ent & optho board review mark heller, md department of emergency medicine mount sinai school of...

ENT & Optho ENT & Optho Board ReviewBoard Review

Mark Heller, MDMark Heller, MD

Department of Emergency Department of Emergency MedicineMedicine

Mount Sinai School of MedicineMount Sinai School of Medicine

Question 1Question 1

A 23-year-old man presents holding both hands over his left eye. He was playing basketball when another player hit him in the eye. He is able to cooperate with the examination and reports decreased vision. The definitive treatment option in the emergency department is?


a) Carbonic anhydrase inhibitorb) Gentle pressure to reduce the eyec) Lateral canthotomyd) Observation pending ophthalmology consultatione) Thyroid-stimulating hormone level measurement

PEER VII Q6


Q1 AnswerQ1 Answer

a) Carbonic anhydrase inhibitorb) Gentle pressure to reduce the eyec) Lateral canthotomyd) Observation pending ophthalmology consultatione) Thyroid-stimulating hormone level measurement

PEER VII Q6


Retrobulbar HemorrhageRetrobulbar HemorrhageRetinal Circulation Compromised

Clinical Findings:

•Proptosis

•Vision Loss

•Decrease Ocular Movement

•Increased Intraocular Pressure

Immediate decompression is Key

Lateral Canthotomy is the Best Option

Anatomy

Lateral canthal tendon - 2 segments: superior crus, inferior crus - attaches orbicularis oculi to lateral wall of orbit - keeps the eyeball in the socket

Cantholysis

• adjunctive procedure to canthotomy • can further reduce orbital compartment pressures • release of inferior crus of lateral canthus• if necessary, may also release superior crus but should avoid if possible as lacrimal gland and artery are in the area

Lateral Canthotomy

• emergent procedure to relieve orbital compartment pressures • release of lateral canthal tendon

Indications

• proptosis• decreased visual acuity• increased intraocular pressure >40mm Hg, resistance on ballotment

Contraindications

• globe rupture

Purpose

• temporizing measure• relieves orbital compartment pressures• prevents further neurovascular damage

Eye Exam

Inspection

Pupillary reaction

Extraocular muscle

Visual acuity

Fundoscopic exam

Ballotment or tonometry (contraindicated w/ globe rupture!)

Equipment

Lidocaine/Epi

Syringe

Hemostat or needle driver

Scissors

Forceps

Saline

1) Irrigate area w/ Saline

Lateral Canthotomy

2) Inject 1-2 cc lido/epi into lateral canthus

4) Make 1cm long horizontal incision laterally along devitalized area

3) Apply hemostat or needle driver over lateral canthus for 30-90 secs

5) Pull lower lid down w/ forceps to visualize the inf. crus of canthal tendon

6) With scissors pointing down, cut inf. crus to separate from orbital rim

Cantholysis

Final Steps…

7) Reassess intraocular pressure. Release sup. crus if necessary

8) Apply erythromycin ointment to prevent corneal dessication, infection.

Do NOT apply gauze dressing to exposed cornea.


A 20 year old woman presents with a painful right ear. She has no history of ear problems but swims several times a week. Examination reveals erythema of the external auditory canal with some purulent discharge and a perforation in the tympanic membrane. The treatment option most likely to damage her ear is:

a) Ciprofloxacin otic and hydrocortisone otic suspensionb) Hydrocortisone and acetic acid otic solutionc) Neomycin/polymyxn/hydrocortisone otic suspensiond) Ofloxacin otic solutione) Penicillinase-resistant penicillin

Q 2 AnswerQ 2 Answer

A 16 year old female presents with a painful right ear. She has no history of ear problems but swims several times a week. Examination reveals erythema of the external auditory canal with some purulent discharge and a perforation in the tympanic membrane. The treatment option most likely to damage her ear is:

a) Ciprofloxacin otic and hydrocortisone otic suspensionb) Hydrocortisone and acetic acid otic solutionc) Neomycin/polymyxn/hydrocortisone otic suspensiond) Ofloxacin otic solutione) Penicillinase-resistant penicillin

