4.12 Uvular edema
Presentation
A patient complains of a foreign body sensation or fullness in the throat, possibly associated with a muffled voice and gagging. Upon examination of the throat, the uvula is swollen, pale, and somewhat translucent (uvular hydrops). If greatly enlarged, the uvula might rest on the tongue and move in and out with respiration. There might be an associated rash or a history of exposure to phsical stimuli, allergens, or a recurrent seasonal indicence.
What to do:
Because of the known association of uvular with hypopharyngeal edema, watch for signs of airway compromise. If a patient complains of resiratory difficulty or breathes with stridor, commence treatment with intravenous lines and intubation and cricothyrotomy equipment at the bedside, and a crosstable lateral soft tissue neck x ray to rule out epiglottic swelling.
If there is no acute respiraory difficulty, ask about precipitating events. Consider foods, drugs, physical agents, inhalants, insect bites and hereditary angioedema.
When fever, sore throat and pharyngeal injection are present, culture the throat with a rapid strep screen and give an antibiotic that covers Haemophilus influenzae (e.g., Biaxin, Augmentin, Bactrim).
It is reasonable to obtain a complete blood count with a manual differential to demonstrate eosinophilia to support the possibility of an allergic reaction or a high leukocyte count with increased granulocytes and bands to support a bacterial infection.
Initially the patient should receive parenteral H1 and H2 antihistamines like hydroxazine 50-100mg im or diphenhydramine 25-50mg iv along with cimetidine 300mg iv or po or ranitidine 50mg iv or 150mg po.
More severe cases should receive repeated doses of epinephrine 0.3ml of 1:1000 sq every 20 minutes x3. Nebulized isomeric or racemic epinephrine or albuterol are also effective.
Parenteral corticosteroids like SoluMedrol 125mg iv are also typically used, although efficacy remains umproven.
If there is a history of recurrent episodes of edema and there is a family history of the same, consider ordering a C4 complement level or C'1 esterase inhibitor levels as a screening test for hereditary angioedema. In this condition, the edema often involves the uvula and soft palate together.
Uvular decompression may be useful in patients that are resistant to medical therapy or whose symptoms progress rapidly. This procedure consists of grasping the uvula with forceps and either making several lacerations with a sterile needle or snippint the distal centimeter as a patial uvulectomy.
All patient s should be observed for an adequate period of time to insure that there is either improvement or no further worsening of the swelling before being discharged home. Upon discharge, they should receive 4-5 days of H1 and H2 blockers and steroids if required.
What not to do:
Do not perform a comprehensive and costly laboratory evaluation on every case. do only specific tests that are clearly indicated with results that will be followed up.
Discussion
The uvula (Latin for "little grape") is a small conical pedulous process hanging from the middle of lower border of the soft palate. It is composed of muscle, connective tissue and mucous membrane, with the bulk of the uvula consisting of glandular tissue with diffuse muscle fibers intersperced throughout. During the acts of degluttination and phonation, the uvula and soft palate are directed upward, thereby walling off the nasal cavity from the pharynx. During swallowing, this prevents ingested substances from entering the nasal cavity.
Angioedema, also known as angioneurotic edema and Quincke's disease, is defined as a well-localized edematous condition that may variably involve the deeper skin layers and subcutaneous tissues as well as mucosal surfaces of the upper respiratory and gastrointestinal tracts.
Immediate hypersnesitivity type I reactions, seen with atopic states and specific allergen sensitivities, are the most common causes of angioedema. These reactions involve the interaction of an allergen with IgE antibodies bound to the surface of basophile or mastocytes. Physical agents, including cold, pressure, light and vibration, or processes that increase core temperature, may also cause edema throuth the IgE pathway.
Hereditary angioedema, a genetic disorder of the complement system, is characterized by either an obsence of functional deficiency of C'1 esterase inhibitor. this allows unopposed activaation of the first component of complement, with subsequent breakdown of its two substrates, the second (C'2) and fourth (C'4) components of the complement cascade. This process, in the presence of plasmin, generates a vasoactive kinin-like molecule that causes angioedema. Acquired C'1 esterase inhibitor deficiency and other complement consumption states have been described in patients with malignancies and immune complex disorders, including serum sickness and vasculidities.
Other causes of angioedema include a direct degranulation effect on mast cells and basophils by certain medications and diagnostic agents (opiates, d-tubocurarine, curare and radiocontrast materials); substances such as aspirin, nonsteroidal anti-inflammatory drugs, azo dyes and benzoates that alter the metabolism of arachidonic acid, thus increasing smooth muscle permeability; and angiotensin converting enzyme inhibitors, implicated presumably by promoting the production of bradykinin.
The known infectious causes of uvulitis include group A streptococci, Haemophilus influenzae, and Streptococcus pneumoniae. An associated cellulitis may contiguouly involve the uvula with the tonsils, posterior pharynx, or epiglottis.
References:
Evans TC, Roberge RJ: Quincke's disease of the uvula. Am J Emerg Med 1987;5:211-216.
Goldberg R, Lawton R, Newton E et al: Evaluationand management of acute uvular edema. Ann Emerg Med 1993;22:251-255.w
Sunday 9 December 2012
Mucocele (Mucous cyst)
4.11 Mucocele (Mucous cyst)
Presentation
A patient may be alarmed by the rapid development of a soft, rounded cyst most often ocuring inside the lower lip. the cyst varies from 2 to 10mm in diameter and the surface is made up of pearly or translucent mucosa. The patient may be aware of previous trauma to the lip.
What to do:
Reassure the patient that this is not a serious tumor.
Refer the patient to an appropriate oral surgeon where laser ablation or total cyst excision can be performed.
Discussion
This cyst is caused by traumatic rupture of the mucus gland duct with extravasation of sialomucin into the submucosa. This most often occurs inside the lower lip but may also occur under the tongue or in the buccal mucosa. These traumatic mucous retention cysts easily rupture, releasing sticky, straw-colored fluid.
Presentation
A patient may be alarmed by the rapid development of a soft, rounded cyst most often ocuring inside the lower lip. the cyst varies from 2 to 10mm in diameter and the surface is made up of pearly or translucent mucosa. The patient may be aware of previous trauma to the lip.
What to do:
Reassure the patient that this is not a serious tumor.
Refer the patient to an appropriate oral surgeon where laser ablation or total cyst excision can be performed.
Discussion
This cyst is caused by traumatic rupture of the mucus gland duct with extravasation of sialomucin into the submucosa. This most often occurs inside the lower lip but may also occur under the tongue or in the buccal mucosa. These traumatic mucous retention cysts easily rupture, releasing sticky, straw-colored fluid.
Burning tongue
4.10 Burning tongue
Presentation
The patient is very uncomfortable with a burning sensation of the tongue or mouth. There may be xerostomia (reduced salivary flow), dental disease, geographic tongue, candidiasis or no visible explanation for the pain.
What to do:
Treat specific causative factors such as candida infections or dental problems.
Provide symptomatic relief with a one-to-one mixture of Benadryl elixir and Kaopectate, or prescribe viscous lidocaine.
If the etiology is uncertain, refer the patient for a comprehensive medical evaluation.
Discussion
Burning tongue or burning mouth symptoms are usually caused by xerostomia, candidiasis, other chronic infections, referred pain from the tongue muscles, dental disease, reflux of gastric acid, medications, noxious oral habits, blood dyscrasias, nutritional deficiencies, allergies, inflammatoriy disorders, psychogenic factors, or unknown causes. Geographic tongue results from loss of filiform papillae from patches on the dorsal surface of the tongue. The location of the patches may appear to shift over a period of weeks. It is usually not painful and does not require specific treatment.
Presentation
The patient is very uncomfortable with a burning sensation of the tongue or mouth. There may be xerostomia (reduced salivary flow), dental disease, geographic tongue, candidiasis or no visible explanation for the pain.
What to do:
Treat specific causative factors such as candida infections or dental problems.
Provide symptomatic relief with a one-to-one mixture of Benadryl elixir and Kaopectate, or prescribe viscous lidocaine.
If the etiology is uncertain, refer the patient for a comprehensive medical evaluation.
Discussion
Burning tongue or burning mouth symptoms are usually caused by xerostomia, candidiasis, other chronic infections, referred pain from the tongue muscles, dental disease, reflux of gastric acid, medications, noxious oral habits, blood dyscrasias, nutritional deficiencies, allergies, inflammatoriy disorders, psychogenic factors, or unknown causes. Geographic tongue results from loss of filiform papillae from patches on the dorsal surface of the tongue. The location of the patches may appear to shift over a period of weeks. It is usually not painful and does not require specific treatment.
Perleche
4.09 Perleche
Presentation
The patient complains of inflammation and soreness of the skin and contiguous labial mucous membranes at the angles of the mouth. On examination, there is erythema, fissuring and maceration of the oral commisures.
What to do:
Atempt to identify a precipitating cause and advise corrective action when possible.
Prescribe an antifungal cream such as naftidine 1% tid followed in a few hours by a corticosteroid in a non-greasy base such as triamcinolone 1%, and discontinue the steroids when the inflammation subsides in favor of a protective lip balm such as Chap Stick.
Discussion
Perleche is associated with the collection of moisture at the corners of the mouth, which encourages invasion by Candida albicans, staphlococci, streptococci and other organisms. In children, this is often caused by lip licking, drooling, thumb sucking and mouth breathing. Adults may be troubled by age-related changes in oral architecture and poorly fitting dentures. The differential diagnosis includes impetigo and herpes simplex infections. Vitamin B deficiency can be the cause, but this is rare and should not be treated presumptively.
Presentation
The patient complains of inflammation and soreness of the skin and contiguous labial mucous membranes at the angles of the mouth. On examination, there is erythema, fissuring and maceration of the oral commisures.
What to do:
Atempt to identify a precipitating cause and advise corrective action when possible.
Prescribe an antifungal cream such as naftidine 1% tid followed in a few hours by a corticosteroid in a non-greasy base such as triamcinolone 1%, and discontinue the steroids when the inflammation subsides in favor of a protective lip balm such as Chap Stick.
Discussion
Perleche is associated with the collection of moisture at the corners of the mouth, which encourages invasion by Candida albicans, staphlococci, streptococci and other organisms. In children, this is often caused by lip licking, drooling, thumb sucking and mouth breathing. Adults may be troubled by age-related changes in oral architecture and poorly fitting dentures. The differential diagnosis includes impetigo and herpes simplex infections. Vitamin B deficiency can be the cause, but this is rare and should not be treated presumptively.
Oral Candidiasis (Thrush)
4.08 Oral Candidiasis (Thrush)
Presentation
An infant (usually with a concurrent diaper rash) will have white patches in his mouth, or an older patient (usually with poor oral hygiene, diabetes, a hematologic malignacy, some immunodeficiency or on antibiotic, cytotoxic or steroid therapy) will complain of a sore mouth and sensitivity to foods that are spicy or acidic. On physical examination, there are painless white patches in the mouth and and on the tongue which wipe off easily with a swab, leaving an erythematous base that may bleed. There may be intense dark red inflammation throughout the oral cavity. .
What to do:
If there is any doubt about the etiology, onfirm the diagnosis by smearing the exudate, Gram staining, and examining under a microscope for large, gram-positive pseudohyphae and spores. A fungal culture may also confirm the diagnosis.
For topical treatment, prescribe an oral suspension of nystatin 200,000 units for infants and 400,000- 600,000 u for children and adults, gargled and swished in the mouth as long as possible before swallowing, four times a day, for at least two days beyond resolution of symptoms. Nystatin is also avilable in pastilles of 200,000 u: one or two can be dissolved in the mouth 4-5 times daily. Alternatively, prescribe clotrimazole in 10mg troches to be dissolved slowly in the mouth 5 times a day for 7-14 days.
For adults, fluconazole 200mg once, then 100mg qd po x7-14d may be a better regimen. Sometimes a single oral dose is effective, but the longer course decreases the risk of relapse.
Look elsewhere for Candida: esophagitis, intertrigo, vaginitis, diaper rash. All should respond to topical treatment with topical nystatin or clotrimazole.
Discussion
In the health newbor, thrush is a self-limited infection, but it should be treated to avoid feeding problems. In adults, oral candidiasis is found in a variety of acute and chronic forms. Localized erythema and erosions with minimal white exudate may be caused by candidal colonies beneath dentures and is commonly called "denture sore mouth." Maintenance prophylaxis may be prequired in patients with AIDS. Nystatin suspension has a high sugar content.
Presentation
An infant (usually with a concurrent diaper rash) will have white patches in his mouth, or an older patient (usually with poor oral hygiene, diabetes, a hematologic malignacy, some immunodeficiency or on antibiotic, cytotoxic or steroid therapy) will complain of a sore mouth and sensitivity to foods that are spicy or acidic. On physical examination, there are painless white patches in the mouth and and on the tongue which wipe off easily with a swab, leaving an erythematous base that may bleed. There may be intense dark red inflammation throughout the oral cavity. .
What to do:
If there is any doubt about the etiology, onfirm the diagnosis by smearing the exudate, Gram staining, and examining under a microscope for large, gram-positive pseudohyphae and spores. A fungal culture may also confirm the diagnosis.
For topical treatment, prescribe an oral suspension of nystatin 200,000 units for infants and 400,000- 600,000 u for children and adults, gargled and swished in the mouth as long as possible before swallowing, four times a day, for at least two days beyond resolution of symptoms. Nystatin is also avilable in pastilles of 200,000 u: one or two can be dissolved in the mouth 4-5 times daily. Alternatively, prescribe clotrimazole in 10mg troches to be dissolved slowly in the mouth 5 times a day for 7-14 days.
For adults, fluconazole 200mg once, then 100mg qd po x7-14d may be a better regimen. Sometimes a single oral dose is effective, but the longer course decreases the risk of relapse.
Look elsewhere for Candida: esophagitis, intertrigo, vaginitis, diaper rash. All should respond to topical treatment with topical nystatin or clotrimazole.
Discussion
In the health newbor, thrush is a self-limited infection, but it should be treated to avoid feeding problems. In adults, oral candidiasis is found in a variety of acute and chronic forms. Localized erythema and erosions with minimal white exudate may be caused by candidal colonies beneath dentures and is commonly called "denture sore mouth." Maintenance prophylaxis may be prequired in patients with AIDS. Nystatin suspension has a high sugar content.
Gingivitis
4.07 Gingivitis
Presentation
The patient will complain of generalized severe pain of the gums, often with a foul taste or odor. The gingiva will appear edematous and red with a grayish necrotic membrane between the teeth. The gums bleed on gentle touch and there is loss of gingival tissue, especially the interdental papillae. The patient is usually afebrile and shows no sign of systemic disease.
What to do:
Prescribe (in order of preference) tetracycline, penicillin VK or erythromycin, 250mg qid for ten days.
Instruct the patient to use warm saline rinses, every one to two hours along with flossing and gentle brushing using sodium bicarbonate toothpaste.
For comfort, prescribe viscous lidocaine.
For definitive care and the prevention of periodontal disease refer the patient for dental followup care. With appropriate treatment, patients usually respond dramatically in 48-72 hours.
Discussion
Acute necrotizing ulcerative gingivitis is also known as Vincent's angina or trench mouth. This condition is usually seen in patients who practice poor oral hygiene, are under stress, smoke, ad sometimes, have immune deficiencies. Systemic diseases that may simulate the appearance of ANUG include infectious mononucleosis, leukemia, aplastic anemia and agranulocytosis.
Presentation
The patient will complain of generalized severe pain of the gums, often with a foul taste or odor. The gingiva will appear edematous and red with a grayish necrotic membrane between the teeth. The gums bleed on gentle touch and there is loss of gingival tissue, especially the interdental papillae. The patient is usually afebrile and shows no sign of systemic disease.
What to do:
Prescribe (in order of preference) tetracycline, penicillin VK or erythromycin, 250mg qid for ten days.
Instruct the patient to use warm saline rinses, every one to two hours along with flossing and gentle brushing using sodium bicarbonate toothpaste.
For comfort, prescribe viscous lidocaine.
For definitive care and the prevention of periodontal disease refer the patient for dental followup care. With appropriate treatment, patients usually respond dramatically in 48-72 hours.
Discussion
Acute necrotizing ulcerative gingivitis is also known as Vincent's angina or trench mouth. This condition is usually seen in patients who practice poor oral hygiene, are under stress, smoke, ad sometimes, have immune deficiencies. Systemic diseases that may simulate the appearance of ANUG include infectious mononucleosis, leukemia, aplastic anemia and agranulocytosis.
Sialolithiasis (Salivary Duct Stones)
4.06 Sialolithiasis (Salivary Duct Stones)
Presentation
Patients of any age may develop salivary duct stones. The vast majority of such stones occur in Wharton's duct from the submaxillary gland. The patient will be alarmed by the rapid swelling beneath his jaw that suddenly appears while he is eating. The swelling may be painful but is not hot or red and usually subsides within two hours. This swelling may only be intermittent and may not occur with every meal. Infection can occur and will be accompanied by increased pain, exquisite tenderness, erythema and fever. Under these circumstances pus can sometimes be expressed from the opening of the duct when the gland is pressed open.
What to do:
Bimanually palpate the course of the salivary duct, feeling for stones.
When a small superficial stone can be felt, anesthetize the tissue beneath the duct and ampule with a small amount of lidocaine 1% with epinephrine. If available, a punctum dilator can be used to widen the orifice of the duct. Then milk the gland and duct with your fingers to express the stone(s).
If the stone cannot be palpated, try to locate it with x rays. Standard x rays of the mandible are likely to demonstrate only large stones. Dental x ray film shot at right angles to the floor of the mouth is much more likely to demonstrate small stones in Wharton's duct. Place film between cheek and gum to visualize Stenson's duct.
When a stone cannot be demonstrated or cannot be manually expressed, the patient should be referred for contrast sialography and/or surgical removal of the stone. Often sialography will show whether an obstruction is due to stenosis, a stone, or a tumor.
Begin treatment of any infection with cefalexin or dicloxacillin 500mg po tid x 10 days after obtaining cultures.
What not to do:
Do not attempt to dilate a salivary duct if mumps is suspected. Acute, persistent pain and swelling of the parotid gland along with inflammation of the papilla of Stenson's duct, fever, lymphocytosis, hyperamylasemia and malaise should alert the examiner to the probability of mumps.
Discussion
Salivary duct stones are generally composed of calcium carbonate and calcium phosphate. Uric acid stones may form in patients with gout. Although the majority form in Wharton's duct in the floor of the mouth, approximately 10% occur in Stenson's duct in the cheek, and 5% in the sublingual ducts. Depending on the location and the size of the stone the presenting symptoms will vary. As a rule, the onset of swelling will be sudden and associated with salivation during a meal.
Presentation
Patients of any age may develop salivary duct stones. The vast majority of such stones occur in Wharton's duct from the submaxillary gland. The patient will be alarmed by the rapid swelling beneath his jaw that suddenly appears while he is eating. The swelling may be painful but is not hot or red and usually subsides within two hours. This swelling may only be intermittent and may not occur with every meal. Infection can occur and will be accompanied by increased pain, exquisite tenderness, erythema and fever. Under these circumstances pus can sometimes be expressed from the opening of the duct when the gland is pressed open.
What to do:
Bimanually palpate the course of the salivary duct, feeling for stones.
