Download MBBS Otolaryngology Lecture Notes

Hearing Loss Tests (1)
? Causes: Air conduction or nerve disease
? Rinne test (Rinne Rings Right Next to the Ear)
?Tuning fork on mastoid, then next to ear

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?Normal: air conduction better than bone
?Bone > air indicates air conduction deficit
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Hearing Loss Tests (2)
? Causes: Air conduction or nerve disease

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? Weber test (Weber Wrinkles Forehead)
?Tuning fork on forehead (normal y sounds
equal y loud in both ears)
?If sound lateralizes to one ear: Decreased
nerve conduction in bad ear, or decreased air

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conduction in louder ear (yes, the louder ear)
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Sudden Hearing Loss
? Usual y cause = sensorineural = most cases are

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idiopathic / isolated tinnitus often has the same
causes / about 4,000 cases a year
? Greater than a 30db loss (half as loud as normal
speech) in 3 frequencies over 72 hours or less
? Rarely is sudden, usual y evolves over hours

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? Usual y unilateral (90%), 1/3 awaken with it
? If bilateral you can get decreased hearing loss
but normal Weber and Rinne tests
? Often accompanied by tinnitus and vertigo
? Tests worth considering if sensorineural loss is

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the probable cause:
?MRI ? tumors, CSF leak, stroke
?Lab ? CBC, sed. rate, FTA (syphilis)
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Sudden Hearing Loss Causes (1)

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? Sensorineural causes
?Viral & bacterial infections
? Mumps in children, Herpes zoster, Epstein-Barr,
cytomegalovirus, syphilis
?Hematologic and vascular (terminal arteries)

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? Leukemia, sickle cel , polycythemia (al sludging)
?Metabolic
? Diabetes, hyperlipidemia
?Rheumatologic
? Temporal arteritis, polyarteritis

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?Other
? Noise, M?ni?re's disease, temporal bone trauma
? Acoustic neuroma (schwannoma)? benign tumor of
the myelin forming cel s (Schwann) of the 8th nerve
(often associated with other cranial nerve deficits)

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? Treatment ? treat cause if known / steroids / 5
carbogen (95% O2, 5% CO2 - vasodilates )

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Sudden Hearing Loss Causes (2)

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? Ototoxic agents

?Loop diuretics (furosemide, bumetanide,
torsemide)
?Salicylates (toxicity is classical y associated with

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decreased hearing and tinnitus)
?NSAIDS
?Quinine
?Antibiotics
? Aminoglycoside (gentamicin, neomycin), erythromycin,

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vancomycin (is not an aminoglycoside)
?Chemotherapeutic agents
?Topical agents ? neomycin, propylene glycol
? Conduction cause of decreased hearing:
?Canal obstruction -- cerumen impaction (most

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frequent) / foreign bodies
?TM abnormalities, middle ear effusion (otitis
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media and serous), ossicle dislocations

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Referred Ear Pain

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? Ear sensation has multiple sources: cranial nerves
V, VII, IX, X plus cervical roots C2,C3
? Dental
?TMJ problems, tooth abscess, malocclusion
? Oropharyngeal tumors and infection

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?Tonsil itis, OM, mastoiditis, tumors
? Other
?Cervical arthritis, sinusitis
?Neuralgias (tic douloureux, Ramsay Hunt)
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Med Chal enger - EM

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Auricular Hematomas
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Cauliflower Ear
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Perichondritis
?Involves perichondrium ? the
tissue between the skin and

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cartilage
?Usual y post-traumatic
?Often associated with ear
piercing thru the cartilage
(along the top of the ear)

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?Can have pain, fever,
swel ing,warmth
?No involvement of pinna
since no cartilage there
?Pseudomonas, Proteus,

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Staph
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TM Perforation (1)
? Cause: Otic barotrauma
?Unequal pressures on either side of TM

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?Blocked eustachian tubes
altitude (gas expands): internal TM pressure
altitude (diving): external TM pressure
? Other causes
?Trauma: blunt (slap) or penetrating (Q-tip)

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?Noise (blast), lightening
?Infections (otitis, myringitis)
? Decreased hearing (conductive), pain, hemorrhage
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TM Perforation (2)

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? Most heal spontaneously / most are anterior or
inferior (pars tensa) ? only a few cel s thick
? Early referral (within 24 hours) for penetrating
trauma or posterior perforation (risk of ossicle
damage if posterior)

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? Late referral OK for blunt trauma or noise
? No water in ear
? Topical or systemic antibiotics not general y
required unless perforation is due to:
?Infection / forceful water entry (e.g. water skiing)

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Chronic TM Perforation
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Otitis Externa

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? Dermatitis cel ulitis chondritis
osteomyelitis
Malignant external otitis =
necrotizing external otitis:
Primarily in elderly diabetics,

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Pseudomonas IV antibiotics
? Causes: Pseudomonas, Staph, Strep, fungal
? Culture only in advanced cases
? Pain on ear movement, canal cel ulitis,
drainage

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? Topical antibiotics with steroids
? Fluoroquinolones (ofloxacin)
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Otitis Media

