ent case
TRANSCRIPT
ENT Case PresentationRunal Shah
PGY-2Masters in Emergency Medicine
KDAH
45/ Female, walks to A&E Triage at 10.45pm on Sunday
Complaints – sudden onset pain, swelling of right cheek for 2 hours.
A, B, C, D – all correct
Vitals◦ T- Afebrile◦ P- 84/min◦ R- 16/min◦ BP- 120/70 mmHg◦ SpO2- 97% on room air
Pain Score – 5/10
So, what is the problem we are dealing with ??
What should be done ?
Consider resources and act wisely !
Triage category ???
Interventions – ◦ IV access – scalp vein◦ Inj Dynapar 75mg in 20ml NS iv
Investigate –◦ CBC
◦ Imaging – CT scan / USG soft parts ??
S – Pain and swelling of the right cheek, for approx 2 hours, following dinner, No fever, similar complaints in the past
A – no allergiesM – no meds on routine basisL – dinner at 8.30pmE – none
Secondary survey –
HEENT –
Inspection – ◦ vague swelling of right cheek, comparable increase in
size as to left cheek◦ asymmetry of face !◦ Oral mucosa healthy, no purulent discharge.
Palpation – ◦ mild tenderness over right cheek◦ on per-oral palpation no stones palpable
Rest of the systems – unremarkable
Reassessment
Pain score 1/10 – discomfort onlySwelling was sameDiscussed with pt regarding need of imaging for
the same to rule out sialolithiasis
USG soft parts – ◦ right parotid gland duct stone of 1.7mm !◦ No obvious inflammatory changes within right parotid
gland
CBC◦ 13.2 / 40 / 7800 / 2,90,000
Disposition
Explained the condition to the patient, discharged with ENT follow up in OPD.
On discharge Rx◦ Tab Voveran-SR 75mg 1—0—0 x 3 days◦ Tab Pantocid 40mg 1—0—0 x 3 days, 30min before
breakfast◦ Warm compresses over right cheek
Concrements (stones) formed in the salivary gland parenchyma or duct due to increased viscosity or stasis.
1% populationM > FAge group : 30-50Submandibular gland (80-90%) >> Sublingual >
Parotid
Case Discussion – Sialolithiasis
Differentials :
1) Infections – Bacterial
(Staphylococcus, Strep Viridans, Pneumococcus, H influenza)
Viral – Mumps
2) Inflammation3) Granulamtous4) Neoplastic
Commonly forms around an organic nidus.
Clinical presentation
Pain, swelling, tenderness overlying the gland, Purulent discharge from the duct
Difficult to differentiate between parotitis and sialolithiasis clinically as they may co-exist or may be causative of each other !!
Features favoring Sialolithiasis :◦ Typically Unilateral◦ Pain, swelling aggravated post meals
Management in ED
Diagnosis is clinicalPer-oral palpation with gland massage may
reveal stone or purulent discharge
Imaging – ◦ X-ray◦ USG◦ CT◦ MRI◦ Sialography
Pain relief by NSAIDs
Ultrasound appearance
Small High Frequency probes (Vascular probe)
DispositionIf palpable stone is removed in ED – f/up with ENT
in 3-4 days
If not, ENT f/up within 24 hours
Discharge treatment – 1) Hydration2) Moist heat3) Massage
4) Analgesics5) Sialogogues (Lemon
drops)6) Antibiotics
Thank You…
Ref :
◦Rosen 8/e◦Tintinalli 7/e
◦http://radiopaedia.org/articles/sialolithiasis