PEER VII Q59

Otitis ExternaOtitis Externa

Inflammatory process involving the Inflammatory process involving the auricle, external auditory canal, and auricle, external auditory canal, and surface of the TMsurface of the TM

Caused by gram-negative organisms, Caused by gram-negative organisms, Staph aureus, Pseudonomas, or fungiStaph aureus, Pseudonomas, or fungi

Peak age 9 to 19 yearsPeak age 9 to 19 years Erythema, edema of EAC, white Erythema, edema of EAC, white

exudates on EAC and TMexudates on EAC and TM Pain with motion of tragus or auriclePain with motion of tragus or auricle

Otitis Externa Otitis Externa (continued)(continued)

TreatmentTreatment Fluoroquinolone otic dropsFluoroquinolone otic drops Oral antibiotics if auricular cellulitis is Oral antibiotics if auricular cellulitis is

present or TM is perforated (Quinolones, present or TM is perforated (Quinolones, Cephalosporins, or penicillinase-resistant Cephalosporins, or penicillinase-resistant pcn)pcn)

Hydrocortisone and acetic acid otic Hydrocortisone and acetic acid otic solution have a pH 3.0 which can be solution have a pH 3.0 which can be toxic to the middle ear in perforationstoxic to the middle ear in perforations

Otitis ExternaOtitis Externa

Otitis MediaOtitis Media Infection of the middle earInfection of the middle ear Infants and Young Children (peaks at 6 to Infants and Young Children (peaks at 6 to

18 months)18 months) 25 to 30 million office visits per year25 to 30 million office visits per year Strep pneumoniae most prevalent causeStrep pneumoniae most prevalent cause Symptoms include fever, poor feeding, Symptoms include fever, poor feeding,

irritability, vomiting, earache, otorrheairritability, vomiting, earache, otorrhea Signs include dull, bulging, immobile TMSigns include dull, bulging, immobile TM

Light reflex is of no diagnostic valueLight reflex is of no diagnostic value TreatmentTreatment

Amoxicillin 80 mg/kg/day PO divided q8 – q12 Amoxicillin 80 mg/kg/day PO divided q8 – q12 for 10 days (High-dose amox therapy)for 10 days (High-dose amox therapy)

Otitis MediaOtitis Media


Which of the following conditions is an unlikely complication of sinusitis?

a) Cavernous sinus thrombosisb) Dental abscessc) Periorbital cellulitisd) Pott’s puffy tumore) Subdural empyema


Which of the following conditions is an unlikely complication of sinusitis?

a) Cavernous sinus thrombosisb) Dental abscessc) Periorbital cellulitisd) Pott’s puffy tumore) Subdural empyema

PEER VII Q76

SinusitusSinusitusPathophysiology:Pathophysiology:

Viral URI and Allergic Rhinitis most Viral URI and Allergic Rhinitis most common causecommon cause

Acute Bacterial - Strep Pneumoniae Acute Bacterial - Strep Pneumoniae & & H. InfluenzaeH. Influenzae

Clinical Features of Bacterial Clinical Features of Bacterial Sinusitus:Sinusitus: Pain in infraorbital, supraorbital, or Pain in infraorbital, supraorbital, or

lower forehead regionlower forehead region Presence of FeverPresence of Fever Symptoms lasting longer than 7 daysSymptoms lasting longer than 7 days Diminished or loss of sense of smellDiminished or loss of sense of smell Purulent nasal dischargePurulent nasal discharge Clinical Diagnosis Clinical Diagnosis

SinusitusSinusitusComplications of Sinusitis:Complications of Sinusitis:

OsteomyelitisOsteomyelitis MeningitisMeningitis Intracranial AbscessIntracranial Abscess Pott’s puffy tumorPott’s puffy tumor Orbital CellulitisOrbital Cellulitis Cavernous sinus thrombosis Cavernous sinus thrombosis

