HEENT

PAINE #PANCE Pearl – HEENT

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Question

62yo man, with a history of pseudotumor cerebri, presents to your clinic with progressive headache and vision changes. You would like to confirm an increased intracranial pressure before sending him to the neurologist.

  1. What are two (2) ways at the bedside you can confirm and what are the thresholds for positive findings?

Answer

  1. The old and busted bedside way to determine if a patient has increased intracranial pressure is the fundoscopic examination. What you are looking for specifically is the cup:disc ratio of the optic nerve. Normal is around 0.3, or 1/3rd. If it is increased, it suggests increased intracranial pressure.

2. The new, hotness is using bedside POCUS to measure the optic nerve directly. Using the high frequency linear probe with a tegaderm placed over the patient eye, place a generous amount of gel over the globe and measure the optic nerve 3mm from the retina. A normal optic nerve should be < 5mm in diameter and anything over than suggests increased intracranial pressure

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Rinne Test

Other Known Aliases – none

Definition – bedside test to evaluate hearing loss using a 512hz tuning fork

Clinical Significance – this maneuver is performed by vibrating a 512hz tuning fork and placing it on the mastoid process. The patient then informs the provider when they no longer can hear the ringing, at which point the tuning fork is moved in front of the canal. In normal hearing, the patient should still be able to hear the ringing (although it can also occur in sensorineural hearing loss). If conductive hearing loss is present, bone conduction is greater than air conduction.

History – Named after Heinrich Adolf Rinne (1819-1868), a German otologist who received his medical doctorate from the University of Göttingen. He would practice here for the majority of his career exploring the diseases of the ears, nose, and throat. He first described his eponymous test in 1855, but did not get widespread recognition for it until 1881 when it was further publicized by otologists Bezold and Lucae

References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Heck WE. Dr. A. Rinne. Laryngoscope. 1962;72(5):647-652. [link]

#67 – Epistaxis

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***LISTEN TO THE PODCAST HERE***

Anatomy

Anterior

  • Kiesselbach’s Plexus (Little’s area)
    • Confluence of three main vessels
      • Septal branch of the anterior ethmoidal artery
      • Lateral nasal branch of the sphenopalatine artery
      • Septal branch of the superior labial branch of the facial artery

Posterior

  • Woodruff’s Plexus
    • Posteriorlateral branches of the sphenopalatine artery
      • Posterior inferior turbinate

Epidemiology

  • Up to 60% of population will experience a significant nosebleed each year
    • Only 10% need to seek attention
  • Common ENT admission condition, but rarely needs surgical intervention
  • Bimodal age distribution
    • Before 10 years or between 45-65 years
  • Male predominance before the age of 49, then equalizes
    • Estrogen has been shown to protective for mucosa
  • Anterior bleeds are significantly more common (>90%) and resolve with minor interventions
  • Posterior bleeds can result in significant hemorrhage

Etiologies

  • Nose picking
  • Low environmental moisture
  • Mucosal hyperemia of viral or allergic rhinitis
  • Trauma
  • Foreign body
  • Anticoagulation
  • Coagulopathies
    • Osler-Weber-Rendu, von Willebrand, hemophilias
  • Connective tissue disease
    • Aneurysm development
  • Neoplasm
    • Squamous cell, inverted papilloma
  • Hypertension
    • Debated as a cause, but has shown to prolong bleeding
  • Nasal medications
    • Steroids, oxymetazoline
  • Heart failure

Patient Assessment

  • Primary
    • Airway assessment
      • RR, O2
    • Cardiovascular stability
      • HR, BP
  • Secondary
    • History
      • Medications
        • Anticoagulation, aspirin, nasal medications
      • PMH
        • Bleeding disorders, HTN, liver disease
        • Recent trauma
        • History of nosebleeds
          • How often, how long do they last, ever been admitted for one
  • Diagnostic Studies
    • Coagulation studies should NOT be routinely ordered
      • Should be in patients on anticoagulation
    • In patients with prolonged bleeds:
      • CBC
      • Type and cross
  • Examination
    • Have patient blow nose to remove clots and blood
    • Examine nasal cavity to see if you can see the bleeding site
      • Otoscope, nasal speculum
      • Don’t have patient tilt head back
        • Nasopharynx lies in anteroposterior plane and this will obscure the majority of the cavity from view