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? Causes
? Bacterial causes = Strep. Pneumo [most
common], H. influenzae, Moraxella catarrhalis
? Virus are the most common cause by far
? TM Physical Signs

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? Bulging TM / TM red, grey, yel ow
? Loss of light reflex
? Decreased movement on insufflation (most sensitive)
? Complications
? Mastoiditis

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? Labyrinthitis
? Cranial nerve deficits (facial palsy)
? Intracranial infections
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Bullous Myringitis
?Painful ear / often
associated with a URI
?Rupture the bul ous to
relieve pain

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?Give antibiotic drops to
decrease the risk of
secondary infection
?Often associated with otitis
media (caused by the same

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organisms that usual y
cause otitis media) --
mycoplasma infections
are uncommon)
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Serous Otitis Media
?Also cal ed "otitis media with
effusion"

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?Painless sequelae of acute OM
?Fluid behind TM (bubbles / levels)
?Decreased hearing
?Potential affects learning, speech
?Ear tubes when persistent

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Cholesteatoma
?Chronic TM perforation
noted

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?Keratin-producing
squamous epithelium
overgrowth in the middle ear
?Often foul-smel ing
drainage

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?Can secrete bone-
absorbing substances than
can destroy inner ear
structures
?Requires surgery

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Characteristics of Vertigo
Peripheral
Central
Onset

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Sudden
Slow
Severity
Intense spinning
Less intense, il -defined

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Pattern
Intermittent
Constant
Worse on movement
Yes

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No
Nausea / sweating
Frequent
Infrequent
Nystagmus

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Horizontal,
Vertical
Rotatory-vertical
Fatigues
Yes

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No
Hearing loss / tinnitus
May occur
No
Abnormal TM

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May occur
No
CNS Symptoms
Absent
Usual y present

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Peripheral Vertigo Causes (1)
(Ear / 8th Nerve Problems)
? Benign paroxysmal positional vertigo (BPPV)
? Most common cause of recurrent peripheral vertigo

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? Precipitated by head turning / mid 50s / females 2:1 male
? Cause ? "canalolithiasis" ? delayed unilateral activation of the
posterior semicircular canal because of impaired endolymph
flow caused by clumped otoliths (= otoconia).
? Lag of endolymph = latency of nystagmus and symptoms

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onset of 1-5 seconds on provocative head turning
? Crescendo / decrescendo nystagmus
? Duration of vertigo and nystagmus = 5-40 seconds - but
recurs
? Vertigo / nystagmus fatigue with repeated head movement

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? Dix-Hal pike diagnostic positioning maneuver
? No associated hearing problems or tinnitus
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? Treatment ? particle repositioning maneuvers / sedatives

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Dix-Hallpike Test
1. 50-80% sensitive for PBBV
2. Sitting position
3. Supine with head turned 45
degrees to one side and

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extended 20 degrees
backwards
4. If no nystagmus is noted,
patient sits up and, after a 30
second rest, the maneuver is

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repeated to the other side
A positive test consists of burst
of rotatory nystagmus with the
fast movement towards the
causative ear (nystagmus on

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right head turning while
reclining with head extension is
caused by the right ear.
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Epley (Particle Repositioning)

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Maneuver ? Treatment of BPPB
Involves sequential movement of the
head into positions staying in each
position for about 30 seconds / goal
? move otolitis into utricle to improve

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flow of endolymph (85% post. canal)
?#1 -- Head is turned to the
symptomatic side (B) for 30 to 60
seconds based on duration of the
vertigo as measured by observation of

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nystagmus
?#2 -- Head is then turned in the
opposite direction for 30-60 seconds
?#3 ? Patient is rol ed in the same
direction so that the head remains

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turned and ultimately is nose down (30
seconds)
?# 4 -- Return to a sitting position
?Bursts of vertigo are common .
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Peripheral Vertigo Causes (2)
(Ear / 8th Nerve Problems)
? Vestibular neuronitis (vestibular neuritis)
?Acute onset, viral etiology? (concurrent / recent URI)
?Lasts days to weeks / nausea, vomiting

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?Worse with change in position / positional nystagmus
(disturbed vision looking to one side indicates the opposite ear
is the cause)
?Symptoms limited to the vestibular system (balance) / no
decreased hearing

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? Labyrinthitis
?Usual y an infection of the labyrinth (concurrent / recent URI)
?Can be the result of ototoxic drugs
?Usual y viral, rarely bacterial / look for OM / mastoiditis as
cause

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?Patients have vestibular and usually hearing symptoms
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Peripheral Vertigo Causes (3)
(Ear / 8th Nerve Problems)
? Meniere's Disease

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?Unilateral (usual y) or bilateral excess production of
endolymph
?Paroxysmal tinnitus, vertigo, progressive hearing
loss, sense of ful ness or pressure in one or both
ears

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?Spel s last 2-8 hrs / weekly - monthly / low salt diet
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Peripheral Vertigo Causes (4)
(Ear / 8th Nerve Problems)
? Ototoxicity

