ENT

Podcast 505: Sleep on Strep Throat 

October 1, 2019 ENT, Infectious Disease, Medical Minute

Contributor: Don Stader, MD

Educational Pearls:

  • Only 10% of patients receiving antibiotics for strep throat actually have the diesease
  • Treatment of strep with antibiotics only slightly reduces the duration of illness. Most studies say the reduction is between 16 and 24 hours
  • Antibiotic treatment may reduce complications such as peritonsilar abscess and otitis media but antibiotics also increase the risk of diarrhea and yeast infection
  • Rheumatic fever is caused by a specific serotype of strep that is no longer prevalent in the United States, so treating strep throat likely has no effect on preventing this complication 

References

Anand Swaminathan, “Do Patients with Strep Throat Need to Be Treated with Antibiotics?”, REBEL EM blog, January 5, 2015. Available at: https://rebelem.com/patients-strep-throat-need-treated-antibiotics/. 

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Check out this episode!

Podcast # 487: Hunting for Epiglottitis

July 10, 2019 Airway, ENT, Medical Minute

Contributor: Michael Hunt, MD

Educational Pearls:

  • Due to the efficacy of vaccination, epiglottitis is now more common in adults than children
  • Risk factors include smoking and other immunocompromising co-morbidities, such as diabetes
  • Epiglottitis can present with sore throat and fever, with potential rapid progression to respiratory distress and stridor
  • Diagnosis can include x-ray to look for the “thumbprint sign,” nasofiberoptics, and/or CT
  • Antibiotics are mainstay of treatment but severe cases may need establishment of a definitive airway, typically done with fiberoptics in the operating room due to the potential to irritate the epiglottitis with traditional laryngoscopy

References

Li RM, Kiemeney M. Infections of the Neck. Emerg Med Clin North Am. 2019 Feb;37(1):95-107. doi: 10.1016/j.emc.2018.09.003. Review. PubMed PMID: 30454783.

Tsai YT, Huang EI, Chang GH, Tsai MS, Hsu CM, Yang YH, Lin MH, Liu CY, Li HY. Risk of acute epiglottitis in patients with preexisting diabetes mellitus: A population-based case-control study. PLoS One. 2018;13(6):e0199036. doi: 10.1371/journal.pone.0199036. eCollection 2018. PubMed PMID: 29889887; PubMed Central PMCID: PMC5995441.

Guerra AM, Waseem M. Epiglottitis. [Updated 2018 Nov 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430960/

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Podcast #397: Pharyngeal Trauma

October 27, 2018 ENT, Trauma

Author: Aaron Lessen, MD

Educational Pearls:

  • 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

References:

 

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

Podcast #384: Don’t stab a PTA?

September 26, 2018 ENT

Author:  Don Stader, MD

Educational Pearls:

  • 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.

 

References:

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.

Podcast # 358: Affordable ear drop alternatives

July 27, 2018 ENT

Educational Pearls:

  • 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

References

https://tgtfiles.target.com/pharmacy/WCMP02-032536_RxGenericsList_NM7.pdf

http://i.walmart.com/i/if/hmp/fusion/four_dollar_drug_list.pdf

https://www.uptodate.com/contents/external-otitis-treatment

Podcast #352: TXA for Epistaxis

July 13, 2018 ENT

Podcast #352: TXA for Epistaxis

Author:  Chris Holmes, M.D.

Educational Pearls:

  • 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.

 

References:

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.

Podcast #245: Are You Listening? – 3 Ear Emergencies You Can’t Miss!

September 2, 2017 ENT

Author: Don Stader, M.D.

Educational Pearls

  • 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.

Podcast #149: TMJ Dislocation

September 28, 2016 ENT, Orthopedic

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Author: Jared Scott M.D.

Educational Pearls:

  • 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/

References: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4668726/

http://www.ncbi.nlm.nih.gov/pubmed/25278137

Podcast #146: Tracheal Foreign Bodies

September 22, 2016 Airway, Critical Care, ENT

65e2e5c6-4107-44ea-89c5-08a58ae3dc72Run Time: 7 minutes

Author: Aaron Lessen M.D.

Educational Pearls:

  • 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/

References: http://journal.publications.chestnet.org/article.aspx?articleid=1080585

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2881610/

Podcast #117: Epistaxis

July 3, 2016 ENT

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Author: Michael Hunt M.D.

Educational Pearls:

  • 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/

References: http://www.hindawi.com/journals/ijoto/2015/283854/

 

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