When a small superficial stone can be felt, anesthetize the tissue beneath the duct and ampule with a small amount of lidocaine 1% with epinephrine. If available, a punctum dilator can be used to widen the orifice of the duct. Then milk the gland and duct with your fingers to express the stone(s).
If the stone cannot be palpated, try to locate it with x rays. Standard x rays of the mandible are likely to demonstrate only large stones. Dental x ray film shot at right angles to the floor of the mouth is much more likely to demonstrate small stones in Wharton's duct. Place film between cheek and gum to visualize Stenson's duct.
When a stone cannot be demonstrated or cannot be manually expressed, the patient should be referred for contrast sialography and/or surgical removal of the stone. Often sialography will show whether an obstruction is due to stenosis, a stone, or a tumor.
Begin treatment of any infection with cefalexin or dicloxacillin 500mg po tid x 10 days after obtaining cultures.
What not to do:
Do not attempt to dilate a salivary duct if mumps is suspected. Acute, persistent pain and swelling of the parotid gland along with inflammation of the papilla of Stenson's duct, fever, lymphocytosis, hyperamylasemia and malaise should alert the examiner to the probability of mumps.
Discussion
Salivary duct stones are generally composed of calcium carbonate and calcium phosphate. Uric acid stones may form in patients with gout. Although the majority form in Wharton's duct in the floor of the mouth, approximately 10% occur in Stenson's duct in the cheek, and 5% in the sublingual ducts. Depending on the location and the size of the stone the presenting symptoms will vary. As a rule, the onset of swelling will be sudden and associated with salivation during a meal.
Oral Herpes Simplex (Cold Sore)
4.05 Oral Herpes Simplex (Cold Sore)
Presentation
Patients have swelling, burning or soreness at an intra- or extra-oral lesion consisting of clusters of small vesicles on an erythematous base, which then rupture to produce red irregular ulcerations with swollen borders and possibly crusting or superinfection. These lesions occur on the hard palate or gingiva or, more commonly, at the vermilion border of the lip.
What to do:
When there is any doubt of the diagnosis, scrape the base of a vesicle (warn the patient this hurts) smear on a slide, stain with Wright's or Giemsa, and examine for multinucleate giant cells (look for nuclear molding). This is called a Tzanck Prep, and establishes the diagnosis of herpes. Alternatively, this swab can be sent for viral cultures, which may take days to grow.
An equal mixture of Kaopectate and Benadryl elixir will coat and dry the area and reduce pain. Topical Orabase, or Xylocaine 2% Viscous Solution will also relieve the pain. Consider oral analgesics for continuous pain relief. Narcotic analgesics and mild sedation may be required to manage the most severe pain.
Instruct the patient to keep lesions clean, and avoid touching lesions (so as not to spread the virus to eyes, unaffected skin, and other people).
Inform the patient that oral herpes need not be related to genital herpes; that the vesicles and pain should resolve over about two weeks (barring superinfection); that they are infectious during this period (and perhaps other times as well); and that the herpes simplex virus, residing in sensory ganglia, can be expected to cause recurrences from time to time (especially during illness or stress).
What not to do:
Do not prescribe topical or systemic acyclovir (Zovirax) unless the patient or household contacts are immunocompromised. It reduces viral shedding, but has not been shown to benefit oral herpes simplex.
Do not use topical anesthetics on keratinized skin. They are only effective on oral mucosa.
Discussion
Herpes simplex infection may be either primary or recurrent. Possible causes of herpes reactivation include stress, fever, menstruation, gastrointestinal distubance, infection, cold, fatigue and sunlight. Primary herpes usually appears as gingivostomatitis, pharyngitis, or a combination of the two, while recurrent infections usually occur as intraoral or labial ulcers. Primary infection tends to be a disease of children or young adults, more severe than recurring episodes, preceded by fever to 105 degrees, sore throat and headache, and followed by red, swollen gums that bleed easily. This gingivostomatitis may need to be differentiated from herpangina, acute necrotizing ulcerative gingivitis, Stevens-Johnson syndrome, Behet's syndrome and hand, foot and mouth disease.
Herpangina is caused by Coxsackie A virus and involves the posterior pharynx. Acute necrotizing ulcerative gingivitis, also known as Vincent's angina or trench mouth, is bacterial in origin, has characteristic blunting of the interdental gingival papillae, and responds rapidly to penicillin. Steven-Johnson sundrome is a severe form of erythema multiforme. There are characteristic lip lesions, the gingiva is only rarely affected, and there may be bull's-eye skin lesions on the hands and feet. Behet's syndrome is thought to be an autoimmune response and is associated with genital ulcers and inflammatory ocular lesions. Hand, foot and mouth disease is also caused by the Coxsackie A virus and is associated with concurrent lesions of the palms and soles.
Home remedies for cold sores include ether, lecithin, lysine, and vitamin E. Because herpes is a self-limiting affliction, all of these work, but, in controlled studies, none have outperformed placebos (which also do very well).
References:
Raborn GW, Dip MS, McGaw WT, Grace M, Percy J: Treatment of herpes labialis with acyclovir. Am J Med 1988;85(suppl 2A):39-42
.
Presentation
Patients have swelling, burning or soreness at an intra- or extra-oral lesion consisting of clusters of small vesicles on an erythematous base, which then rupture to produce red irregular ulcerations with swollen borders and possibly crusting or superinfection. These lesions occur on the hard palate or gingiva or, more commonly, at the vermilion border of the lip.
What to do:
When there is any doubt of the diagnosis, scrape the base of a vesicle (warn the patient this hurts) smear on a slide, stain with Wright's or Giemsa, and examine for multinucleate giant cells (look for nuclear molding). This is called a Tzanck Prep, and establishes the diagnosis of herpes. Alternatively, this swab can be sent for viral cultures, which may take days to grow.
An equal mixture of Kaopectate and Benadryl elixir will coat and dry the area and reduce pain. Topical Orabase, or Xylocaine 2% Viscous Solution will also relieve the pain. Consider oral analgesics for continuous pain relief. Narcotic analgesics and mild sedation may be required to manage the most severe pain.
Instruct the patient to keep lesions clean, and avoid touching lesions (so as not to spread the virus to eyes, unaffected skin, and other people).
Inform the patient that oral herpes need not be related to genital herpes; that the vesicles and pain should resolve over about two weeks (barring superinfection); that they are infectious during this period (and perhaps other times as well); and that the herpes simplex virus, residing in sensory ganglia, can be expected to cause recurrences from time to time (especially during illness or stress).
What not to do:
Do not prescribe topical or systemic acyclovir (Zovirax) unless the patient or household contacts are immunocompromised. It reduces viral shedding, but has not been shown to benefit oral herpes simplex.
Do not use topical anesthetics on keratinized skin. They are only effective on oral mucosa.
Discussion
Herpes simplex infection may be either primary or recurrent. Possible causes of herpes reactivation include stress, fever, menstruation, gastrointestinal distubance, infection, cold, fatigue and sunlight. Primary herpes usually appears as gingivostomatitis, pharyngitis, or a combination of the two, while recurrent infections usually occur as intraoral or labial ulcers. Primary infection tends to be a disease of children or young adults, more severe than recurring episodes, preceded by fever to 105 degrees, sore throat and headache, and followed by red, swollen gums that bleed easily. This gingivostomatitis may need to be differentiated from herpangina, acute necrotizing ulcerative gingivitis, Stevens-Johnson syndrome, Behet's syndrome and hand, foot and mouth disease.
Herpangina is caused by Coxsackie A virus and involves the posterior pharynx. Acute necrotizing ulcerative gingivitis, also known as Vincent's angina or trench mouth, is bacterial in origin, has characteristic blunting of the interdental gingival papillae, and responds rapidly to penicillin. Steven-Johnson sundrome is a severe form of erythema multiforme. There are characteristic lip lesions, the gingiva is only rarely affected, and there may be bull's-eye skin lesions on the hands and feet. Behet's syndrome is thought to be an autoimmune response and is associated with genital ulcers and inflammatory ocular lesions. Hand, foot and mouth disease is also caused by the Coxsackie A virus and is associated with concurrent lesions of the palms and soles.
Home remedies for cold sores include ether, lecithin, lysine, and vitamin E. Because herpes is a self-limiting affliction, all of these work, but, in controlled studies, none have outperformed placebos (which also do very well).
References:
Raborn GW, Dip MS, McGaw WT, Grace M, Percy J: Treatment of herpes labialis with acyclovir. Am J Med 1988;85(suppl 2A):39-42
.
Aphthous Ulcer (Canker Sore)
4.04 Aphthous Ulcer (Canker Sore)
Presentation
The patient complains of a painful lesion in the mouth, and may be worried about having herpes. A pale yellow, flat, even-bordered ulcer surrounded by a red halo may be seen on the buccal or labial mucosa, lingual sulci, soft palate, pharynx, tongue, or gingiva. Lesions are usually solitary, but can be multiple and recurrent. The pain is usually greater than the size of the lesions would suggest, and major aphthae (larger than 1 cm) indicate a severe form of the disease which may last for weeks of months.
What to do:
Attempt to differentiate from lesions of herpes simplex and reassure the patient of the benign nature of most canker sores.
Inform the patient that these lesions usually last 1-2 weeks, and that they should avoid hot, acidic or irritating food and drink.
For transient pain relief, try a tablet of sucralfate crushed in a small amount of warm water, swirled in the mouth or gargled. Tetracycline elixir (or a capsule dissolved in water) not swallowed, but applied to cauterize lesions or used as a mouth wash can relieve pain after single or repeated application. Benadryl elixir mixed one-to-one with Kaopectate, Xylocaine 2% Viscous Solution, and Orabase HC applied topically can also provide symptomatic relief.
For more severe cases, prescribe triamcinolone acetonide 0.1% suspension (add injectable Kenolog to sterile water without preservatives) in a 5ml oral rinse and spit out four times a day after meals and before bed, taking nothing by mouth for an hour afterward. An alternative regimen is dexamathasone elixir 1.5mg in 15ml qid rinse and swallow, tapering to three days of 0.5ml in 5ml, then three days swallowing every other dose, but discontinuing the regimen as soon as the mouth becomes comfortable.
In very severe cases, try a burst dose of prednisone 40-60mg qd x5 (no tapering).
Discussion
Aphthous stomatitis has been studied for many years by numerous investigators. Although many exacerbating factors have been identified, the cause as yet remains unknown. Lesions can be precipitated by minor trauma, food allergy, stress, and systemic illness. Recurrent aphthous ulcers may accompany malignancy or autoimmune disease. At present, the treatment is only palliative, and may not alter the course of the syndrome. Apthous ulcers may be an immune reaction to damaged mucosa or altered oral bacteria. Herpangina and hand-foot-and-mouth disease can produce ulcers resembling aphthous ulcers, but which are instead part of coxsackie viral exanthems, usually with fever and occurring in clusters among children. Behcet's syndrome is an idiopathic condition characterized by oral ulcers clinically indistinguishable from aphthae but accompanied by genital ulcers, conjunctivitis, retinitis, iritis, leukocytosis, eosinophilia and increased erythrocyte sedimentation rate.
References:
Vincent SD, Lilly GE: Clinical, historic and therapeutic features of aphthous stomatitis. Oral Surg Oral Med Oral Pathol 1992;74:79-86.
Presentation
The patient complains of a painful lesion in the mouth, and may be worried about having herpes. A pale yellow, flat, even-bordered ulcer surrounded by a red halo may be seen on the buccal or labial mucosa, lingual sulci, soft palate, pharynx, tongue, or gingiva. Lesions are usually solitary, but can be multiple and recurrent. The pain is usually greater than the size of the lesions would suggest, and major aphthae (larger than 1 cm) indicate a severe form of the disease which may last for weeks of months.
What to do:
Attempt to differentiate from lesions of herpes simplex and reassure the patient of the benign nature of most canker sores.
Inform the patient that these lesions usually last 1-2 weeks, and that they should avoid hot, acidic or irritating food and drink.
For transient pain relief, try a tablet of sucralfate crushed in a small amount of warm water, swirled in the mouth or gargled. Tetracycline elixir (or a capsule dissolved in water) not swallowed, but applied to cauterize lesions or used as a mouth wash can relieve pain after single or repeated application. Benadryl elixir mixed one-to-one with Kaopectate, Xylocaine 2% Viscous Solution, and Orabase HC applied topically can also provide symptomatic relief.
For more severe cases, prescribe triamcinolone acetonide 0.1% suspension (add injectable Kenolog to sterile water without preservatives) in a 5ml oral rinse and spit out four times a day after meals and before bed, taking nothing by mouth for an hour afterward. An alternative regimen is dexamathasone elixir 1.5mg in 15ml qid rinse and swallow, tapering to three days of 0.5ml in 5ml, then three days swallowing every other dose, but discontinuing the regimen as soon as the mouth becomes comfortable.
In very severe cases, try a burst dose of prednisone 40-60mg qd x5 (no tapering).
Discussion
Aphthous stomatitis has been studied for many years by numerous investigators. Although many exacerbating factors have been identified, the cause as yet remains unknown. Lesions can be precipitated by minor trauma, food allergy, stress, and systemic illness. Recurrent aphthous ulcers may accompany malignancy or autoimmune disease. At present, the treatment is only palliative, and may not alter the course of the syndrome. Apthous ulcers may be an immune reaction to damaged mucosa or altered oral bacteria. Herpangina and hand-foot-and-mouth disease can produce ulcers resembling aphthous ulcers, but which are instead part of coxsackie viral exanthems, usually with fever and occurring in clusters among children. Behcet's syndrome is an idiopathic condition characterized by oral ulcers clinically indistinguishable from aphthae but accompanied by genital ulcers, conjunctivitis, retinitis, iritis, leukocytosis, eosinophilia and increased erythrocyte sedimentation rate.
References:
Vincent SD, Lilly GE: Clinical, historic and therapeutic features of aphthous stomatitis. Oral Surg Oral Med Oral Pathol 1992;74:79-86.
Lacerations of the Mouth
4.03 Lacerations of the Mouth
Presentation
Because of the rich vascularity of the soft tissues of the mouth, impact injuries often lead to dramatic hemorrhages that send patients to the emergency department with relatively trivial lacerations. Blunt trauma to the face can cause secondary lacerations of the lips, frenulum, buccal mucosa, gingiva, and tongue. Active bleeding has usually stopped by the time a patient with a minor laceration has reached the emergency department.
What to do:
Provide appropriate tetanus prophylaxis and check for associated injuries such as loose teeth, mandibular or facial fractures .
When only small lacerations are present and only minimal gaping of the wound occurs, reassurance and simple aftercare is all that is required. Let the patient know the wound will become somewhat uncomfortable and covered with pus over the next 48 hours and tell him to rinse with lukewarm water or half strength hydrogen peroxide after meals and every one to two hours while awake for one week. Picture
If there is continued bleeding, the wound edges gape significantly or there is a flap or deformity when the underlying musculature contracts, the wound should be anesthetized using lidocaine with epinephrine, cleansed thoroughly with saline and loosely approximated using a 4-0 or 5-0 absorbable suture. Consider using conscious sedation when suturing children who cannot cooperate. A traction stitch or special rubber-tipped clamp can be very helpful when attempting to suture the tongue of a small child or intoxicated adult. The same aftercare as above applies.
When the exterior surface of the lip is lacerated, any separation of the underlying musculature must be repaired with buried absorbable sutures. To avoid an unsightly scar when the lip heals, precise skin approximation is very important. One must first approximate the vermilion border, making this the key suture. Fine non-absorbable suture material (e.g., 6-0 nylon or Prolene) is most appropriate for the skin surfaces of the lip while a fine absorbable suture (e.g., 6-0 Dexon or Vicryl) is quite acceptable on the mucosa and vermilion.
For deep lacerations of the mucosa or lip, or any sutured laceration in the mouth, prescribe prophylactic penicillin (penicillin VK 500mg tid x 3-4 days) to prevent deep tissue infections (erythromycin may be substituted in penicillin-allergic individuals). Recommend acetaminophen for pain.
Have patients return in 48 hours for a wound re-evaluation.
Recommend cool liquids and soft foods beginning four hours after the repair
What not to do:
Do not bother to repair a simple laceration or avulsion of the frenulum of the upper lip. It will heal quite nicely on its own.
Do not use non-absorbable suture material on the tongue, gingiva or buccal mucosa. There is no advantage and suture removal on a small child will be an unpleasant struggle at best.
Discussion
Imprecise repair of the vermilion border will lead to a "step-off" or puckering that is unsightly and difficult to repair later on. Fortunately, the tongue and oral mucosa usually heals with few complicating infections and there is a low risk of subsequent tissue necrosis.
Presentation
Because of the rich vascularity of the soft tissues of the mouth, impact injuries often lead to dramatic hemorrhages that send patients to the emergency department with relatively trivial lacerations. Blunt trauma to the face can cause secondary lacerations of the lips, frenulum, buccal mucosa, gingiva, and tongue. Active bleeding has usually stopped by the time a patient with a minor laceration has reached the emergency department.
What to do:
Provide appropriate tetanus prophylaxis and check for associated injuries such as loose teeth, mandibular or facial fractures .
When only small lacerations are present and only minimal gaping of the wound occurs, reassurance and simple aftercare is all that is required. Let the patient know the wound will become somewhat uncomfortable and covered with pus over the next 48 hours and tell him to rinse with lukewarm water or half strength hydrogen peroxide after meals and every one to two hours while awake for one week. Picture
If there is continued bleeding, the wound edges gape significantly or there is a flap or deformity when the underlying musculature contracts, the wound should be anesthetized using lidocaine with epinephrine, cleansed thoroughly with saline and loosely approximated using a 4-0 or 5-0 absorbable suture. Consider using conscious sedation when suturing children who cannot cooperate. A traction stitch or special rubber-tipped clamp can be very helpful when attempting to suture the tongue of a small child or intoxicated adult. The same aftercare as above applies.
When the exterior surface of the lip is lacerated, any separation of the underlying musculature must be repaired with buried absorbable sutures. To avoid an unsightly scar when the lip heals, precise skin approximation is very important. One must first approximate the vermilion border, making this the key suture. Fine non-absorbable suture material (e.g., 6-0 nylon or Prolene) is most appropriate for the skin surfaces of the lip while a fine absorbable suture (e.g., 6-0 Dexon or Vicryl) is quite acceptable on the mucosa and vermilion.
For deep lacerations of the mucosa or lip, or any sutured laceration in the mouth, prescribe prophylactic penicillin (penicillin VK 500mg tid x 3-4 days) to prevent deep tissue infections (erythromycin may be substituted in penicillin-allergic individuals). Recommend acetaminophen for pain.
Have patients return in 48 hours for a wound re-evaluation.
Recommend cool liquids and soft foods beginning four hours after the repair
What not to do:
Do not bother to repair a simple laceration or avulsion of the frenulum of the upper lip. It will heal quite nicely on its own.
Do not use non-absorbable suture material on the tongue, gingiva or buccal mucosa. There is no advantage and suture removal on a small child will be an unpleasant struggle at best.
Discussion
Imprecise repair of the vermilion border will lead to a "step-off" or puckering that is unsightly and difficult to repair later on. Fortunately, the tongue and oral mucosa usually heals with few complicating infections and there is a low risk of subsequent tissue necrosis.