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?Drugs accumulate in the endolymph and cause damage to the
cochlear and vestibular hair cel s
?Drugs known to be ototoxic
?Aminoglycosides ? dose dependent / irreversible
?Erythromycin ? not dose dependent / reversible

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?Minocycline ? not dose dependent / reversible
?Quinolones ? not dose dependent / reversible
?NSAIDS (ASA) ? dose dependent / reversible
?Loop diuretics ? not dose dependent / may be irreversible
?Cytostatic drugs ? dose dependent / not reversible

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?Antimalarials ? not dose dependent / reversible
?Vertigo is uncommon with these agents because the damage is
bilateral and vertigo requires an imbalance of sensory input
between the vestibular mechanisms
?The three sources of input regarding position in space are

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vision, vestibular and joint proprioception ? al must by in sync 27

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Peripheral Vertigo Causes (4)
(Ear / 8th Nerve Problems)
? Eighth nerve lesions
?Tumor involving the 8th nerve directly

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?Meningiomas, acoustic neuromas (schwannomas)
?Gradual onset of mild vertigo and unsteadiness
?Tumors of the cerebel opontine angle
?Neuromas / meningiomas / dermoids
?Deafness, ataxia, facial weakness

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?Loss of corneal reflex, cerebel ar signs
?Herpes zoster oticus
?Also cal ed Ramsay Hunt syndrome
?Deafness, vertigo, facial palsy
?Grouped vesicles on an erythematous base inside the

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ear canal
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Central Vertigo Causes
(Cerebellum and Brainstem Problems)
? Cerebel ar or brain stem hemorrhage and infarction

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? Vertebrobasilar insufficiency
? Multiple sclerosis
?Due to demyelination (brain and spinal cord) due to
autoimmune-induced inflammation
?Onset age 20-40, female predominance

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?Episodes may last hours to weeks
?Look for other signs of MS ? ataxia, optic neuritis (eye pain
with decreased vision)
? Migraine-related dizziness and vertigo
?Basilar type (brainstem) migraine (rare) auras:

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?Vertigo / decreased hearing / visual disturb.
?Dysarthria (motor speech difficulty) / diplopia /
decreased LOC
Vertical nystagmus suggests central origin
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Sinusitis
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Sinusitis
? X-rays not required for diagnosis

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? Purulent nasal discharge
? Pain in upper molars, sinuses
? Complications
?Brain abscess, meningitis
?Cavernous sinus thrombosis

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?Skul osteomyelitis
?Orbital cel ulitis
? Same causes as otitis media (Strep. pneumo
[most common bacterial cause] , H. flu., M.
cat., anaerobes / viruses = causes most cases

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Maxillary Sinusitis

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Sinusitis Complications
Osteomyelitis with
Brain Abscess
Orbital Cel ulitis

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Prefrontal Facial Edema
Frontal Sinusitis
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Nosebleeds
Anterior (Kiesselbach's plexus)

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? If severe or recurrent, consider coagulopathy or
systemic disease
Posterior epistaxis (less common)
? Associated with atherosclerosis
? Elderly, hypertensive patients

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? Complications of posterior packing
? Infection (toxic shock), septal necrosis
? Cardiac ischemia, arrhythmias, syncope
? Dislodgement of packing into the airway
? Sinusitis, otitis media

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? Risk factors for severe hypoxia and CO2 retention
? COPD, CHF, altered mental status
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Nasal Fracture
? Most common facial fracture / value of plain x-ray?

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? Septal hematoma: I&D, pack
? Abscess formation and septal perforation are
complications of septal hematomas
?If untreated (requires intranasal drainage) causes
saddle nose deformity

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? Fracture of cribriform plate (ethmoid bone) causes
CSF rhinorrhea. Diagnosed by CT
? CSF rhinorrhea (antibiotics controversial)
?Increased by jugular compression,
leaning forward

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?Ring sign (filter paper / bed sheet)
? 2 rings = CSF
?Dipstick: CSF glucose > 30 mg/dL
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(Both tests of inconsistent reliability)

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Nasal Fracture / Septal Hematoma
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Saddle Nose Deformity
Saddle nose deformity most commonly results from
septal trauma

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Bonus!!! ? cauliflower ear ? both entities result from
the destruction of cartilage by blood-induced lysis
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Midfacial Fracture
? LeFort classification

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I - Horizontal maxil ary fracture
? Free-floating upper alveolar process
II - Pyramid fracture
? Free-floating mid-face (maxil a, nose, cheeks)
III - Upper jaw, nose and lateral orbits (zygoma)

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? Concerns
?Especial y II, III
? C-spine injury
? Airway compromise (retropharyngeal hematoma)
? CSF rhinorrhea

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? Bleeding
? Malocclusion if diagnosis missed
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Med Chal enger - EM

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Med Chal enger - EM

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Med Chal enger - EM

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Cavernous Sinus Thrombosis

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? Complication of central facial infection
? Veins of face, oral cavity, middle ear, mastoid
drain to cavernous sinus
?Dental extraction, sinusitis, periorbital cel ulitis
?High fever, toxic appearance (late findings)