ED Treatment:ED Treatment: Nasal Decongestant SpraysNasal Decongestant Sprays AntibioticsAntibiotics

14-21 day regimens14-21 day regimens AmpicillinAmpicillin BactrimBactrim ClarithromycinClarithromycin Second-Generation CephalosporinsSecond-Generation Cephalosporins AugmentinAugmentin


A 57-year-old man is transferred form a skilled nursing facility because his tracheostomy tube cuff is not inflating. The tracheostomy was done 5 days earlier for repeated pneumonia and is still in place. The patient has no active bleeding and is in no distress. The most likely complication of replacing the tube is:

a) Air Trappingb) Creating a false passagec) Significant bleedingd) Tracheostomy site closinge) Tube directed upwards


A 57-year-old man is transferred form a skilled nursing facility because his tracheostomy tube cuff is not inflating. The tracheostomy was done 5 days earlier for repeated pneumonia and is still in place. The patient has no active bleeding and is in no distress. The most likely complication of replacing the tube is:

a) Air Trappingb) Creating a false passagec) Significant bleedingd) Tracheostomy site closinge) Tube directed upwards

PEER VII Q130

TracheostomyTracheostomy Within the first 7 days post-Within the first 7 days post-

op, the opening is not op, the opening is not mature, and manipulating mature, and manipulating the tube can lead to false the tube can lead to false passage in the soft tissues passage in the soft tissues of the neck.of the neck. Necessary to have ENT Necessary to have ENT

change tube with in the first change tube with in the first week post-opweek post-op

If tube is out for several If tube is out for several hours, there is a risk of a hours, there is a risk of a closed stoma and dilation closed stoma and dilation may be required.may be required.

The Eye QuizThe Eye Quiz


Britney Spears

President Franklin D. Roosevelt


Britney Spears

Denzel Washington


President Bill Clinton


Peter Shearer M.D.


A 20 year old man presents with left eye irritation. He was walking in a park and accidentally ran into a tree branch. He believes the branch scratched his eye. Examination reveals a corneal abrasion. The best treatment option is:

a) Erythromycin ophthalmic ointment, no patch.b) Erythromycin ophthalmic ointment, patchc) Homatropine, no patchd) Homatropine, patche) Topical anesthetic


A 20 year old man presents with left eye irritation. He was walking in a park and accidentally ran into a tree branch. He believes the branch scratched his eye. Examination reveals a corneal abrasion. The best treatment option is:

a) Erythromycin ophthalmic ointment, no patchb) Erythromycin ophthalmic ointment, patchc) Homatropine, no patchd) Homatropine, patche) Topical anesthetic

PEER VII Q 160

Corneal AbrasionsCorneal Abrasions

Corneal AbrasionsCorneal Abrasions Very PainfulVery Painful Fluorescein reveals dye update at abrasion Fluorescein reveals dye update at abrasion

sitesite TreatmentTreatment

Topical ErythromycinTopical Erythromycin, Tobramycin, or , Tobramycin, or Bacitracin/PolymyxinBacitracin/Polymyxin

Tetanus updatedTetanus updated Patching does not facilitate abrasion healingPatching does not facilitate abrasion healing Topical anesthetics strictly contraindicatedTopical anesthetics strictly contraindicated

Cause corneal breakdown and ulcerationCause corneal breakdown and ulceration Cycloplegic agents (homatropine) not Cycloplegic agents (homatropine) not

recommended recommended Recent studies show no benefit (Carley and Carley Recent studies show no benefit (Carley and Carley

2001)2001)