Jaw Dislocation
4.02 Jaw Dislocation
Presentation
The patient's jaw is "out" and will not close, usually following a yawn, or perhaps after laughing, a dental extraction, jaw trauma or a dystonic drug reaction. The patient has difficulty speaking ans may have severe pain anterior to the ear. A depression can be seen or felt in the preauricular area and the jaw may appear prominent.
What to do:
If there was no trauma (and especially if the patient is a chronic dislocator) proceed directly to attempt reduction. If there is any possibility of an associated fracture, obtain x rays first.
Have the patient sit on a low stool, his back and head braced against something firm--either against the wall, facing you, or with the back of his head braced against your body, facing away from you.
With gloved hands, wrap your thumbs in gauze, seat them upon the lower molars, grasp both sides of the mandible, lock your elbows, and, bending from the waist, exert slow, steady pressure down and posteriorly. The mandible should be at or below the level of your forearm. Picture
In a bilateral dislocation, attempt to reduce one side at a time.
If the jaw does not relocate easily or convincingly, you may want to reassess the dislocation with x rays, and try again using intravenous midazolam to overcome the muscle spasm and 1-2ml of intraarticular 1% lidocaine to overcome the pain. Inject directly into the palpable depression left by the displaced condyle.
After reducing the dislocation it will be comforting to apply a soft cervical collar to reduce the range of motion at the temperomandibular joint (TMJ). Recommend a soft diet and instruct thepatient to refrain from opening his mouth too widely. Prescribe analgesics if needed.
If reduction cannot be obtained using the above techniques, then consider admission for reduction under general anesthesia.
What not to do:
Try not to get your thumbs bitten when the jaw snaps back into position. Maintain firm, steady traction and protect your thumbs with gauze.
Do not put pressure on oral prostheses that could cause them to break.
Do not attempt to reduce a TMJ dislocation with the patient's jaw at the height of your shoulders or above. You will need the leverage you get from having the patient in a lower position.
Do not try to force the patient's jaw shut.
Discussion
The mandible usually dislocates anteriorly, and subluxes when the jaw is opened wide. Other dislocations imply the presence of a fracture and require referral to a surgeon. Dislocation is often a chronic problem (avoided by limiting motion) and associated with temporomandibular joint dysfunction. If dislocation is not obvious, then consider other conditions, such as fracture, hemarthrosis, closed lock of the joint meniscus, and myofascial pain.
References:
Luyk NH, Larsen PE: The diagnosis and treatment of the dislocated mandible. Am J Emerg Med 1989;7:329-335.
Presentation
The patient's jaw is "out" and will not close, usually following a yawn, or perhaps after laughing, a dental extraction, jaw trauma or a dystonic drug reaction. The patient has difficulty speaking ans may have severe pain anterior to the ear. A depression can be seen or felt in the preauricular area and the jaw may appear prominent.
What to do:
If there was no trauma (and especially if the patient is a chronic dislocator) proceed directly to attempt reduction. If there is any possibility of an associated fracture, obtain x rays first.
Have the patient sit on a low stool, his back and head braced against something firm--either against the wall, facing you, or with the back of his head braced against your body, facing away from you.
With gloved hands, wrap your thumbs in gauze, seat them upon the lower molars, grasp both sides of the mandible, lock your elbows, and, bending from the waist, exert slow, steady pressure down and posteriorly. The mandible should be at or below the level of your forearm. Picture
In a bilateral dislocation, attempt to reduce one side at a time.
If the jaw does not relocate easily or convincingly, you may want to reassess the dislocation with x rays, and try again using intravenous midazolam to overcome the muscle spasm and 1-2ml of intraarticular 1% lidocaine to overcome the pain. Inject directly into the palpable depression left by the displaced condyle.
After reducing the dislocation it will be comforting to apply a soft cervical collar to reduce the range of motion at the temperomandibular joint (TMJ). Recommend a soft diet and instruct thepatient to refrain from opening his mouth too widely. Prescribe analgesics if needed.
If reduction cannot be obtained using the above techniques, then consider admission for reduction under general anesthesia.
What not to do:
Try not to get your thumbs bitten when the jaw snaps back into position. Maintain firm, steady traction and protect your thumbs with gauze.
Do not put pressure on oral prostheses that could cause them to break.
Do not attempt to reduce a TMJ dislocation with the patient's jaw at the height of your shoulders or above. You will need the leverage you get from having the patient in a lower position.
Do not try to force the patient's jaw shut.
Discussion
The mandible usually dislocates anteriorly, and subluxes when the jaw is opened wide. Other dislocations imply the presence of a fracture and require referral to a surgeon. Dislocation is often a chronic problem (avoided by limiting motion) and associated with temporomandibular joint dysfunction. If dislocation is not obvious, then consider other conditions, such as fracture, hemarthrosis, closed lock of the joint meniscus, and myofascial pain.
References:
Luyk NH, Larsen PE: The diagnosis and treatment of the dislocated mandible. Am J Emerg Med 1989;7:329-335.
Temporomandibular Joint (TMJ) Pain-Dysfunction Syndrome
4.01 Temporomandibular Joint (TMJ) Pain-Dysfunction Syndrome
Presentation
Patients usually complain of poorly-localized facial pain or headache that does not appear to conform to a strict anatomical distribution. The pain is generally dull and unilateral, centered in the temple, above and behind the eye, in and around the ear. The pain may be associated with instability of the temporomandibular joint (TMJ), crepitus, or clicking with movement of the jaw. It is often described as an earache. Other less obvious symptoms include radiation of pain down the carotic sheath, tinnitus, dizziness, decreased hearing, itching, sinus symptoms, a foreign body sensation in the external ear canal, trigenimal, occipital and glossopharyngeal neuralgias. Patients may have been previously diagnosed as suffering from migraine headaches, sinusitis or recurrent external otitis. Predisposing factors include malocclusion, recent extensive dental work, or a habit of grinding the teeth (bruxism), all of which put unusual stress upon the TM joint. Clinical signs include tenderness of the chewing muscles, the ear canal or the joint itself, restricted opening of the jaw or lateral deviation on opening, and a normal neurological examination.
What to do:
Examine the head thoroughly for other causes of the pain, including visual acuity, cranial nerves, and palpation of the scalp muscles and the temporal arteries. Pain and popping on moving the TMJ is a useful but not infallible sign. Look for signs of bruxism, such as ground-down teeth. If there is a headache, perform a complete neurologic examination, including fundoscopy. If the temporal artery is tender, swollen or inflamed, send blood for an erythrocyte sedimentation rate.
If pain is severe, you may try injecting the TMJ, just anterior to the tragus, with l ml of plain lidocaine or bupivicaine, along with 10mg of DepoMedrol. If this helps, you may have made the diagnosis, and possibly provided long-term relief.
Explain to the patient the pathophysiology of the syndrome: how many different symptoms may be produced by inflammation at one joint, how TMJ pain is not necessarily related to arthritis at other joints, and how common it is (some estimates are as high as 20% of the population).
Prescribe anti-inflammatory analgesics (e.g., aspirin, ibuprofen, naproxen), a soft diet, heat, and muscle relaxants (e.g., diazepam) if necessary for muscle spasm.
Refer the patient for followup to a dentist or otolaryngologist who has some interest in and experience with TMJ problems. Long-term treatments include orthodontic correction, physical therapy and sometimes psychotherapy and antidepressants.
What not to do:
Do not rule out TMJ arthritis simply because the joint is not tender on your examination. This syndrome typically fluctuates, and the diagnosis often is made on history alone.
Do not omit the TMJ in your workup of any headache.
Do not give narcotics unless there is going to be early follow up.
Discussion
The relative etiologic roles of inadequate dentition, unsatisfactory occlusion, dysfunction of the masticatory muscles and emotional disorders remain controversial. To stress the role played by muscles, it has been suggested that the term "myofascial pain-dysfunction (MPD) syndrome is more accurate than "TMJ arthritis." There is also much debate as to the indications for and the efficacy of treatment modalities aimed at the presumed etiologies. At the least, irreversible treatments such as surgery should be replaced by more conservative therapy. The use of bite blocks for bruxism was based on outdated information and may only serve to alter normal dental occlusion with deleterious effects.
Perhaps everyone suffers pain in the TMJ occasionally, and only a few require treatment or modification of lifestyle to reduce symptoms. In the ED the diagnosis of TMJ pain is often suspected, but seldom made definitively. It can be gratifying, however, to see patients with a myriad of seemingly unrelated symptoms respond dramatically after only conservative measures and advice.
References:
Guralnick W, Kaban LB, Merrill RG: Temperomandibular joint afflictions. N Eng J Med 1978:299:123-128.
Presentation
Patients usually complain of poorly-localized facial pain or headache that does not appear to conform to a strict anatomical distribution. The pain is generally dull and unilateral, centered in the temple, above and behind the eye, in and around the ear. The pain may be associated with instability of the temporomandibular joint (TMJ), crepitus, or clicking with movement of the jaw. It is often described as an earache. Other less obvious symptoms include radiation of pain down the carotic sheath, tinnitus, dizziness, decreased hearing, itching, sinus symptoms, a foreign body sensation in the external ear canal, trigenimal, occipital and glossopharyngeal neuralgias. Patients may have been previously diagnosed as suffering from migraine headaches, sinusitis or recurrent external otitis. Predisposing factors include malocclusion, recent extensive dental work, or a habit of grinding the teeth (bruxism), all of which put unusual stress upon the TM joint. Clinical signs include tenderness of the chewing muscles, the ear canal or the joint itself, restricted opening of the jaw or lateral deviation on opening, and a normal neurological examination.
What to do:
Examine the head thoroughly for other causes of the pain, including visual acuity, cranial nerves, and palpation of the scalp muscles and the temporal arteries. Pain and popping on moving the TMJ is a useful but not infallible sign. Look for signs of bruxism, such as ground-down teeth. If there is a headache, perform a complete neurologic examination, including fundoscopy. If the temporal artery is tender, swollen or inflamed, send blood for an erythrocyte sedimentation rate.
If pain is severe, you may try injecting the TMJ, just anterior to the tragus, with l ml of plain lidocaine or bupivicaine, along with 10mg of DepoMedrol. If this helps, you may have made the diagnosis, and possibly provided long-term relief.
Explain to the patient the pathophysiology of the syndrome: how many different symptoms may be produced by inflammation at one joint, how TMJ pain is not necessarily related to arthritis at other joints, and how common it is (some estimates are as high as 20% of the population).
Prescribe anti-inflammatory analgesics (e.g., aspirin, ibuprofen, naproxen), a soft diet, heat, and muscle relaxants (e.g., diazepam) if necessary for muscle spasm.
Refer the patient for followup to a dentist or otolaryngologist who has some interest in and experience with TMJ problems. Long-term treatments include orthodontic correction, physical therapy and sometimes psychotherapy and antidepressants.
What not to do:
Do not rule out TMJ arthritis simply because the joint is not tender on your examination. This syndrome typically fluctuates, and the diagnosis often is made on history alone.
Do not omit the TMJ in your workup of any headache.
Do not give narcotics unless there is going to be early follow up.
Discussion
The relative etiologic roles of inadequate dentition, unsatisfactory occlusion, dysfunction of the masticatory muscles and emotional disorders remain controversial. To stress the role played by muscles, it has been suggested that the term "myofascial pain-dysfunction (MPD) syndrome is more accurate than "TMJ arthritis." There is also much debate as to the indications for and the efficacy of treatment modalities aimed at the presumed etiologies. At the least, irreversible treatments such as surgery should be replaced by more conservative therapy. The use of bite blocks for bruxism was based on outdated information and may only serve to alter normal dental occlusion with deleterious effects.
Perhaps everyone suffers pain in the TMJ occasionally, and only a few require treatment or modification of lifestyle to reduce symptoms. In the ED the diagnosis of TMJ pain is often suspected, but seldom made definitively. It can be gratifying, however, to see patients with a myriad of seemingly unrelated symptoms respond dramatically after only conservative measures and advice.
References:
Guralnick W, Kaban LB, Merrill RG: Temperomandibular joint afflictions. N Eng J Med 1978:299:123-128.
Saturday 8 December 2012
Mononucleosis (Glandular Fever)
3.14 Mononucleosis (Glandular Fever)
Presentation
The patient is usually of school age (nursery through night school) and complains of several days of fever, malaise, lassitude, myalgias, and anorexia, culminating in a severe sore throat. The physical examination is remarkable for generalized lymphadenopathy, including the anterior and posterior cervical chains and huge tonsils, perhaps meeting in the midline and covered with a dirty-looking exudate. There may also be palatal petechiae and swelling, splenomegaly, hepatomegaly, and a diffuse maculopapular rash.
What to do:
Perform a complete physical examination, looking for signs of other ailments, and the rare complication of airway obstruction, encephalitis, hemolytic anemia, thrombocytopenic purpura, myocarditis, pericarditis, hepatitis, and rupture of the spleen.
Send off blood tests: a differential white cell count (looking for atypical lymphocytes) and a heterophil or monospot test. Either of these tests, along with the generalized lymphadenopathy, confirms the diagnosis of mononucleosis, but atypical lymphocytes are less specific, being present in several viral infections.
Culture the throat. Patients with mononucleosis harbor group A streptococcus and require penicillin with about the same frequency as anyone else with a sore throat.
Warn the patient that the convalescence is longer than that of most viral illnesses (typically 2-4 weeks, occasionally more), and that he should seek attention in case of lightheadedness, abdominal or shoulder pain,or any other sign of the rare complications above.
Despite controversy, prednisolone is widely employed for symptomatic relief of infectious mononucleosis, usually 40mg of Prednisone qd for five days. It is particularly helpful in young adults with severe pharyngeal pain, odynophagia or marked tonsillar enlargement with impending oropharyngeal obstruction.
Arrange for medical followup.
What not to do:
Do not routinely give penicillin for the pharyngitis, and certainly do not give ampicillin. In a patient with mononucleosis, ampicillin can produce an uncomfortable rash, which, incidentally, does not imply allergy to ampicillin.
Do not unnecessarily frighten the patient about splenic rupture. If the spleen is clinically enlarged, he should avoid contact sports, but spontaneous ruptures are rare.
Discussion
All of the above probably apply to cytomegalovirus as well, although the severe tonsillitis and positive heterophil test are both less likely. Some who report having mono twice probably actually had CMV once and mono once.
Presentation
The patient is usually of school age (nursery through night school) and complains of several days of fever, malaise, lassitude, myalgias, and anorexia, culminating in a severe sore throat. The physical examination is remarkable for generalized lymphadenopathy, including the anterior and posterior cervical chains and huge tonsils, perhaps meeting in the midline and covered with a dirty-looking exudate. There may also be palatal petechiae and swelling, splenomegaly, hepatomegaly, and a diffuse maculopapular rash.
What to do:
Perform a complete physical examination, looking for signs of other ailments, and the rare complication of airway obstruction, encephalitis, hemolytic anemia, thrombocytopenic purpura, myocarditis, pericarditis, hepatitis, and rupture of the spleen.
Send off blood tests: a differential white cell count (looking for atypical lymphocytes) and a heterophil or monospot test. Either of these tests, along with the generalized lymphadenopathy, confirms the diagnosis of mononucleosis, but atypical lymphocytes are less specific, being present in several viral infections.
Culture the throat. Patients with mononucleosis harbor group A streptococcus and require penicillin with about the same frequency as anyone else with a sore throat.
Warn the patient that the convalescence is longer than that of most viral illnesses (typically 2-4 weeks, occasionally more), and that he should seek attention in case of lightheadedness, abdominal or shoulder pain,or any other sign of the rare complications above.
Despite controversy, prednisolone is widely employed for symptomatic relief of infectious mononucleosis, usually 40mg of Prednisone qd for five days. It is particularly helpful in young adults with severe pharyngeal pain, odynophagia or marked tonsillar enlargement with impending oropharyngeal obstruction.
Arrange for medical followup.
What not to do:
Do not routinely give penicillin for the pharyngitis, and certainly do not give ampicillin. In a patient with mononucleosis, ampicillin can produce an uncomfortable rash, which, incidentally, does not imply allergy to ampicillin.
Do not unnecessarily frighten the patient about splenic rupture. If the spleen is clinically enlarged, he should avoid contact sports, but spontaneous ruptures are rare.
Discussion
All of the above probably apply to cytomegalovirus as well, although the severe tonsillitis and positive heterophil test are both less likely. Some who report having mono twice probably actually had CMV once and mono once.
Foreign Body in Throat
3.13 Foreign Body in Throat
Presentation
The patient thinks he recently swallowed a fish or a chicken bone, pop top from an old-style can, or something of the sort, and still can feel a foreign body sensation in his throat, especially (perhaps painfully) when swallowing. He may be convinced that there is a bone or other object stuck in the throat. He may be able to localize the foreign body sensation precisely above the thyroid cartilage (implying a foreign body in the hypopharynx you may be able to see), or he may only vaguely localize the foreign body sensation to the suprasternal notch (which could imply an foreign body anywhere in the esophagus). A foreign body in the tracheobronchial tree usually stimulates coughing and wheezing. Obstruction of the esophagus produces drooling and spitting up of whatever fluid is swallowed.
What to do:
Establish exactly what was swallowed, when, and the progression of symptoms since then. Patients can accurately tell if a foreign body is on the left or right side.
If symptoms are mild, test the patient's ability to swallow, first using a small cup of water and then small piece of bread. See what symptoms are reproduced, or if the bread eliminates the foreign body sensation.
Percuss and auscultate the patient's chest. A foreign body sensation in the throat can be produced by a pneumothorax, pneumomediastinum, or esophageal disease, all of which may show up on a chest x ray.
With the patient sitting in a chair, inspect the oropharynx with a tongue depressor, looking for foreign bodies or abrasions
Inspect the hypopharynx with a good light or headlamp mirror, paying special attention to the base of the tongue, tonsils and vallecula, where foreign bodies are likely to lodge. Maximize your visibility and minimize gagging by holding the patient's tongue out (use a washcloth or 4x4" gauze for traction and take care not to lacerate the frenulum of the tongue on the lower incisors) and have the patient raise his soft palate by panting "like a dog." This may be accomplished without topical anesthesia, but if the patient is skeptical or tends to gag, you may anesthetize the soft palate and posterior pharynx with a spray (Cetacaine, Hurricaine or 10% lidocaine) or by having the patient gargle with viscous Xylocaine diluted 1:1 with tap water. Some patients may continue to gag even with the entire pharynx anesthetized.
If you find an foreign body to pluck out or an abrasion of the mucosa, you may have diagnosed the problem. A small fish bone is frequently difficult to see. It may be overlooked entirely except for the tip, or it may look like a strand of mucus. If the object can been seen directly, carefully grasp and remove it with bayonet forceps or hemostat. Objects in the base of the tongue or the hypopharynx require a mirror or indirect laryngoscope for visualization. Fiberoptic nasopharyngo- scopy is preferred when available. Further treatment is probably not required, but you should instruct the patient to seek followup if pain worsens, fever develops, breathing or swallowing is difficult, or if the foreign body sensation has not totally resolved in 2 days.