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?Eyelid edema, proptosis, conjunctival edema
(chemosis), facial edema
?Cranial nerve palsies (III, IV, V, VI ? VI is most
common)
?Pupil ary dysfunction (mydriasis from III

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dysfunction
? MRI, CT
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Head /neck infection + venous obstruction + ophthalmoplegia

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Cavernous Sinus Thrombosis
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Salivary Gland Problems
? Viral infections (sialoadenitis)
? Parotid gland: mumps (usual y bilateral, increased

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amylase)
? Bacterial infections
? Debilitated patients, post-op, often unilateral,
? Pus from parotid duct / erythema / pain / usual y Staph
? Dehydration / diabetes / dry mouth drugs predispose

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? Calculi
? Usual y submandibular (80-95%) / males x2 incidence
? Increased symptoms with meals
? Often (80% submandibular / 60% parotid) seen on X-
ray (calcification)

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? Secondary Staph infections
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Salivary Duct Stones
Submandibular Duct Stone with
Submandibular Gland Stone

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Dilated Duct Proximal y
Note on Plain X-ray
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Parotid Duct / Facial Nerve Proximity

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Important Relationship
A vertical y oriented
laceration posterior to the
corner of the eye and
bisecting a line drawn from

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the tragus of the ear to the
center of the upper lip can
involve both the facial nerve
and the parotid duct
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Infectious Mononucleosis
?Epstein Barr virus = Human herpes virus 4
?90-95% of the population is serological y positive for prior exposure
?Transmission via saliva

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?Fever, malaise, fatigue, sore throat, exudates, lymphadenopathy
(posterior cervical chain is considered pathognomonic),
splenomegaly, atypical lymphocytosis, elevated transaminase levels
?If given ampicil in, 95% get EBV-induced antibodies to it and a rash
?Care regarding potential splenic trauma

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Ludwig's Angina
? Bilateral cel ulitis of the submandibular space
? Involves connective tissue, fascia and muscles
? Usual y odontogenic in origin (as are most

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deep neck infections (posterior molars,
abscess, trauma, recent extraction)
? Brawny, painful edema of submandibular area
? Can progress to restricted neck motion,
trismus, dysphonia, posterior tongue

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dislocation
? Airway compromise may be precipitated by
direct visualization
? Fever, leukocytosis
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? Mixed aerobic and anaerobic infection

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Ludwig's Angina

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Med Chal enger - EM

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Acute Necrotizing Ulcerative Gingivitis
?Acute necrotizing ulcerative gingivitis

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(ANUG) / trench mouth ? can look
Trench Mouth / ANUG
like herpes gingivostomatitis
?Cause = fusobacteria and
spirochetes

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?Vincent's angina (extension to
pharynx and tonsils)
?Gums are red, swol en, painful,
ulcerated with foul odor
Acute

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Phenytoin Gum
?Young adults (troops WWI), poor
Leukemia
Hyperplasia
oral hygiene, rule out HIV

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?Fever, malaise
?Metronidazole, clindamycin
?Gingival hyperplasia: consider
phenytoin, leukemia, cyclosporin,
calcium channel blockers

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Lemierre's Syndrome
Internal jugular

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?Begins as strep pharyngitis
thrombosis with
(may subside as infection in
sternocleidomastoid
the neck progresses)

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swelling and septic emboli
to the lungs
?Usual cause = Secondary
Fusobacterium necrophorum
?Complicated by septic

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thrombophlebitis of the
internal jugular vein (usual y
unilateral)
?Pain, edema and tenderness
in the anterior cervical triangle

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?Septic emboli to the lungs
may lead to pulmonary
abscesses and empyema
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Peritonsillar Abscess

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? Most common deep facial infection in adults
? Rare in children under 12
? Fever, sore throat, trismus, peritonsil ar mass
displacing soft palate and uvula
? Complications

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?Airway obstruction, aspiration of abscess contents
?Sepsis, retropharyngeal / parapharyngeal abscess
?Mediastinitis
? Treatment: ENT I&D, needle aspiration (no
deeper than 1cm), watch for internal carotid

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artery (consider ultrasound)
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Peritonsillar Abscess
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Retropharyngeal Abscess

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? Infants and young children (but adult cases are seen ?
if so, look for mediastinal extension)
? Fever, neck pain, difficulty talking, swal owing and
breathing, torticol is
? "Cri du canard" (duck-like voice)

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? Intraoral exam shows anterior displacement of
posterior pharyngeal wal
? X-ray may show posterior pharyngeal wal anterior
soft tissue displacement (neck flexion may give a
false-positive X-ray)

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? Diagnosis: CT / Hx (e.g. fal with stick/pencil in mouth)
? ENT consult
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Retropharyngeal Abscess
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Med Chal enger - EM

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Diphtheria
? Corynebacterium diphtheriae = club-shaped Gram + bacil us
? Respiratory droplet transmission or via skin lesions
(cutaneous diphtheria -- less severe ? urban outbreaks)

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? Upper respiratory variant (pharyngeal pseudomembrane
forms as the result of exotoxin-induced necrosis)
? The extent of the membrane paral els clinical severity and is
associated with cervical adenopathy ("bull neck")
? Exotoxin causes disruption of protein synthesis

