Diagnosis At A Glance

Harry Kopolovich

31 y/o female presents with tooth pain and a swollen neck

Ludwig's Angina

- Submandibular space is primary site of infection

- Subdivided by mylohyloid muscle- Sublingual space superiorly- Submandibular space inferiorly

- Odontogenic source in >90% cases- Others include: Trauma, tongue

piercing, sialedenitis, neoplasm, other parapharnygeal infections

- Definitive Airway Management is Key

• Direct vs. fiber optic visualization

• No blind nasotracheal attempts

– May rupture abscess

- Empiric antibiotics

• Primary flora: Strep, Staph, Bacteroides

• 3rd Generation Cephalosporins plus clindamycin

• No definite role of steroids

- Definitive management is surgical

- Prior to antibiotics: Mortality >50%

- Currently: Antibiotics + Surgery Mortality 8%

75 y/o white man presents with 5 days of rash and pain to forehead

Herpes Zoster Opthalmicus

VZV causative agent Reactivation produces typical dermatomal

distribution Dissemination occurs in immunocompromised

patients Anterior horn cells Muscular weakness,

diaphragmatic paralysis, colon pseudo obstruction Spinal cord GBS like syndrome, Transverse myelitis

Phases of Presentation

Three phases Pre-eruptive

Pain or dysesthesia occurs 48-72 hours prior Eruptive

Heralded by emergence of skin lesion Erythematous macules Vesicles Ruptured Vesicles Ulcers Crusted

lesions Lesions can last 10-15 days Not considered healed until lesion are crusted

Considered a TORCH infection Post-Eruptive

Post-herpetic neuralgia is pain lasting or recurring >30 days Most t frequent complication: Occurs in 9-45% of cases Higher incidence in elderly males

Herpes Zoster Opthalmicus Reactivation of VZV in trigeminal nerve CN V Usually V1 affected

Hutchinson’s Sign Lesion on tip of nose Indicates higher likelihood of ocular involvement (76% vs. 34%) Pseudo-dendrites

Peripherally located, poorly stain with fluorescein Partial thickness (can be wiped clean as compared to dendrites in

herpes keratitis which are full thickness and cannot be wiped clean) Ophthalmology Consult

Complications Post-herpetic neuralgia Corneal Anesthesia or hypoesthesia Secondary Infection

Treatment Anti-virals

Proven benefit when instituted within 48-72 hours Reduces viral shedding and accelerated resolution

of symptoms

Corticosteroids Controversial at best Two studies conducted using steroids + acyclovir only

Current indications Only in moderate to severe pain Or in severe CNS symptoms or paralysis exist

Use of steroid contraindicated in isolation Concern exists for promotion of viral replication

Optimal Duration uncertain Should not exceed duration of anti-viral agent

24 year old man presents with pain to nose after being hit in the head with a soccer ball

Examination reveals the following

Nasal Septal Hematoma

Uncommon complication following direct nasal trauma

Associate with fracture of septal cartilage Nasal septum composed of

a thin cartilaginous plate with a closely adherent perichondrirum and mucosa

Septal Hematoma Occurs as perichondrium separated from septum Accumulation of blood results

Avascular necrosis Septal perforation, saddle nose deformity

Abscess Possible meningitis, encephalitis, cavernous sinus

thrombosis

Make sure to examine nostril on all patients with facial trauma Visual inspection with otoscope or nasal speculum

Nasal septum 2-4mm thick (possible bilateral hematomas)

Digital inspection

Treatment is I & D

70 year old Asian woman present with headache, nausea and eye pain while watching a movie at a local movie theater

Acute Angle Closure Glaucoma

Aqueous humor produced in ciliary body in the posterior chamber

It diffuses through the pupil into the anterior chamber

Drains into the vascular system through the canal of Schlemm

Acute Angle Closure Glaucoma (AACG) Defined by the presence of 2 of the following symptoms

Ocular pain, nausea/vomiting, hx of intermittent blurring of vision with halos

And 3 of the following signs IOP >21mmHg (Usually >50), conjunctival injection, corneal epithelial edema, mid-dilated non-

reactive pupil, shallow anterior chamber

End result is sustained production of aqueous humor which is unable to pass from posterior to anterior chamber, resulting in an increased IOP, culminating ultimately in retinal damage, and visual loss