If you and your patient are not satisfied, you may proceed to a soft tissue lateral x ray of the neck. This will probably not show radiolucent or small foreign bodies, such as fish bones, or aluminum pop tops, but may point out other pathology, such as a retropharyngeal abscess, Zenker's diverticulum, or severe cervical spondylosis, which might account for symptoms (and also allows some time for the patient's gag reflex to settle down, in case you were not able to inspect the hypopharynx on the first try). Lateral soft-tissue x rays can be very misleading because ligaments and cartilage in the neck calcify at various rates and patterns. The foreign body you see on a plain x ray may simply be normal calcification of thyroid cartilage.
You may also want to proceed to a barium swallow, if available, to demonstrate with fluoroscopy any problems with swallowing motility, or perhaps coat and thus visualize a radiolucent foreign body. Remember that endoscopy is technically difficult after barium has coated the mucosa and possibly obscured a foreign body. It may be preferable to use a water-soluble contrast (e.g., Gastrographin) but even under the best of circumstances, contrast studies are of limited value.
Reserve rigid laryngoscopy, esophagoscopy, and bronchoscopy under general anesthesia for the few cases where your suspicion of a perforating foreign body remains high (e.g., when the patient has moderate to severe pain, is febrile or toxic, cannot swallow, is spitting blood, or has respiratory involvement.
If x rays are negative and careful inspection does not reveal a foreign body, and the patient is afebrile with only mild discomfort, the patient may be sent home and observed. Reassure him that a scratch on the mucose can produce a sensation that the foreign body is still there, but that if the symptoms worsen the next day or fail to resolve within two days he may need further endoscopic studies. If there are any continued symptoms, the patient should have an otolaryngology referral and consultation within two to three days.
What not to do:
Do not assume that a foreign body is absent just because the pain disappears after swallowing local anesthetic.
Do not reassure the patient that you have ruled out an foreign body if you have not. Explain what is likely and why invasive evaluation is more dangerous than careful follow up.
Do not miss preexisting pathology incidentally discovered during swallowing.
Do not attempt to remove a foreign body blindly from the throat with a finger or instrument, as you may push it farther down into the airway and obstruct it or cause damage to surrounding structures.
Discussion
During swallowing, as the base of the tongue pushes a bolus of food posteriorly, any sharp object hidden in that bolus may become embedded in the tonsil, the tonsillar pillar, the pharyngeal wall, or the tongue base itself. In one study, the majority of patients presenting with symptoms of an impacted fish bone had no demonstrated pathology, and their symptoms resolved in 48 hours. Twenty per cent did have an impacted fish bone, and the majority of these were easily identified and removed on initial visit.
All patients who complain of a foreign body of the throat should be taken seriously. Even relatively smooth or rounded objects that remain impacted in the esophagus have the potential for serious problems, and a fish bone can perforate the esophagus in only a few days. Impacted button batteries represent a true emergency and require rapid intervention and removal because leaking alkali produces liquefactive necrosis. A pill, composed of irritating medicine (e.g., tetracycline) swallowed without adequate liquid, may stick to the mucosa of the pharynx or esophagus and cause an irritating ulcer. Bay leaves, invisible on x rays and laryngoscopy, have lodged in the esophagus at the cricopharyngeus and produced severe symptoms until removed via rigid endoscope.
The sensation of a lump in the throat, unrelated to swallowing food or drink, may be globus hystericus, which is related to crico- pharyngeal spasm and anxiety. The initial workup is the same as with any foreign body sensation in the throat.
Presentation
The patient thinks he recently swallowed a fish or a chicken bone, pop top from an old-style can, or something of the sort, and still can feel a foreign body sensation in his throat, especially (perhaps painfully) when swallowing. He may be convinced that there is a bone or other object stuck in the throat. He may be able to localize the foreign body sensation precisely above the thyroid cartilage (implying a foreign body in the hypopharynx you may be able to see), or he may only vaguely localize the foreign body sensation to the suprasternal notch (which could imply an foreign body anywhere in the esophagus). A foreign body in the tracheobronchial tree usually stimulates coughing and wheezing. Obstruction of the esophagus produces drooling and spitting up of whatever fluid is swallowed.
What to do:
Establish exactly what was swallowed, when, and the progression of symptoms since then. Patients can accurately tell if a foreign body is on the left or right side.
If symptoms are mild, test the patient's ability to swallow, first using a small cup of water and then small piece of bread. See what symptoms are reproduced, or if the bread eliminates the foreign body sensation.
Percuss and auscultate the patient's chest. A foreign body sensation in the throat can be produced by a pneumothorax, pneumomediastinum, or esophageal disease, all of which may show up on a chest x ray.
With the patient sitting in a chair, inspect the oropharynx with a tongue depressor, looking for foreign bodies or abrasions
Inspect the hypopharynx with a good light or headlamp mirror, paying special attention to the base of the tongue, tonsils and vallecula, where foreign bodies are likely to lodge. Maximize your visibility and minimize gagging by holding the patient's tongue out (use a washcloth or 4x4" gauze for traction and take care not to lacerate the frenulum of the tongue on the lower incisors) and have the patient raise his soft palate by panting "like a dog." This may be accomplished without topical anesthesia, but if the patient is skeptical or tends to gag, you may anesthetize the soft palate and posterior pharynx with a spray (Cetacaine, Hurricaine or 10% lidocaine) or by having the patient gargle with viscous Xylocaine diluted 1:1 with tap water. Some patients may continue to gag even with the entire pharynx anesthetized.
If you find an foreign body to pluck out or an abrasion of the mucosa, you may have diagnosed the problem. A small fish bone is frequently difficult to see. It may be overlooked entirely except for the tip, or it may look like a strand of mucus. If the object can been seen directly, carefully grasp and remove it with bayonet forceps or hemostat. Objects in the base of the tongue or the hypopharynx require a mirror or indirect laryngoscope for visualization. Fiberoptic nasopharyngo- scopy is preferred when available. Further treatment is probably not required, but you should instruct the patient to seek followup if pain worsens, fever develops, breathing or swallowing is difficult, or if the foreign body sensation has not totally resolved in 2 days.
If you and your patient are not satisfied, you may proceed to a soft tissue lateral x ray of the neck. This will probably not show radiolucent or small foreign bodies, such as fish bones, or aluminum pop tops, but may point out other pathology, such as a retropharyngeal abscess, Zenker's diverticulum, or severe cervical spondylosis, which might account for symptoms (and also allows some time for the patient's gag reflex to settle down, in case you were not able to inspect the hypopharynx on the first try). Lateral soft-tissue x rays can be very misleading because ligaments and cartilage in the neck calcify at various rates and patterns. The foreign body you see on a plain x ray may simply be normal calcification of thyroid cartilage.
You may also want to proceed to a barium swallow, if available, to demonstrate with fluoroscopy any problems with swallowing motility, or perhaps coat and thus visualize a radiolucent foreign body. Remember that endoscopy is technically difficult after barium has coated the mucosa and possibly obscured a foreign body. It may be preferable to use a water-soluble contrast (e.g., Gastrographin) but even under the best of circumstances, contrast studies are of limited value.
Reserve rigid laryngoscopy, esophagoscopy, and bronchoscopy under general anesthesia for the few cases where your suspicion of a perforating foreign body remains high (e.g., when the patient has moderate to severe pain, is febrile or toxic, cannot swallow, is spitting blood, or has respiratory involvement.
If x rays are negative and careful inspection does not reveal a foreign body, and the patient is afebrile with only mild discomfort, the patient may be sent home and observed. Reassure him that a scratch on the mucose can produce a sensation that the foreign body is still there, but that if the symptoms worsen the next day or fail to resolve within two days he may need further endoscopic studies. If there are any continued symptoms, the patient should have an otolaryngology referral and consultation within two to three days.
What not to do:
Do not assume that a foreign body is absent just because the pain disappears after swallowing local anesthetic.
Do not reassure the patient that you have ruled out an foreign body if you have not. Explain what is likely and why invasive evaluation is more dangerous than careful follow up.
Do not miss preexisting pathology incidentally discovered during swallowing.
Do not attempt to remove a foreign body blindly from the throat with a finger or instrument, as you may push it farther down into the airway and obstruct it or cause damage to surrounding structures.
Discussion
During swallowing, as the base of the tongue pushes a bolus of food posteriorly, any sharp object hidden in that bolus may become embedded in the tonsil, the tonsillar pillar, the pharyngeal wall, or the tongue base itself. In one study, the majority of patients presenting with symptoms of an impacted fish bone had no demonstrated pathology, and their symptoms resolved in 48 hours. Twenty per cent did have an impacted fish bone, and the majority of these were easily identified and removed on initial visit.
All patients who complain of a foreign body of the throat should be taken seriously. Even relatively smooth or rounded objects that remain impacted in the esophagus have the potential for serious problems, and a fish bone can perforate the esophagus in only a few days. Impacted button batteries represent a true emergency and require rapid intervention and removal because leaking alkali produces liquefactive necrosis. A pill, composed of irritating medicine (e.g., tetracycline) swallowed without adequate liquid, may stick to the mucosa of the pharynx or esophagus and cause an irritating ulcer. Bay leaves, invisible on x rays and laryngoscopy, have lodged in the esophagus at the cricopharyngeus and produced severe symptoms until removed via rigid endoscope.
The sensation of a lump in the throat, unrelated to swallowing food or drink, may be globus hystericus, which is related to crico- pharyngeal spasm and anxiety. The initial workup is the same as with any foreign body sensation in the throat.
Pharyngitis (Sore Throat)
3.12 Pharyngitis (Sore Throat)
Presentation
The patient with a bacterial pharyngitis complains of a rapid onset of throat pain worsened by swallowing. There is usually a fever, pharyngeal erythema, and a purulent, patchy, yellow, gray or white exudate, tender cervical adenopathy, headache and absence of cough. Viral infections are typically accompanied by conjunctivitis, nasal congestion, hoarseness, cough, aphthous ulcers on the soft palate and myalgias. It is helpful to differentiate pain on swallowing (odynophagia) from difficulty swallowing (dysphagia), the latter being more likely caused by obstruction or abnormal muscular movement.
What to do:
First examine the ears, nose, and mouth, which are, after all, connected to the pharynx, and often contain clues to the diagnosis.
Depress the tongue with a blade, have the patient raise his soft palate by saying " ah," inspect the posterior pharynx, and swab both tonsillar pillars for a culture. (You can decide later whether you really need to plant the culture. Rapid strep tests may provide results in a few minutes, while cultures may take 1-2 days to incubate and interpret. This delay does not alter the effectiveness of therapy, however. Treatment may begin up to nine days after symptoms and still prevent rheumatic fever.)
If you are in the middle of an epidemic of group A streptococcal pharyngitis; if the patient is between 3 and 25 years old, has a history of rheumatic fever and recurrent "strep throats" and has been exposed; and if the patient has a red throat, fever, tender anterior cervical nodes, and no viral URI symptoms (or any convincing subset of the above); give antibiotics. Throat culture is optional, at the preference of the follow-up physician. The recommended treatment for streptococcal pharyngitis is oral penicillin VK 250mg q8h for 10 days. Injectable penicillins are preferred for patients unlikely to finish ten days of pills and those with a personal or family history of rheumatic fever. Patients under 60 lbs (30 kg) get one intramuscular injection of benzathine penicillin G 600,000 units and those over 60 lbs get 1,200,000u im. For those allergic to penicillin give erythromycin 250mg qid (or 333mg of erythromycin base tid) for 10 days. Amoxicillin offers no significant advantage for treating group A strep.
When the infection is not clearly bacterial or you are unsure about the need for an antibiotic (or you or the patient "need to know" if this is a strep infection) then you may obtain a rapid strep test. If the rapid strep test is positive, then treat with antibiotics as above. If the test is negative or unavailable and you have a high clinical suspicion that this is a viral pharyngitis, provide symptomatic treatment (below), send a culture, and hold antibiotics pending results.
For reistant or recurrent infections with possible beta-lactamase- producing co-pathogens, consider instead 10 days of cephalexin (Keflex), cefadroxil (Duricef, Ultracef), cefaclor (Ceclor), or cefurooxime (Ceftin, Zinacef).
If you suspect mononucleosis, draw blood for atypical lymphocytes and a heterophile or monospot to confirm the diagnosis (see below).
Relieve pain with acetaminophen ibuprofen, aspirin, warm saline gargles, and gargles or lozenges containing phenol as a mucosal anesthetic (e.g., Chloraseptic, Cepastat). A one-to-one mixture of diphenhydramine and kaolin-pectin suspension can also provide temporary relief of throat pain. Viscous Xylocaine gargles anesthetize the throat but patients may still have difficult swallowing because of the lack of sensation. For severe pain in patients without contraindications, dexamethasone 10mg im once has been used along with antibiotics.
What not to do:
Do not miss an acute epiglottitis or supraglottitis. In a child, this presents as a sudden, severe pharyngitis, with a gutteral, rather than hoarse voice (because it hurts to speak), drooling (because it hurts to swallow), and respiratory distress (because swelling narrows the airway). Adults usually have a more gradual onset, over several days, and are not as prone to a sudden airway occlusion, unless they present later in the progression of the swelling, already with some respiratory distress.
Do not give ampicillin to a patient with mononucleosis. The resulting rash helps make the diagnosis, and does not imply ampicillin allergy, but can be uncomfortable.
Do not miss abscesses, which usually require hospitalization and intravenous penicillin, if not drainage. Peritonsillar abcesses or cellulitis make the tonsillar pillar bulge towards the midline. Retropharyngeal abscesses (and epiglottitis) may require soft tissue lateral neck films to visualize.
Do not miss gonococcal pharyngitis, which can produce a mild clinical syndrome and requires special cultures on Thayer-Martin medium.
Do not miss the rare but deadly causes of sore throat. A patient with paresthesia at the site of an old, healed bite and painful spasms when he even thinks of swallowing may have rabies. A patient with facial palsy, myocarditis, and a tough, white, membrane adherent to the posterior pharynx may have diptheria. You cannot diagnose them unless you think of them.
Discussion
The general public knows to see a doctor for a sore throat, but the actual benefit of this visit is unclear. Rheumatic fever is a sequela of about 1% of group A streptococcal infections, and only about 10% of sore throats seen by physicians represent group A streptococcal infections. Post-streptococcal glomerulonephritis is usually a self- limiting illness and is not prevented with antibiotic treatment. Penicillin therapy does avoid acute rheumatic fever and may sometimes reduce symptoms or shorten the course of a sore throat. Antibiotics probably inhibit progress of the infection into tonsillitis, peritonsillar and retropharyngeal abscesses, adenitis, and pneumonia.
Group A streptococcal infection cannot be diagnosed reliably by clinical signs and symptoms. Typically, a quarter of throat cultures grown group A strep, and half of those represent carriers who do do not raise anti-streptococcal antibodies and risk rheumatic fever. Rapid strep screens are less sensitive than cultures. The best approach to the identification and treatment of streptococcal pharyngitis depends on the prevalence of group A streptococcal infection in the patient population, the cost and availability of culture and rapid test methods, the reliability of communication and follow up and the relative values of cost, antibiotic overuse, and adverse outcomes.
References
Coonan KM, Kaplan EL: In vitro susceptibility of recent North American group A streptococcal isolates to eleven oral antibiotics. Pediatr Infect Dis J 1994;13:630-635.
Hall CB, Breese BB: Does Penicillin make Johnny's strep throat better? Pediatric Infectious Disease 1984:3:7-9.
O'Brien JF, Meade JL, Falk JL: Dexamethasone as adjuvant therapy for severe acute pharyngitis. Ann Emerg Med 1993;22:212-214.
Huovinen P, Lahhtonen R, Ziegler T et al: Pharyngitis in adults: the presence and coexistence of viruses and bacterial organisms. Ann Intern Med. 1989;110:612-616.
Presentation
The patient with a bacterial pharyngitis complains of a rapid onset of throat pain worsened by swallowing. There is usually a fever, pharyngeal erythema, and a purulent, patchy, yellow, gray or white exudate, tender cervical adenopathy, headache and absence of cough. Viral infections are typically accompanied by conjunctivitis, nasal congestion, hoarseness, cough, aphthous ulcers on the soft palate and myalgias. It is helpful to differentiate pain on swallowing (odynophagia) from difficulty swallowing (dysphagia), the latter being more likely caused by obstruction or abnormal muscular movement.
What to do:
First examine the ears, nose, and mouth, which are, after all, connected to the pharynx, and often contain clues to the diagnosis.
Depress the tongue with a blade, have the patient raise his soft palate by saying " ah," inspect the posterior pharynx, and swab both tonsillar pillars for a culture. (You can decide later whether you really need to plant the culture. Rapid strep tests may provide results in a few minutes, while cultures may take 1-2 days to incubate and interpret. This delay does not alter the effectiveness of therapy, however. Treatment may begin up to nine days after symptoms and still prevent rheumatic fever.)
If you are in the middle of an epidemic of group A streptococcal pharyngitis; if the patient is between 3 and 25 years old, has a history of rheumatic fever and recurrent "strep throats" and has been exposed; and if the patient has a red throat, fever, tender anterior cervical nodes, and no viral URI symptoms (or any convincing subset of the above); give antibiotics. Throat culture is optional, at the preference of the follow-up physician. The recommended treatment for streptococcal pharyngitis is oral penicillin VK 250mg q8h for 10 days. Injectable penicillins are preferred for patients unlikely to finish ten days of pills and those with a personal or family history of rheumatic fever. Patients under 60 lbs (30 kg) get one intramuscular injection of benzathine penicillin G 600,000 units and those over 60 lbs get 1,200,000u im. For those allergic to penicillin give erythromycin 250mg qid (or 333mg of erythromycin base tid) for 10 days. Amoxicillin offers no significant advantage for treating group A strep.
When the infection is not clearly bacterial or you are unsure about the need for an antibiotic (or you or the patient "need to know" if this is a strep infection) then you may obtain a rapid strep test. If the rapid strep test is positive, then treat with antibiotics as above. If the test is negative or unavailable and you have a high clinical suspicion that this is a viral pharyngitis, provide symptomatic treatment (below), send a culture, and hold antibiotics pending results.
For reistant or recurrent infections with possible beta-lactamase- producing co-pathogens, consider instead 10 days of cephalexin (Keflex), cefadroxil (Duricef, Ultracef), cefaclor (Ceclor), or cefurooxime (Ceftin, Zinacef).
If you suspect mononucleosis, draw blood for atypical lymphocytes and a heterophile or monospot to confirm the diagnosis (see below).
Relieve pain with acetaminophen ibuprofen, aspirin, warm saline gargles, and gargles or lozenges containing phenol as a mucosal anesthetic (e.g., Chloraseptic, Cepastat). A one-to-one mixture of diphenhydramine and kaolin-pectin suspension can also provide temporary relief of throat pain. Viscous Xylocaine gargles anesthetize the throat but patients may still have difficult swallowing because of the lack of sensation. For severe pain in patients without contraindications, dexamethasone 10mg im once has been used along with antibiotics.
What not to do:
Do not miss an acute epiglottitis or supraglottitis. In a child, this presents as a sudden, severe pharyngitis, with a gutteral, rather than hoarse voice (because it hurts to speak), drooling (because it hurts to swallow), and respiratory distress (because swelling narrows the airway). Adults usually have a more gradual onset, over several days, and are not as prone to a sudden airway occlusion, unless they present later in the progression of the swelling, already with some respiratory distress.
Do not give ampicillin to a patient with mononucleosis. The resulting rash helps make the diagnosis, and does not imply ampicillin allergy, but can be uncomfortable.