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? Multiorgan system damage (primarily heart, CNS, kidneys,
liver)
? Neuropathy is routine in severe il ness as is myocarditis
? Death due to myocarditis / airway obstruction
? Treatment = equine serum diphtheria antitoxin plus

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antibiotics (erythyromycin / penicil in) / antibiotics to carriers
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Diphtheria Pseudomembrane
Child with "bull neck" appearance of
diphtheritic cervical lymphadenopathy

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Med Chal enger - EM

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Bacterial Tracheitis
? Rare, life-threatening disease of childhood
? Most common in children under age 3

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? Can mimic croup, but more toxic, high fever
? Bacterial superinfection of a preceding viral infection
? Respiratory distress, septic appearance
? Severe inspiratory and expiratory wheezes
? Purulent secretions

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? Clinical y similar to epiglottitis
? Staph, H. flu, Strep
? Airway obstruction
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Epiglottitis

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? Now more common in adults than children
? Airway obstruction, stridor (rapid onset)
? Severe sore throat with largely negative
oropharynx exam
? Pain on moving thyroid cartilage

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Notify ENT, anesthesia and operating room
if airway compromise is a significant concern
? X-ray: "Thumb shaped" epiglottis
? Direct laryngoscopy OK (possible intubation or
tracheostomy)

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? Treatment: Consult, ceftriaxone, oxygen, heliox 59

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Epiglottitis
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Cervical Adenopathy
? Primary infection
? Staph and Strep
? Response to local infection
? Response to systemic

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disease
?Mononucleosis
?Sarcoid
?Tuberculosis
?Toxoplasmosis

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61

---

Croup
?Laryngotracheobronchitis
?Most common cause of upper
respiratory obstruction in

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childhood
?6 mo ? 6 yr (2 yr peak)
?Parainfluenza virus (50%)
?Subglottic edema, respiratory
distress, barking seal cough

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?Treatment:
? Epinephrine (either racemic or L
epi),
? Steroids, No antibiotics,
? Beta-adrenergics not advised ?

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may cause vasodilation due to
vascular beta receptor activation
and increase airway narrowing
62

---

Mandible

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? Causes of Trismus (DATE)
? Dystonia
? Abscess (peritonsil ar, Ludwig's angina)
? Tetany (tetanus, hypocalcemia)
? Epiglottitis

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? Mandible Fracture
? Malocclusion, mental nerve anesthesia (chin / lip)
? Blood in mouth suggests open fracture (admit, antibiotics)
? Jaw may deviate to side of fracture
? Often have multiple fractures (rings break in two places)

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? Children 4-11 at risk for facial growth disturbances if
fracture missed ? consider in al cases with a blow to the
chin and any trismus or TMJ area tenderness
63

---

Mandible Fracture

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Fracture Type
Prevalence
Body
30 - 40 %
Angle

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25 - 31 %
Condyle
15 - 17 %
Symphysis
7 - 15 %

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Ramus
3 - 9 %
Alveolar
2 - 4 %
Coronoid process

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1 - 2 %
64

---

Candidiasis / Moniliasis
?White, curd-like
plaques of C. albicans

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on erythematous base
?Easily scraped off
?Risk factors:
?Extremes of age
?Antibiotics

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?Dentures
?Diabetes
?Steroids
?HIV
?Chemotherapy

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?Treatment:
?Clotrimazole
?Fluconazole
65

---

Leukoplakia

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? White plaque on
mucosal surfaces
that cannot be
scraped off (unlike
candidiasis)

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? Precancerous,
males, smoking,
trauma
? Refer for biopsy
66

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---

Aphthous Ulcers (Canker Sores)
?"Aphtha" is Greek for "ulcer"
?Painful red macules with
ulcerations / typical y inner lips

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and cheek
?Believed to be a cel -mediated
immune response to an
unknown trigger
?Topical steroids (Kenalog) /

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benzocaine (Ambesol) /
antihistamine mixed with
antacid mouth rinse / antibiotic
mouth rinse / amlexanox
(Aphthasol) is probably most

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effective (an anti nflammatory,
antial ergic immunomodulator
67

---

Herpes Simplex Gingivostomatitis
?Also cal ed "fever blisters" or

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"cold sores" / HSV 1 or 2
?Fever and adenopathy (may
precede lesions by 3 days)
?Initial y, vesicular lesions
?Painful ulcers on gingiva and

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mucosa
?Secondary infection of lip
lesions is common
?Dormant virus activated by sun,
stress, unknown factors

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?Acyclovir-type drugs may lessen
severity and duration
68

---

Herpangina
? Coxsackie virus

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? Sudden onset high
fever, sore throat,
headache
? Fol owed by
multiple oral

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vesicles that
rupture, then
develop into painful
ulcers
? Lesions on soft

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palate, uvula,
posterior pharynx,
sparing the
buccal mucosa,
gingiva and

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tongue
? Lasts 7-10 days
69

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Dental Caries / Pulpitis
? Reversible pulpitis with caries
? Sharp intermittent tooth pain,
subsides quickly
? Worse with cold temperature