Interventions

  • Initial (Woodpecker/Walrus technique)
    • Have patient blow nose to remove clots
    • In a small basin mix any or all of the following:
      • Oxymetazoline
      • Lidocaine with epinephrine
      • Tranexamic acid
      • If available, soak GelFoam/Surgicel in this fluid and place BEFORE the sponge sticks
    • Trim two oral sponge swabs to better fit in the nasal cavity and soak in the fluid
    • Make a nasal bridge clamp by taping two tongue depressors together on one end
    • Place swabs in nasal cavities and apply nasal clamp for 10-15 minutes
    • Ice pack can also be used
  • Cautery
    • If the bleeding site can be visualized on direct examination
    • Apply topical anesthetic
    • Silver nitrate sticks
      • Start from periphery and roll to center of bleeding
      • No more than 10 seconds
      • A white eschar should form
  • Nasal packing
    • Use if cautery fails
    • Ensure topical anesthesia
    • Soak in sterile water
    • Insert by sliding along the floor of the nasal cavity PARALLEL to floor
    • Insufflate the balloon with air
  • Nasal Balloon Catheters
    • For posterior bleeds
    • Follow same steps for nasal packing
    • Insufflate posterior balloon FIRST and apply gently traction
    • Then insufflate the anterior balloon
  • Foley Catheters
    • If you don’t have a prefabricated nasal balloons, a foley catheter can work
    • Insert the catheter until you can see it in the posterior oropharynx
    • Insufflate with 5-10cc of water
    • Apply traction to seat balloon in posterior choana
    • Add additional water to tamponade
    • Clamp catheter with umbilical clamp or c-clamp from NG tube

Disposition and Follow-up

  • For simple nasal packing, patients should be evaluated by ENT within 24-48 hours
    • Discuss with consultant need for antibiotic prophylaxis
      • No good evidence supports routine use, but ENT often prefers
        • Amoxicillin-Clavulanate is most commonly used
        • Clindamycin or trimethoprim/sulfamethoxazole should be used if concern for nasal carrier of MRSA
  • Posterior bleeds should be immediately assessed by ENT for potential surgical intervention
    • Endoscopic sphenopalatine artery ligation
    • Anterior ethmoid artery ligation
      • Open or endoscopic

1893 Cottage Physician

References

  1. Kucik CJ, Clenney T. Management of epistaxis. Am Fam Physician. 2005; 71(2):305-11. [pubmed]
  2. Villwock JA, Jones K. Recent Trends in Epistaxis Management in the United States JAMA Otolaryngol Head Neck Surg. 2013; 139(12):1279-84. [pubmed]
  3. Kotecha B, Fowler S, Harkness P, Walmsley J, Brown P, Topham J. Management of epistaxis: a national survey. Ann R Coll Surg Engl. 1996; 78(5):444-6. [PDF]
  4. Fishpool SJ, Tomkinson A. Patterns of hospital admission with epistaxis for 26,725 patients over an 18-year period in Wales, UK. Ann R Coll Surg Engl. 2012; 94(8):559-62. [PDF]
  5. Min HJ, Kang H, Choi GJ, Kim KS. Association between Hypertension and Epistaxis: Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg. 2017; 157(6):921-927. [pubmed]
  6. Shakeel M, Trinidade A, Iddamalgoda T, Supriya M, Ah-See KW. Routine clotting screen has no role in the management of epistaxis: reiterating the point. Eur Arch Otorhinolaryngol. 2010; 267(10):1641-4. [pubmed]
  7. Lin G, Bleier B. Surgical Management of Severe Epistaxis. Otolaryngol Clin North Am. 2016; 49(3):627-37. [pubmed]

PAINE #PANCE Pearl – HEENT

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Question

62yo man, with a history of pseudotumor cerebri, presents to your clinic with progressive headache and vision changes. You would like to confirm an increased intracranial pressure before sending him to the neurologist.

  1. What are two (2) ways at the bedside you can confirm and what are the thresholds for positive findings?

#54 – Dacryocystitis

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***LISTEN TO THE PODCAST HERE***

Definition

  • Infection of the lacrimal sac usually due to obstruction of the nasolacrimal systems

Anatomy

The lacrimal apparatus is responsible for tear production and drainage of the eye and consists of 3 main structures:

  • Lacrimal gland
    • Serous gland located in the superiorlateral corner of the orbit in the lacrimal fossa
    • Responsible for tear secretion onto the globe
  • Lacrimal canaliculi
    • Drainage ducts located in the medial corner of the eye and drain into the nasolacrimal duct
  • Nasolacrimal duct
    • Drains into the inferior nasal meatus of the nasal cavity