Do not miss abscesses, which usually require hospitalization and intravenous penicillin, if not drainage. Peritonsillar abcesses or cellulitis make the tonsillar pillar bulge towards the midline. Retropharyngeal abscesses (and epiglottitis) may require soft tissue lateral neck films to visualize.
Do not miss gonococcal pharyngitis, which can produce a mild clinical syndrome and requires special cultures on Thayer-Martin medium.
Do not miss the rare but deadly causes of sore throat. A patient with paresthesia at the site of an old, healed bite and painful spasms when he even thinks of swallowing may have rabies. A patient with facial palsy, myocarditis, and a tough, white, membrane adherent to the posterior pharynx may have diptheria. You cannot diagnose them unless you think of them.
Discussion
The general public knows to see a doctor for a sore throat, but the actual benefit of this visit is unclear. Rheumatic fever is a sequela of about 1% of group A streptococcal infections, and only about 10% of sore throats seen by physicians represent group A streptococcal infections. Post-streptococcal glomerulonephritis is usually a self- limiting illness and is not prevented with antibiotic treatment. Penicillin therapy does avoid acute rheumatic fever and may sometimes reduce symptoms or shorten the course of a sore throat. Antibiotics probably inhibit progress of the infection into tonsillitis, peritonsillar and retropharyngeal abscesses, adenitis, and pneumonia.
Group A streptococcal infection cannot be diagnosed reliably by clinical signs and symptoms. Typically, a quarter of throat cultures grown group A strep, and half of those represent carriers who do do not raise anti-streptococcal antibodies and risk rheumatic fever. Rapid strep screens are less sensitive than cultures. The best approach to the identification and treatment of streptococcal pharyngitis depends on the prevalence of group A streptococcal infection in the patient population, the cost and availability of culture and rapid test methods, the reliability of communication and follow up and the relative values of cost, antibiotic overuse, and adverse outcomes.
References
Coonan KM, Kaplan EL: In vitro susceptibility of recent North American group A streptococcal isolates to eleven oral antibiotics. Pediatr Infect Dis J 1994;13:630-635.
Hall CB, Breese BB: Does Penicillin make Johnny's strep throat better? Pediatric Infectious Disease 1984:3:7-9.
O'Brien JF, Meade JL, Falk JL: Dexamethasone as adjuvant therapy for severe acute pharyngitis. Ann Emerg Med 1993;22:212-214.
Huovinen P, Lahhtonen R, Ziegler T et al: Pharyngitis in adults: the presence and coexistence of viruses and bacterial organisms. Ann Intern Med. 1989;110:612-616.
Sinusitis
3.11 Sinusitis
Presentation
Following a viral infection, the patient will usually complain of a dull pain in the face, gradually increasing over a couple of days, exacerbated by sudden motion of the head, or holding the head dependent, between the knees, and perhaps radiating to the upper molar teeth (via the maxillary antrum), or with eye movement (via the ethmoid sinuses). Often there is a sensation of facial congestion and stuffiness. Children with sinusitis often present with cough and fetid breath. Fever is only present in half of patients with acute infection and is usually low grade. A high fever usually indicates a serious complication such as meningitis or another diagnosis altogether. Transillumination of sinuses in the ED is usually unrewarding, but you may elicit tenderness on gentle percussion or firm palpation over the maxillary or frontal sinuses or between the eyes (ethmoid sinuses). Swelling and erythema may exist and you may even see pus draining below the nasal turbinates, with a purulent, yellow-green and sometimes foul-smelling or bloody discharge from the nose or running down the posterior pharynx. The patient's voice may have a resonance similar to that of a "stopped up" nose, and he may complain of a foul taste in his mouth. Stuffy ears and impaired hearing are common because of associated serous otitis media and eustachian tube dysfunction.
What to do:
Rule out other causes of facial pain or headache via history (did the patient wake up with a typical migraine?) and physical examination (palpate scalp muscles, temporal arteries, temperomandibular joints, eyes, and teeth).
Shrink swollen nasal mucosa (and thereby open the ostia draining the sinuses) with 1% phenylephrine (Neo-Synephrine) or 0.05% oxymetazoline (Afrin) nose drops. Drip 2 drops in each nostril, have the patient lie supine 2 minutes, and then repeat the process (this allows the first application to open the anterior nose so the second gets farther back). Have the patient repeat this process every 4 hours, but for no more than three days (to avoid rhinitis medicamentosa).
Examine the nose for purulent drainage before and after shrinking the nasal mucosa with topical vasoconstrictor.
Add systemic sympathomimetic decongestants (e.g., pseudephedrine (Sudafed) 60mg q6h or phenylpropanolamine (Entex LA) 75mg q12h).
If there is fever, pus, heat, or any other sign of a bacterial superinfection, add antibiotics (e.g., amoxicillin, trimethoprim plus sulfamethoxazole, amoxicillin plus clavulinate, erythromycin plus sulfasoxazole, cefuroxime). First-line antibiotic therapy is amoxicillin, or, for patients with penicillin allergy, Bactrim or Sulfa. If the patient has been recently treated with these medications or if the infection appears to be serious, then treat with a second-line drug like Ceftin or Augmentin.
Provide pain relief, when necessary (e.g., ibuprofen, naproxyn, acetaminophen, oxycodone, hydrocodone)
Recommend symptomatic relief with hot water vapor inhalation using a simple teakettle or hot shower or, if available, a steam vaporizer or home facial sauna device.
Sinusitis can sometimes be demonstrated on x rays, and you can usually get adequate visualization of maxillary, frontal, and ethmoid sinuses with one upright Water's view. Chronic sinusitis appears as thickened mucosa; acute as an air-fluid level or complete opacification. Films are usually not necessary, however, on an emergency basis. If symptoms and physical findings of sinusitis are classic, plain sinus radiographs need not be obtained before treatment. If an acute attack does not resolve with medical treatment, or the diagnosis of sinusitis is in doubt, plain films are helpful as the primary imaging study.
Arrange for followup within 1-7 days.
What not to do
Do not ignore signs of an orbital cellulitis with swelling erythema, decreased extraocular movements and possible proptosis. These patients require consultation and admission for intravenous antibiotics.
Do not ignore the toxic patient with marked swelling, high fever, severe pain, profuse drainage, or other signs and symptoms of a serious infection. See potential complications below. These patients require immediate consultation and intervention.
Do not prescribe antihistamines, which can make mucous secretions dry and thick, and interfere with necessary drainage. Antihistamines only cure sinusitis on television, or when it is due to allergic rhinitis.
Do not allow patients to use decongestant nose drops more than 3 days, thereby allowing their nasal mucosa to become habituated to sympathomimetic medication. When they stop the drops they will suffer a rebound nasal congestion (rhinitis medicamentosa) which requires time, topical steroids, and reeducation to resolve.
Do not prescribe topical or systemic sympathomimetic decongestants to a patient who suffers from hypertension, tachycardia or difficulty initiating urination, all of which may be exacerbated.
Discussion
The paranasal sinuses drain through tiny ostia under the nasal turbinates which, if occluded, allow secretions and pressure differences to build up, resulting in pressure and pain of acute sinusitis, and the air-fluid levels sometimes visible on upright x rays. Sinus infections are relatively common and complications relatively rare, but the bony walls of the paranasal sinuses are so thin that bacterial infections can spread through them. Most sinusitis begins with mucosal swelling from a viral upper respiratory infection. Other causes include dental infection, allergic rhinitis, barotrauma from flying, swimming or diving, nasal polyps and tumors and foreign bodies, including nasogastric and endotracheal tubes in hospitalized patients. Abscessed teeth can be the source of a maxillary sinusitis. If there is tenderness to percussion of the bicuspids or molars, arrange for dental referral.
Complications such as orbital cellulitis, osteomyelitis, epidural abscell, meningitis, cavernous sinus thrombosis and subdural empyema can be devastating and therefore patients must be instructed to get early follow up when signs and symptoms worsen or do not improve in 48-72 hours, or if there is any change in mentation. Frontal sinusitis has the greatest potential for serious complications, particularly in adolescent males, the group at greatest risk for intracranial complications.br Computerized tomographic scanning of the sinuses is more accurate than plain x rays, particularly when evaluating the ethmoid or sphenoid sinuses, but CT scans are needed from the ED only in unusual circumstances. Most patients can have initial treatment begun on the basis of history and physical findings alone. Anyone who has facial pain, headache, purulent nasal discharge and nasal congestion persisting for more than ten days, with or without a fever, should probably be treated empirically for sinusitis.
Many patients have been conditioned by the advertising of over-the-counter antihistamines for "sinus" problems (usually meaning "allergic rhinitis"), and may relate a history of "sinuses" which, on closer questioning, turns out to have been rhinitis.
References:
Williams JW, Simel DL: Does this patient have sinusitis? Diagnosing acute sinusitis by history and physical examination. J Am Med Assoc 1993;270:1242-1246.
Presentation
Following a viral infection, the patient will usually complain of a dull pain in the face, gradually increasing over a couple of days, exacerbated by sudden motion of the head, or holding the head dependent, between the knees, and perhaps radiating to the upper molar teeth (via the maxillary antrum), or with eye movement (via the ethmoid sinuses). Often there is a sensation of facial congestion and stuffiness. Children with sinusitis often present with cough and fetid breath. Fever is only present in half of patients with acute infection and is usually low grade. A high fever usually indicates a serious complication such as meningitis or another diagnosis altogether. Transillumination of sinuses in the ED is usually unrewarding, but you may elicit tenderness on gentle percussion or firm palpation over the maxillary or frontal sinuses or between the eyes (ethmoid sinuses). Swelling and erythema may exist and you may even see pus draining below the nasal turbinates, with a purulent, yellow-green and sometimes foul-smelling or bloody discharge from the nose or running down the posterior pharynx. The patient's voice may have a resonance similar to that of a "stopped up" nose, and he may complain of a foul taste in his mouth. Stuffy ears and impaired hearing are common because of associated serous otitis media and eustachian tube dysfunction.
What to do:
Rule out other causes of facial pain or headache via history (did the patient wake up with a typical migraine?) and physical examination (palpate scalp muscles, temporal arteries, temperomandibular joints, eyes, and teeth).
Shrink swollen nasal mucosa (and thereby open the ostia draining the sinuses) with 1% phenylephrine (Neo-Synephrine) or 0.05% oxymetazoline (Afrin) nose drops. Drip 2 drops in each nostril, have the patient lie supine 2 minutes, and then repeat the process (this allows the first application to open the anterior nose so the second gets farther back). Have the patient repeat this process every 4 hours, but for no more than three days (to avoid rhinitis medicamentosa).
Examine the nose for purulent drainage before and after shrinking the nasal mucosa with topical vasoconstrictor.
Add systemic sympathomimetic decongestants (e.g., pseudephedrine (Sudafed) 60mg q6h or phenylpropanolamine (Entex LA) 75mg q12h).
If there is fever, pus, heat, or any other sign of a bacterial superinfection, add antibiotics (e.g., amoxicillin, trimethoprim plus sulfamethoxazole, amoxicillin plus clavulinate, erythromycin plus sulfasoxazole, cefuroxime). First-line antibiotic therapy is amoxicillin, or, for patients with penicillin allergy, Bactrim or Sulfa. If the patient has been recently treated with these medications or if the infection appears to be serious, then treat with a second-line drug like Ceftin or Augmentin.
Provide pain relief, when necessary (e.g., ibuprofen, naproxyn, acetaminophen, oxycodone, hydrocodone)
Recommend symptomatic relief with hot water vapor inhalation using a simple teakettle or hot shower or, if available, a steam vaporizer or home facial sauna device.
Sinusitis can sometimes be demonstrated on x rays, and you can usually get adequate visualization of maxillary, frontal, and ethmoid sinuses with one upright Water's view. Chronic sinusitis appears as thickened mucosa; acute as an air-fluid level or complete opacification. Films are usually not necessary, however, on an emergency basis. If symptoms and physical findings of sinusitis are classic, plain sinus radiographs need not be obtained before treatment. If an acute attack does not resolve with medical treatment, or the diagnosis of sinusitis is in doubt, plain films are helpful as the primary imaging study.
Arrange for followup within 1-7 days.
What not to do
Do not ignore signs of an orbital cellulitis with swelling erythema, decreased extraocular movements and possible proptosis. These patients require consultation and admission for intravenous antibiotics.
Do not ignore the toxic patient with marked swelling, high fever, severe pain, profuse drainage, or other signs and symptoms of a serious infection. See potential complications below. These patients require immediate consultation and intervention.
Do not prescribe antihistamines, which can make mucous secretions dry and thick, and interfere with necessary drainage. Antihistamines only cure sinusitis on television, or when it is due to allergic rhinitis.
Do not allow patients to use decongestant nose drops more than 3 days, thereby allowing their nasal mucosa to become habituated to sympathomimetic medication. When they stop the drops they will suffer a rebound nasal congestion (rhinitis medicamentosa) which requires time, topical steroids, and reeducation to resolve.
Do not prescribe topical or systemic sympathomimetic decongestants to a patient who suffers from hypertension, tachycardia or difficulty initiating urination, all of which may be exacerbated.
Discussion
The paranasal sinuses drain through tiny ostia under the nasal turbinates which, if occluded, allow secretions and pressure differences to build up, resulting in pressure and pain of acute sinusitis, and the air-fluid levels sometimes visible on upright x rays. Sinus infections are relatively common and complications relatively rare, but the bony walls of the paranasal sinuses are so thin that bacterial infections can spread through them. Most sinusitis begins with mucosal swelling from a viral upper respiratory infection. Other causes include dental infection, allergic rhinitis, barotrauma from flying, swimming or diving, nasal polyps and tumors and foreign bodies, including nasogastric and endotracheal tubes in hospitalized patients. Abscessed teeth can be the source of a maxillary sinusitis. If there is tenderness to percussion of the bicuspids or molars, arrange for dental referral.
Complications such as orbital cellulitis, osteomyelitis, epidural abscell, meningitis, cavernous sinus thrombosis and subdural empyema can be devastating and therefore patients must be instructed to get early follow up when signs and symptoms worsen or do not improve in 48-72 hours, or if there is any change in mentation. Frontal sinusitis has the greatest potential for serious complications, particularly in adolescent males, the group at greatest risk for intracranial complications.br Computerized tomographic scanning of the sinuses is more accurate than plain x rays, particularly when evaluating the ethmoid or sphenoid sinuses, but CT scans are needed from the ED only in unusual circumstances. Most patients can have initial treatment begun on the basis of history and physical findings alone. Anyone who has facial pain, headache, purulent nasal discharge and nasal congestion persisting for more than ten days, with or without a fever, should probably be treated empirically for sinusitis.
Many patients have been conditioned by the advertising of over-the-counter antihistamines for "sinus" problems (usually meaning "allergic rhinitis"), and may relate a history of "sinuses" which, on closer questioning, turns out to have been rhinitis.
References:
Williams JW, Simel DL: Does this patient have sinusitis? Diagnosing acute sinusitis by history and physical examination. J Am Med Assoc 1993;270:1242-1246.
Nasal Fracture
3.10 Nasal Fracture
Presentation
After a direct blow to the nose the patient usually arives at the emergency department with minimal continued hemorrhage. There is usually tender ecchymotic swelling over the nasal bones or the anterior maxillary spine; inspection and palpation may (or may not) disclose a nasal deformity.
What to do:
Examine for any associated injuries (i.e., blowout fractures, zygoma fractures).
With minor injuries, explain that x rays are not routinely used or useful, because all therapeutic decisions are made on the basis of the physical examination. If there is a fracture, but it is stable and in good position clinically, it need not be reset. Conversely, a broken and displaced cartilage may obstruct breathing and require operation, but never show up on the film. Send the patient for x rays of the nasal bones only if there is a good reason.
If bleeding continues, instill cotton pledgets soaked in 4% cocaine or 2% tetracaine (Pontocaine) mixed 1:1 with 1% Neo-Synephrine or epinephrine 1:1000 into both nasal cavities.
After removing the.cotton pledgets, inspect the nasal mucosa for large lacerations or a septal hematoma.
Patients with nondisplaced fractures without deformity should be sent home with analgesics, cold packs, and instructions to avoid contact sports and related activities for six weeks.
Patients with displaced fractures and/or nasal deformity should have otolaryngologic or plastic surgery consultation for immediate or delayed reduction. Patients can be instructed that reduction is more accurate after the swelling subsides and there is no greater difficulty if it is done within six days of the injury.
Septal hematomas should be drained to prevent septal necrosis and the development of a saddle nose deformity. Otolaryngologic consultation is advisable.
An isolated fracture of the anterior nasal spine (in the columella of the nose), does not necessitate restricting activities. It only hurts when you smile.
What not to do:
Do not automatically x ray every injured nose. Patients may expect this, because it is the old practice, but routine films have turned out not to help.
Do not assume a negative x ray means no fracture when a deformity is apparent. X rays can often be inaccurate in determining the presence and nature of a nasal fracture. Rely on your clinical assessment. When there is swelling, arrange for re-examination in 3-4 days when the swelling subsides, to look for subtle deformities.
Do not pack an injured nose that does not continue to bleed. Packing is generally unnecessary and will only add to the patient's discomfort.
Discussion
The two most common indications for reducing a nasal fracture are an unacceptable appearance and inability of the patient to breathe through the nose. Regardless of x-ray findings, if neither breathing nor cosmesis is a concern, it is not necessary to reduce the fracture. Nasal fractures are uncommon in young children, because their noses are mostly pliable cartilage. Suspect septal hematoma when a patient's nasal airway is completely occluded. Within 48 to 72 hours a hematoma can compromise the blood supply to the cartilage and cause irreversable damage.
Presentation
After a direct blow to the nose the patient usually arives at the emergency department with minimal continued hemorrhage. There is usually tender ecchymotic swelling over the nasal bones or the anterior maxillary spine; inspection and palpation may (or may not) disclose a nasal deformity.
What to do:
Examine for any associated injuries (i.e., blowout fractures, zygoma fractures).
With minor injuries, explain that x rays are not routinely used or useful, because all therapeutic decisions are made on the basis of the physical examination. If there is a fracture, but it is stable and in good position clinically, it need not be reset. Conversely, a broken and displaced cartilage may obstruct breathing and require operation, but never show up on the film. Send the patient for x rays of the nasal bones only if there is a good reason.
If bleeding continues, instill cotton pledgets soaked in 4% cocaine or 2% tetracaine (Pontocaine) mixed 1:1 with 1% Neo-Synephrine or epinephrine 1:1000 into both nasal cavities.
After removing the.cotton pledgets, inspect the nasal mucosa for large lacerations or a septal hematoma.
Patients with nondisplaced fractures without deformity should be sent home with analgesics, cold packs, and instructions to avoid contact sports and related activities for six weeks.
Patients with displaced fractures and/or nasal deformity should have otolaryngologic or plastic surgery consultation for immediate or delayed reduction. Patients can be instructed that reduction is more accurate after the swelling subsides and there is no greater difficulty if it is done within six days of the injury.
Septal hematomas should be drained to prevent septal necrosis and the development of a saddle nose deformity. Otolaryngologic consultation is advisable.
An isolated fracture of the anterior nasal spine (in the columella of the nose), does not necessitate restricting activities. It only hurts when you smile.
What not to do:
Do not automatically x ray every injured nose. Patients may expect this, because it is the old practice, but routine films have turned out not to help.
Do not assume a negative x ray means no fracture when a deformity is apparent. X rays can often be inaccurate in determining the presence and nature of a nasal fracture. Rely on your clinical assessment. When there is swelling, arrange for re-examination in 3-4 days when the swelling subsides, to look for subtle deformities.
Do not pack an injured nose that does not continue to bleed. Packing is generally unnecessary and will only add to the patient's discomfort.
Discussion
The two most common indications for reducing a nasal fracture are an unacceptable appearance and inability of the patient to breathe through the nose. Regardless of x-ray findings, if neither breathing nor cosmesis is a concern, it is not necessary to reduce the fracture. Nasal fractures are uncommon in young children, because their noses are mostly pliable cartilage. Suspect septal hematoma when a patient's nasal airway is completely occluded. Within 48 to 72 hours a hematoma can compromise the blood supply to the cartilage and cause irreversable damage.
Nasal Foreign Bodies
3.10 Nasal Foreign Bodies
Presentation
Children may admit to parents that they have inserted something into their noses, but sometimes the history is obscure and the child presents with a purulent unilateral nasal discharge. Most commonly encountered are beans or other foodstuffs, beads, pebbles, paper wads, and eraser tips. These foesign bodies usually lodge on the floor of the anterior or middle third of the nasal cavity. Occasionally, caustic material was sniffed into the nose or coughed up into the posterior nasopharynx (e.g., a ruptured tetracycline capsule), the patient will present with much discomfort and tearing, and inspection will reveal mucous membranes covered with particulate debris.
What to do:
Explain the procedure beforehand in detail to patient and parents. Explain that it will be a little uncomfortable, and that aspiration of the foreign body into the trachea is a real but remote possibility.
After initial inspection using a nasal speculum and bright light, suction out any purulent discharge and insert a cotton pledget soaked in 4% cocaine or a solution of one part phenylephrine (Neo-Synephrine) and one part tetracaine (Pontocaine) to shrink the nasal mucosa and provide local anesthesia. Be careful to avoid pushing the foreign body posteriorly. Remove the pledget after approximately 5-10 minutes.
If the patient is able to cooperate, have him try to blow his nose to remove the foreign body. With an infant it is sometimes possible to have the parent blow a sharp puff into the baby's mouth whild holding the opposite nostril closed to blow the object out of the nose.
Before attempting any removal using surgical instruments, a potentially uncooperative child must be firmly restrained and sedated (see below)
Alligator forceps should be used to remove cloth, cotton, or paper foreign bodies. Pebbles, beans, and other hard foreign bodies are more easily grasped using bayonet forceps or Kelly clamps, or they may be rolled out by getting behind it using an ear curette, single skin hook, or right angle ear hook. A soft-tipped hook can be made by bending the tip of a metal-shaft calcium alginate swab (Calgiswab) to a 90 degree angle. An additional approach is to bypass the object with a Fogarty, biliary or small Foley catheter, passing it superior to the foreign body, inflating the balloon with approximately 1ml of air and pulling the object out through the nose.
Any bleeding can be stopped by reinserting a cotton pledget soaked in the topical solution used initially.
To irrigate loose foreign bodies and particulate debris from the nasal cavity and posterior nasopharynx, simply insert the bulbous nozzle of an irrigation syringe into one nostril while the patient sits up and forward, ask the patient to close off the back of his throat by repeating the sound "eng" and flush the irrigating solution out through the opposite nostril into an emesis basin.
After the foreign body is removed, inspect the nasal cavity again and check for additional objects that may have been placed in the patient's nose. Look also for unsuspected foreign bodies in the ears. Picture
What not to do:
Do not ignore a unilateral nasal discharge in a child. It must be assumed to be secondary to a foreign body until proven otherwise.
Do not push a foreign body down the back of a patient's throat, where it may be aspirated into the trachea.
Do not attempt to remove a foreign body from the nose without first using a topical anesthetic and vasoconstrictor.
Discussion
The mucous membrane lining the nasal cavity allows you the tactical advantages of vasoconstriction and topical anesthesia. In cases where patients have unsuccessfully attempted to blow foreign bodies out of their noses, they may be successful after instillation of an anesthetic vasoconstriction solution. If a patient swallows a foreign body that has been pushed back into the nasopharynx, this is usually harmless and the the patient and parents can be reassured (see Swallowed foreign body). If the object is aspirated into the tracheobronchial tree, it may produce coughing and wheezing and bronchoscopy under anesthesia will be required for retrieval. Button batteries can cause serious local damage and should be removed quickly.
References:
Backlin SA: Positive-pressure technique for nasal foreign body retrieval in children. Ann Emerg Med 1995;25:554-555.
Presentation
Children may admit to parents that they have inserted something into their noses, but sometimes the history is obscure and the child presents with a purulent unilateral nasal discharge. Most commonly encountered are beans or other foodstuffs, beads, pebbles, paper wads, and eraser tips. These foesign bodies usually lodge on the floor of the anterior or middle third of the nasal cavity. Occasionally, caustic material was sniffed into the nose or coughed up into the posterior nasopharynx (e.g., a ruptured tetracycline capsule), the patient will present with much discomfort and tearing, and inspection will reveal mucous membranes covered with particulate debris.
What to do:
Explain the procedure beforehand in detail to patient and parents. Explain that it will be a little uncomfortable, and that aspiration of the foreign body into the trachea is a real but remote possibility.
After initial inspection using a nasal speculum and bright light, suction out any purulent discharge and insert a cotton pledget soaked in 4% cocaine or a solution of one part phenylephrine (Neo-Synephrine) and one part tetracaine (Pontocaine) to shrink the nasal mucosa and provide local anesthesia. Be careful to avoid pushing the foreign body posteriorly. Remove the pledget after approximately 5-10 minutes.
If the patient is able to cooperate, have him try to blow his nose to remove the foreign body. With an infant it is sometimes possible to have the parent blow a sharp puff into the baby's mouth whild holding the opposite nostril closed to blow the object out of the nose.
Before attempting any removal using surgical instruments, a potentially uncooperative child must be firmly restrained and sedated (see below)
Alligator forceps should be used to remove cloth, cotton, or paper foreign bodies. Pebbles, beans, and other hard foreign bodies are more easily grasped using bayonet forceps or Kelly clamps, or they may be rolled out by getting behind it using an ear curette, single skin hook, or right angle ear hook. A soft-tipped hook can be made by bending the tip of a metal-shaft calcium alginate swab (Calgiswab) to a 90 degree angle. An additional approach is to bypass the object with a Fogarty, biliary or small Foley catheter, passing it superior to the foreign body, inflating the balloon with approximately 1ml of air and pulling the object out through the nose.
Any bleeding can be stopped by reinserting a cotton pledget soaked in the topical solution used initially.
To irrigate loose foreign bodies and particulate debris from the nasal cavity and posterior nasopharynx, simply insert the bulbous nozzle of an irrigation syringe into one nostril while the patient sits up and forward, ask the patient to close off the back of his throat by repeating the sound "eng" and flush the irrigating solution out through the opposite nostril into an emesis basin.
After the foreign body is removed, inspect the nasal cavity again and check for additional objects that may have been placed in the patient's nose. Look also for unsuspected foreign bodies in the ears. Picture
What not to do:
Do not ignore a unilateral nasal discharge in a child. It must be assumed to be secondary to a foreign body until proven otherwise.
Do not push a foreign body down the back of a patient's throat, where it may be aspirated into the trachea.
Do not attempt to remove a foreign body from the nose without first using a topical anesthetic and vasoconstrictor.
Discussion
The mucous membrane lining the nasal cavity allows you the tactical advantages of vasoconstriction and topical anesthesia. In cases where patients have unsuccessfully attempted to blow foreign bodies out of their noses, they may be successful after instillation of an anesthetic vasoconstriction solution. If a patient swallows a foreign body that has been pushed back into the nasopharynx, this is usually harmless and the the patient and parents can be reassured (see Swallowed foreign body). If the object is aspirated into the tracheobronchial tree, it may produce coughing and wheezing and bronchoscopy under anesthesia will be required for retrieval. Button batteries can cause serious local damage and should be removed quickly.
References:
Backlin SA: Positive-pressure technique for nasal foreign body retrieval in children. Ann Emerg Med 1995;25:554-555.
Epistaxis (Nosebleed)
3.08 Epistaxis (Nosebleed)
Presentation
A patient generally arrives in the emergency department with active bleeding from his nose or spitting up blood that is draining into his throat. There may or may not be a report of minor trauma such as sneezing, nose blowing or nasal manipulation. On occasion the hemorrhage has stopped but the patient is concerned because the bleeding has been recurring over the past few hours or days. Bleeding is most commonly visualized on the anterior aspect of the nasal septum within Kiesselbach's plexus. The anterior end of the inferior turbinate is another site where bleeding can be seen. Often, especially with posterior hemorrhaging, a specific bleeding site cannot be discerned.
What to do:
If significant blood loss is suspected, gain vascular access and administer crystalloid intravenous solution.
Have the patient maintain compression on the nostrils by pinching with a gauze sponge while you assemble all equipment and supplies at the bedside. Inform the patient that you will be controlling the bleeding in a stepwise fashion.
Have the patient sit upright (unless hypotensive) Sedate the patient if necessary with a mild tranquilizer such as hydroxyzine (Vistaril) or midazolam (Versed). Cover the patient and yourself to protect your clothes. Wear gloves.
Prepare 5 ml of 4% cocaine solution or a 1:1 mixture of tetracaine 2% (Pontocaine) for local anesthesia and epinephrine 1:1000 or pseudophedrine 1% (Neo-Synephrine) for vasoconstriction.
Form two elongated cotton pledgets and soak them in the solution.
Use a bright headlight or head mirror to free up hour hands and help insure good visualization.
Have the patient blow the clots from his nose and quickly inspect for a bleeding site using a nasal speculum and Frazier suction tip. Clear out any additional clots or foreign bodies.
Insert the medicated cotton pledgets as far back as possible into both nostrils.
Have the patient relax with the pledgets in place for approximately 5-10 minutes. You may use this lull to ask the patient about any past history of nosebleeds or other bleeding problems, the pattern of this nosebleed, which side the bleeding seems to be coming from, any aspirin or blood thinning medication, and any significant medical or surgical problems.
In the vast majority of cases, active bleeding will stop with this treatment. The cotton pledgets can be removed and the nasal cavity can be inspected using a nasal speculum and head lamp. If bleeding continues, insert another pair of medicated cotton pledgets.
If the bleeding point can be located, cauterize a l cm area of mucosa around the bleeding site with a silver nitrate stick and then cauterize the site itself. Observe the patient for 15 minutes. If this stops the bleeding, cover the cauterized area with antibiotic ointment and instruct the patient in prevention (avoid picking the nose, bending over, sneezing, and straining) and treatment of recurrences (compress below the bridge of the nose with thumb and finger for five minutes).
If the bleeding point cannot be located or if bleeding continues after cauterization, insert an anterior pack. The best is a 1 cm by 10 cm stick of compressed cellulose which expands to conform (Merocel, Rhino Rocket). To prevent putrification of the pack, partly cover it with antibiotic ointment before insertion. Leave some cellulose exposed to allow for water absorption. Instill a few drops of saline if it does not expand spontaneously.
An alternative anterior pack can be made from up to six feet of half-inch ribbon gauze impregnated with petroleum jelly (Vaseline). Cover the gauze with antibiotic ointment and insert it with bayonet forceps. Start with 3-4 plies layered accordian fashion on the floor of the nasal cavity, placing it as far posteriorly as possible, and pressing it down firmly with each subsequent layer. Continue inserting the gauze until the affected nasal cavity is tightly filled (expect to use about 3 to 5 feet per nostril). If unilateral anterior nasal packing does not provide enough pressure, packing the opposite side of the nose anteriorly can sometimes increase the pressure by preventing the septum from bowing over into the side of the nose that is not packed.
Observe the patient for 15 minutes. If no further bleeding occurs in the nares or the posterior oropharynx, discharge him on a broad spectrum antibiotic (amoxicillin tid 250mg) for five days to help prevent a secondary sinusitis. The packing should be removed in 2-4 days.
Tape a small folded gauze pad beneath the nose to catch any minor drainage. The patient can replace this from time to time if necessary.
Instruct the patient against sneezing with his mouth closed, bending over, straining, or nose picking. The patient's head should be kept elevated for 24-48 hours. Provide detailed printed instructions on home care.
If the hemorrhage is suspected to have been severe, obtain orthostatic blood pressure and pulse recordings along with an hematocrit before making a disposition for the patient.
If the hemorrhage does not stop after adequate packing anteriorly, then one or two posterior packs or nasal balloons should be inserted, and the patient should be admitted to the hospital under the care of an otolaryngologist.
What not to do:
Do not waste time trying to locate a bleeding site while brisk bleeding obscures your vision in spite of vigorous suctioning. Have the patient blow out any clots and insert the medicated cotton pledgets.
Do not get routine clotting studies unless there is other evidence of an underlying bleeding disorder.
Do not cauterize or use instruments within the nose before providing adequate topical anesthesia (some initial blind suctioning may, however, be required to clear the nose of clots before instilling anesthetics).
Do not discharge a patient as soon as the bleeding stops, but keep him in the ED for 15-30 minutes more. Look behind the uvula. If it is dripping blood, the bleeding has not been controlled adequately. Posterior epistaxis typically stops and starts cyclically and may not be recognized until all the above treatments have failed.
Discussion
Nosebleeds are more common in winter, no doubt reflecting the low ambient humidity indoors and outdoors and the increased incidence of upper respiratory tract infections. Troublesome nosebleeds are more common in middle-aged and elderly patients. Causes are numerous: dry nasal mucosa, nose picking and vascular fragility are the most common, but others include foreign bodies, blood dyscrasias, nasal or sinus neoplasm or infection, septal deformity, atrophic rhinitis, hereditary hemorrhagic telaniectasis and angiofibroma. High blood pressure makes epistaxis difficult to control but is rarely the sole precipitating cause.
Drying and crusting of the bleeding site, along with nose picking, may result in recurrent nasal hemorrhage. It may be helpful to instruct the patient on gently inserting Vaseline onto his nasal septum once or twice a day to prevent future drying and bleeding. Other useful techniques include electrocautery down a metal suction catheter, ophthalmic electrocautery tips (see subungual hematoma), submucosal injection of lidocaine with epinephrine, and application of hemostatic collagen (Gelfoam). There are also several balloon devices to provide anterior and posterior tamponade, some with a channel to maintain a patent nares. Because of the nasopulmonary reflex, arterial oxygen pressure will drop about 15mmHg after the nose is packed, which can be troublesome in a patient with heart or lung disease, and usually requires hospitalization and supplemental oxygen.
References:
Viducich RA, Blanda MP, Gerson LW: Posterior epistaxis: clinical features and acute complications. Ann Emerg Med 1995;25:592-596.
Presentation
A patient generally arrives in the emergency department with active bleeding from his nose or spitting up blood that is draining into his throat. There may or may not be a report of minor trauma such as sneezing, nose blowing or nasal manipulation. On occasion the hemorrhage has stopped but the patient is concerned because the bleeding has been recurring over the past few hours or days. Bleeding is most commonly visualized on the anterior aspect of the nasal septum within Kiesselbach's plexus. The anterior end of the inferior turbinate is another site where bleeding can be seen. Often, especially with posterior hemorrhaging, a specific bleeding site cannot be discerned.
What to do:
If significant blood loss is suspected, gain vascular access and administer crystalloid intravenous solution.
Have the patient maintain compression on the nostrils by pinching with a gauze sponge while you assemble all equipment and supplies at the bedside. Inform the patient that you will be controlling the bleeding in a stepwise fashion.
Have the patient sit upright (unless hypotensive) Sedate the patient if necessary with a mild tranquilizer such as hydroxyzine (Vistaril) or midazolam (Versed). Cover the patient and yourself to protect your clothes. Wear gloves.
Prepare 5 ml of 4% cocaine solution or a 1:1 mixture of tetracaine 2% (Pontocaine) for local anesthesia and epinephrine 1:1000 or pseudophedrine 1% (Neo-Synephrine) for vasoconstriction.
Form two elongated cotton pledgets and soak them in the solution.
Use a bright headlight or head mirror to free up hour hands and help insure good visualization.
Have the patient blow the clots from his nose and quickly inspect for a bleeding site using a nasal speculum and Frazier suction tip. Clear out any additional clots or foreign bodies.
Insert the medicated cotton pledgets as far back as possible into both nostrils.
Have the patient relax with the pledgets in place for approximately 5-10 minutes. You may use this lull to ask the patient about any past history of nosebleeds or other bleeding problems, the pattern of this nosebleed, which side the bleeding seems to be coming from, any aspirin or blood thinning medication, and any significant medical or surgical problems.
In the vast majority of cases, active bleeding will stop with this treatment. The cotton pledgets can be removed and the nasal cavity can be inspected using a nasal speculum and head lamp. If bleeding continues, insert another pair of medicated cotton pledgets.
If the bleeding point can be located, cauterize a l cm area of mucosa around the bleeding site with a silver nitrate stick and then cauterize the site itself. Observe the patient for 15 minutes. If this stops the bleeding, cover the cauterized area with antibiotic ointment and instruct the patient in prevention (avoid picking the nose, bending over, sneezing, and straining) and treatment of recurrences (compress below the bridge of the nose with thumb and finger for five minutes).
If the bleeding point cannot be located or if bleeding continues after cauterization, insert an anterior pack. The best is a 1 cm by 10 cm stick of compressed cellulose which expands to conform (Merocel, Rhino Rocket). To prevent putrification of the pack, partly cover it with antibiotic ointment before insertion. Leave some cellulose exposed to allow for water absorption. Instill a few drops of saline if it does not expand spontaneously.
An alternative anterior pack can be made from up to six feet of half-inch ribbon gauze impregnated with petroleum jelly (Vaseline). Cover the gauze with antibiotic ointment and insert it with bayonet forceps. Start with 3-4 plies layered accordian fashion on the floor of the nasal cavity, placing it as far posteriorly as possible, and pressing it down firmly with each subsequent layer. Continue inserting the gauze until the affected nasal cavity is tightly filled (expect to use about 3 to 5 feet per nostril). If unilateral anterior nasal packing does not provide enough pressure, packing the opposite side of the nose anteriorly can sometimes increase the pressure by preventing the septum from bowing over into the side of the nose that is not packed.
Observe the patient for 15 minutes. If no further bleeding occurs in the nares or the posterior oropharynx, discharge him on a broad spectrum antibiotic (amoxicillin tid 250mg) for five days to help prevent a secondary sinusitis. The packing should be removed in 2-4 days.
Tape a small folded gauze pad beneath the nose to catch any minor drainage. The patient can replace this from time to time if necessary.
Instruct the patient against sneezing with his mouth closed, bending over, straining, or nose picking. The patient's head should be kept elevated for 24-48 hours. Provide detailed printed instructions on home care.
If the hemorrhage is suspected to have been severe, obtain orthostatic blood pressure and pulse recordings along with an hematocrit before making a disposition for the patient.
If the hemorrhage does not stop after adequate packing anteriorly, then one or two posterior packs or nasal balloons should be inserted, and the patient should be admitted to the hospital under the care of an otolaryngologist.
What not to do:
Do not waste time trying to locate a bleeding site while brisk bleeding obscures your vision in spite of vigorous suctioning. Have the patient blow out any clots and insert the medicated cotton pledgets.
Do not get routine clotting studies unless there is other evidence of an underlying bleeding disorder.
Do not cauterize or use instruments within the nose before providing adequate topical anesthesia (some initial blind suctioning may, however, be required to clear the nose of clots before instilling anesthetics).
Do not discharge a patient as soon as the bleeding stops, but keep him in the ED for 15-30 minutes more. Look behind the uvula. If it is dripping blood, the bleeding has not been controlled adequately. Posterior epistaxis typically stops and starts cyclically and may not be recognized until all the above treatments have failed.
Discussion
Nosebleeds are more common in winter, no doubt reflecting the low ambient humidity indoors and outdoors and the increased incidence of upper respiratory tract infections. Troublesome nosebleeds are more common in middle-aged and elderly patients. Causes are numerous: dry nasal mucosa, nose picking and vascular fragility are the most common, but others include foreign bodies, blood dyscrasias, nasal or sinus neoplasm or infection, septal deformity, atrophic rhinitis, hereditary hemorrhagic telaniectasis and angiofibroma. High blood pressure makes epistaxis difficult to control but is rarely the sole precipitating cause.
Drying and crusting of the bleeding site, along with nose picking, may result in recurrent nasal hemorrhage. It may be helpful to instruct the patient on gently inserting Vaseline onto his nasal septum once or twice a day to prevent future drying and bleeding. Other useful techniques include electrocautery down a metal suction catheter, ophthalmic electrocautery tips (see subungual hematoma), submucosal injection of lidocaine with epinephrine, and application of hemostatic collagen (Gelfoam). There are also several balloon devices to provide anterior and posterior tamponade, some with a channel to maintain a patent nares. Because of the nasopulmonary reflex, arterial oxygen pressure will drop about 15mmHg after the nose is packed, which can be troublesome in a patient with heart or lung disease, and usually requires hospitalization and supplemental oxygen.
References:
Viducich RA, Blanda MP, Gerson LW: Posterior epistaxis: clinical features and acute complications. Ann Emerg Med 1995;25:592-596.
Split Earlobes
3.07 Split Earlobes
Presentation
A patient will present with an earlobe split by a sudden pull on an earring.
What to do:
Excise the skin edges on both sides of the wound, leaving the apical epithelium intact. Suture these freshened wound edges together using a fine monofilament material.
If the patient wants to maintain a pierced ear lobe, tie a loop of sterile suture material through the hole to maintain a tract while the rest of the lobe heals.
Provide tetanus prophylaxis if needed
What not to do:
Do not suture the wound primarily. The edges may epithelialize, resulting in the split redeveloping after the sutures are removed.
Discussion
There are many techniques for the repair of split earlobes. Some methods, including this one, attempt to preserve the earring hole while others use a Z-plasty on the free margins of the lobes to prevent notching at the points of reunion. Depending on the specific circumstances, it may be advisable to consult with a plastic surgeon before attempting to repair this type of earlobe injury.
Presentation
A patient will present with an earlobe split by a sudden pull on an earring.
What to do:
Excise the skin edges on both sides of the wound, leaving the apical epithelium intact. Suture these freshened wound edges together using a fine monofilament material.
If the patient wants to maintain a pierced ear lobe, tie a loop of sterile suture material through the hole to maintain a tract while the rest of the lobe heals.
Provide tetanus prophylaxis if needed
What not to do:
Do not suture the wound primarily. The edges may epithelialize, resulting in the split redeveloping after the sutures are removed.
Discussion
There are many techniques for the repair of split earlobes. Some methods, including this one, attempt to preserve the earring hole while others use a Z-plasty on the free margins of the lobes to prevent notching at the points of reunion. Depending on the specific circumstances, it may be advisable to consult with a plastic surgeon before attempting to repair this type of earlobe injury.
Serous Otitis Media
3.06 Serous Otitis Media
Presentation
Following an upper respiratory infection or an airplane flight, an adult may complain of a feeling of fullness in the ears, inability to equalize middle ear pressure, decreased hearing, and clicking, popping, or crackling sounds, especially when the head is moved. There is little pain or tenderness. Through the otoscope, the tympanic membrane appears retracted, with a dull to normal light reflex, minimal if any injection, and poor motion on insufflation. You may see an air-fluid level or bubbles through the ear drum. Hearing will be decreased and the Rinne test will show decreased air conduction (i.e., a tuning fork will be heard no better through air than through bone).
What to do:
Tell the patient to lie supine with head tilted back and toward the affectide side and then instill vasoconstrictor nose drops like phenylephrine 1% (Neo-Synephrine) or oxymetazoline 0.05% (Afrin), wait two minutes for the nasal mucosa to shrink, reinstill nose drops, and wait an additional 2 minutes for the medicine to seep down to the posterior pharyngeal wall, around the opening of the eustachian tube. Have him repeat this procedure with drops (not spray) every 4 hours during the day for no more than 3 days.
After each treatment with nose drops, instruct the patient to insufflate his middle ear via his eustachian tube by closing his mouth, pinching his nose shut, and blowing until his ears "pop."
Unless contraindicated by hypertension or other medical conditions, add a systemic vasoconstrictor (pseudoephedrine 60mg qid).
Instruct the patient to seek otolaryngologic followup if not better in a week.
What not to do:
Do not allow the patient to become habituated to vasoconstrictor nose drops. After a few days, they become ineffective, and then the nasal mucosa develop a rebound swelling known as "rhinitis medicamentosa" when the medicine is withdrawn.
Do not prescribe antihistamines (which dry out secretions) unless clearly indicated by an allergy.
Discussion
Acute serous otitis media is probably caused by obstruction of the eustachian tube, creating negative pressure in the middle ear, which then draws a fluid transudate out of the middle ear epithelium. The treatment above is directed solely at reestablishing the patency of the eustachian tube, but further treatment includes insufflation of the eustachian tube or myringotomy. Fluid in the middle ear is more common in children, because of frequent viral upper respiratory infections and an underdeveloped eustachian tube. Children are also more prone to bacterial superinfection of the fluid in the middle ear, and, when accompanied by fever and pain, merit treatment with analgesics and antibiotics (e.g., ibuprofen and amoxicillin) (see above). Repeated bouts of serous otitis in an adult, especially if unilateral, should raise the question of obstruction of the eustachian tube by tumor or lymphatic hypertrophy.
References:
Csortan E, Jones J, Haan M, et al: Efficacy of pseudoephedrine for the prevention of barotrauma during air travel. Ann Emerg Med 1994;23:1324-1327.
Presentation
Following an upper respiratory infection or an airplane flight, an adult may complain of a feeling of fullness in the ears, inability to equalize middle ear pressure, decreased hearing, and clicking, popping, or crackling sounds, especially when the head is moved. There is little pain or tenderness. Through the otoscope, the tympanic membrane appears retracted, with a dull to normal light reflex, minimal if any injection, and poor motion on insufflation. You may see an air-fluid level or bubbles through the ear drum. Hearing will be decreased and the Rinne test will show decreased air conduction (i.e., a tuning fork will be heard no better through air than through bone).
What to do:
Tell the patient to lie supine with head tilted back and toward the affectide side and then instill vasoconstrictor nose drops like phenylephrine 1% (Neo-Synephrine) or oxymetazoline 0.05% (Afrin), wait two minutes for the nasal mucosa to shrink, reinstill nose drops, and wait an additional 2 minutes for the medicine to seep down to the posterior pharyngeal wall, around the opening of the eustachian tube. Have him repeat this procedure with drops (not spray) every 4 hours during the day for no more than 3 days.
After each treatment with nose drops, instruct the patient to insufflate his middle ear via his eustachian tube by closing his mouth, pinching his nose shut, and blowing until his ears "pop."
Unless contraindicated by hypertension or other medical conditions, add a systemic vasoconstrictor (pseudoephedrine 60mg qid).
Instruct the patient to seek otolaryngologic followup if not better in a week.
What not to do:
Do not allow the patient to become habituated to vasoconstrictor nose drops. After a few days, they become ineffective, and then the nasal mucosa develop a rebound swelling known as "rhinitis medicamentosa" when the medicine is withdrawn.
Do not prescribe antihistamines (which dry out secretions) unless clearly indicated by an allergy.
Discussion
Acute serous otitis media is probably caused by obstruction of the eustachian tube, creating negative pressure in the middle ear, which then draws a fluid transudate out of the middle ear epithelium. The treatment above is directed solely at reestablishing the patency of the eustachian tube, but further treatment includes insufflation of the eustachian tube or myringotomy. Fluid in the middle ear is more common in children, because of frequent viral upper respiratory infections and an underdeveloped eustachian tube. Children are also more prone to bacterial superinfection of the fluid in the middle ear, and, when accompanied by fever and pain, merit treatment with analgesics and antibiotics (e.g., ibuprofen and amoxicillin) (see above). Repeated bouts of serous otitis in an adult, especially if unilateral, should raise the question of obstruction of the eustachian tube by tumor or lymphatic hypertrophy.
References:
Csortan E, Jones J, Haan M, et al: Efficacy of pseudoephedrine for the prevention of barotrauma during air travel. Ann Emerg Med 1994;23:1324-1327.
Foreign Body in Ear
3.05 Foreign Body in Ear
Presentation
Sometimes a young child admits to putting something like a bead or a bean in his ear, or an adult witnesses the act. Sometimes the history is hidden and the child simply presents with a purulent discharge, pain, bleeding or hearing loss. Most dramatically, a patient arrives at the emergency department panic-stricken because he feels and hears a bug crawling around in his ear.
What to do:
If there is a live insect in the patient's ear, simply fill the canal with mineral oil (e.g., microscope immersion oil). Lay the patient on his side and drop the oil down the canal while pulling on the pinna to remove air bubbles. This will suffocate the intruder, so it can be removed using one of the techniques below. The least invasive methods should be tried first.
Water irrigation is often effective for safely removing a foreign body that is not tightly wedged in the ear canal. This can be accomplished with an irrigation syringe, Water Pik, or a standard syringe and scalp vein needle catheter cut short (see above). Tap water or normal saline at body temperature can be used to flush out the foreign body by directing the stream along the wall of the ear canal and around the object, thereby flushing it out.
If the object is light and moves easily, attempt to suction it out with a standard metal suction tip or specialized flexible tip, whichever can make a vacuum seal on the foreign body.
If a hard or spherical foreign body remains in the ear canal, and the patient is able to hold still, you can attempt to roll it out with a right-angle hook, ear curette or wire loop. Stabilize the patient's head and fix your hand against it, holding the instrument loosely between your fingers to reduce the risk of injury should the patient move suddenly. Under direct visualizaton through an ear speculum, slide the tip of the right-angle hook, ear curette or wire loop behind the object (rotate the hook to catch) and then roll or slide the foreign body out of the ear.
Alligator forceps are best for grasing soft objects like cotton or paper. The wooden shaft of a long cotton swab can be armed with one drop of cyanoacrylate (Super Glue) to adhere to a smooth, clean, dry foreign body. Touch it to the foreign body, hold for ten seconds, then pull. Try not to glue the stick to the wall of the ear canal, but if you do, be thankful for cerumen (above).
What not to do:
Do not use a rigid instrument to remove an object from an uncooperative patient's ear. An unexpected movement might lead to a serious injury of the middle ear.
Do not attempt to remove a large bug or insect without killing it first. They tend to be wily, evasive little creatures well equipped for fighting in tunnels. In the heat of battle, the patient can become terrorized by the noise and pain and the instrument that you are using is likely to damage the ear canal.
Do not attempt to irrigate a tightly wedged bean or seed from an ear canal. The water may cause the bean to swell.
Do not attempt to remove a large or hard object with bayonet or similar forceps. The bony canal will slowly close the forceps as they are advanced and the object will be pushed farther into the canal. Alligator forceps are designed for the canal, but even they will push a large, hard foreign body farther into the ear.
Discussion
The cutaneous lining of the bony canal of the ear is very sensitive and is not much affected by topical anesthetics. If your patient is an uncooperative child, you might make one cautious attempt at removal under conscious sedation (see below) with firm head restraint, but your most prudent strategy is to schedule elective removal under general anesthesia by a specialist.
Irrigation techniques and the use of the ear curette can also be effective in removing excess cerumen from an ear canal (see above). Whenever an instrument is used in an ear canal it is a good idea to warn the patient or parents beforehand that there may be a small amount of bleeding.
There should be no delay in removing an external auditory canal foreign body when there is an obvious infection or when the foreign body is a disk batters. On contact with most tissue, this type of alkaline battery is capable of producing a liquefactive necrosis extending into deep tissues. After removal, the canal should be irrigated to remove alkalai residue. Styrofoam beads can be instantly dissolved by spraying them with a small amount of ethyl chloride. Lidocaine has been shown to make cockroaches exit the ear canal, but this may be unpleasant for the patient. On telephone consultation, patients can be instructed to use cooking or baby oil to kill an intra-aural insect, which can then be removed in a subsequent office visit.
Complications of foreign body removal include trauma to the skin of the canal, canal hematoma, otitis externa, tympanic membrane perforations, ossicular dislocations and facial nerve palsy.
References:
Bressler K, Shelton C: Ear foreign-body removal: a review of 98 consecutive cases. Laryngoscope 1993;103:367-370.
O'Toole K, Paris PM, Stewart RD, Martinez R: Removing cockroaches from the auditory canal: controlled trial. N Eng J Med 1985;312:1197.
Leffler S, Cherney P, Tandberg D: Chemical immobilization and killing of intra-aural roaches. An in-vitro comparative study. Ann Emerg Med 1993;22:1795-1798.
Brunskill AJ, Satterwaite K: Foreign bodies. Ann Emerg Med 1994;24:757.
Skinner DW, Chui P: The hazard of button-sized batteries as foreign bodies in the nose and ear. J Laryngol Otol 1986;100:1315- 1319.
Presentation
Sometimes a young child admits to putting something like a bead or a bean in his ear, or an adult witnesses the act. Sometimes the history is hidden and the child simply presents with a purulent discharge, pain, bleeding or hearing loss. Most dramatically, a patient arrives at the emergency department panic-stricken because he feels and hears a bug crawling around in his ear.
What to do:
If there is a live insect in the patient's ear, simply fill the canal with mineral oil (e.g., microscope immersion oil). Lay the patient on his side and drop the oil down the canal while pulling on the pinna to remove air bubbles. This will suffocate the intruder, so it can be removed using one of the techniques below. The least invasive methods should be tried first.
Water irrigation is often effective for safely removing a foreign body that is not tightly wedged in the ear canal. This can be accomplished with an irrigation syringe, Water Pik, or a standard syringe and scalp vein needle catheter cut short (see above). Tap water or normal saline at body temperature can be used to flush out the foreign body by directing the stream along the wall of the ear canal and around the object, thereby flushing it out.
If the object is light and moves easily, attempt to suction it out with a standard metal suction tip or specialized flexible tip, whichever can make a vacuum seal on the foreign body.
If a hard or spherical foreign body remains in the ear canal, and the patient is able to hold still, you can attempt to roll it out with a right-angle hook, ear curette or wire loop. Stabilize the patient's head and fix your hand against it, holding the instrument loosely between your fingers to reduce the risk of injury should the patient move suddenly. Under direct visualizaton through an ear speculum, slide the tip of the right-angle hook, ear curette or wire loop behind the object (rotate the hook to catch) and then roll or slide the foreign body out of the ear.
Alligator forceps are best for grasing soft objects like cotton or paper. The wooden shaft of a long cotton swab can be armed with one drop of cyanoacrylate (Super Glue) to adhere to a smooth, clean, dry foreign body. Touch it to the foreign body, hold for ten seconds, then pull. Try not to glue the stick to the wall of the ear canal, but if you do, be thankful for cerumen (above).
What not to do:
Do not use a rigid instrument to remove an object from an uncooperative patient's ear. An unexpected movement might lead to a serious injury of the middle ear.
Do not attempt to remove a large bug or insect without killing it first. They tend to be wily, evasive little creatures well equipped for fighting in tunnels. In the heat of battle, the patient can become terrorized by the noise and pain and the instrument that you are using is likely to damage the ear canal.
Do not attempt to irrigate a tightly wedged bean or seed from an ear canal. The water may cause the bean to swell.
Do not attempt to remove a large or hard object with bayonet or similar forceps. The bony canal will slowly close the forceps as they are advanced and the object will be pushed farther into the canal. Alligator forceps are designed for the canal, but even they will push a large, hard foreign body farther into the ear.
Discussion
The cutaneous lining of the bony canal of the ear is very sensitive and is not much affected by topical anesthetics. If your patient is an uncooperative child, you might make one cautious attempt at removal under conscious sedation (see below) with firm head restraint, but your most prudent strategy is to schedule elective removal under general anesthesia by a specialist.
Irrigation techniques and the use of the ear curette can also be effective in removing excess cerumen from an ear canal (see above). Whenever an instrument is used in an ear canal it is a good idea to warn the patient or parents beforehand that there may be a small amount of bleeding.
There should be no delay in removing an external auditory canal foreign body when there is an obvious infection or when the foreign body is a disk batters. On contact with most tissue, this type of alkaline battery is capable of producing a liquefactive necrosis extending into deep tissues. After removal, the canal should be irrigated to remove alkalai residue. Styrofoam beads can be instantly dissolved by spraying them with a small amount of ethyl chloride. Lidocaine has been shown to make cockroaches exit the ear canal, but this may be unpleasant for the patient. On telephone consultation, patients can be instructed to use cooking or baby oil to kill an intra-aural insect, which can then be removed in a subsequent office visit.
Complications of foreign body removal include trauma to the skin of the canal, canal hematoma, otitis externa, tympanic membrane perforations, ossicular dislocations and facial nerve palsy.
References:
Bressler K, Shelton C: Ear foreign-body removal: a review of 98 consecutive cases. Laryngoscope 1993;103:367-370.
O'Toole K, Paris PM, Stewart RD, Martinez R: Removing cockroaches from the auditory canal: controlled trial. N Eng J Med 1985;312:1197.
Leffler S, Cherney P, Tandberg D: Chemical immobilization and killing of intra-aural roaches. An in-vitro comparative study. Ann Emerg Med 1993;22:1795-1798.
Brunskill AJ, Satterwaite K: Foreign bodies. Ann Emerg Med 1994;24:757.
Skinner DW, Chui P: The hazard of button-sized batteries as foreign bodies in the nose and ear. J Laryngol Otol 1986;100:1315- 1319.
Perforated Tympanic Membrane (Ruptured ear drum)
3.04 Perforated Tympanic Membrane (Ruptured ear drum)
Presentation
The patient will present with ear pain after barotrauma, such as a blow to the ear or deep-water diving; or after direct trauma with a stick or other sharp object. Hemorrhage will often be noticed within the external canal and the patient will experience some hearing loss. Tinnitus or vertigo may also be present. Otoscopic examination will reveal a defect in the tympanic membrane that may or may not be accompanied by disruption of the ossicles.
What to do
Clear out any debris from the canal, using gentle suction.
Test for nystagmus and gross hearing loss.
Place a protective cotton plug inside of the ear canal and instruct the patient to keep the canal dry.
Prescribe an appropriate analgesic (e.g., ibuprofen, naproxen, acetaminophen with codeine or oxycodone).
Insure that the patient gets early follow up by an otolaryngologist.
What not to do:
Do not instill any fluid into the external canal or allow the patient to get water into his ear. Water in the middle ear is painful, irritating and may introduce bacteria. Covering the cotton plug with petroleum jelly will allow the patient to shower safely.
Discussion
Small uncomplicated perforations usually heal. When there is nystagmus, vertigo, profound hearing loss, or disruption of the ossicles, then early otolaryngologic consultation is advisable.
Presentation
The patient will present with ear pain after barotrauma, such as a blow to the ear or deep-water diving; or after direct trauma with a stick or other sharp object. Hemorrhage will often be noticed within the external canal and the patient will experience some hearing loss. Tinnitus or vertigo may also be present. Otoscopic examination will reveal a defect in the tympanic membrane that may or may not be accompanied by disruption of the ossicles.
What to do
Clear out any debris from the canal, using gentle suction.
Test for nystagmus and gross hearing loss.
Place a protective cotton plug inside of the ear canal and instruct the patient to keep the canal dry.
Prescribe an appropriate analgesic (e.g., ibuprofen, naproxen, acetaminophen with codeine or oxycodone).
Insure that the patient gets early follow up by an otolaryngologist.
What not to do:
Do not instill any fluid into the external canal or allow the patient to get water into his ear. Water in the middle ear is painful, irritating and may introduce bacteria. Covering the cotton plug with petroleum jelly will allow the patient to shower safely.
Discussion
Small uncomplicated perforations usually heal. When there is nystagmus, vertigo, profound hearing loss, or disruption of the ossicles, then early otolaryngologic consultation is advisable.
Otitis Media
3.03 Otitis Media
Presentation
Adults and older children will complain of ear pain. There may or may not be accompanying symptoms of upper respiratory infection. In younger children and infants, parents may report that their child is irritable and sleepless, with or without fever, and possibly pulling at his ears. The tympanic menbrane is inflammed and may be bulging with loss of landmarks. It may be dull or opacified with reduced mobility on pneumatic otoscopy. and may or may not be accompanied by otorrhea.
What to do:
Investigate for any other underlying illness.
Inquuire as to whether or not the patient has had a recent or unresponsive ear infection, and whether or not the patient has recently been on an antibiotic.
If the patient has no recent histoyr of otitis media or antibiotic use, then prescribe an appropriate dose of amoxicillin for ten days. Trimethoprim plus sulfamethoxazole may be substituted in the penicillin-allergic patient.
More expensive antibiotics such as amoxicillin plus clavulinate, erythromycin plus sulfamethoxazole, and cephalosporins should be reserved for treatment failures and where there is associated illness requiring a beta-lactamase-stable antimicrobial
Provide pain and fever control with acetaminophen or ibuprofen elixir.
Recommend a ten-day follow-up examination on all patients under two years of age and in those cases where the parents do not feel the infection has resolved or where a child's symptoms persist, there is a family history of recurrent otitis or the accuracy of the parental observations may be in doubt.
What not to do:
Do not overlook serious underlying illness such as meningitis.
Do not prescribe antihistamines or decongestants. These drugs do not decrease the incidence nor hasten the resolution of otitis media. Antihistamines can make children drowsy and decongestants can cause irritability.
Discussion
Most otitis is caused by a viral infection, and most patients do well regardless of the antibiotic chosen. Despite the increase in antimicrobial resistance of community-acquired Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis and the plethora of alternative antibiotics available, amoxicillin remains the drug of choice, because it concentrates in middle ear fluid.
References:
Niemela M, Uhari M, Jounio-Ervasti K et al: Lack of specific symptomology in children with acute otitis media. Pediatr Infect Dis J 1994;13:765-768.
Rosenfeld RM, Vertrees JE, Carr J et al: Clinical efficacy of antimicrobial drugs for acute otitis media: metaanalysis of 5400 children from thirty-three randomized trials. J Pediatr 1994;124:355-367.
Presentation
Adults and older children will complain of ear pain. There may or may not be accompanying symptoms of upper respiratory infection. In younger children and infants, parents may report that their child is irritable and sleepless, with or without fever, and possibly pulling at his ears. The tympanic menbrane is inflammed and may be bulging with loss of landmarks. It may be dull or opacified with reduced mobility on pneumatic otoscopy. and may or may not be accompanied by otorrhea.
What to do:
Investigate for any other underlying illness.
Inquuire as to whether or not the patient has had a recent or unresponsive ear infection, and whether or not the patient has recently been on an antibiotic.
If the patient has no recent histoyr of otitis media or antibiotic use, then prescribe an appropriate dose of amoxicillin for ten days. Trimethoprim plus sulfamethoxazole may be substituted in the penicillin-allergic patient.
More expensive antibiotics such as amoxicillin plus clavulinate, erythromycin plus sulfamethoxazole, and cephalosporins should be reserved for treatment failures and where there is associated illness requiring a beta-lactamase-stable antimicrobial
Provide pain and fever control with acetaminophen or ibuprofen elixir.
Recommend a ten-day follow-up examination on all patients under two years of age and in those cases where the parents do not feel the infection has resolved or where a child's symptoms persist, there is a family history of recurrent otitis or the accuracy of the parental observations may be in doubt.
What not to do:
Do not overlook serious underlying illness such as meningitis.
Do not prescribe antihistamines or decongestants. These drugs do not decrease the incidence nor hasten the resolution of otitis media. Antihistamines can make children drowsy and decongestants can cause irritability.
Discussion
Most otitis is caused by a viral infection, and most patients do well regardless of the antibiotic chosen. Despite the increase in antimicrobial resistance of community-acquired Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis and the plethora of alternative antibiotics available, amoxicillin remains the drug of choice, because it concentrates in middle ear fluid.
References:
Niemela M, Uhari M, Jounio-Ervasti K et al: Lack of specific symptomology in children with acute otitis media. Pediatr Infect Dis J 1994;13:765-768.
Rosenfeld RM, Vertrees JE, Carr J et al: Clinical efficacy of antimicrobial drugs for acute otitis media: metaanalysis of 5400 children from thirty-three randomized trials. J Pediatr 1994;124:355-367.
Cerumen Impaction (Ear Wax Blockage)
3.01 Cerumen Impaction (Ear Wax Blockage)
Presentation
The patient may complain of "wax in the ear," a "stuffed up" or foreign body sensation, pain, itching, decreased hearing, tinnitus, or dizziness. On physical examination, the dark brown, thick, dry cerumen, perhaps packed down against the ear drum, where it does not occur normally, obscures further visualization of the ear canal.
What to do:
Explain what you are going to do to the patient. Cover him with a waterproof drape, have him hold a basin or thick towel below his ear, and tilt the ear slightly over it.
Fill a 20ml syringe with warm water at approximately 98.6F (37C) and fit it with a soft tubing catheter. Aim along the anterior superior wall of the external ear canal (visualize directly) and squirt with all your might.
Repeat until all of the cerumen is gone. Dry the canal.
If multiple attempts at irrigation prove to be unsuccessful, then gentle use of a cerumen spoon (ear curette) may be necessary to pull out the excess wax. Warning the patient about potential discomfort or minor bleeding before using the ear curette will save lengthy explanations and apologies later.
Reexamine the ear and test the patient's hearing.
Warn the patient that he has thick ear wax, that he may need this procedure done again someday, and that he should never use swabs in his ear.
What not to do:
Do not irrigate an ear with a suspected or known tympanic membrane perforation, or myringotomy tubes.
Do not waste time attempting to soften wax with ceruminolytic detergents.
Do not irrigate with a cold (or hot) solution.
Do not blindly insert a rigid instrument down the canal.
Do not irrigate with a stiff over-needle catheter. It can cause a painful abrasion and bleeding or even perforate the tympanic membrane.
Do not leave water pooled in the canal. That can cause an external otitis. A final instillation of 2% acetic acid (Acetasol, Domboro Otic, half-strength vinegar) will also prevent iatrogenic swimmer's ear.
Discussion
This technique virtually always works within 5-10 squirts. If the irrigation fluid is at body temperature, it will soften the cerumen just enough that it floats out as a plug. If the fluid is too hot or cold it can produce vertigo, nystagmus, nausea, and vomiting.
A conventional blood-drawing syringe, fitted with a butterfly catheter, its tubing cut l cm from the hub, seems to work better than the big chrome-plated syringes manufactured for irrigating ears. An alternative technique is to use a WaterPik. Cerumen spoons can be dangerous and painful, especially with children, for whom this irrigation technique has proven more effective in cleaning the ear canal to provide for assessment of the tympanic membrane.
Cerumen is produced by the sebaceous glands of the hair follicles in the ear canal, and naturally flows outward along these hairs. One of the problems with ear swabs is that they can push wax inwards away from these hairs and against the ear drum, where it can then stick and harden. Patients may ask about "ear candles" to remove wax, but these are also not very effective compared to the technique above.
References
Robinson AC, Hawke M: The efficacy of ceruminolytics: everything old is new again. J Otolaryngol 1989;18:263-267.
Presentation
The patient may complain of "wax in the ear," a "stuffed up" or foreign body sensation, pain, itching, decreased hearing, tinnitus, or dizziness. On physical examination, the dark brown, thick, dry cerumen, perhaps packed down against the ear drum, where it does not occur normally, obscures further visualization of the ear canal.
What to do:
Explain what you are going to do to the patient. Cover him with a waterproof drape, have him hold a basin or thick towel below his ear, and tilt the ear slightly over it.
Fill a 20ml syringe with warm water at approximately 98.6F (37C) and fit it with a soft tubing catheter. Aim along the anterior superior wall of the external ear canal (visualize directly) and squirt with all your might.
Repeat until all of the cerumen is gone. Dry the canal.
If multiple attempts at irrigation prove to be unsuccessful, then gentle use of a cerumen spoon (ear curette) may be necessary to pull out the excess wax. Warning the patient about potential discomfort or minor bleeding before using the ear curette will save lengthy explanations and apologies later.
Reexamine the ear and test the patient's hearing.
Warn the patient that he has thick ear wax, that he may need this procedure done again someday, and that he should never use swabs in his ear.
What not to do:
Do not irrigate an ear with a suspected or known tympanic membrane perforation, or myringotomy tubes.
Do not waste time attempting to soften wax with ceruminolytic detergents.
Do not irrigate with a cold (or hot) solution.
Do not blindly insert a rigid instrument down the canal.
Do not irrigate with a stiff over-needle catheter. It can cause a painful abrasion and bleeding or even perforate the tympanic membrane.
Do not leave water pooled in the canal. That can cause an external otitis. A final instillation of 2% acetic acid (Acetasol, Domboro Otic, half-strength vinegar) will also prevent iatrogenic swimmer's ear.
Discussion
This technique virtually always works within 5-10 squirts. If the irrigation fluid is at body temperature, it will soften the cerumen just enough that it floats out as a plug. If the fluid is too hot or cold it can produce vertigo, nystagmus, nausea, and vomiting.
A conventional blood-drawing syringe, fitted with a butterfly catheter, its tubing cut l cm from the hub, seems to work better than the big chrome-plated syringes manufactured for irrigating ears. An alternative technique is to use a WaterPik. Cerumen spoons can be dangerous and painful, especially with children, for whom this irrigation technique has proven more effective in cleaning the ear canal to provide for assessment of the tympanic membrane.
Cerumen is produced by the sebaceous glands of the hair follicles in the ear canal, and naturally flows outward along these hairs. One of the problems with ear swabs is that they can push wax inwards away from these hairs and against the ear drum, where it can then stick and harden. Patients may ask about "ear candles" to remove wax, but these are also not very effective compared to the technique above.
References
Robinson AC, Hawke M: The efficacy of ceruminolytics: everything old is new again. J Otolaryngol 1989;18:263-267.
Cerumen Impaction (Ear Wax Blockage)
3.01 Cerumen Impaction (Ear Wax Blockage)
Presentation
The patient may complain of "wax in the ear," a "stuffed up" or foreign body sensation, pain, itching, decreased hearing, tinnitus, or dizziness. On physical examination, the dark brown, thick, dry cerumen, perhaps packed down against the ear drum, where it does not occur normally, obscures further visualization of the ear canal.
What to do:
Explain what you are going to do to the patient. Cover him with a waterproof drape, have him hold a basin or thick towel below his ear, and tilt the ear slightly over it.
Fill a 20ml syringe with warm water at approximately 98.6F (37C) and fit it with a soft tubing catheter. Aim along the anterior superior wall of the external ear canal (visualize directly) and squirt with all your might.
Repeat until all of the cerumen is gone. Dry the canal.
If multiple attempts at irrigation prove to be unsuccessful, then gentle use of a cerumen spoon (ear curette) may be necessary to pull out the excess wax. Warning the patient about potential discomfort or minor bleeding before using the ear curette will save lengthy explanations and apologies later.
Reexamine the ear and test the patient's hearing.
Warn the patient that he has thick ear wax, that he may need this procedure done again someday, and that he should never use swabs in his ear.
What not to do:
Do not irrigate an ear with a suspected or known tympanic membrane perforation, or myringotomy tubes.
Do not waste time attempting to soften wax with ceruminolytic detergents.
Do not irrigate with a cold (or hot) solution.
Do not blindly insert a rigid instrument down the canal.
Do not irrigate with a stiff over-needle catheter. It can cause a painful abrasion and bleeding or even perforate the tympanic membrane.
Do not leave water pooled in the canal. That can cause an external otitis. A final instillation of 2% acetic acid (Acetasol, Domboro Otic, half-strength vinegar) will also prevent iatrogenic swimmer's ear.
Discussion
This technique virtually always works within 5-10 squirts. If the irrigation fluid is at body temperature, it will soften the cerumen just enough that it floats out as a plug. If the fluid is too hot or cold it can produce vertigo, nystagmus, nausea, and vomiting.
A conventional blood-drawing syringe, fitted with a butterfly catheter, its tubing cut l cm from the hub, seems to work better than the big chrome-plated syringes manufactured for irrigating ears. An alternative technique is to use a WaterPik. Cerumen spoons can be dangerous and painful, especially with children, for whom this irrigation technique has proven more effective in cleaning the ear canal to provide for assessment of the tympanic membrane.
Cerumen is produced by the sebaceous glands of the hair follicles in the ear canal, and naturally flows outward along these hairs. One of the problems with ear swabs is that they can push wax inwards away from these hairs and against the ear drum, where it can then stick and harden. Patients may ask about "ear candles" to remove wax, but these are also not very effective compared to the technique above.
References
Robinson AC, Hawke M: The efficacy of ceruminolytics: everything old is new again. J Otolaryngol 1989;18:263-267.
Presentation
The patient may complain of "wax in the ear," a "stuffed up" or foreign body sensation, pain, itching, decreased hearing, tinnitus, or dizziness. On physical examination, the dark brown, thick, dry cerumen, perhaps packed down against the ear drum, where it does not occur normally, obscures further visualization of the ear canal.
What to do:
Explain what you are going to do to the patient. Cover him with a waterproof drape, have him hold a basin or thick towel below his ear, and tilt the ear slightly over it.
Fill a 20ml syringe with warm water at approximately 98.6F (37C) and fit it with a soft tubing catheter. Aim along the anterior superior wall of the external ear canal (visualize directly) and squirt with all your might.
Repeat until all of the cerumen is gone. Dry the canal.
If multiple attempts at irrigation prove to be unsuccessful, then gentle use of a cerumen spoon (ear curette) may be necessary to pull out the excess wax. Warning the patient about potential discomfort or minor bleeding before using the ear curette will save lengthy explanations and apologies later.
Reexamine the ear and test the patient's hearing.
Warn the patient that he has thick ear wax, that he may need this procedure done again someday, and that he should never use swabs in his ear.
What not to do:
Do not irrigate an ear with a suspected or known tympanic membrane perforation, or myringotomy tubes.
Do not waste time attempting to soften wax with ceruminolytic detergents.
Do not irrigate with a cold (or hot) solution.
Do not blindly insert a rigid instrument down the canal.
Do not irrigate with a stiff over-needle catheter. It can cause a painful abrasion and bleeding or even perforate the tympanic membrane.
Do not leave water pooled in the canal. That can cause an external otitis. A final instillation of 2% acetic acid (Acetasol, Domboro Otic, half-strength vinegar) will also prevent iatrogenic swimmer's ear.
Discussion
This technique virtually always works within 5-10 squirts. If the irrigation fluid is at body temperature, it will soften the cerumen just enough that it floats out as a plug. If the fluid is too hot or cold it can produce vertigo, nystagmus, nausea, and vomiting.
A conventional blood-drawing syringe, fitted with a butterfly catheter, its tubing cut l cm from the hub, seems to work better than the big chrome-plated syringes manufactured for irrigating ears. An alternative technique is to use a WaterPik. Cerumen spoons can be dangerous and painful, especially with children, for whom this irrigation technique has proven more effective in cleaning the ear canal to provide for assessment of the tympanic membrane.
Cerumen is produced by the sebaceous glands of the hair follicles in the ear canal, and naturally flows outward along these hairs. One of the problems with ear swabs is that they can push wax inwards away from these hairs and against the ear drum, where it can then stick and harden. Patients may ask about "ear candles" to remove wax, but these are also not very effective compared to the technique above.
References
Robinson AC, Hawke M: The efficacy of ceruminolytics: everything old is new again. J Otolaryngol 1989;18:263-267.
Complete Eye Exam
2.13 Complete Eye Exam
What to do:
Visual acuity, using Snellen (wall) or Jaeger (hand-held) chart without then with the patients own corrective lenses. If glasses are not available, a pinhold will compensate for most refractory errors.
Wearing gloves, inspect lids, conjunctivae, extraocular movements and pupillary reflexes.
Use a 10x slit lamp to examine the cornea and anterior chamber, looking for any injection of ciliary vessels at the corneal limbus, indicating iritis. Look for light reflected from protein exudate or suspended white cells in the normally-clear aqueous humor when the slit lamp is stopped down to a pinhole (later signs of iritis). Look for red cells (hyphema) or white cells (hypopion) settling to the bottom of the anterior chamber after the patient has been sitting up for 15 minutes.
Demonstrate the integrity of the corneal epithelium with fluorescein dye, which is taken up by exposed stroma or non-viable epithelium, and glows green in ultraviolet or cobalt blue light.
Note the depth of the anterior chamber with tangential lighting
What to do:
Visual acuity, using Snellen (wall) or Jaeger (hand-held) chart without then with the patients own corrective lenses. If glasses are not available, a pinhold will compensate for most refractory errors.
Wearing gloves, inspect lids, conjunctivae, extraocular movements and pupillary reflexes.
Use a 10x slit lamp to examine the cornea and anterior chamber, looking for any injection of ciliary vessels at the corneal limbus, indicating iritis. Look for light reflected from protein exudate or suspended white cells in the normally-clear aqueous humor when the slit lamp is stopped down to a pinhole (later signs of iritis). Look for red cells (hyphema) or white cells (hypopion) settling to the bottom of the anterior chamber after the patient has been sitting up for 15 minutes.
Demonstrate the integrity of the corneal epithelium with fluorescein dye, which is taken up by exposed stroma or non-viable epithelium, and glows green in ultraviolet or cobalt blue light.
Note the depth of the anterior chamber with tangential lighting
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