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? Irreversible pulpitis with caries
? Dul , continuous tooth pain,
persists minutes to hours
? Worse with hot temperature
? Penicil in, referral and pain meds

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Pericoronitis: Gum inflammation
due to food impaction around crowded,
malerupted or impacted third molars
70

---

Dental Abscesses

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? Periapical abscess
? Most common cause of severe tooth pain
? Inflammation, infection and necrosis of the apical
portion of the tooth (the bottom of the tooth)
? Abscess can erode through cortical bone and drain

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external y on gums = Parulis
? Periodontal abscess
? Gum disease is the most common cause of tooth loss
? Gum inflammation, calculus, infection, abscess
? Treatment

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? I & D, PCN + clindamycin or metronidazole
71

---

Dental Abscesses
Periodontal Abscess
Periapical Abscess

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Periapical Abscess
Arrows denote areas of abscess formation with
decreased bone density and possible gas formation
72

---

Common Dental Emergencies

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Diagnosis

Definition

Presentation

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Complications
Treatment
Reversible
Pulpal inflammation
Pain with hot, cold,

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Periapical abscess,
Filling
pulpitis
or sweet stimuli
cel ulits

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Irreversible pulpitis
Pulpal inflammation
Spontaneous, poorly
Periapical abscess,
Root canal

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localized pain
cel ulitis
Extraction
Periodontal abscess
Gum abscess

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Pain, local gum mass
Cellulitis
I/D, penicil in
+/- metronidazole
or clindamycin

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Periapical abscess
Infection / necrosis
Toothache
Rupture through
Root canal &

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of the tooth apex
Most commonly
alveolar bone
Antibiotics
due to a dead

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(= parulis)
Extraction
tooth
Pericoronitis
Inflamed gum over

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Pain, erythema
Cellulitis
Irrigation
partial y erupted
local swel i ng

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Antibiotics if
molar due to food
cel ulitis noted
impaction
Tooth fracture with

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Broken tooth into
Bleeding from
Pulpitis
Fil ings with
bleeding or pulp

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the viable area
center of tooth
Tooth death
or without
exposed

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or reddish central
root canal
blush noted
Tooth fracture with
No viable part of

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No bleeding or
Cosmesis
Cosmesis
only enamel involved
tooth involved

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reddish blush
Rough edges
Tooth loose
Traumatic
Loose / bleeding

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Pulpitis, aspiration
Splint, root ca 73
nal?
Tooth avulsed
Traumatic

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Absent tooth
Anklyosis, resorption
Reimplant / splint

---

Alveolar Osteitis (Dry Socket)

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? 2-5 days post-extraction
? Severe pain due to localized osteomyelitis as a result
of loss of protective clot
? Risk factors: females on HRT, preexisting tooth and
gum infections, traumatic extraction, impacted third

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molar extractions
? Treatment
? Anesthetize
? Irrigate socket
? Pack with iodoform

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gauze plus eugenol (a
topical anesthetic and
antiseptic from clove oil)
? Antibiotics
? Early referral

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74

---

Avulsed Teeth / Tooth Fracture
? Replant quickly (1% loss of survival per minute)
? Rinse first (scrubbing injures periodontal ligament)
? Storage media: saliva, milk. No dry storage

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? Only permanent teeth need replantation
(no reimplantation of "baby" teeth)
? Bone fusion can prevent permanent teeth erupting
? Tooth fractures exposing dentin (yel owish core) or
pulp (reddish blush or frank blood) require early

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dental referral to prevent infection ? pain on air
passing over / pain with hot or cold
? Cover exposed dentin with glass ionomer dental
cement to decrease contamination ? early referral
? Other dental fractures: see dentist for cosmesis and

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75
functional issues

---

76
Med Chal enger - EM

---

Neck Masses

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? Infant
?Hemangioma, lymphangioma
?Branchial cleft cyst, rhabdomyosarcoma
? Child
?Reactive lymphadenopathy

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?Branchial cleft cyst (laterally located)
?Thyroglossal duct cyst (centrally located)
? Young adult
?Reactive lymphadenopathy, mononucleosis
?Cysts (as above), Hodgkin's disease

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? In adults, 75% of lateral neck masses present
for more than 6 weeks are cancer
77

---

Neck Masses
Thyroglossal Duct Cyst

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Lymph Node Metastasis
78

---

Facial Nerve Palsy
Differentiation from central origin: forehead
muscles don't work in peripheral seventh nerve lesions

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? Facial droop, can't close eye
? Causes
? Bel 's palsy (idiopathic)
? Herpes zoster =
(Ramsay Hunt Syndrome)

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? Herpes simplex
? Lyme disease
? Otitis media
? Treatment
? If Bel 's, steroids (no acyclovir)

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? If not Bel 's, treat cause
? Protect with artificial tears and patch at night to
prevent keratitis
79

---

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Herpes Zoster Oticus
(Dr. James Ramsay Hunt Syndrome)
?

