1. ENT Oral Emergencies, Ear, Nose, and Upper Airways Gabriella Minera, PGY-4

2. Oral Emergencies Pulp: Sensory, makes Dentin Crown: Covered with Enamel Root: Covered with Cementum Innervation:Maxillary Teeth by Superior Alveolar Nerves (branch from CN V2) Mandibular Teeth by Inferior Alveolar Nerve (branch from CV V3) 3. Oral Emergencies Nomenclature Clockwise from maxillary 3rd molar to bottom mandibular molars 4. Oral Emergencies Trauma Primary Tooth: No tx required Secondary Tooth: Reimplant within 20 minutes. Peridontal ligaments die >60 minutes. Rinse with water, milk or Hank Solution. Do not Scrub. Grasp tooth by crown. Brace with zinc oxide paste (Coe-Pak)Abx: Pcn VK or Erythromycin 5. Oral EmergenciesEllis Classification Class I: Enamel injury, Painless Class II: Dentin and Enamel, Hot/Cold Sensitivity, Yellow Dentin exposed Tx: Calcium Hydroxide, Urgent referralClass III: Enamel, Dentin, Pulp, Pain/painless (NV supply dependent), Pink tinge indicates exposed pulpTx: Emergent/Immediate OMFS, Abx 6. Oral Emergencies Concussions: injuries that involve tenderness to percussion but no mobility Subluxation: ttp, mobility, without evidence of dislogementTx: NSAIDs, soft diet, referral to dentistExtrusive Luxation: tooth is partially avulsed from alveolar boneTx: reposition the tooth, splint with zinc oxideLateral Luxation: lateral displacement with fracture of alveolar bone Intrusive Luxation: tooth is forced below the gingiva, poor outcome Avulsion: tooth has been completely removed from its socket. 7. Oral Emergencies Cheek Lacerations: Check for involvement of salivary ducts and injury to facial nerveParotid (Stensen) and Submandibular(Wharton) MC injured ENT consult if duct injuryPerioral Electrical Burns: Full-Thickness Burn at Lip Commissure Delayed Bleeding from Labial Artery 5-21 days postinjuryAnticipate bleeding/Apply direct pressure Involve plastics/ENT as outpatient 8. Oral Emergencies Acute Necrotizing Ulcerative Gingivitis (ANUG)/Vincents Angina/Trench Mouth: overgrowth of normally present bacteria which invade nonnecrotic tissue Pseudomembrane, Metallic Taste, FriablePeriapical Abscess: Infection of root apex, usually confined to alveolar bone, facial edemaTx: Pcn VK, Clinda, referral, +/- I+D 9. Oral Emergencies Alveolar Osteitis (Dry Socket): sudden excruciating pain 3-4 days after extraction caused by displacement of clot from socket and local osteomyelitis Tx: Pack with iodoform gauze (Euginol) Abx: usually not required 10. Oral Emergencies Trigeminal Neuralgia High Rate of spontaneous remission Tx: Tegretol, also Dilantin, Baclofen, Sx (relief of vascular compression) Often seen with Multiple Sclerosis 11. Oral Emergencies Oral Manifestations of Systemic Disease: Heavy Metal: Lead (Gingival lead line) Dilantin: Gingival Hyperplasia in 40%Coxsackie (Hand-foot-mouth syndrome): Vesicles spare buccal mucosa, gingiva, and tongue. Hairy Leukoplakia: EBV, white patches on side of tongue that cannot be removed with tongue blade. Tx: Acyclovir Kaposi Sarcoma: malignant cancer of lymphatic endothelium, HHV8, AIDS defining, MC on hard palate 12. Ear Emergencies 13. Ear Emergencies Acute Otitis Media: Viral > Bacterial S. pneumo > H. Flu > M. Cat Most Sensitive Test is mobility of TM with pneumatic ototscopyTreatment: 2years: tx only if certain and illness severe Abx: Amoxicillin (80 mg/kg/day x 10 days), if fails, give second course with Augmentin x 3 daysComplications: Hearing Loss, Cholesteotoma (accumulation of keratin-producing squamous epithelium in middle ear, destructive epidermoid cyst) 14. Ear Emergencies Mastoiditis: complication of AOM when infection spreads to adjacent mastoid air cells via the aditus ad antrum MCC: S. pneumo High risk of meningitis, need admission for IV abx and possible surgical drainage 15. Ear Emergencies Otitis Externa (Swimmers Ear) Pseudomonas (MC etiology)Aspergillus and Candida are MC fungal pathogens. Pain with movement of pinna or tragus Tx: Keep Canal DryAbx: FQs Cipro Otic: Children > 6 months of age Use suspension if TM perforated: Cortisporin Otic suspension (Neomycin, Polymyxin B, hydrocortisone). Aminoglycosides avoided because of ototoxicity***Steroids: topical hydrocortisone reduces symptoms but not time to clinical resolutionNecrotizing (Malignant) Otitis Externa: through the periauricular tissue and into the temporal bone. Tx with systemic abx. 16. Ear Emergencies Herpes Zoster Oticus (Ramsey-Hunt Syndrome) Triad: vesicles in the auricle/canal, ipsilateral facial paralysis, ear pain CN V, VII, IX, and X Tx: Acyclovir, referralBullous Myringitis Viral: MycoplasmaHemorrhagic or clear blisters on TM Tx: Macrolide 17. Ear Emergencies TraumaEar Laceration Skin is vascular but cartilage is avascular and relies on overlying tissueAll exposed cartilage must be completely covered suture through skin and perichondrium with 6-0 nylonSubperichondral HematomaAspiration vs. I +D, pressure x 48-72 hrs. Complications - Cauliflower Ear 18. Nasal Emergencies 19. Nasal Emergencies Sinusitis Imaging: CT preferred to plain films (air fluid levels, 4 mm of sinus wall thickening) For purulant discharge, symptoms > 1week: Augmentin x 10 days, another option: Azithromycin or Levaquin x 3 days Complications: Frontal Bone Osteomyelitis (Pott puffy tumor) Acute Sphenoid Sinusitis (Most posterior of sinuses). Cavernous Sinuses located laterally (Internal carotids, CN II, III, IV, V3, VI). Sx drainage if no improve x 24 hrs. 20. Nasal Emergencies Trauma Septal Hematoma: Drainage followed by anterior packing Saddle Nose Deformity 21. Oral and Upper Airway Emergencies Ludwigs Angina Polymicrobial cellulitis of oral floor Consider prophylactic intubation as airway compromise occurs quickly. May not be able to cric.Sialadenitis and Sialolithiasis Sialadenitis: inflammation of salivary glands (parotid, submandibular, sublingual) Sialolithiasis (stone formation in salivary gland) Submandibular form of both MCEtiology: Viral (Mumps/HIV) and Bacterial (S.aureus). Pus from Whartons duct (submandibular) or Stensons duct (parotid) 22. Oral and Upper Airway Emergencies Peritonsillar Abscess Hot Potato voice The abscess is PERItonsillar so the needle is not placed into the tonsil Carotid Artery is located 2.5 cm inferior lateral to tonsilRetropharyngeal and prevertebral space abscesses MC in children < 6 years (lymph nodes regress in adulthood) Posterior to pharynx/Anterior to vertebral bodies/Carotid sheaths laterally/Inferiorly by mediastinum Duck quack (cri du canard) Holds neck extended/ Trismus/Stridor X-ray: Obtain in full extension, inspiration, tissue space should be no wider than vertebral body 23. Oral and Upper Airway Emergencies PharyngitisBacterial: Group A Strep Rapid Strep Test: variable sensitivity and specificity Culture: 95% sensitive Centor Criteria: All four 55% probability of Strep etiology 1. Tonsillar exudate 2. Fever 3. Tender cervical LAD 4. Absence of coughTreatment: tx within 9 days to prevent rheumatic fever (Glomerulonephritis not prevented by abx administration). PCN VK (erythro if PCN allergic)Viral (60%):Enterovirus MC from spring through fall, Adenovirus associated with unilateral conjunctivitis in 50% 24. Oral and Upper Airway Emergencies Epiglottis More in Adults now since the H. Flu vaccine. Vaccination efficacy decreases with age. Diagnosis initially missed in 33% of casesEtiology: H Flu, S. pneumo, S.aureus Patient sitting in sniffing position, tripod Tx: Manage in OR for kids, airway compromise less common in adults (increased ratio of trachea diameter to 25. Oral and Upper Airway Emergencies Croup (Laryngotracheobronchitis) MCC of upper respiratory obstruction in kids Peak Incidence: 2 years old 50% by Parinfluenza virus Tx: Cool mist, racemic epi (observe for 4-6 hours for rebound), Steroids (controversial) Admission Criteria: Hypoxia, respiratory distress/stridor persists, 8 pointsBacterial Tracheitis Laryngeal/Tracheal/Bronchial inflammation Etiology: Staph Peaks in ages 3-4 y/o Barky cough, inspiratory/expiratory stridor - difficult to differentiate from croup or epiglottis but in BT patients have mucopurulant cough and are toxic appearing X-rays show subglottic narrowing as in croup Tx: OR for intubation, Bronchoscopy may be diagnostic 26. Some Extras... Chalazion Chronic Stye, Not infected Point inside to the lid Meibomian glandHordeolum Hordeolum is a painful