A 55-year-old woman presents complaining of loss of vision in her right eye that occurred suddenly and without pain. Examination reveals a pale, edematous retina with a visible red macula. The most likely cause of this condition is:

a) Bell’s Palsyb) Cataractc) Embolusd) Glaucomae) Optic Neuritis


A 55-year-old woman presents complaining of loss of vision in her right eye that occurred suddenly and without pain. Examination reveals a pale, edematous retina with a visible red macula. The most likely cause of this condition is:

a) Bell’s Palsyb) Cataractc) Embolusd) Glaucomae) Optic Neuritis

PEER VII Q145

Central Retinal Artery Central Retinal Artery OcclusionOcclusion

CausesCauses EmbolusEmbolus ThrombosisThrombosis Giant-cell arteritisGiant-cell arteritis Sickle Cell DiseaseSickle Cell Disease TraumaTrauma

Clinical Findings:Clinical Findings: PainlessPainless Complete or near complete vision lossComplete or near complete vision loss Afferent pupillary defect presentAfferent pupillary defect present Pal fundus on funduscopy examinationPal fundus on funduscopy examination

ED Treatment:ED Treatment: Ocular Massage (digital pressure for 15 seconds followed by Ocular Massage (digital pressure for 15 seconds followed by

sudden release)sudden release) Topical TimololTopical Timolol IV acetazolamideIV acetazolamide Emergent Optho consultationEmergent Optho consultation


A 50-year-old man presents with right eye pain, blurred vision, watery discharge, and photophobia that began 2 days earlier. He has no history of recent illness or trauma or past medical history. The patient is in moderate discomfort and is shielding his right eye from the light. Physical examination findings are depicted in the picture. Visual acuity is slightly decreased in the right eye and normal in the L eye. Pain with a consensual light reflex is present. Flare is noted on slit-lamp examination, and the intraocular pressure is within normal limits. What is the most likely diagnosis?


a) Acute narrow-angle glaucomab) Corneal abrasionc) Iritisd) Orbital cellulitise) Scleritis

PEER VII Q220

Iritis / UveitisIritis / Uveitis Consensual Light Reflex in presence of a red eye Consensual Light Reflex in presence of a red eye

is highly suggestive of iritis.is highly suggestive of iritis. Inflammation of the anterior uvea and spasm of Inflammation of the anterior uvea and spasm of

the ciliary body results in symptomsthe ciliary body results in symptoms Eye PainEye Pain Blurred VisionBlurred Vision TearingTearing Consensual PhotophobiaConsensual Photophobia

Treatment:Treatment: Anticholinergic PreparationsAnticholinergic Preparations Topical SteroidsTopical Steroids Oral AnalgesicsOral Analgesics

Urgent Optho ConsultationUrgent Optho Consultation

Acute Angle Closure Acute Angle Closure GlaucomaGlaucoma

Clinical Presentation:Clinical Presentation: Eye PainEye Pain HeadacheHeadache Cloudy VisionCloudy Vision Colored halos around lightsColored halos around lights Fixed, mid-dilated pupilFixed, mid-dilated pupil Increased intraocular pressure of 40 to 70 mm Hg Increased intraocular pressure of 40 to 70 mm Hg

(normal 10-20)(normal 10-20) ED CareED Care

Decrease intraocular pressureDecrease intraocular pressure TimololTimolol ApraclonidineApraclonidine Prednisolone AcetatePrednisolone Acetate Acetazolamide IV for pressures > 50mm HgAcetazolamide IV for pressures > 50mm Hg If pressure does not decrease in 1 hour, give IV If pressure does not decrease in 1 hour, give IV

MannitolMannitol


A 50-year-old man presents with fever and pain on swallowing. Examination reveals a nontoxic man with neck swelling, tongue elevation, and trismus. The most likely diagnosis is:

a) Epiglottitisb) Exudative pharyngitisc) Ludwig anginad) Peritonsillar abscesse) Pharyngeal tumor


A 50-year-old man presents with fever and pain on swallowing. Examination reveals a nontoxic man with neck swelling, tongue elevation, and trismus. The most likely diagnosis is:

a) Epiglottitisb) Exudative pharyngitisc) Ludwig anginad) Peritonsillar abscesse) Pharyngeal tumor

