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Conference November 2020 (HEENT)

Welcome back, November has been a busy month for us with residency interviews and activities. The weather has been nice for the most part as well which is a nice break from the summer heat. This month’s content will be a short review to give you some room for the holidays.

From left to right – Dr Soliman (PGY3), Dr Klein (PGY2), Dr Pavelka (PGY2)

But First

Congratulations to Dr Vo and Dr Blustein for their awesome matches to Ultrasound Fellowships! Congratulations to Dr Posey for an awesome match in Critical Care Fellowship! Congratulations to Dr Scarborough for an awesome match as the first Street Medicine Fellow!

Also congrats to the wellness event winners and participants!

Onto business

EMDOCS put together a pretty awesome rundown article including facial wound closure and tips, Suture placement and removal techniques, mandibular dislocation reductions, Auricular hematoma management, eyelid lacs, nasal septal hematoma drainage, nasal FB removal and PTA aspiration:

Link Above for EMDOCS

Check out the article and see what you think. Its pretty extensive and touches on alot of topics we covered in lecture presentations and sim, so I’ll leave the link above for your recap.

I’m also going to include a few procedural videos below courtesy of EMRAP for recap of procedures we didn’t cover in sim lab but are good for a refresher (1).

How to perform a lateral canthotomy:

How to Perform an Auricular block for ear laceration repair:

Also some tips for epistaxis management:

Next

Did you forget about the Weber and Rinne test? This likes to surface on boards and ITE from time to time (2, 3):

Rinne test: Tuning fork is placed on the mastoid then placed
next to external ear canal. Normally, air conduction is better than
bone. If the patient hears the sound better when the fork is placed on the
mastoid, this indicates a conductive hearing loss in this ear.

Weber test: Tuning fork is placed on the center of the forehead. The
sound should be equal in both ears if normal. If unequal, the side where the sound
is heard better is the source of a conductive hearing loss. The side
where the sound is heard less is the source of a sensorineural hearing loss.

Next

Ever heard of a ZMC or ZMOC fracture? The Zygomatico-Maxillary-Orbital Complex Fracture is basically a “Tripod” fracture which involves trauma to the the zygoma. The term tripod refers to the three fracture sites: (1) the zygomaticfrontal suture, (2) connection to the inferior orbit floor and rim, and (3) the zygomatic-temporal suture (zygomatic arch). The patient may have facial flattening and asymmetry with paresthesia of cheek due to injury to the maxillary branch of the trigeminal nerve, Periorbital crepitus, trismus or mandibular pain, as well as diplopia in setting of concurrent orbital blowout fracture. (3,4). This type of fracture is typically a plastic surgery consult for open repair. (5)

Open Correction of Zygomatic Fractures | Plastic Surgery Key
Courtesy of Plasicsurgerykey

Next

Cavernous sinus thrombosis

This is a life-threatening infection and associated thrombosis of the cavernous
sinus typically originating in the sinuses or midface. Other sources of infection include facial veins, oral cavity/dental infections, middle ear and mastoiditis. The most common organism is S. aureus, but can also have mixed flora and oral flora such as Fusiforum, or fungal if immunocompromised. Causes fever, headache, and cranial nerve palsies- CN VI is most commonly affected, presenting as a
lateral gaze palsy, can also have chemosis and conjunctival injection. Pts appear typically toxic in nature. Workup – CT/MRI, BCx, sepsis workup. Tx – Empiric abx – broad spectrum ie Vanc/Zosyn/Cefepime. Heparin used to prevent septic emboli although limited evidence (3), ICU admit, possible Neurosurgery consult or ENT consult for sphenoid sinus surgical drainage.

Study cavernous sinus thrombosis Flashcards | Quizlet
Courtesy of Quizlet (4)

Next

ANUG – Acute Necrotizing Ulcerative Gingivitis

Caused by overgrowth of normal oral bacteria or periodontal infections (usually fusobacteria or oral spirochetes). Also called “trench mouth” which comes from the high incidence of this disease in World War I trench-bound soldiers. Causes foul breath, metallic taste, necrotic tissue around the gumline and grey pseudomembranes along gums and teeth. Also gingival retraction is common. Tx – Chlorhexidine rinse, PO PCN, Flagyl or Clindamycin. Dental followup. If extensive or immunocompromised – admit for IV Abx.

emDOCs.net – Emergency Medicine EducationEM@3AM: Acute Necrotizing  Ulcerative Gingivitis - emDOCs.net - Emergency Medicine Education
Courtesy of EMDOCS (5)

Thats all for now, Enjoy your holiday and see you at the next conference!

From left to right – Dr Khong (PGY3), Dr Bigot (PGY2), Dr Sweeney (PGY1)

References

  1. Youtube/EMRAP
  2. First aid for the Emergency Medicine Boards Copyright © 2009 by The McGraw-Hill Companies, Inc. ISBN: 978-0-07-149617-9, MHID: 0-07-149617-3.f
  3. Current Emergency Diagnosis and Treatment, 5th ed. New York: McGraw-Hill, 2004:629
  4. Tintinalli JE, Kelen GD, Stapczynski SJ. Emergency Medicine: A Comprehensive Study Guide, 6th ed. New York: McGraw-Hill, 2004:1477
  5. Semer N. Practical plastic surgery for non-surgeons. Philadelphia: Haley and Belfus; 2001. p. 145-159.
  6. Hafner H, Rocken M, Breuninger H. Epinephrine-supplemented local anesthetics for ear and nose surgery: clinical use without complications in more than 10,000 surgical procedures. J Dtsch Dermatol Ges. 2005; 3(3):195-199.
  7. Hutchens, D and Raghavendra M. Ear Anesthesia. Medscape. 2016. Available from: http://emedicine.medscape.com/article/82698-overview#a1
  8. Iserson K, Luke-Blyden Z, Clemans S. Orbital compartment syndrome: alternative tools to perform a lateral canthotomy and cantholysis. Wilderness Environ Med. 2016; 27:85-91.

Image Credits

  1. S. Meyering DO FAAEM FACEP
  2. FortworthEM.com
  3. Warren Schubert – https://plasticsurgerykey.com/open-correction-of-zygomatic-fractures/
  4. https://quizlet.com/313460750/cavernous-sinus-thrombosis-flash-cards/
  5. http://www.emdocs.net/em3am-acute-necrotizing-ulcerative-gingivitis/

Stefan Meyering DO, FAAEM, FACEP

Dad, Academic EM Attending Physician, Fish Nerd & Backyard Mechanic | APD @ Ft Worth EM | Interests: Graduate Medical Education, Risk Management and Legal Medicine, POCUS, Free Open Access Medical Education (FOAMed), Physician Wellness

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