Caused by reactivation of herpes zoster virus (the chicken pox

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virus) involving the geniculate ganglion
? The geniculate ganglion causes:
? Facial movement (via the 7th cranial [facial] nerve)
? Touch sensation to part of the external ear and canal
? Taste sensation to the anterior 2/3rds of the tongue

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? Additional manifestations:
? Vesicles in the ear canal, tongue and/or hard palate
? Can also cause hearing loss, tinnitus and vertigo
? Treatment ? early steroids and acyclovir-like drugs
80

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---

Ramsay Hunt Syndrome
81

---

Herpes Zoster Ophthalmicus
?Involves tissues innervated by the

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ophthalmic division of the trigeminal
nerve
?Eye and eyelid pain / redness,
decreased vision, fever, malaise,
vesicular rash

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?Can also cause keratitis, iritis,
glaucoma when the eye is involved
?Involvement of the nasociliary
dermatome (tip, side and root of the
nose) is a reliable prognostic sign

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for sight-threatening cases =
Hutchinson's sign
?Treatment is
complex but
includes antivirals

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and steroids
82

---

Tongue Angioedema
?Angioedema - similar to urticaria but
involves the deeper dermal and

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subcutaneous tissue
?Typical y involves little pruritus /
predilection for face, extremities and
male genitalia
?ACE inhibitor angioedema ?

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0.1-0.2% / Can develop years after
starting ACEI treatment
?Cases of angioedema without
urticaria could represent C1 inhibitor
deficiency

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?Hereditary angioedema is an
autosomal dominant and can respond
to fresh frozen plasma (contains C1
inhibitor)
83

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---

Strawberry Tongue / Scarlet Fever
?Caused by erythrogenic toxin
producing strains of Group A (and

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C) beta hemolytic streptococci
?Exudative pharyngitis / fever /
headache / sandpaper rash (1-2
days after onset of il ness)
?Rash begins in neck, groin and

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axil ae with accentuation over
flexure creases (Pastia's lines)
?Antibiotics (penicil in)
84

---

Streptococcal Pharyngitis

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? Centor Criteria
?One point for each = fever / no cough / anterior
cervical adenopathy / tonsil exudates
?McIsaac modification = age younger that 15 add
a point / over 45, subtract a point

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? Rheumatic fever can be prevented with
antibiotic treatment (treatment within 9 days)
? Glomerulonephritis cannot be prevented and is
cause by selected nephritogenic strains
85

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---

Posttonsillectomy Bleeding
? Most occur 5-10 days post surgery
? Frequency 1-6% of cases / half need surgery
? Most frequent in those 21-30

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? Treatment:
?Direct pressure with gauze held by forceps
moistened with thrombin or 1:10,000 epi and 1%
lidocaine
?Silver nitrate cautery if bleeder

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noted ? after infiltration with
lidocaine and epi
?ENT see patient in ED
86

---

Uvular Edema (Quincke Syndrome)

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? Usual y caused by the same causes of
angioedema
? Can be associated with upper airway infection
? Often is idiopathic
? Treatment if needed ? dexamethasone 4mg IV

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or PO
87

---

Esophageal Foreign Bodies
? It is very hard to find a

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picture of a coin in the
trachea!!
? Because the posterior
tracheal wal is soft tissue
and not cartilage,

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orientation of tracheal
coins should be opposite
to that seen when in the
esophagus
? The addition of a lateral

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chest x-ray may reveal
two coins or the step-off of
a button battery
88

---

89

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---

ENT QUESTIONS
90

---

A stridorous, barky cough, high fever and
toxic appearance is most consistent with
which of the following?

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A. Bacterial tracheitis
B. Croup
C. Laryngotracheobronchitis
D. Acute bronchitis
E. Acute bronchiolitis

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ENT 1

---

Which of the following is most consistent
with alveolar osteitis?
A. It occurs about two weeks after tooth
extraction

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B. It is associated with a localized infection of
the bone
C. The area of involvement should be left open
D. Residual clot results in periosteal irritation
E. Antibiotics do not alter the course

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ENT 2

---

A 30 y/o patient presents with submental
fullness and brawny edema following a
dental extractions. Which of the following
is the most likely diagnosis?

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A. Peritonsilar abscess
B. Ludwig's angina
C. Alveolar osteitis
D. Sialadenitis
E. Buccal cel ulitis

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ENT 3

---

A patient was struck in the face with a
baseball bat. He has a nasal deformity
and a unilateral mass arising from the
septum. What is the most appropriate

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next step?
A. CT of the face to diagnose a LeFort fracture
B. Insert a posterior nasal pack
C. Incision and drainage
D. Insert an anterior nasal pack

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E. Discharge the patient with analgesics and
reassurance.
ENT 4

---

A patient presents with a diffusely
swollen, warm, reddened, tender external

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ear after some recent minor trauma.
Hearing, along with the TM and canal, are
normal. What organism is the likely cause
of this process?
A. H. influenza

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B. Streptococcus pyogenes
C. Pseudomonas
D. E. coli
E. Staphylococcus
ENT 5

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---

Pain on moving the thyroid cartilage, a
negative oropharyngeal exam, severe sore
throat and a muffled voice suggest which
diagnosis:
A. Streptococcal abscess

