Author: Aaron Lessen, MD
- Injuries from penetrating pharyngeal trauma are often subtle on examination in children
- Potentially serious complications including carotid artery injury, mediastinitis from spreading infection, or airway compromise from hematoma formation
- Imaging choice is typically CTA to assess for vascular injuries
- These injuries may require antibiotics
Zonfrillo MR, Roy AD, Walsh SA. Management of pediatric penetrating oropharyngeal trauma. Pediatr Emerg Care. 2008 Mar;24(3):172-5. doi: 10.1097/PEC.0b013e3181669072. PubMed PMID: 18347498.
Sasaki T, Toriumi S, Asakage T, Kaga K, Yamaguchi D, Yahagi N. The toothbrush: a rare but potentially life-threatening cause of penetrating oropharyngeal trauma in children. Pediatrics. 2006 Oct;118(4):e1284-6. PubMed PMID: 17015515.
Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD
Author: Don Stader, MD
- Recent study suggests we may not need to drain uncomplicated peritonsillar abscesses.
- Patients who received medical therapy alone had no difference in complications and failure compared to those who received surgical drainage plus medical therapy.
- Medical therapy in study was ceftriaxone, clindamycin, and dexamethasone.
- Medical therapy was also associated with fewer opioid prescriptions, sore days, and days off from work.
Battaglia A, Burchette R, Hussman J, Silver MA, Martin P, Bernstein P. Comparison of Medical Therapy Alone to Medical Therapy with Surgical Treatment of Peritonsillar Abscess. Otolaryngol Head Neck Surg. 2018 Feb;158(2):280-286. doi: 10.1177/0194599817739277. Epub 2017 Nov 7. PubMed PMID: 29110574.
- Otic (ear) specific antibiotic drops can be expensive
- Opthalmic (eye) versions are basically identical and can be used as an affordable substitute as many are on the $4 drug lists
- But don’t do the reverse (don’t use ear drops on the eye)
- Use caution when administering aminoglycoside if tympanic membrane rupture is present
Podcast #352: TXA for Epistaxis
Author: Chris Holmes, M.D.
- TXA: tranexamic acid; used in control of bleeding in major trauma, postpartum hemorrhage, etc.
- In study of 216 patients with epistaxis, TXA placed on a pledget was compared to anterior cotton nasal packing.
- The TXA group had faster time to bleeding control, quicker time to discharge, better patient satisfaction, and lower rates of re-bleeding.
Zahed R, Moharamzadeh P, Alizadeharasi S, Ghasemi A, Saeedi M. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med. 2013 Sep;31(9):1389-92. doi: 10.1016/j.ajem.2013.06.043.
Author: Don Stader, M.D.
- Ear pain is a common complaint in adults and kids.
- A red, hot, painful ear with involvement of the pinna could indicate perichondritis – an infection of the cartilage that is usually caused by pseudomonas.
- A painful, swollen ear with involvement of the mastoid process could be mastoiditis, which needs to be treated with IV antibiotics to avoid cerebellar abscess.
- Ear pain with significant drainage and a cranial nerve deficit points to malignant otitis externa, which needs to be treated with IV antibiotics.
References: John W. Ely, Marlan R. Hansen, Elizabeth C. Clark. Diagnosis Of Ear Pain. 2008. American Family Physician.
Run Time: 3 minutes
Author: Jared Scott M.D.
- TMJ dislocations are generally a rare occurrence. Connective tissue disorders such as Ehlers-Danlos syndrome and Marfan syndrome increase the likelihood of dislocation.
- TMJ dislocations can occur after benign activities such as eating, yawning, vomiting, dental treatment, and laughing, but also occur after trauma.
- Three common techniques for reduction include: 1) Hooking both thumbs over the patient’s canines, placing a Bite Block in the mouth, and pulling down on the jaw 2) Performing the same technique as #1, but from behind the patient 3) Placing a 5-10g syringe in the back of the patient’s mouth near the molars and instructing the patient to attempt to roll the syringe around.