Pathophysiology

  • The most common cause of dacryocystitis is obstruction of the nasolacrimal duct
  • Adults
    • Chronic inflammation leading to fibrosis/stenosis of the duct
    • Most commonly in postmenopausal women
  • Infants/Children
    • Persistent membrane covering the Valve of Hasner
      • Occurs in up to 90% of newborns
        • Becomes patent by the end of the first month of life in 90%

Microbiology

  • Pediatric
    • Streptococcus pneumoniae
    • Staphylococcus species
    • Haemophilus influenza
    • Entrobacteriaceae species
  • Adults
    • Staphylococcus aureus
    • Staphylococcus epidermidius
    • Pseudomonas aeruginosa
    • Propionibacterium species

Clinical Findings

  • The main clinical finding is tearing and discharge
  • Acute
    • Inflammation, pain, swelling, and tenderness beneath the medial canthal tendon around the lacrimal sac
      • Purulence can be expressed through the lacrimal puncta with direct pressure on the lacrimal sac
  • Chronic
    • Tearing and matting of the eyelashes is most common
    • Mucoid material can be expressed occasionally

Diagnostic Studies

  • Although this is clearly a clinical diagnosis and the majority do not need further studies, you can do a bedside test called “Dye Disappearance Test”
    • Apply a drop of topical anesthetic
    • Place a drop of fluorescein stained saline in the inferior cul-de-sac of each of the patient’s eyes
    • Wipe away excess tears from eyelids
    • Observe patient for 5 minutes with careful instructions that the eye should not be rubbed and cheeks should not be wiped
    • After 5 minutes inspect eye, nose, and cheek
      • All of the fluorescein should have drained into the nose within 5 minutes if there is no obstruction
      • If any fluorescein remains in eye or drained down the cheek, then the test is positive

Treatment

  • Most cases respond to appropriate systemic antibiotic therapy
    • Culture expressed purulence to aid in antibiotic selection
    • Acute (7-10 days of therapy)
      • Mild cases – Clindamycin
      • Severe – Vancomycin + 3rd generation cephalosporin
  • For infants:
    • External digital massage of the lacrimal sac is first line
      • Increases the hydrostatic pressure to force open the obstructed membrane
  • Nasolacrimal probing is indicated in acute cases and cases persisting for > 6 months
    • Some cases require balloon dilation, silicone stent placement, or inferior turbinate fracture
  • For adults:
    • Chronic topical antibiotic drops can help keep patent, but this is only symptomatic relief
      • Fluoroquinolones – moxifloxacin, ciprofloxacin, ofloxacin
      • Aminoglycoside – tobramycin, gentamicin
    • Dacryocystorhinostomy is required to prevent recurrence
      • Permanent fistula formed between lacrimal sac and the nose

The Cottage Physician (1893)

References

  1. Duncan JL, Parikh NB, Seitzman GD, Riordan-Eva P. Disorders of the Lids & Lacrimal Apparatus. In: Papadakis MA, McPhee SJ, Rabow MW. eds. Current Medical Diagnosis and Treatment 2020. New York, NY: McGraw-Hill
  2. Orbit. In: Morton DA, Foreman K, Albertine KH. eds. The Big Picture: Gross Anatomy, 2e New York, NY: McGraw-Hill;
  3. Vagefi M. Lids & Lacrimal Apparatus. In: Riordan-Eva P, Augsburger JJ. eds. Vaughan & Asbury’s General Ophthalmology, 19e New York, NY: McGraw-Hill
  4. 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
  5. Hoffmann J, Lipsett S. Acute Dacryocystitis. The New England journal of medicine. 2018; 379(5):474. [pubmed]
  6. Campolattaro BN, Lueder GT, Tychsen L. Spectrum of pediatric dacryocystitis: medical and surgical management of 54 cases. Journal of pediatric ophthalmology and strabismus. ; 34(3):143-53; quiz 186-7. [pubmed]
  7. Qian Y, Traboulsi EI. Lacrimal sac compression, not massage. Journal of pediatric ophthalmology and strabismus. ; 46(4):252. [pubmed]
  8. Örge FH, Boente CS. The lacrimal system. Pediatric clinics of North America. 2014; 61(3):529-39. [pubmed]

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Le Fort Fractures

Other Known Aliases – transfacial fracture of the midface

Definition – These fractures involve the maxillary bone and are graded based on their direction and involvement of surrounding structures. The key distinguishing feature of this type of fracture is separation of the pterygoid plates from the maxillary sinuses.

