reduction of vision
• Pain with extraocular movement
• Visual field cuts
• Afferent pupillary defect
• Swelling of Optic Disc
• Color vision affected more than visual acuity
• ED Care
• IV Steroids lower risk of MS in 2 years (oral
  steroids actually did worse than placebo).
• Admission / consult neuro, ophthalmology

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Optic Neuritis

• Sxs decreased vision over hours to days, pain
  increased by EOM, unilateral (70)
• PE dilated pupil, may have APD, field defect
  common especially central scotoma (blind spot),
  red desaturation test (dullness of color),
  minimal disc elevation
• Causes Multiple Sclerosis common (25), sarcoid,
  leukemia, viruses, TB, heavy metal ingestion
• Rx ED mgmt is controversial, Ophtho consult

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Acute Angle Closure Glaucoma

• Clinical Presentation
• Eye Pain
• Headache, N/V
• steamy hazy cornea
• Fixed, mid-dilated pupil
• Increased intraocular pressure of 40 to 70 mm Hg
  (10-20)

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Acute Angle Closure Glaucoma

• ED Care
• Decrease intraocular pressure
• Timolol
• Apraclonidine
• Acetazolamide IV for pressures gt 50mm Hg
• If pressure does not decrease in 1 hour, give IV
  Mannitol

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Question 18
Which of the following physical examination
findings most strongly indicates that an eye
infection is only a preseptal cellulitis?

• Decreased visual acuity
• suggests orbital cellulitis
• Fever
• nonspecific
• Pain with blinking
• Nonspecific, maybe suggests orbital
• Recent abrasion on the eyelid
• Hard to go from here to orbital cellulitis
• Swelling around the eye
• nonspecific

PEER VII Q260
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Periorbital (Preseptal) Cellulitis

• History
• Trauma, otitis
• Clinical Presentation
• Warm, indurated, erythematous eyelids
• No restriction of ocular motility
• No Proptosis
• No painful eye movement
• No impairment of pupillary function
• ED Care
• Oral Abx Augmentin (staph, h. flu)
• Need to admit
• Under 5 years-old
• Toxic Appearing
• Start on IV Abx Vanco and Ceftriaxone

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Orbital Cellulitis

• History
• Sinus infection
• Clinical Presentation
• Warm, indurated, erythematous eyelids
• Fever
• Toxicity
• Restriction of ocular motility
• Proptosis
• Painful eye movement
• Diagnosis
• Orbital and Sinus CT scan w/ and w/out contrast
• ED Care
• IV Abx Cefuroxime or Vanc
• Ophtho Consult
• Admit

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Question 19
A 23-year-old man with sickle cell disease
presents with blurred vision after being poked in
the eye. He has a hyphema. Intraocular pressure
is 30. Which of the following drugs might worsen
his condition?

• Carbonic anhydrase inhibitor
• Contraindicated in sicklers because lower IO pH,
  stiffer RBC
• Mannitol
• Optic ciprofloxacin
• Topical alpha-adrenergic agonist
• Topical beta-blocker

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Question 20
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Question 20
A 23-year-old man presents holding both hands
over his left eye. He was playing basketball
when another player hit him in the eye. He is
able to cooperate with the examination and
reports decreased vision. The definitive
treatment option in the emergency department is?

• Carbonic anhydrase inhibitor
• Useful in glaucoma-mediated elevated IOP
• Gentle pressure to reduce the eye
• Would make things worse (this isnt CRAO)
• Lateral canthotomy
• Because retrobulbar hemorrhage raises IOP, can
  compromise retina
• Observation pending ophthalmology consultation
• This is a true emergency, cant wait
• Thyroid-stimulating hormone level measurement
• Maybe useful in nontraumatic exophalptosis

PEER VII Q6
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Retrobulbar Hemorrhage

• Retinal Circulation Compromised
• Clinical Findings
• Proptosis
• Vision Loss
• Decrease Ocular Movement
• Increased Intraocular Pressure
• Immediate decompression is Key
• Lateral Canthotomy is the Best Option

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Lateral Canthotomy

• emergent procedure to relieve orbital
  compartment pressures
• release of lateral canthal tendon

Cantholysis

• adjunctive procedure to canthotomy
• can further reduce orbital compartment
  pressures
• release of inferior crus of lateral canthus
• if necessary, may also release superior crus
  but should
• avoid if possible as lacrimal gland and
  artery are in the area

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Indications
Contraindications

• proptosis
• decreased visual acuity
• increased intraocular pressure
• gt40mm Hg, resistance on ballotment

• globe rupture

Purpose

• temporizing measure
• relieves orbital compartment pressures
• prevents further neurovascular damage

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Question 21
A 6-year-old boy presents complaining of severe
eye pain and blurred vision. He had tipped over
a cup of plaster, and some of it splashed in his
eye. What is the proper order of management?

• Document visual acuity, irrigate, perform slit
  lamp exam, measure pH
• Document visual acuity, measure pH, irrigate,
  perform slit lamp exam
• Irrigate, measure pH, document visual acuity,
  perform slit lamp exam
• Time is vision! No justification for delaying
  irrigation. Talk to triage nurse.
• Measure pH, irrigate, document visual acuity,
  perform slit lamp exam
• Perform slit lamp exam, document visual acuity,
  measure pH, irrigate

PEER VII Q328
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Chemical Ocular Injury

• Acid and Alkali burns are managed in similar
  manner
• Time is Vision
• Flush eye immediately
• Normal Saline or Ringers Lactate 1-2 Liters
  (any drinkable fluid)
• Morgan Lens topical anesthesia may help
• Continue to flush until pH is normal (7.0-7.5)
• Recheck pH in 20-30 minutes to ensure no
  additional corrosive is leaching out of tissue
• Document Visual Acuity
• Rx
• Cycloplegic
• Erythromycin Ointment
• Narcotic pain medications
• Tetanus updated
• Ophtho Consultation

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Chemical Ocular Injury

• Acid and Alkali burns are managed in similar
  manner
• Whats worse?

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Chemical Burn

• Alkali substances (worse than acids)
• Liquefaction Necrosis
• Damage is related to initial pH
• Tear gas and mace are similar
• Acid
• Coaguation Necrosis
• Penetration is not as deep as with alkali
• Chlorine, sulfur

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The end