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EYE, EAR, NOSE, AND THROAT*
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PEARLS, PITFALLS, AND UPDATES
+ .20
EYE, EAR, NOSE, AND THROAT James A. Pfaff, MD, FACEP, and Gregory P. Moore, MD, FACEP
UPDATE: OTITIS MEDIA Otitis media is an extremely ubiquitous disease with most children having at least one episode before age 2 years.% It is debatable whether treatment of the disease is even required. Some European practitioners have developed an expectant approach to the treatment, recognizing that over 80% of cases resolve ~pontaneously.4~ Other authors question both antibiotic efficacy6 and the wisdom of widespread antibiotic use in the face of increasing Streptococcus pneumoniae drug resi~tance.~~ Conversely, the use of antibiotics has greatly decreased the incidence of complications, and it is impossible to predict which patients will develop them precluding selective management. Despite the increasing incidence of B-lactamase and S. pneumoniae resistance, amoxicillin remains an excellent first-line therapy. An alternative first-line medication includes trimethoprim-sulfamethoxazole, which is administered twice a day but may have a higher incidence of complications owing to sulfa sensitivities. Antibiotics useful as second-line therapy include amoxicillin-clavulanic acid and erythromycin-sulfisoxazole. It would be optimal for individual providers to know the drug resistance and susceptibility in their practice areas. A single dose of ceftriaxone (50 mg/kg) intramuscularly (IM)has been shown to be effective and may be useful in individuals in whom compliance may be a p r ~ b l e m . ’ ~ Traditionally, the recommendation was to follow up in 2 to 3 weeks to verify resolution of the infection. Although the acute infection may resolve in that time, it is still probable that the child will have a persistent effusion. In fact, it takes 3 months for 90% of effusions to clear.5 The child’s age is helpful in clinically determining the likelihood of resolution of otitis media. Children older than 2 years without symptoms generally have resolution of their infection.44 Parental perception of resolution and the absence of symptoms are also useful The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Departments of the Army, Air Force, or the Department of Defense. All material in this article is in the public domain. From the Department of Emergency Medicine, Brooke Army Medical Center (JAP), Methodist Hospital (GPM), and Indiana University School of Medicine (GPM), Indianapolis, Indiana
EMERGENCY MEDICINE CLINICS OF NORTH AMERICA VOLUME 1 5 . NUMBER 2 M A Y 1997
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indicators in identifying resolution of acute otitis media.I6Two-week follow-up is still important in children whose symptoms persist, children younger than 15 months old, or children with a family history of recurrent otitis media.I6 The treatment of children with persistent effusion has been problematic and controversial. A recent expert panel recommended some basic treatment guidelines." It recommended a trial of antibiotics in children with persistent effusion. The use of steroids, antihistamines, decongestants, tonsillectomy, or adenoidectomy were not believed to be statistically useful. Because there is some correlation between persistent effusion and speech and language delay,2O the use of tympanostomy tubes with persistent effusion of 4 to 6 months and a hearing loss of greater than 20 dB was recommended. PEARL: THE USE OF STEROIDS IN UPPER AIRWAY DISEASE In the past, individuals with exudative pharyngitis, regardless of the cause, have been anecdotally prescribed steroids assuming that this would reduce pharyngeal swelling. One prospective, randomized, double-blinded and placebocontrolled study, using a single IM injection of 10 mg of dexamethasone, resulted in significant improvement compared with the control group.35Although this study did not identify the cause of the pharyngitis, it seems reasonable to use steroids in patients with significant pharyngeal edema and concern for potential airway compromise. Steroids are also useful in treating croup, specifically laryngotracheobronchitis. Clearly, in severe croup where there are few other available treatment options, the use of 0.6 mg/kg has become a common practice. Several studies have evaluated the use of steroids in the inpatient setting in children