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B. Infectious mononucleosis
C. Epiglottitis
D. Diphtheria
E. Posterior pharyngeal abscess
ENT 6

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---

Which of the following is a true
statement concerning cavernous
sinus thrombosis?
A. It is a complication of a central facial infection
(dental, sinus, periorbital)

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B. Ocular signs are general y not present
C. Cranial nerve deficits are not associated with
the diagnosis
D. The patients are general y afebrile and
nontoxic appearing

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E. Seizures are common
ENT 7

---

Which of the following is true of
diphtheria?
A. Symptoms are largely limited to the pharynx

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B. Elaboration of exotoxin is a major source of
the pathology
C. It is unnecessary to treat carriers
D. Prominent exudates characterize the
infection

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E. Cervical adenopathy is uncommon
ENT 8

---

A patient is suspected of having bacterial
sinusitis. Which of the pathogens below
is the most likely cause (PS, it is also the

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most likely cause of bacterial otitis media)
A. M. catarrhalis
B. H. influenza
C. M. pneumoniae
D. S. pneumoniae

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E. C. pneumoniae
ENT 9

---

Which of the following is associated
with an enlargement of the
prevertebral soft-tissue on a lateral

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neck imaging?
A. Peritonsil ar abscess
B. Ludwig's angina
C. Epiglottitis
D. Retropharyngeal abscess

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E. Idiopathic uvulitis
ENT 10

---

Which of the following is a true statement
regarding salivary gland disorders?
A. Calculi are more commonly associated with

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the parotid gland vs the submandibular
B. Calculi are rarely radio-opaque
C. Parotid duct injury should be considered
when the facial nerve, over the cheek, has
been injured

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D. Pus draining from the parotid duct is usual y
caused by streptococcal infection
E. Needle aspiration is indicated for suspected
abscess
ENT 11

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---

Which of the following is true statement
concerning infectious mononucleosis?
A. Use of ampicil in frequently triggers a rash
that does not indicate a true al ergy
B. Anterior cervical chain lymph nodes are

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pathognomic for the diagnosis
C. Most of the population is seronegative for
prior EB-virus exposure
D. Transaminase levels are rarely elevated
E. White cel morphology is usual y normal

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ENT 12

---

Which of the following is consistent with
the diagnosis of trench mouth
(acute necrotizing ulcerative gingivitis)?
A. Older adults

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B. Gum trauma from excessive brushing
C. Reddened, painful, swol en gums with
halitosis
D. General y resistant to treatment with penicil in
and metronidazole.

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E. Painless
ENT 13

---

Which of the following is routinely
associated with a LeFort I fracture?
A. CSF rhinorhea

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B. Mobility of the maxil a
C. Airway compromise
D. Extensive bleeding
E. Malocclusion
ENT 14

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---

Regarding dental emergencies, which of
the following statements is correct?
A. An avulsed tooth in a 4-year-old should be
replaced in the socket
B. Reversible pulpitis is characterized by dul ,

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boring, pain precipitated by hot food
C. Periapical abscesses are the most common
cause of severe tooth pain
D. The antibiotic of choice for dental infections
is ciprofloxacin

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E. Pericoronitis is common after third molar
extractions
ENT 15

---

Which of the following statements
accurately describes benign

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paroxysmal positional vertigo?
A. A negative Hal pike test is confirmatory
B. BPV is caused by free floating otoliths in the
semi-circular canals
C. These symptoms typical y last for years

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D. This finding is caused by excess endolymph
volume
E. Men are affected twice as often as women
ENT 16

---

A 75 y/o patient presents with anterior

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epistaxis. BP = 210/115. Which of the
following is the most appropriate next
step?
A. Administer clonidine P.O.
B. Put the patient in a supine position for

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comfort with ice packs to the forehead
C. Stop the bleeding
D. Administer labetalol IV
E. Reassure and calm the patient and wait for
the blood pressure to normalize

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ENT 17

---

Which of the following is consistent
with herpangina?
A. 2-4 day duration
B. Caused by Coxsackie virus

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C. Vesicular lesions are uncommon
D. Rarely associated with fever
E. Lesions are limited to buccal mucosa, gingiva
and tongue
ENT 18

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---

A 23 y/o patient reports yawning and
subsequently could not move her jaw.
Which is true regarding the most likely
diagnosis?
A. The mandibular condyle dislocates posterior

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to the articular surface
B. The mouth wil be closed due to associated
trismus
C. Reduction is performed by downward and
backward pressure on the mandible

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D. Dislocations are commonly associated with
condylar fractures
E. The mandible can only dislocate bilateral y
ENT 19

---

Which of the following is consistent

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with central vertigo?
A. Sudden onset
B. Intermittent
C. Not exacerbated by movement
D. Associated with intense "spinning"

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E. Moderate hearing loss is usual y present
ENT 20

---

ENT Answer Key
1. A
11. C

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2. B
12. A
3. B
13. C
4. C

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14. B
5. C
15. C
6. C
16. B

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7. A
17. C
8. B
18. B
9. D

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19. C
10.D
20. C
111

---