Risk Factors Older age, female, Asian descent, shallow anterior angle, excessive sympathetic tone, thin iris,

darkened environment Essentially, any condition which cause the iris to heap up, and become closer to pupil, thus

preventing egress of aqueous humor Or any condition that disrupts the egress of aqueous from the anterior chamber

Diagnosis Clinical suspicion: Anyone with headache and eye pain, make sure to

examine eye Tono pen

If not working or stolen, use your finger

Treatment Lie patient flat: May cause separation of Iris from lens Analgesia Topical β- blockers or α- agonists

Decreases aqueous humor production (Timolol 0.5% 1 drop) Topical Steroids

Reduce inflammation (Prednisolone 1 drop Q15min Hyperosmotic agents

Decrease fluid volume in eye (Mannitol 1-2 g/kg IV over 30-60min) Topical Miotics

Pulls the iris back away from pupil (Pilocarpine ½% 1 drop Q6hr) Will not work unless IOP <40mmg

50 year old female presents with headache and blurry vision

CN III Palsy

Anatomy Originates in the brainstem continues within sub-arachnoid

space traverses the cavernous sinus terminates within the orbit after exiting the superior orbital ridge

Contains voluntary muscle fibers and parasympathetic control Responsible for majority of EOM Pupillary Constriction Raises eyebrow (Levator palpebrae superiorus has dual innervation)

Presentation Typically down and out pupil, which doesn't’t constrict or

accommodate Ptosis

Why is the anatomy important?

Disposition Because of the origin and course CN III, deficits can indicate

PCA Aneurysm Uncal Herniation Compressive Neoplasms Inflammatory Conditions Trauma Cavernous sinus neoplasm Cavernous sinus thrombosis Carotid-Cavernous fistula

MRI/MRA Imaging and neurology consult strongly recommended

It is possible to have isolated CNIII deficits affecting primarily the EOM and rarely the pupil Adjunct indicator for micro vascular disease in HTN and DM Usually a painful condition Low threshold for neurology involvement

20 year old wrestler presents with ear pain

Auricular Hematoma

Develop when the ear sustains blunt trauma Causing auricular perichondrium to separate from

underlying cartilage Tearing of the perichondrial blood vessels results in

subsequent hematoma Chronic presence of blood stimulates new cartilage

deposition and subsequent cauliflower ear

Auricular Hematoma

Treatment >7 days

Referral to ENT <7 days

I & D Needle aspiration no longer recommended as hematoma

tends to re-accumulate

Pressure dressing Follow-up in 24 hours

Most pressure dressing are inadequate, tend to allow hematoma to re-accumulate

18 year old woman presents with ear pain and fever

Examination reveals a tender, erythematous bulge posterior to ear

Mastoiditis

Mastoid bone is directly contiguous to and is an extension of the middle ear cleft Mastoidits is the result of an extension of purulent

otitis media Medial wall erosion can result in

Cavernous sinus thrombosis, CN VII palsy, Meningitis, Brain abscess

Treatment Flora is similar to causes of AOM Strep Pneumo most common

Risk Factors Likely multifactorial

Invasive species vs. host anatomy (Eg. Congenitally narrow mastoid antrum)

Disposition Broad spectrum antibiotics: Semi-synthetic PCN’s, 3rd

generation cephalosporins, Vanco Imaging Admission Surgery in refractory cases

20 year old man presents with eye pain and fever after being scratched by his cats claws 2 days ago

Orbital Cellulitis

Orbital septum is a fascial layer which extends vertically from the periosteum of the orbital rim to the inferior border of the tarsal plate in the lower eyelid

Orbital cellulitis is an infection posterior to the septum

Etiology 1) Extension of an infection from the periorbital

structures Usually ethmoid sinusitis

2) Direct inoculation from trauma or surgery 3) Hematogenous spread from bacteremia

Veins in this region are valveless allowing retrograde and anterograde flow

Presentation Pain, fever, chemosis Important findings are proptosis, painful EOM’s

Disposition Imaging: CT with contrast Broad spectrum abx (MRSA becoming common) Admission

Complications Visual Loss Cavernous sinus thrombosis Meningitis Abscess Osteomyelitis

7 year old boy is brought in by mom for evaluation of a bump next to his eye

Dacrocystitis

Lacrimal excretory system Drain tears from the medial aspect of the eye

through a series of canal which ultimately terminate in the nose

Prone to infection as system is contiguous with conjunctiva proximally and nasal mucosa distally

Infection usually develops when stagnation occurs secondary to obstructed lacrimal sac

Microbiology Usual nasal and skin flora

Management Most case are self limited

Warm compresses, massage lacrimal sac, oral anti-biotic (β- lactamase resistant)

Consider imaging for recurrent causes Obstruction caused by malignancy

25 year old brought to ER screaming.

