Author: Kristopher Maday PA-C

Ep-PAINE-nym

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Dix-Hallpike Manuever

Other known aliases – Nylen-Barany test

Definition – Starting supine, the patient’s head is rotated to one side and then quickly lowered to supine with the neck extended over the exam table.  Patient is observed for nystagmus for 30 seconds and then returned to supine and observed for another 30 seconds.  This is then repeated for the other side.

Clinical Significance – The Dix-Hallpike maneuver is the diagnostic maneuver to induce vertigo and nystagmus in patients with benign paroxysmal positional vertigo by relocating canaliths to the posterior semicircular canals.

History – Named after Margaret Ruth Dix (1902-1991), a British neuro-otologist, and Charles Skinner Hallpike (1900-1979), an English otologist.  Dr. Dix earned her medical doctorate in 1937 from the Royal Free Hospital School of Medicine and Dr. Hallpike earned his from the University of London in 1926.  Dr. Dix was training to become a surgeon when she was injured during the World War II air raids of London and suffered facial and ocular injuries which forced her to change her medical career path.  It was during this time she was hired by Dr. Hallpike to pursue the field of neuro-otology.  Their work resulted in a landmark series in the Proceedings of the Royal Society of Medicine and Annals of Otology, Rhinology, and Laryngology.  It was this series in 1952 where one of the papers describing their eponymous finding  entitled “The Pathology, Symptomatology, and Diagnosis of Certain Common Disorders of the Vestibular System” was published.

References

  • Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  • Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  • Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  • Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  • Up To Date. www.uptodate.com
  • DIX MR, HALLPIKE CS. The pathology symptomatology and diagnosis of certain common disorders of the vestibular system. Proceedings of the Royal Society of Medicine. 1952; 45(6):341-54. [pubmed]
  • Margaret Ruth Dix – Royal College of Surgeons [link]

#45 – Preseptal vs Orbital Cellulitis

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***LISTEN TO THE PODCAST HERE***

Definitions

  • Orbital Septum
    • Membranous structure that extends from orbit to the tarsal plate and is the anterior boundary of the orbital compartment
  • Preseptal Cellulitis
    • Infection of the soft tissues ANTERIOR to the orbital septum
  • Orbital Cellulitis
    • Infections of the soft tissues POSTERIOR to the orbital septum

Numbers

  • Preseptal cellulitis is much more common than orbital (>90%)
  • Both conditions are more common in children than adults

Pathogenesis

  • Preseptal
    • Usually due to superficial dermatologic infections (though the data has wide variability in reported causes)
  • Orbital
    • Bacterial rhinosinusitis
      • Due to perforations in the lamina papyracea
    • Other causes:
      • Ophthalmologic surgery
      • Dacrocystitis
      • Orbital trauma
      • Dental infections

Microbiology

  • Preseptal
    • Staphylococcus aureus (skin causes)
      • Increasing incidence of MRSA
    • Streptococcus pneumoniae (sinus/nasopharynx causes)
  • Orbital
    • Same as preseptal, but include:
      • Fungal (mucormycosis and Aspergillus spp.)

Signs and Symptoms

  • Both present with unilateral eyepain, erythema, and edema, but:
  • Preseptal
    • No pain with eye movement
    • Sclera is white
Preseptal Cellulitis (sclera is white and quiet)

    • Orbital
      • Painful eye movement
      • Vision changes (acuity, diplopia)
      • Proptosis
      • Sclera injection and chemosis
      • Decreased pupillary response
Orbital cellulitis (notice sclera is red and angry with chemosis)

Complications

  • Complications of preseptal cellulitis are rare, but orbital cellulitis can lead to:
    • Vision loss (3-11%)
    • Subperiosteal abscess
    • Orbital abscess
    • Cavernous sinus thrombosis