- Once the jaw is reduced, patient’s with brackets will have their jaw wired shut, which is the same principle as a shoulder dislocation getting a sling to promote healing.
- Be aware of where the wire cutters are in the emergency room in case of a patient with a wired jaw needs an emergent airway.
Link to Podcast: http://medicalminute.madewithopinion.com/tmj-dislocation/
Run Time: 7 minutes
Author: Aaron Lessen M.D.
- It is important to differentiate between an airway foreign body, which presents as more respiratory choking and difficulty breathing VS esophageal foreign body, patients often complain “I can’t swallow” or spit up what they try to drink /swallow.
- 1-2 year old children are the most common patient to get airway foreign body, and the most common foreign bodies are food – grapes or hot dogs, round and smooth objects like balloons, and small toys.
- Patients present with a history of choking, stridor, respiratory distress, wheezing, retractions, and increased work of breathing.
- It is important to differentiate between a complete obstruction versus an incomplete obstruction.
- Incomplete obstruction patients will be more awake, but in distress – the patient could decompensate and turn to a complete obstruction if there is too much intervention. Patients should be observed in the ER and move to the OR as soon as possible where peds ENT can perform a controlled removal of the foreign body.
- With complete obstruction patients BLS measures are the first intervention techniques that should be taken – for a patient <1yo: 5 back blows followed by chest compressions, and for a patient >1yo the heimlich maneuver is recommended.
- Laryngoscopic removal with magill forceps is the next intervention.
- In more severe and rare cases where the foreign body is lodged at the trachea or below the vocal cords there are a few techniques that can be used: Needle transtracheal ventilation (you cannot cric a child under 8yo because they do not have a cricothyroid membrane), or possible endotracheal tube and try to advance the foreign body into the right mainstem bronchus so you can oxygenate the left lung until you can get the patient to the OR.
Link to Podcast: http://medicalminute.madewithopinion.com/tracheal-foreign-bodies/
Run Time: 3 minutes
Author: Michael Hunt M.D.
- Epistaxis accounts for a 1-2% incidence of all ER visits, approximately 450,00 patients per year are seen in the Emergency Room with epistaxis.
- Anatomically categorized into 2 realms: Anterior: when you can see the source of the bleed after clearing the nose, and posterior: when the source of the bleed cannot be seen once the nose is cleared.
- There are arterioles that come into the septum at Kiesselbach’s plexus, which accounts for 95% of anterior nosebleeds.
- Nosebleeds are almost always on 1 sided, although they can work up and over the septum if there is a large amount of bleeding.
- The first thing that a patient should do when they get a nosebleed is hold the nose right below the nasal bone and squeeze for 10 minutes. If that does not stop then the patient should seek treatment in the Emergency Room.
- If pressure, and silver nitrate does not work then the patient will get their nose packed. Anterior packs have 1 balloon and posterior packs require 2 balloons and have the potential to repress respiratory drive in older patients causing hypoxia.
- Literature suggests that antibiotics are not necessary when a patient gets a nasal packing, this avoids complications like diarrhea, allergic reactions, and C. diff infection.
Link to Podcast: http://medicalminute.madewithopinion.com/epistaxis/
Run Time: 7 minutes
Author: Dr. Eric Miller
- There are three types of dental fractures or Ellis fractures. Ellis I is through the enamel, Ellis II is into the dentin, and Ellis III is into the nerve pulp of the tooth.
- For fractures, any bleeding should be controlled and the tooth should be completely dried out before calcium hydroxide can be placed on the tooth as a hardened cover.
- For a tooth avulsion, the tooth should be placed in milk or normal saline initially. You should not clean or scrub the ligaments on the bottom of the tooth and the tooth should be handled by the crown only. The tooth should then be replaced within 15-20 minutes for best results of re-implantation.
- There are 5 million tooth avulsions per year.
Link to Podcast: http://medicalminute.madewithopinion.com/dental-injuries/