PEER VII Q223

Ludwig AnginaLudwig Angina Clinical FeaturesClinical Features

Dental disease is the most common causeDental disease is the most common cause Severe Inflammation caused by infection of Severe Inflammation caused by infection of

both sides of the floor of the mouthboth sides of the floor of the mouth Massive swelling of the tongueMassive swelling of the tongue DysphagiaDysphagia TrismusTrismus Edema of the upper midline neckEdema of the upper midline neck Can lead to airway obstructionCan lead to airway obstruction Anxiety, drooling, and stridor suggest Anxiety, drooling, and stridor suggest

impending airway collapseimpending airway collapse Diagnose with CTDiagnose with CT ED Care:ED Care:

ENT ConsulationENT Consulation Fiberoptic intubation for airway controlFiberoptic intubation for airway control Cricothyroidotomy if fiberoptic intubation Cricothyroidotomy if fiberoptic intubation

unsuccessfulunsuccessful Abx – ClindamycinAbx – Clindamycin Needs OR drainageNeeds OR drainage All patients should be admittedAll patients should be admitted

PharyngitisPharyngitis Clinical FeaturesClinical Features

Group A Beta-Hemolytic Strep (GABHS) Group A Beta-Hemolytic Strep (GABHS) causes up to 15% of acute pharyngitiscauses up to 15% of acute pharyngitis

Sore ThroatSore Throat Painful Swallowing Painful Swallowing ChillsChills FeverFever Clinical Criteria for GABHS Pharyngitis:Clinical Criteria for GABHS Pharyngitis:

Tonsillar ExudateTonsillar Exudate Tender Anterior Cervical AdenopathyTender Anterior Cervical Adenopathy History of FeverHistory of Fever Absence of CoughAbsence of Cough

Diagnose with Rapid Strep Antigen Diagnose with Rapid Strep Antigen Detection TestDetection Test

Sensitivities 80-90%Sensitivities 80-90% Specificities >95%Specificities >95%

ED Care:ED Care: Penicillin (Bicillin 1.2 million units IM)Penicillin (Bicillin 1.2 million units IM)

Peritonsillar AbscessPeritonsillar Abscess Clinical FeaturesClinical Features

FeverFever MalaiseMalaise Sore ThroatSore Throat OdynophagiaOdynophagia DysphagiaDysphagia ““Hot potato voice”Hot potato voice” TrismusTrismus

ED CareED Care Aspiration of purulent material with 18- or 20- gauge Aspiration of purulent material with 18- or 20- gauge

needleneedle Diagnostic and TherapeuticDiagnostic and Therapeutic

Try to avoid puncturing Internal Carotid Artery located Try to avoid puncturing Internal Carotid Artery located 2.5cm behind and lateral to the tonsil2.5cm behind and lateral to the tonsil

Antibiotic therapy with PenicillinAntibiotic therapy with Penicillin

EpiglottitisEpiglottitis Clinical Features:Clinical Features:

Can lead to rapid airway obstructionCan lead to rapid airway obstruction 1-2 day history of worsening dysphagia, odynophagia, 1-2 day history of worsening dysphagia, odynophagia,

dysphoniadysphonia Throat pain is disproportionate to clinical examinationThroat pain is disproportionate to clinical examination Clinical Indicators of Imminent Airway Obstruction:Clinical Indicators of Imminent Airway Obstruction:

Dyspnea, Drooling, Aphonia, StridorDyspnea, Drooling, Aphonia, Stridor Diagnosis:Diagnosis:

Lateral soft-tissue neck radiographsLateral soft-tissue neck radiographs Epematous epiglottis (“thumbprint sign”)Epematous epiglottis (“thumbprint sign”)