Diagnostic Studies

  • CBC with differential may be helpful in risk stratification or atypical presentation
  • Preseptal
    • None! –> Clinical diagnosis
  • Orbital
    • Indications for CT scan
      • Inability to assess vision or deteriorating vision
      • Double vision
      • Inability to examine due to age
      • Proptosis
      • Restricted, limited, and/or painfuleye movement
      • Edema extending beyond eyelid margin
      • Lack of improvement in 24 hours on antibiotics
      • Cyclical fevers
      • Signs of CNS involvement
      • ANC > 10,000 cell/microL
a. proptosis, b. soft tissue inflammation, c. choroidal detachment, d. retrobulbar inflammation, e. optic nerve sheet enhancement
medial orbital subperiosteal abscess with left sided ethmoid sinusitis
  • Blood cultures are not routinely recommended but should be entertained in ill appearing children prior to antibiotic administration

Treatment

  • Preseptal
    • Outpatient
      • > 1 year old and no signs of systemic toxicity
      • Treatment duration typically 5-7days, but treatment should continue until eyelid erythema and swelling have resolved
    • Inpatient
      • < 1 year old, children who can’t cooperate with exam, toxic appearance, or outpatient treatment failing to improve in 24-48 hours
      • Follow orbital cellulitis treatment
  • Orbital
    • Medical
      • Staphylococcal coverage
        • Vancomycin
      • Streptococcal coverage
        • Ceftriaxone
        • Cefotaxime
      • Anaerobic coverage
        • Metronidazole
      • Improvement should occur within24-48 hours
      • Transition to oral therapy when:
        • Afebrile and periorbital signs are resolving
        • Typically 3-5 days
        • Follow culture data (if obtained) or follow outpatient preseptal cellulitis regimen
      • Treat for a total of 2-3 weeks
    • Surgical indications
      • Radiographically identified abscess
        • Typically > 10mm, though small abscesses respond to antibiotics well
      • Intracranial extension
      • Failure to respond to antibiotic treatment
      • Threat to vision

References

  1. Hauser A, Fogarasi S. Periorbital and orbital cellulitis. Pediatrics in review. 2010; 31(6):242-9. [pubmed]
  2. Botting AM, McIntosh D, Mahadevan M. Paediatric pre- and post-septal peri-orbital infections are different diseases. A retrospective review of 262 cases. International journal of pediatric otorhinolaryngology. 2008; 72(3):377-83. [pubmed]
  3. Horton JC. Disorders of the Eye. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison’s Principles of Internal Medicine, 20e New York, NY: McGraw-Hill; http://accessmedicine.mhmedical.com/content.aspx?bookid=2129&sectionid=192011900
  4. Chaudhry IA, Shamsi FA, Elzaridi E, Al-Rashed W, Al-Amri A, Arat YO. Inpatient preseptal cellulitis: experience from a tertiary eye care centre. The British journal of ophthalmology. 2008; 92(10):1337-41. [pubmed]
  5. Moran GJ, Krishnadasan A, Gorwitz RJ, et al. Methicillin-resistant S. aureus infections among patients in the emergency department. The New England journal of medicine. 2006; 355(7):666-74. [pubmed]
  6. Brook I, Frazier EH. Microbiology of subperiosteal orbital abscess and associated maxillary sinusitis. The Laryngoscope. 1996; 106(8):1010-3. [pubmed]
  7. Erickson BP, Lee WW. Orbital Cellulitis and Subperiosteal Abscess: A 5-year Outcomes Analysis. Orbit (Amsterdam, Netherlands). 2015; 34(3):115-20. [pubmed]
  8. Howe L, Jones NS. Guidelines for the management of periorbital cellulitis/abscess. Clinical otolaryngology and allied sciences. 2004; 29(6):725-8. [pubmed]
  9. Rudloe TF, Harper MB, Prabhu SP, Rahbar R, Vanderveen D, Kimia AA. Acute periorbital infections: who needs emergent imaging? Pediatrics. 2010; 125(4):e719-26. [pubmed]
  10. Tanna N, Preciado DA, Clary MS, Choi SS. Surgical treatment of subperiosteal orbital abscess. Archives of otolaryngology–head & neck surgery. 2008; 134(7):764-7. [pubmed]
  11. Greenberg MF, Pollard ZF. Medical treatment of pediatric subperiosteal orbital abscess secondary to sinusitis. Journal of AAPOS : the official publication of the American Association for Pediatric Ophthalmology and Strabismus. 1998; 2(6):351-5. [pubmed]

PAINE #PANCE Pearl – HEENT

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Question

Benign paroxysmal positional vertigo (BPPV) can be quite a debilitating condition for patient it effects.  What are the two maneuvers that are used at the bedside for this condition and how do they differ?