nodule from blocked Zeiss + Moll gland (abscess on lid margin) Points externally Hordeolum is a stye because horders live in a pig stye. 27. Questions Ludwigs Angina is an infection that most typically originated from which previous location? Mandibular odontogenic infection Maxillary odontogenic infection Peritonsilar abscess Retropharyngeal abscess 28. Questions A 48 year-old man with no previous medical history presents with dizziness and hearing loss. He reports recurrent episodes of dizziness with ringing in one ear, severe nausea and vomiting, and feels that his hearing has decreased over time. Which of the following statements is TRUE regarding his condition? High-frequency hearing loss is commonly observed HCTZ is treatment of choice Perilymphatic fistula is the underlying etiology Vertical nystagmus is observed during an episode 29. Menieres Disease: Recurrent but also progressive hearing loss, tinnitus and vertigo.Etiology thought to be due to excessive endolymphatic fluid and endolymphatic distension. The diagnosis if often made clinically, with horizontal nystagmus seen. Low-frequency sensorineural hearing loss is also seen on audiometry.The treatment is salt restriction and diuretics. 30. Questions A 22-month-old girl is brought in parents for concern of an ear infection. She was recently seen for an ear infection 10 days ago and was prescribed high-dose amoxicillin, but continues to have ear pain. On exam, the child appears listless and limp. Vital signs are BP 85/55, P 135, RR 35, T104F (40C), O2Sat 99% room air. ENT exam shows a red and bulging right tympanic membrane with an air-fluid level, and fluctuance and erythema behind the auricle. The remainder of the physical exam is unremarkable, including a grossly intact neurologic exam. Broad-spectrum antibiotics and IV crystalloid fluid bolus resuscitation are initiated. Which of the following is the next best step in managing this patient? Admit to pediatrics ICU pending culture results Consult ENT for drainage CT head and temporal bones with contrast Lumbar puncture to rule out meningitis 31. Questions While imaging of the temporal bone is indicated in this patient, this patient is not stable for radiographic studies and ENT should be emergently consulted for drainage, based on high clinical suspicion (given postauricular fluctuance in the setting of an obvious acute otitis media failing outpatient antibiotics).The choice of antimicrobial therapy should be directed to the most common microorganisms involved, which are S. pneumoniae, S. aureus. Antibiotics against pseudomonal species should be considered when there is a history of recurrent otitis media or recent antibiotics use. 32. Questions A homeless patient presents complaining of a white film to the surface of his tongue and burning pain. What findings are suggestive of oral candidiasis versus oral hairy leukoplakia? HIV Positive White plaques can be scraped off with red friable tissue underneath Immunocomprimised Previous viral pharyngitis in an immunocompetent individual 33. Questions Oral candidiasis and oral hairy leukoplakia both occur in HIV positive and immunocompromised patients. Oral candidiasis can be diagnosed as a white film that can be easily scraped off to reveal red friable tissue underneath on the tongue . 34. Questions A 5-year-old previously healthy boy is brought in by mom for fever and decreased appetite for 2 days. Mom has not noticed any runny nose or cough, but patient has been complaining of mouth pain. Oropharyngeal exam is shown, with exquisitely painful lesions. Which of the following most accurately describes this condition? Adenopathy and fever typically precede the appearance of ulcersAntiviral can shorten duration of symptoms and reduce recurrence Coxackievirus is likely the causative agentThroat culture is the gold standard for diagnosis 35. Questions Herpes gingivostomatitis is the likely causative agent in this case scenario. While both herpes gingivostomatitis and herpangina can lead to painful vesicles and ulcers in the oropharynx, herpangina generally spares the buccal mucosa, gingivae and the tongue (unlike herpes gingivostomatitis). 36. ENT The END Questions?