Direct fiberoptic laryngoscopyDirect fiberoptic laryngoscopy ED CareED Care

Emergent ENT consultationEmergent ENT consultation Preperation for definitive airwayPreperation for definitive airway Awake nasotracheal fiberoptic intubation is preferred methodAwake nasotracheal fiberoptic intubation is preferred method IV CefuroximeIV Cefuroxime AdmissionAdmission

EpiglottitisEpiglottitis

The ENT QuizThe ENT Quiz


Spock


Michael Jackson


Gene Simmons


A 75-year-old man presents with fever and ear pain. He has had the earache for several weeks and has been treating it at home with warm mineral oil. On further questioning, he says he is diabetic and that his sugars are running higher than normal. Examination is normal except for the ear, which has granulation tissue on the floor of the external auditory canal. The most likely pathogen causing this infection is:

a) Aspergillus sp.b) Candida sp.c) Pseudomonas aeruginosad) Staphylococcus epidermidise) Streptococcus pneumoniae


A 75-year-old man presents with fever and ear pain. He has had the earache for several weeks and has been treating it at home with warm mineral oil. On further questioning, he says he is diabetic and that his sugars are running higher than normal. Examination is normal except for the ear, which has granulation tissue on the floor of the external auditory canal. The most likely pathogen causing this infection is:

a) Aspergillus sp.b) Candida sp.c) Pseudomonas aeruginosad) Staphylococcus epidermidise) Streptococcus pneumoniae

PEER VII Q231

Malignant Otitis ExternaMalignant Otitis Externa Seen in the elderly, diabetic, and Seen in the elderly, diabetic, and

immunocompromised patientimmunocompromised patient Failing 2-3 weeks of antibiotic Failing 2-3 weeks of antibiotic

therapytherapy Potentially life-threatening diseasePotentially life-threatening disease Most Common Organism = Most Common Organism =

Pseudomonas aeruginosaPseudomonas aeruginosa Physical Exam Findings:Physical Exam Findings:

OtalgiaOtalgia OtorrheaOtorrhea Granulation tissue on floor of Granulation tissue on floor of

external auditory canalexternal auditory canal Treatment:Treatment:

AdmissionAdmission Parenteral antibioticsParenteral antibiotics Possible surgical debridementPossible surgical debridement


A 17-year-old girl presents with a painful right ear. She has had the pain for 2 weeks but has not had time to see her family doctor. She is worried because her boyfriend said her ear was red and looked funny. On examination, the ear appears as in the picture, and a posterior auricular crease is not noted. The best treatment option is:


a) Administer oral antibiotics and discharge

b) Administer topical antibiotics and discharge

c) Admit for treatment with parenteral antibiotics

d) Perform typanocentesis and discharge

e) Refer to an ENT for follow up care

PEER VII Q241

MastoiditisMastoiditis Infection spreads from the middle ear (otitis media) to the Infection spreads from the middle ear (otitis media) to the

mastoid air cellsmastoid air cells Clinical Presentation:Clinical Presentation:

OtalgiaOtalgia FeverFever Postauricular erythemaPostauricular erythema SwellingSwelling tendernesstenderness Protrusion of the auricleProtrusion of the auricle Obliteration of the postauricular creaseObliteration of the postauricular crease

ImaginingImagining CT Scan – assess extentCT Scan – assess extent

TreatmentTreatment Emergent ENT ConsultationEmergent ENT Consultation IV CefuroximeIV Cefuroxime AdmissionAdmission Possible surgical drainagePossible surgical drainage


A 32-year-old man presents 30 minutes after getting a tooth knocked out in a fight. On examination, a small clot in the socket is noted. The next step in management is:

a) Call the patient’s dentistb) Clean the tooth with a brushc) Gently irrigate the socketd) Immediately replace the toothe) Tell the patient the tooth cannot be reimplanted


A 32-year-old man presents 30 minutes after getting a tooth knocked out in a fight. On examination, a small clot in the socket is noted. The next step in management is:

a) Call the patient’s dentistb) Clean the tooth with a brushc) Gently irrigate the socketd) Immediately replace the toothe) Tell the patient the tooth cannot be reimplanted