Answer

The two maneuvers used clinically in the evaluation and treatment of BPPV are:

  • Dix-Hallpike Maneuver (diagnosis)
    • This is used to diagnosis BPPV and is performed by having the patient starting sitting upright.  The head is then turned to one side and the patient is rapidly lowered to the supine position with their extended over the examination table.  The provider then watches for nystagmus or vertigo symptoms.  If this side is negative, then the maneuver is repeated on the other side.
Dix-Hallpike
  • Epley Maneuver (treatment)
    • This is used to treat active vertigo in BPPV by attempting to relocate the canalith back into the utricle by using a series of repositioning techniques.
Epley

References

  • Shim DB, Ko KM, Kim JH, Lee WS, Song MH. Can the affected semicircular canal be predicted by the initial provoking position in benign paroxysmal positional vertigo? The Laryngoscope. 2013; 123(9):2259-63. [pubmed]
  • Furman JM, Cass SP. Benign paroxysmal positional vertigo. The New England journal of medicine. 1999; 341(21):1590-6. [pubmed]
  • Woodworth BA, Gillespie MB, Lambert PR. The canalith repositioning procedure for benign positional vertigo: a meta-analysis. The Laryngoscope. 2004; 114(7):1143-6. [pubmed]
  • White J, Savvides P, Cherian N, Oas J. Canalith repositioning for benign paroxysmal positional vertigo. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology. 2005; 26(4):704-10. [pubmed]

Ep-PAINE-nym

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Epley Manuever

Other known aliases – canalith repositioning manuever

Definition – series of positions and manual manipulations used to reposition free-floating otoconia in the semicircular canals of the inner ear

Clinical Significance – The Epley maneuver is used to treat benign paroxysmal positional vertigo (BPPV) by relocating the otoconia back to the utricle where they can no longer stimulate the cupula of the semicircular canal and cause vertigo. 

History – Named after John Epley, an American otolaryngologist from Portland, OR, who received his medical degree from the Oregon Health Sciences University and fellowship from Stanford Medical Center.  He pioneered the “canalith theory” of vestibular disease and published his eponymous maneuver in 1980 in the article entitled “New Dimensions of Benign Paroxysmal Positional Vertigo”.  Dr. Epley is still in practice today.

References

  • Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  • Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  • Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  • Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  • Up To Date. www.uptodate.com
  • Epley JM. New dimensions of benign paroxysmal positional vertigo. Otolaryngology and head and neck surgery. 1980;88(5):599-605. [pubmed]


PAINE #PANCE Pearl – Emergency Medicine

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Question

You have a patient in the ED with an aortic dissection and are managing them while awaiting the cardiovascular surgeon to arrive.

  1. What are the two most important things to control?
  2. How do you go about doing that?

Answer

  1. The main aims of acute medical management of aortic dissections are to decrease the rate of left ventricular contraction and decrease the velocity of the contraction, which will overall decrease the shear stress at the site of the tear and slow progression.
  2. Start with intravenous beta-blockade and titrate to a heart rate of 60 betas/minute
  1. If systolic blood pressure is > 120 mmHg after successful beta-blockade, then add a vasodilator or afterload reducer.

For a deep dive into aortic dissections, check out the podcast

References

  1. Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation. 2010; 121(13):e266-369. [pubmed]
  2. Tsai TT, Nienaber CA, Eagle KA. Acute aortic syndromes. Circulation. 2005; 112(24):3802-13. [pubmed]