Pain began while yawning when trying to fall asleep

TMJ Dislocation

Mandibular dislocations occur when the mandibular condyle disarticulates from the articular groove in the temporal bone

Dislocations can occur in Anterior (Most common) Superior Posterior Lateral

Patients present with an inability to close jaw

Treatment aimed at analgesia and reduction

48 year old woman with no past medical history presents with the following midline neck mass

She states it is has been present for as long as she can remember, but now wants it removed

Thyroglossal Duct Cyst

Thyroglossal Duct Cyst

Most common form of congenital neck cyst Arises embryologically from the thyroid gland Presence of cysts indicates failure of tract to involute

Distinguishing feature Midline Non-tender Moves with swallowing and tongue protrusion due to

proximal attachment to hyoid bone

Treatment Rarely gets infected

Abx Imaging if concern for airway exists

ENT referral for excision Send TSH (May contain ectopically located thyroid

tissue)

58 year old man with a 2 week history of progressive DOE, neck swelling, decreased appetite and fatigue

Quit smoking in 2012

SVC Syndrome

Superior vena cava carries blood form the head, arms and upper torso to the heart

Carries 1/3 of the bodies circulating volume

SVC is pliable and easily compressible

Compression leads to retrograde flow into collateral vessels

Etiology Carcinoma (90%)

Bronchogenic, Lymphoma, Teratoma, Thymoma Infectious

TB, Syphilis Thrombus

CVP placement

Symptoms Limb/facial edema, Headache, Confusion, Dyspnea

Treatment Directed at underlying condition Poor prognosis

Radiotherapy Palliative stents Tumor debulking

EMS brings in a restrained driver who was involved in a frontal collision on I-95

Seat Belt Sign

Two and 3 point seat belts, when worn correctly have significantly reduced mortality in MVC

Abrasions from seat belts occur in ~20% of MVC

Presence of these abrasions increases the likelihood of underlying thoracic injuries four fold and abdominal injury by eight fold Neck abrasion: Carotid artery injury, laryngeal injury, c-spine

injury Chest abrasion fracture of sternum, ribs, clavicles; injuries to

aorta and heart Abdomen abrasion: mesenteric injury, bowel

perforation/hematoma, Chance fracture

Presence of seat belt sign should heighten suspicion of potential underlying injury

Thorough exam, liberal imaging, frequent re-assessment are cardinal points to remember

50 year old man, was curling 100lb dumbbells at the gym

The patient heard a pop, and then felt pain in his right arm

Biceps Tendon Rupture

Ruptured Biceps Tendon

Biceps Anatomy Proximal Biceps: Two heads which attach proximally about

the scapula Distal Biceps: Solitary attachment to the radial tuberosity

Biceps function to cause forearm flexion and supination

Most common location of injury is proximal attachment Long head (90-97%)

Most patient describe a pop and simultaneous loss of strength in affected arm

Predisposing Factors Repetitive micro trauma Steroid injection Muscle over usage

Management X-ray: Rule out concomitant avulsion fracture Sling, NSAIDS Ortho referral

37 year old man presents with pain to left hand after getting it scraped along a brick wall

Fight Bite

Clenched Fist Injury (Fight Bite)

All wound at the MCP joint, especially when on the dominant hand are fight bites until proven otherwise

Infections tend to be polymicrobial and aggressive Staph, strep, E. Corrodens, anaerobes

Complications Rapidly progressive infections Loss of function Septic Arthritis Flexor Tenosynovitis Amputation

Management Irrigation Tendon strength testing Debridement Radiography Prophylactic anti-biotics Splinting & Elevation Close follow-up or admission

42 year old dental assistant presents with painful and swollen finger

Herpetic Whitlow

Primary or recurrent HSV lesion HSV-1

Seen in children who auto-inoculate their digits with oral secretions

Health care workers who are exposed to oral secretions HSV-2

More common in adults due to digital/genital contact May be confused with paronychia

Clear vesicles seen early, coalesce and may appear purulent, actually contains necrotic epithelial cells

Symptoms Painful and red distal digit Axillary lymphadenopathy

Treatment Local wound care Pain control Topical Acyclovir: Decreases Duration of Symptoms Oral anti-virals Do not I & D