PEER VII Q250

Tooth AvulsionTooth Avulsion

Tooth completely removed from the socketTooth completely removed from the socket Primary teeth in children should not be Primary teeth in children should not be

replacedreplaced Permanent teeth avulsed for less than 3 hours Permanent teeth avulsed for less than 3 hours

can be reimplantedcan be reimplanted Rinse tooth with Hank’s solution, sterile saline, or Rinse tooth with Hank’s solution, sterile saline, or

milkmilk Irrigate socket with sterile NS prior to Irrigate socket with sterile NS prior to

reimplantationreimplantation Emergent Dental ConsultEmergent Dental Consult Do NOT scrub toothDo NOT scrub tooth


A 35-year-old woman presents with a painful right eye. She has had the pain for 1 day and some blurred vision as well. Ophthalmoscope examination reveals a swollen optic disc. She has never experienced this and has no medical problems. The best treatment options is:

a) Admit for MRIb) Admit for treatment with methylprednisolonec) Begin treatment with oral prednisoned) Perform lumbar puncturee) Obtain CBC


A 35-year-old woman presents with a painful right eye. She has had the pain for 1 day and some blurred vision as well. Ophthalmoscope examination reveals a swollen optic disc. She has never experienced this and has no medical problems. The best treatment options is:

a) Admit for MRIb) Admit for treatment with methylprednisolonec) Begin treatment with oral prednisoned) Perform lumbar puncturee) Obtain CBC

PEER VII Q260

Optic NeuritisOptic Neuritis Inflammation of Optic NerveInflammation of Optic Nerve

Caused by:Caused by: InfectionInfection DemyelinationDemyelination Autoimmune DisordersAutoimmune Disorders

Clinical Presentation:Clinical Presentation: Reduction of visionReduction of vision Pain with extraocular movementPain with extraocular movement Visual field cutsVisual field cuts Afferent pupillary defectAfferent pupillary defect Swelling of Optic DiscSwelling of Optic Disc Color vision affected more than visual acuityColor vision affected more than visual acuity

ED CareED Care IV SteroidsIV Steroids AdmissionAdmission


Mick Jagger


Anjelina Jolie


Julia Roberts

Question 13Question 13Which of the following physical examination findings most strongly indicates that an eye infection is only a preseptal cellulitis?

a) Decreased visual acuityb) Fever c) Pain with blinkingd) Recent abrasion on the eyelide) Swelling around the eye

Q 13 AnswerQ 13 AnswerWhich of the following physical examination findings most strongly indicates that an eye infection is only a preseptal cellulitis?

a) Decreased visual acuityb) Fever c) Pain with blinkingd) Recent abrasion on the eyelide) Swelling around the eye

PEER VII Q260

Periorbital CellulitisPeriorbital Cellulitis Clinical Presentation:Clinical Presentation:

Warm, indurated, Warm, indurated, erythematous eyelidserythematous eyelids

No restriction of ocular No restriction of ocular motilitymotility

No ProptosisNo Proptosis No painful eye movementNo painful eye movement No impairment of pupillary No impairment of pupillary

functionfunction ED Care:ED Care:

Oral Antibiotics – AugmentinOral Antibiotics – Augmentin Need to admit:Need to admit:

Under 5 years-oldUnder 5 years-old Toxic AppearingToxic Appearing Start on IV Abx – Start on IV Abx –

Vancomycin and CeftriaxoneVancomycin and Ceftriaxone

Orbital CellulitisOrbital Cellulitis Clinical Presentation:Clinical Presentation:

Warm, indurated, Warm, indurated, erythematous eyelidserythematous eyelids

FeverFever ToxicityToxicity Restriction of ocular motilityRestriction of ocular motility ProptosisProptosis Painful eye movementPainful eye movement

