DOS Course 2015 1 DOS CME Course 2011 1 October 2010 1 Confidential

Common ENT Challenges

Cerumen Removal Nasal Cautery for Epistaxis

Foreign Body – Ears and Nose Peritonsillar Abscess

Tom I. Abelson M.D.

Medical Director Cleveland Clinic Beachwood Family Health and Surgery Center Department of Otolaryngology Head and Neck Institute Cleveland Clinic

© Cleveland Clinic 2014

Cerumen Removal

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Roland P S et al. Otolaryngology -- Head and Neck Surgery 2008;139:S1-S21

Ear Candling

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Cerumen Removal

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Cerumen Removal

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Cerumen wire loop

Small blunt hook

Cerumen (or Foreign Body) Removal

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Cerumen Removal

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Cerumen Removal

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Cerumen Removal

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Cerumen Removal

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Cerumen Removal

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Cerumen Removal

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Nasal Cautery

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• Remove blood and clots from nose

• Place topical medication using cotton pledget – 50-50 mixture of:

–4% topical lidocaine or other topical anesthetic –Oxymetazoline or Phenylephrine

• Repeat

• Cauterize with silver nitrate – Apply – Dry – Repeat until epistaxis controlled

• May pack with merocel, perhaps covered with resorbable packing material (fibrillar or gelfoam) – leave 4-5 days

Nasal Cautery

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• Nasal speculum • Cotton pledget • Bayonet forceps • Silver nitrate • Applicator

Nasal Cautery

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Posterior epistaxis

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Nasal Packing

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• Nasal packing can be Vaseline gauze, merocel sponge, dissolvable material such as fibrillar or gelfoam

• Leave packing for 4-5 days

• Put patient on broad spectrum antibiotic such as cephalexin to prevent bacterial overgrowth and toxic shock

• Expect a small amount of oozing of blood for a brief period of time after removal of packing because of mucosal irritation.

Peritonsillar Abscess

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• Symptom – Unilateral throat pain – Trismus – “Hot potato” voice

• Physical Exam – Unilateral swelling of the peritonsillar tissues, extending into the

soft palate – Deviation of the uvula to the opposite side – Effacing of the junction between the tonsil and the soft palate and

anterior tonsil pillar – Cervical adenopathy or soft tissue swelling and tenderness

• Lab – Increase WBC with left shift

Peritonsillar Abscess

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Peritonsillar Abscess

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Peritonsillar Abscess

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Dental Trauma in Primary Care

Thanks to:

Tod Coy DDS Cleveland Clinic

Edward Ginsberg DDS

Assistant Clinical Professor University of Maryland School of Dentistry

Johns Hopkins Hospital

• Check for other facial fractures or head and neck trauma

• 70% of all dental injuries involve maxillary central incisors

• Check for dental fractures, mobility, tooth malposition

• Question regarding sensitivity to hot/cold

• Prefer panorex or intraoral dental radiography over CT

Clinical Evaluation

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Dental Anatomy and Numbering

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• Fracture

• Avulsion

• Luxation

Injury Classification

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Dental Injury Classification

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• Ellis Class I – Enamel only – No emergency care. Follow-up with dentist.

• Ellis Class II – Enamel / dentin with sensitivity – Cover exposed dentin with dental cement (dycal) and referral to

dentist within 24 hours.

• Ellis Class III – Enamel / dentin / pulp – Cover with dental cement (dycal) and immediate dental referral.

Fracture

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Dental Anatomy

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• Adult teeth should be reimplanted as soon as possible and handled only by the crown portion of the tooth.

• If reimplantation is not possible then place in a protective medium (Hank’s Balanced Salt Solution, saline, milk).

• In children with avulsions primary teeth are never reimplanted.

Avulsion

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• Concussion – Mild injury to periodontal ligament, no mobility. – Soft diet, NSAIDs, dental referral

• Subluxation – Tenderness to palpation, slight mobility of tooth. – Soft diet, NSAIDs, dental referral

• Extrusion – Reposition tooth to original position and splint in place.

Luxation

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• Lateral luxation – Reposition tooth and splinting. – Should be done by dentist or oral surgeon if significant alveolar

fracture is present.

• Intrusion – Typically no emergency care by general practitioner. – Referral to dentist within 24 hours.

Luxation

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References

Harrison L. Dental trauma: guidelines for pediatricians updated. Medscape Medical News. January 27, 2014. Available at http://www.medscape.com/viewarticle/819755. Accessed February 3, 2014.

Keels MA. Management of dental trauma in a primary care setting. Pediatrics. Feb 2014;133(2):e466-76.

Dentaltraumaguide.com Per Dr. Ginsberg

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