Clinical Significance – Continuity of the pterygoid plates is essential for midface structural stability and any disruption requires surgical fixation. There are three types of Le Fort fractures:

  1. Type I – Horizontal fracture – involves the lateral bony margin of the nasal opening
  2. Type II – Pyramidal fracture – involves the inferior orbital rim
  3. Type III – Transverse fracture – involves the zygomatic arch, vomer, and across the orbital floor and walls

History – Named after René Le Fort (1869-1951), who was a French surgeon and received his medical doctorate at the age of 21 while serving in the French military. He taught and practice in Lille, France for the majority of his career. He served his country numerous times when called to serve as a military physician, as well as coming out of retirement during World War II to teach at the University of Lille to replace colleagues called to the war effort. He published the findings of his eponymous conditions in 1901 in a treatise entitled “Étude expérimentale sur les fractures de la mâchoire supérieure”, where he described his experiments of dropping cannon balls from varying directions and heights on the faces of cadavers to describe the predictable injury patterns

References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Gartshore L. A brief account of the life of René Le Fort. The British journal of oral & maxillofacial surgery. 2010; 48(3):173-5. [pubmed]
  7. Patterson R. The Le Fort fractures: René Le Fort and his work in anatomical pathology. Canadian journal of surgery. Journal canadien de chirurgie. 1991; 34(2):183-4. [pubmed]
  8. Le Fort R. Étude expérimentale sur les fractures de la machoire supérieure. Revue de chirurgie, Paris 1901; 23: 208-27; 360-79; 479-507

PAINE #PANCE Pearl – HEENT

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Question

One of the visual disturbances that can be seen with carotid atherosclerosis is transient, painless, monocular vision loss.

  • What is this condition called?
  • Why does it occur?

Answer

  1. Transient monocular vision loss is called amaurosis fugax
    • Amaurosis is Latin for darkening/dark/obscure
    • Fugux is Latin for fleeting
  2. The most common cause of amaurosis fugax is ischemia from carotid artery atherosclerotic microemboli. The ophthalmic artery is the first branch off the internal carotid artery and gives rise to the central retinal artery, as well as the anterior and posterior ciliary arteries.
    1. Other causes include retinal vein occlusion, giant cell arteritis, optic neuropathy, papilledema, and retinal vasospasm

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Lemierre Syndrome

Other Known Aliases – septic phlebitis

Definition – infectious thrombophlebitis of the internal jugular vein.

Clinical Significance – Often this starts out as a simple oropharyngeal infection, but if it goes untreated, it can quickly spread to the deep spaces of the neck and infiltrate the carotid sheath. Septic emboli can travel the body and cause severe bacterial complications, resulting in a mortality of up to 15%. The common pathogen for this condition is Fusobacterium necrophorum.

History – Named after André-Alfred Lemierre (1875-1956), who was a French bacteriologist and received his medical doctorate in 1904. He became Médicine de Hôpitaux (hospitalist) in 1912 and later worked at the famed Hôspital Bischat. He was promoted to professor of microbiology in 1926 due to his work on septicemia, typhus, and GI/GU infections. It was in 1936 when he published a case series in The Lancet describing his eponyomous disease.

References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. EM Docs. Lemierre’s Syndrome. http://www.emdocs.net/em-in-5-lemierres-syndrome/
  7. Lemierre AA. On certain septicaemias due to anaerobic organisms. Lancet. 1936;227(5874):701-703. [link]

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Roth’s Spots

Other know aliases – Litten’s spots

Definition – exudative, edematous hemorrhagic lesions of the retina with pale, white centers that can be composed of coagulated fibrin, platelets, infectious organisms, or neoplastic cells

Clinical Significance – one of the classic physical examination findings in bacterial endocarditis seen on fundoscopy. Further research and analysis has shown these can be present in leukemia, diabetes, and hypertensive retinopathy

History – named after Mortiz Roth (1839-1914), who was a Swiss pathologist and recieved his medical doctorate from University of Basel in 1864. He practiced all around Switzerland before returning to Basel as professor extraordinary of pathology in 1872, when he published his now eponymous findings in an article entitled “Uber Netzhauteffecstionen bei wundfiebren [Retinal Manifestations of wound fever]”. Dr. Roth, though, never described the classic appearance of the retinal red spot with a white center. Dr. Moritz Litten described this finding 6 years later and would coin the term we still use 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
  • Roth Spots – StatPearls. [article]
  • Roth M. Uber Netzhauteffecstionen bei wundfiebren [Retinal manifestations of wound fever]. Deutsch A Chir. 1872;1:471–84.
  • Litten M. Ueber akute maligne endocarditis
  • und die dabei vorkommenden retinal veranderungen.
  • Charite-Ann 1878;3:135.