Diagnosis:Diagnosis: Orbital and Sinus CT scan w/ Orbital and Sinus CT scan w/

and w/out contrastand w/out contrast ED Care:ED Care:

IV Abx – Cefuroxime or IV Abx – Cefuroxime or VancomycinVancomycin

Optho ConsultOptho Consult AdmitAdmit

Question 14Question 14A 2-year-old boy presents with a 2-week history of purulent discharge from the right nostril that has not responded to a 7-day course of amoxicillin. At this point which of the following management plans is most appropriate?

a) Change the antibiotic to amoxicillin-clavulanic acidb) Continue amoxicillin for at least 2 more weeksc) Examine the nose, looking for a foreign bodyd) Order plain radiographs of the sinusese) Start a course of an oral nonsedating antihistamine

Q 14 AnswerQ 14 AnswerA 2-year-old boy presents with a 2-week history of purulent discharge from the right nostril that has not responded to a 7-day course of amoxicillin. At this point which of the following management plans is most appropriate?

a) Change the antibiotic to amoxicillin-clavulanic acidb) Continue amoxicillin for at least 2 more weeksc) Examine the nose, looking for a foreign bodyd) Order plain radiographs of the sinusese) Start a course of an oral nonsedating antihistamine

PEER VII Q301

Nasal Foreign BodyNasal Foreign Body Unilateral purulent nasal discharge in a Unilateral purulent nasal discharge in a

preschool-aged child is considered a preschool-aged child is considered a foreign body until proven otherwiseforeign body until proven otherwise

Plain radiographs unlikely to be of valuePlain radiographs unlikely to be of value Tools for removal include forceps, suction Tools for removal include forceps, suction

catheters, hooked probes, balloon-tipped catheters, hooked probes, balloon-tipped cathetercatheter

Question 15Question 15A 6-year-old boy presents complaining of severe eye pain and blurred vision. He had tipped over a cup of plaster, and some splashed in his eye. What is the proper order of management?

a) Document visual acuity, irrigate, perform slit lamp exam, measure pHb) Document visual acuity, measure pH, irrigate, perform slit lamp examc) Irrigate, measure pH, document visual acuity, perform slit lamp examd) Measure pH, irrigate, document visual acuity, perform slit lamp exame) Perform slit lamp exam, document visual acuity, measure pH, irrigate

Q 15 AnswerQ 15 AnswerA 6-year-old boy presents complaining of severe eye pain and blurred vision. He had tipped over a cup of plaster, and some oit splashed in his eye. What is the proper order of management?

a) Document visual acuity, irrigate, perform slit lamp exam, measure pHb) Document visual acuity, measure pH, irrigate, perform slit lamp examc) Irrigate, measure pH, document visual acuity, perform slit lamp examd) Measure pH, irrigate, document visual acuity, perform slit lamp exame) Perform slit lamp exam, document visual acuity, measure pH, irrigate

PEER VII Q328

Chemical Ocular InjuryChemical Ocular Injury Acid and Alkali burns are managed in similar Acid and Alkali burns are managed in similar

mannermanner Time is VisionTime is Vision Flush eye immediatelyFlush eye immediately

Normal Saline or Ringer’s Lactate – 1-2 LitersNormal Saline or Ringer’s Lactate – 1-2 Liters Morgan LensMorgan Lens

Continue to flush until pH is normal (7.0)Continue to flush until pH is normal (7.0) Recheck pH every 10 minutes to ensure no additional Recheck pH every 10 minutes to ensure no additional

corrosive is leaching out of tissuecorrosive is leaching out of tissue Document Visual AcuityDocument Visual Acuity Rx:Rx:

CycloplegicCycloplegic Erythromycin OintmentErythromycin Ointment Narcotic pain medicationsNarcotic pain medications

Tetanus updatedTetanus updated Optho ConsultationOptho Consultation

The EndThe End

ent & optho board review mark heller, md department of emergency medicine mount sinai school of...

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