with severe croup. While difficult to obtain a consensus, it has become accepted practice to use them in this manner.21,52 Whether steroids have benefit in the moderate to mild croup cases is less clear, though there are some data to support the use of dexamethasone in this setting.lo In addition, the use of nebulized budesonide has also been effective.24, 25 Nebulized budesonide has also been compared favorably with nebulized adrenaline in croup." Although most children will improve with general supportive measures, such as humidified oxygen, steroids are an additional treatment option. PEARL: NONINVASIVE NASAL FOREIGN BODY REMOVAL Nasal foreign bodies consist of a multitude of objects, most commonly food, hair beads, paper, and toy parts, and occur primarily in 2 and 3 year olds.' The child may present to the emergency department (ED) after a parent has visualized the object in the child's nose, watched the child put the object into his or her nose, or because of a unilateral foul-smelling discharge or epistaxis. Several methods have been described for removal including right angle hooks, wire loops, alligator forceps, or even small Fogarty catheter^.^ One very simple, noninvasive method that has been described is that of positive pressure rem0va1.~A vasoconstrictor may be used initially to decrease mucosal edema. The unobstructed naris is occluded, and the parent is instructed to give a puff of air, much like giving mouth-to-mouth resuscitation. For a right-sided foreign body, the parent is usually on the left side of the child, holding the mouth open
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with the left hand and occluding the unobstructed naris with the right thumb.3 Repeat attempts may be necessary to fully dislodge the foreign body. If unsuccessful or the child is uncooperative, placing the child in restraints, putting him or her in the Trendelenburg position, and repeating the mouth-to-mouth technique or Ambu bag should result in successful expulsionP PITFALLS: IDENTIFYING HEAD AND NECK MALIGNANCIES
Failing to diagnose head and neck cancers are not high on the list of emergency medicine malpractice claims. Nonetheless, because many eye, ear, nose, and throat (ENT) problems present to the ED, it is an excellent place to identify a number of head and neck malignancies. When evaluating someone with an ENT problem, identify (in the patient history) the risk factors that may predispose a patient to these malignancies. These risk factors include alcohol and tobacco use, viruses, sunlight exposure, genetics, and a history of exposure to dust and inhalation products."R The oropharynx is obviously the most accessible area to identify ENT malignancies. Leukoplakia is a common, white oral patch that cannot be scratched off the oral surface and is considered a precancerous le~ion.~" Dental follow-up is recommended especially in patients with multiple lesions that do not resolve. Many carcinomas are painless and do not become symptomatic until an ulceration develops. The lesions may be small with an erosion or erythema that has been nonhealing. If the lesion involves the tongue, tonsil, or soft palate, the patient may additionally complain of a persistent so;e throat or dysphagia. Any nonhealing lesion should have follow-up for potential biopsy and histologic examination. Occasionally, although uncommonly, a patient may present with unilateral neck swelling, as the presenting sign of oral pharyngeal cancer.so Lesions of the nasopharynx are difficult to visualize. Presenting signs and symptoms include otitis media with effusion that is unresponsive to therapy, patients with local invasion of cranial nerves and a resulting palsy, or patients who present with unilateral effusion and a neck mass, deafness, otalgia, progressive nasal obstruction, and e p i s t a x i ~ .Some ~ ~ authors advocate the need for evaluation for any patient over 10 years old with a persistent effusion and the above-mentioned signs.5yPrompt ENT referral is recommended if these symptoms exist. Malignant lesion of the nose and sinuses are infrequent and most commonly affect men in the fifth to seventh decades of life.zyPatients that have persistent nasal obstruction, drainage, epistaxis, bloody discharge, or persistent sinus pain after treatment should be referred for suspicion of malignancy.2y Masses of the salivary glands may include the parotid, submandibular, or minor salivary glands. Most inflammatory conditions are non-neoplastic and include viral infections (most commonly mumps), bacterial infections, or salivary duct calculi. Lesions that persist after treatment should be considered suspicious for neoplasm. Most salivary gland tumors involve the parotid with 80% to 90% of these being benign. Tumors of the submandibular and minor glands are malignant in 50% and 75% of the time, respectively.2zWhen swelling of these areas persist after observation or antibiotics, suspect tumor as a cause and refer to an ENT specialist. Laryngeal tumors often present with persistent sore throat, hoarseness, or altered voice and should be considered particularly when these symptoms present in a smoker. The tumors are found predominantly in men and can be
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divided into supraglottic, glottic, and subglottic forms. Glottic tumors involve the true vocal cords and are the most common laryngeal malignancy.30They are also the most easily detected usually because of voice change. Supraglottic tumors are the next most common tumor often invading superior lymph nodes in the neck. When detected, they are often advanced.30Subglottic tumors are difficult to detect early and, fortunately, are uncommon. One problematic area in the emergency department is the evaluation of a neck mass that the patient or parent may notice and present for evaluation. There is significant difference in the appearance of a neck mass between adults and children. In adults, approximately 80% of masses are malignant, whereas in children, 80% to 90% of them are caused by benign conditions. Malignant lesions are rare in children and, when present, are usually mesothelial tumors, such as lymphomas and sarc0mas.3~In adults, most masses are metastatic, most commonly head and neck squamous cell carcinoma with metastasis to regional lymph Neck masses in children are commonly inflammatory (reactive lymphadenopathy or lymphadenitis), congenital (including thyroglossal duct, dermoid, In children, the location of the mass is and brachial cleft cysts), and neopla~tic.~~ also helpful in determining its cause. Posterior solitary nodes and supraclavicular masses have a high likelihood of malignancy, whereas anterior lymphadenopathy suggests infections from the n a s ~ p h a r y n x In . ~ ~adults, lymph nodes found in the upper and middle portions of the neck are usually affected from a primary lesion in the upper aerodigestive tract, whereas supraclavicular and lower posterior triangular lymph nodes arise from carcinoma below the clavicie.33 There are many symptoms that should increase the suspicion of head and neck disease, especially in the presence of a neck mass. These include dysphagia, odynophagia (pain on swallowing),hoarseness, stridor, otalgia, speech disorder (or "hot potato speech"), and globus (a sensation of a lump in the throat). Treating a mass in children initially as inflammatory is a reasonable course of action, but there should be improvement in 2 weeks. Adults with masses, particularly with any of the above-mentioned signs, should be referred for further evaluation. The workup of head and neck tumors is beyond the scope of the emergency department and involves direct visualization, fine-needle aspiration, endoscopy, CT, and MR imaging. In summary, there are several key points that can be made about head and neck cancers whose presence indicate the need for prompt referraP: 1. Any persistent sore throat, hoarseness, voice change, or nonhealing mouth ulcers for greater than 2 weeks duration in adults over age 40 years should be promptly referred for evaluation. 2. Solitary neck masses in adults should be considered neoplastic until proven otherwise. 3. Unilateral otitis media with effusion in patients over 10 years of age with a neck mass, deafness, otalgia, progressive nasal obstruction, and epistaxis should be evaluated for nasopharyngeal carcin0ma.5~ PEARL: DO PATIENTS GIVEN RACEMIC EPINEPHRINE NEED TO BE ADMllTED WITH CROUP?
Racemic epinephrine has been used in patients with moderate to severe croup who do not improve with humidification or are in extremis. Racemic
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epinephrine contains both the D and L isomers, and it was chosen because it was thought to have fewer side effects than the cheaper, more commercially available, and bioactive L is0mer.5~In a prospective randomized study, the L isomer was shown to be at least as effective as racemic epinephrine and is recommended for cr0up.5~The recommended dose is 5 mL of the 1: 1000 Lisomer aerosol.48, 57 Traditionally, the disposition of patients given racemic epinephrine has been hospitalization because of the concern for the return of the patient’s symptoms or worsening of their condition secondary to a rebound phenomena. Since the half-life of epinephrine is less than 2 hours, it seemed reasonable that patients without symptoms at this interval could be safely discharged home. Many authors have looked at outpatient management with new disposition recommendations. Patients can be safely and appropriately discharged home if they have received steroids, are observed for 2 to 3 hours, are free of stridor or 43, 47 retractions and have access to appropriate f~llow-up?~,
UPDATE: BELL’S PALSY
Seventh nerve peripheral palsy is caused by a multitude of causes. In one series of over 2800 patients, 51% of the cases were idiopathic (Bell’s). Other common causes included trauma (22%), herpes zoster (7%), and tumor (6%).31 Even though Bell’s is idiopathic, there is good clinical and serologic evidence of an infectious cause in a sizable minority of cases.% The incidence is 15 to 40 per 100,000 people, involves both sexes equally and is recurrent approximately 10% of the time. Eight percent of patients have a family history of the disorder.%In a large study of the natural course of the disease, 85% of patients had complete resolution or minimal sequelae if resolution started in the first 3 weeks.%Another favorable prognostic indicator is the occurrence in younger patients.39Patients presenting with posterior auricular pain and those over 60 years old have a worse prognosis.39 Ensuring that it is really Bell’s palsy is important once a patient presents to the emergency department. By definition, its idiopathic nature should make it a diagnosis of exclusion. Nonetheless, there are certain characteristics that make it likely to be Bell’s. These include sudden onset, unilateral presence, and the absence of other cranial nerve involvement. There is little workup required in the ED management of peripheral nerve palsy. Describing the extent of involvement to a consultant is often challenging. Table 1 identifies a facial grading system recommended by the American Academy of Otolaryngology, which is useful in describing the involvement of the seventh nerve fun~tion.’~ The need for treatment continues to be controversial because most patients improve with minimal sequelae. Eye care is very important. The use of eye drops during the day and ointment at night will prevent drying of secretions until the return of function. Though no definitive study has proved the benefit of the use of prednisone 1 mg/kg/d for 10 to 14 days followed by a taper is a recommended practice,18provided there are no contraindications. The role of surgery is very controversial with some recommending middle fossa decompression of the seventh nerve. The efficacy of surgery must be clear because of the complications of hearing loss, vertigo, and facial paralysis.49 Discussion with your consultant to arrange close follow-up and potential treatment is essential.
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Table 1. FACIAL NERVE GRADING SYSTEM Grade
Description
II
Normal Mild dysfunction
Ill
Moderate dysfunction
IV
Moderately severe dysfunction
V
Severe dysfunction
VI
Total paralysis
I
Characteristics Normal facial function in all areas Gross: slight weakness noticeable on close inspection; may have very slight synkinesis At rest: normal symmetry and tone Motion Forehead: moderate to good function Eye: complete closure with minimum effort Mouth: slight asymmetry Gross: obvious but not disfiguring difference between two sides; noticeable but not severe synkinesis, contracture, or hemifacial spasm At rest: normal symmetry and tone Motion Forehead: slight to moderate movement Eye: complete closure with effort Mouth: slightly weak with maximum effort Gross: obvious weakness and/or disfiguring asymmetry At rest: normal symmetry and tone Motion Forehead: none Eye: incomplete closure Mouth: asymmetric with maximum effort Gross: only barely perceptible motion At rest: asymmetry Motion Forehead: none Eye: incomplete closure Mouth: slight movement No movement
From House JW, Brackmann DE: Facial nerve grading system. Otolatyngol Head Neck Surg 93:146147, 1982; with permission.
PEARL: THERAPY FOR OPHTHALMOLOGIC PROBLEMS.. PATCHES AND MEDICATIONS
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There are several topics in ED ophthalmologic therapy that can be a source of confusion and frustration, and these are highlighted as follows. Antibiotics are one of the most frequent ophthalmologic medications used by emergency physicians. Two questions often arise: Which is appropriate to use?; and How should it be administered? The advantage of ointments is that they stay on the conjunctivae longer and thus require less frequent administration for higher concentrations. Thus, they are especially useful in children who may be difficult to elicit compliance with these medications. A negative aspect of ointments is that they interfere with vision of adults who desire to remain visually active (i.e., drive, read). They should be avoided in cases of large or deep corneal abrasions as they may fill in and be incorporated into the defect
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as the epithelium heels over it. Antibiotic drops do not impair vision but dissolute quickly via the lacrimal apparatus. One way to increase local effect, absorption, and concentration is to have the patient squeeze the bridge of his or her nose or simply squeeze his or her eyes shut for 5 minutes after administration. This blocks the outflow tract. Drops may be difficult to administer to a combative child with forcefully closed eyes. A way around this is to place a couple drops on the outside lid in the sulcus of the medial eye with the patient in a reclining position. Eventually, the child will voluntarily open his or her eye and the medicine will flow in. When prescribing ophthalmologic antibiotics it would seem natural to prescribe the highest concentration available. This may not be true, especially if there is a corneal defect or abrasion. It has been shown in several animal studies that when higher concentrations of antibiotics are used, there is slower healing of the corneal epithelium. So, for example, when the choice is between using 30% sulfacetamide or lo%, the latter is probably preferredPo Neomycin is notorious for causing sensitization and redness in 15% of cases, and should be avoided for this reason. Gentamicin may also do this in a lower percentage, and when faced with a patient who has “worse” conjunctivitis, the cause may not be resistance but iatrogenic medication effect. When treating corneal abrasions or foreign bodies, classically antibiotics are instilled and an eyepatch is applied. The traditional teaching has been the eyepatch prevents movement of the lids over the defect and thus prevents further injury and promotes healing. This is also promoted to decrease discomfort. Recent literature has questioned this practice. One controlled randomized study of 30 patients with corneal defects after foreign body removal compared treatment with or without an eyepad. There was no difference in rate of healing, and 75% of patients treated with eyepads reported discomfort at 24 hours ’~ prospective, controlled, randomcompared with 29% of those w i t h o ~ t .Another ized study of 44 patients with corneal abrasions used a similar design and found that the epithelial defects healed significantly quicker without use of an eyepad. There was no difference between the groups when they rated their pain by a visual analog These and other studies have recommended treatment of corneal abrasions should not include an eyepatch. There is one clinical situation in which the use of a corneal eyepad in treatment of an abrasion may be considered malpractice. The eyepad should not be used when a corneal abrasion is secondary to contact lenses. These wounds are extremely prone to pseudomonas, and patching predisposes to corneal ulceration.8 PEARLS: KEYS TO THE DIAGNOSIS OF IRlTlS
One area that emergency physicians often express insecurity about is definitively diagnosing iritis. When using the slit lamp, they relate difficulty seeing the cells and flare that accompany the condition. It is important for the instrument’s beam of light to be oriented properly, or picking these features up is next to impossible. A narrow slit should be used with high intensity of light. The beam should then be shortened to almost pinpoint height and directed at a 45-degree angle to disappear into the posterior part of the globe. This allows minimization of reflection of light, and the cells and flare can be searched for in the normally dark anterior chamber (appearing as small flashes of light). Many physicians will adjust the beam to maximum height thinking they need to visualize the entire height of the anterior chamber. This causes more light
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Figure 1. Proper orientation of slit-
lamp beam to detect cells and flare.
scattering and reflection back at the examiner, making subtle cells and flare more difficult to see (Fig. 1). If you still feel uncertain with the slit lamp, there are shortcuts that you can rely on to make or rule out this diagnosis in patients with a painful eye. One study looked at 71 patients with corneal abrasions versus other causes of eye pain in a prospective, controlled fashion. Pain was assessed using visual analogue scales before and after administration of the topical anesthetic proparacaine. When pain reduction was used as a diagnostic tool, it had a sensitivity of 80% and a specificity of 86% in determining whether a simple corneal injury was present. So, if putting anesthetic in the eye relieves the pain, you can be fairly sure that the diagnosis is not iriti~.~l There are two easy findings that help me determine that there is likely iritis present before doing a slit-lamp examination. These patients will present with a red, painful eye. In iritis, there is inflammation of the iris, so naturally the injection will be localized predominantly around the iris and not diffusely over the conjunctiva. Second, the consensual light reflex can be used to make the diagnosis. Of course, shining a light in the affected eye will cause pain, but in iritis shining a light in the normal, unaffected eye (by causing consensual movement of the other affected iris) will cause pain if iritis is present. A study found this physical finding to be reliable and actually more sensitive than the slit-lamp examination.2 UPDATES: HOW SHOULD I TREAT STREP THROAT?
Recent reviews confirm that penicillin is still the drug of choice for treatment of streptococcal pharyngitis.z6,27 The treatment of this disease is important to prevent rheumatic fever, glomerulonephritis, and peritonsillar abscess, and to shorten the duration of symptoms.3z Group A beta-hemolytic strep (GABHS) has shown an increasingly higher resistance rate. It is thought that the coexistent presence of beta-lactam-resistant organisms is the reason for this phenomena.
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These organisms are proposed to "eat up" the penicillin, which leaves none left to work on the primary GABHS infection. Many are now advocating cephalosporin (or other beta-lactam agents, such as amoxicillin-clavulinic acid and azithromycin) play a more prominent role in the primary treatment of streptococcal p h a r y n g i t i ~Meta-analysis .~~ of 19 studies showed streptococcal cure and eradication rates are higher with these agents than with penicillin.6 The increased cost must be balanced against the true likelihood of the disease being present, as well as the financial and time impact as a result of increased physician visits owing to treatment failure. Cephalosporins that have proved effective include cefaclor, cefixime, cephalexin, cefuroxime, cefpodoxime, loracarbef, cefadroxil, and cefpodoxime.6,32 In the near future, these agents may replace penicillin as the drug of choice. PITFALL: THE "NORMAL" SORE THROAT (CONSIDER A LATERAL NECK RADIOGRAPH) Scenario 1: A 40-year-old man comes in complaining of severe sore throat. He appears to be in marked pain without stridor or drooling. On pharyngeal examination, there is some injection, but no purulence or deviation in anatomy. Scenario 2: A 2-year-old girl is brought in with a fever to 104 degrees. Her mother wants her checked for sore throat as ahe child appears to be in pain. Earlier, the mother had noted "wheezing." On examination, the child is nontoxic, without drooling or stridor. Pharynx is mildly injected without deviation in anatomy or purulence. The remainder of the physical examination and a chest radiograph result is normal. Infrequently, but not rarely, patients will present with a symptom complex suggestive of pharyngitis; however, on examination, the findings are surprisingly unimpressive. In these situations, it is important to step back and think of the diagnosis below. All can be easily diagnosed with a lateral neck radiograph. In the first scenario, adult epiglottitis and pneumomediastinum should be considered. With the advent of Hib vaccine, childhood epiglottitis has decreased while the adult form of the disease is more common than previously recognized and usually occurs in middle age.I2 Lack of suspicion and delayed diagnosis leads to overall mortality of 7y0.'~ Adults often present with a nontoxic appearance and normal or low grade temperature.'2 Because the upper airway diameter is larger than in children, stridor is a late finding and adults can often be managed without active airway intervention. The diagnosis should be suspected whenever there is dysphagia out of proportion to the examination. In adults, the lateral neck radiograph may be helpful. Epiglottic width over 50% of third vertebrae or greater than 60% of the height of epiglottis are very sensitive and specific parameter^.^^ If suspicion is high, than direct laryngoscopy can also be safely used in adults.' Responsible organisms are Hemopkilus influenzae, Streptococcus pneumoniae, and beta-hemolytic streptococcus, and treatment should cover these. In adults, observation without intubation in an intensive care unit setting is acceptable if clinical situation allows it.' Another important consideration in the first scenario is pneumomediastinum. Patients may present with neck pain and more commonly with chest pain.53The disease primarily occurs when air from ruptured alveoli (usually caused by Valsalva mechanism) coalesces and tracks back into the mediastinum and up into the subcutaneous tissues of the neck. Other causes are iatrogenic airway trauma and rupture of the esophagus (Booerhaves's). The feared complications are mediastinitis and tension pneumomediastinum, and for this reason,
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patients were previously universally admitted. Recent literature has shown that recreational drug use accounts for most cases and have a benign clinical course. Once the more morbid causes are ruled out by history and, if indicated, by esophagram, patients may be discharged. The way to make the diagnosis on physical examination is to palpate subcutaneous emphysema in the neck (the neck should be palpated in all ”sore throats”), or to auscultate a mediastinal crunch over the heart (sounds like crackling cereal), which is referred to as Hamman’s crunch. The diagnosis can be confirmed radiographically with neck or chest films. It is important to get lateral films of the chest as up to 50% of cases may be missed otherwise.53 The pediatric scenario is based on an actual case seen recently in our ED. What the mother interpreted as wheezing was actually stridor, and the child was diagnosed on lateral neck radiograph as having a retropharyngeal abscess. It primarily occurs in infants to age 3 years (an uncommon age for strep throat). The most common organism is group A streptococcus, but anaerobes are also frequent. It is thought that children may puncture their retropharynx with objects (i.e., popsicle sticks, toys) thus seeding the infection. Presentation is usually with fever, stiff neck, and ”sore throat.” Airway compromise is the lifethreatening complication. Most patients can be successfully managed using IV antibiotics without surgical drainage.z8 PEARLS: WHAT YOUR ENT CONSULTANT WANTS TO TELL YOU ABOUT EPlSTAXlS
Epistaxis is one of the most unpopular chief complaints in emergency medicine. The ENT specialists do not love them either. When they are asked about salient management advice they would pass on, the following are frequently mentioned:
1. When examining the epistaxis patient, it is important to visualize as much of the nasal vestibule as possible. It is important to keep the patient’s head upright, for if he or she tilts backwards, then only the roof will be seen (Fig. 2). The nasal speculum should be held in a horizontal position to allow an optimum view of the nasal septum, which is the site of most bleeding. 2. When using silver nitrate sticks to cauterize a bleeding vessel, the attempt is often unsuccessful because every attempt to contact the site inactivates the cautery because of moisture. A way to avoid this is to cauterize concentrically in a circle around the vessel from the outside in. This sequentially decreases collateral flow and allows for a drier field. 3. When a nasal tampon or anterior pack is used, patients will often return with oozing. Rather than immediately removing the product of your previous hard work, try injecting a vasoconstrictive solution into the material with a needle and syringe. It often works! 4. If using a balloon device for nasal packing, water or saline should be used to inflate rather than air. Air tends to escape in an unnoticed fashion, rendering the pack ineffective. 5 . Antibiotics should be strongly considered whenever a nose is packed. Not only does obstruction increase the likelihood of iatrogenic sinusitis, but toxic shock is a real and known complication of nasal packing. Upper respiratory and skin organisms should be covered. 6. Patients with coagulopathies (i.e., hemophilia, thrombocytopenia) should
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A Figure 2. Proper (A) and improper (6) head orientation the nasal cavity.
for maximal visual examination of
never have cautery or anterior packs placed. The former will cause increased bleeding, and the latter induces bleeding when removed in these patients, which leaves you where you started. These patients are best treated with topical agents that induce clot formation, such as gelfoam or surgicel (this author uses this as a primary treatment in all patients not easily managed with cautery, as it also avoids the discomfort of obstruction of the nares and the pack itself). Correcting the underlying medical problem may also be required. PITFALLS: NO COMMUNICATION WITH THE ELDERLY
There is no doubt that emergency physicians are encountering geriatric patients with increasing frequency. It is often difficult to obtain necessary historical information owing to problems in communication secondary to a natural age-related decrease in hearing ability. Elderly patients and others with decreased hearing are a source of frustration, especially in the absence of family members who are able to easily communicate, or those who know sign language. The typical physician response is to ask questions extremely loudly or give up. One technique that can be used in this situation is to put the stethoscope in the patient’s ears and speak into the bell. This serves two functions: the first is amplification of the sound and the second is elimination of extraneous distracting noises present in the environment (by the obstructive seal of the ear attachments). Elderly, who have decreased hearing, usually compensate by picking up on visual clues from the environment. They will depend more on gestures and expressions. Very importantly, however, they will rely on lip reading. If someone begins to speak quicker and louder to “get their message through,” the interaction may deteriorate. An extremely effective technique in this situation is to present yourself directly in the patient’s sight so they may receive these important clues. Yelling from above the patient’s head or behind the bed deprives them of important visual clues. Then talk slowly to facilitate this process, not louder. You will be amazed at the immediate reward and sudden under-
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standing and communication you will achieve by simply moving around in front of the patient and speaking slower, not louder. Try these two techniques, and you will frequently be pleasantly surprised with an easily obtained history. References 1. Andreassen UK, Baer S, Nielsen TG, et al: Acute epiglottitis-25 years' experience with nasotracheal intubation, current management policy and future trends. J Laryngol Otol 106:1072-1075, 1992 2. Au YK, Henkind P: Pain elicited by consensual pupillary reflex: A diagnostic test for acute iritis. Lancet 2:1254-1255, 1981 3. Backlin SA: Positive-pressure technique for nasal foreign body removal in children. Ann Emerg Med 25:554555, 1995 4. Baker M D Foreign bodies of the ear and nose in childhood. Pediatr Emerg Care 3:67-70, 1987 5. Bluestone CD, Klein JO: Otitis media, atelectasis and eustachian tube dysfunction. In Bluestone CD, Stool SE (eds): Pediatric Otolaryngology. Philadelphia, WB Saunders, 1990, pp 3 2 M 8 6 6. Blumer JL, Goldfarb J: Meta-analysis in the evaluation treatment for streptococcal pharyngitis: A review. Clin Ther 16:604-620, 1994 7. Brownstein DR, Hodge D: Foreign bodies of the eye, ear, and nose. Pediatr Emerg Care 4:215--218, 1988 8. Clemons CS, Cohen EJ, Arentsen JJ, et al: Pseudomonas ulcers following patching of corneal abrasions associated with contact lens wear. CLAO 13:161-164, 1987 9. Cohen HA, Goldberg E, Horev Z : Removal of nasal foreign bodies in children. Clin Pediatr 32:192, 1993 10. Cruz MN, Stewart G, Rosenberg N: Use of dexamethasone in the outpatient management of acute laryngotracheitis. Pediatrics 96:220-223, 1995 11. Fitzgerald D, Mellis C, Johnson M, et al: Nebulized Budesonide is as effective as nebulized adrenaline in moderately severe croup. Pediatrics 97722-725, 1996 12. Fontanarosa PB, Polsky SS, Goldman GE: Adult epiglottitis. J Emerg Med 7223-231, 1989 13. Garlington JC, Neminoff P M Emergency aspects of head and neck neoplasms. In Harwood-Ness AL (ed): The Clinical Practice of Emergency Medicine. Philadelphia, Lippincott-Raven, 1996, pp 124-128 14. Glock JL, Morales W: Acute epiglottitis during pregnancy. South Med J 865336-838, 1993 15. Green SM, Rothrock SG: Single dose intramuscular ceftriaxone for acute otitis media in children. Pediatrics 91:23-30, 1993 16. Hathaway TJ, Katz HP, Dershewitz RA, et al: Acute otitis media: Who needs posttreatment follow-up? Pediatrics 94143-147, 1994 17. House JW, Brackmann DE: Facial nerve grading system. Otolaryngol Head Neck Surg 93:146-147, 1982 18. Hughes GB: Practical management of Bell's palsy. Otolaryngol Head Neck Surg 102:658-663, 1990 19. Hulbert MFG: Efficacy of eyepad in corneal healing after corneal foreign body removal. Lancet 337643, 1991 20. Infante-Rivard C, Fernandez A: Otitis media in children: Frequency, risk factors and research avenues. Epidemiol Rev 153444463, 1993 21. Kairys SW, Olmstead EM, OConnor G T Steroid treatment of laryngotracheitis: A meta-analysis of the evidence form randomized trials. Pediatrics 83:683-693, 1989 22. Keiner DJ: Disorders of salivary glands. Zn Common Problems of the Head and Neck Region. Philadelphia, WB Saunders, 1995, pp 167-186 23. Kelley PB, Simon JE: Racemic epinephrine use in croup and disposition. Am J Emerg Med 10:181-183, 1992 24. Klassen TI', Feldman ME, Watters LK, et al: Nebulized budesonide for children with mild to moderate croup. N Engl J Med 331:285-289, 1994
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25. Klassen TP, Walters LK, Feldman, et al: The efficacy of nebulized budesonide in dexamethasone treated outpatients with croup. Pediatrics 97:463466, 1996 26. Lein J O Management of streptococcal pharyngitis. