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Common Call Problems

last modified on: Fri, 08/30/2019 - 08:07

Common call problems

Note: The ETC has ear scopes stored in room 35

Common questions
  • Post-op stapedectomy with vertigo (delayed onset) or hearing loss
    • This is an emergency and the patient should have an audiogram and likely admission.  After hours audios are available.
  • Sudden sensorineural hearing loss
    • Needs audiometric evaluation and MRI during normal business hours.
    • If you get an afterhours or weekend call, it can wait until next AM or Monday ROD.
  • "Runny ear" in child
    • Oral antibiotics (eg. Augmentin)
    • Ciprodex (3 drops TID x 10 days)
    • RTC 2 (pt to make appt)
    • Do not prescribe cortisporin otic in case there is a perforation
  • "Runny ear" in adult
    • Ciprodex otic suspension gtts (3 gtts TID x l0d)
    • RTC 2-3 weeks if not resolved.
  • Post-op bleeding
    • See in ER here or ER locally that night
  • "Sinus"
    • If complications (vision, extreme pain), see in ER.
Epistaxis

See Nose Bleed Management and Epistaxis Control  

  • History: trauma, mucosal dryness, nasal steroid use (should be directed laterally, not at septum), coagulopathies, thrombocytopenia, ASA or anticoagulation use, chemotherapy, chronic EtOH use, JNA
  • Anterior bleeds (Kiesselbach'€™s plexus)
    • Topical vasoconstrictors (Afrin, phenylephrine with lidocaine spray)
    • Cauterization with€“ silver nitrate, electrocautery.
    • Packing
      • Absorbable-€“ surgicel, gelfoam, floseal
      • Needs removal-€“ petroleum impregnated strip gauze, RhinoRocket, anterior RapidRhino. Remove in 1-5 days.
    • Posterior bleeds (Woodruff'€™s plexus)
      • Pack-€“ anterior-posterior RapidRhino, Foley (12-14F) with anterior strip gauze pack--€“ fill with 5-10cc of saline and secure with a soft bolster between the nasal ala/columella and umbilical clamp to prevent necrosis.
      • Should have pulse ox monitoring for hypoxia/apnea while packs in place. Consider tele cardiac monitoring for bradycardia.
    • Antibiotics to prevent sinusitis and toxic shock syndrome (TSS) while any packs are in place
    • Sphenopalatine artery injection: bend a 25g needed @2.5 cm and insert transorally into the greater palatine foramen to the bend. Aspirate to confirm not intravascular, then slowly inject 1.5ml of 1:100,000 epinephrine
    • Pearls:
      •  With cautery, do not cauterize both sides of the septum.  Try not to cauterize coagulopathic patients.  It does not work.
      •  After cautery, prescribe mupirocin ointment to cautery site TID to promote healing. Give recommendations for improved humidification and apply AYR gel prn.
      • Surgicel with a small amount of Bactroban or bacitracin can work well on persistent slow nosebleeds. 
      • Rapid Rhino/rhino rocket (in cart) work well as they are less traumatic to pull out. For the RapidRhino, remove the blue covering and soak the pack with sterile water, not saline. Inflate with air after inserting.
      • When pulling Merocel or Rhinorockets out, get them sopping wet.  Also spray around pack with Afrin to reduce any rebleeding. 
Peritonsillar Abscess
Facial trauma
  • ABCs!  Ensure that the patient is stable and does not have any other life-threatening injuries!  Follow the ABCs in terms of initial management. 
  • If you are concerned about the possibility of facial fractures, obtain a maxillofacial CT scan.  If you want fine cuts through the orbit or mandible, you should specify.  Standard noncontrast maxillofacial CT at UIHC does not go all the way down through the mandible nor does it include orbital fine cuts, and it is only an axial scan.  If the pt is not in a c-collar, consider getting both true axial and true coronal cuts
  • Consult optho if there is any trauma near to or involving the eye.  Do a basic vision exam and document!
  • Be sure to rule out facial nerve branch injury with any facial laceration and document
  • Ask whether the neck has been cleared and if there are any other injuries. Document if C collar present, and state in your note that the exam was limited by the collar and the neck was not disturbed.
Physical exam for facial trauma
  • Head: normocephalic, atraumatic?  Note lacs
  • Ocular exam: If patient is conscious, vision test is mandatory!  Peri-orbital swelling does not excuse a lack of direct vision of the orbit!  Funk has a trick where he uses paper clip ends as tools to open the lids without injury to examine the globe directly.  Note visual acuity (small print, fingers, light),  pupillary reflex (direct and consensual!), range of motion, visual fields, inflammation, chemosis, proptosis, telecanthus, pain, pupillary reactions, lacerations.
  • Face: do thorough CN exam, focusing particularly on the facial and mandibular nerve.  Although the patient may be sedated, many times they can be briefly off sedation and tested for responses to pain (ie symmetric grimace).  Note lacerations: size and depth.  Note bony step-offs, tenderness, swelling.
  • Otic: hemotympanum, otorrhea (clear or bloody), canal lacerations, hearing exam (if cooperative).  For EAC stenosis, swelling, or lacs: wick placement with otic drops.
  • Nasal: scope or direct visualization to assure nasal patency.  Rule out septal hematomas that can lead to future perforations!  Assess for displacement, bowing, deviation, rhinorrhea
  • Oral: dentition is key.. are there any teeth missing that could be in the airway?  Lacs?  Occlusion… maxillary or mandibular laxity/movement. Maximal incisor opening.
  • Neck: midline trachea, C-spine, assess anatomy
Management of facial lacerations
  • Consent patients for laceration repair. Risks: infection, bleeding, scarring, need for further procedures, damage to surrounding structures, poor cosmetic result
  • Supplies: to save time, call the ER and ask for the ER nurse taking care of the patient to set up Oto suture trays, get gloves, sterile water with irrigation tip, chucks, yankauer suction and lidocaine/syringes/needles for you.
  • Mixing 9cc of lidocaine with 1cc of sodium bicarb can make it less acidic and less painful for the patient.  Remember how much lidocaine you are injecting, especially on peds patients: 4mg/kg without epi, 7mg/kg with epi;  1cc=10mg of 1% solution
  • Suture:
    • deep-€“ monocryl or vicryl 3-0, 4-0
    • oral mucosa- chromic 3-0, 4-0
    • skin: 5-0 fast absorbing gut does not have to be removed, which is particularly helpful for kids. Could consider putting Dermabond/ Indermil on top. Could also use prolene or nylon 4-0 to 6-0 (cut tails long).
  • Antibiotics:
    • facial: Keflex 500mg bid x 7days
    • with intraoral communication: Augmentin 500mg po bid (if d/c) or Unasyn 3g IV q6h (if admitted). Peridex 10cc swish & spit x 7 days.
  • Wound care
    • clean TID with half strength H202 until all crusts are gone, then cover in bacitracin.
    • if near the eyes, use erythromycin ophthalmic ointment instead.
    • tell the patient to cover the wound with sunscreen for a year to make the appearance of the scar better
Management of facial fractures
  • Emergencies: airway distress, exsanguinating hemorrhage, expanding pneumocephalus, open brain injury, immediate total visual loss, immediate partial or total facial nerve paralysis (Funk wants to be called about facial fractures to be fixed acutely if they are on call).
  • Frontal sinus fractures: huge complication is mucocele formation!
    • Observation if:
      • No cosmetic deformity: isolated anterior table
      • < 1-2 mm displacement of post table-transverse fx, lateral to supraorbital notch, no NOE fx
      • F/u: 2-3 wks w/ imaging to show aerated sinus, then 6-12 mths to r/o mucocele
      • No other indication to go to the OR
    • Surgery: ORIF w/ obliteration and/or cranialization
      • Nasofrontal duct and floor fx
      • Ant & Post table fx
      • Associated NOE fx
      • Dural/intracranial injury/CSF leak
      • Comminuted fx medial to supraorbital notch
      • Anticipated poor f/u
      • F/u: CT 1 yr after repair, lifelong f/u for mucocele risk
Orbital fracture
  • get optho involved!
  • Sxs: edema, ecchymosis, diplopia, enopthalmos (A/P displacement), dystopia (pupillary vertical displacement), entrapment
  • Indications for repair: entrapment (test via forced ductions), significant enopthalmos (> 2mm); displacement or comminution > 50% of orbital floor w/ herniation of soft tissue into maxillary sinus; orbital and medial wall defect w/ soft tissue displacement; persistent diplopia after 7 days: + forced duction test
NOE fracture
  • involves nasal, orbital, and ethmoid areas
  • Sxs: periorbital ecchymosis: diplopia, entrapment; pignose deformity, telecanthus: > 35 mm, (normal intercanthal distance is appx. 30-31 mm and normal interpupillary distance is <65 mm), medial canthal blunting
  • Manage bleeding, CSF rhinorrhea, orbital injury, intracranial injury
  • ORIF
Le Fort facial fracture
  • Sxs: midfacial edema: airway obstruction, nasal bleeding, midface instability: palpate maxilla and tug!; pain in V2, malocclusion, diplopia, rhinorrhea
  • Types: (diagram)
    • Le Fort I: "floating maxilla".
      • transverse lower midfacial fracture through lower maxilla & nasal cavity + pterygoid plates
      • usually from a central midline blow
      • SSx: buccal vestibule ecchymosis, maxillary crepitus, lengthening of face, septal deformity, V2 paresthesia
    • Le Fort II: "pyramid fracture"
      • fracture through nasal & lacrimal bones, floor of orbit, inferior orbital rim, upper portion of maxillary sinus, pterygoid plates to pterygomaxillary fossa
      • Ssx: naso-orbital flattening, mobile nasal bridge, epistaxis, orbital rim & nasofrontal step-offs, CSF rhinorrhea, V2 paresthesia
    • Le Fort III: craniofacial dysjunction
      • fracture line across suture line between nasal & frontal bones, along ethmoid bone, across superior orbital fissure, lateral wall of orbit, across frontomaxillary & zygomaticomaxillary suture lines, pterygoid plates & septum
      • Ssx: as above + basilar skull injuries > Battle's sign (mastoid ecchymosis), Raccoon eyes, CSF otorrhea, hemotympanum
ZMC (‘tripod’) fracture
  • actually a tetrapoid fracture of ZM: frontal, temporal, maxillary, and sphenoidal suture lines
  • Sxs: trismus/pain with mouth opening, midfacial asymmetry, dishpan appearance, V2 paresthesias, bony stepoff
  • Tx: (algorithm diagram)
Temporal bone fx
  • Evaluation
    • H&P: hemodynamically stable (carotid canal injury), facial nerve function, cochleovestibular function (hearing, vertigo), CSF leak, check other CNs. Weber fork.
    • Get maxface CT. Only need T-bone/IAC CT if suspect carotid canal
  • Classification
    • longitudinal vs. transverse: longitudinal more common, transverse more likely to involve facial nerve injury
    • Otic capsule sparing (nonpetrous) vs. otic capsule violating (petrous): violating more likely to have facial nerve injury, SNHL, CSF leak, epidural hematoma / SAH
  • Management
    • Blood / swelling in EAC: if canal stenosis is possible (not all will need it), consider placing wick 3-5 days. Ciprodex while in. Note: do not irrigate EAC or pack if suspect CSF leak
    • FN injury: most at geniculate (66%)
      • If immediate, suspect transection, surgically explore
      • If delayed onset, likely edema or expanding hematoma. ENOG 3-5 days after total paralysis. If <90%, do EMG, possible decompression surgery. Otherwise, treat with prednisone 1 mg/kg for 1-3 weeks. Most recover, may be in 1 day to 1 year
    • CSF leak: HOB up, bedrest, Colace. No nose blowing and sneeze with mouth open. Consider LD if no improvement; surgery if lasts > 7-10 days
    • Vertigo: low salt diet, steroids, diuretics
    • HL: Audiogram in 6 weeks after blood has resolved
Penetrating Neck Injuries
  • Zones
    • Zone 1: base of neck---thoracic inlet to cricoid. This region contains the major vascular structures of the subclavian artery and vein, jugular vein, and common carotid artery, as well as the esophagus, thyroid, and trachea.
    • Zone 2: cricoid to angle of jaw. Contains the common carotid artery, internal and external carotid arteries, jugular vein, larynx, hypopharynx, and cranial nerves X, XI, and XII.
    • Zone 3: angle of mandible to skull base. This region contains the internal and external carotid arteries, jugular vein, lateral pharynx, and cranial nerves VII, IX, X, XI, and XII.
  • Management
    • CT scan if patient is stable
    • Vessel injury greatest in zones 1 & 3.  Less displaceable d/t fixation to bony structures, feeder vessels, muscles.
    • Typically, both symptomatic and asymptomatic zone 1 and zone 3 injuries are evaluated with angiography. These zones are difficult to assess clinically, and surgical access is challenging.  
    • Zone 2 injuries are usually explored surgically if they are symptomatic, and they can be followed up clinically or evaluated with angiography if they are asymptomatic.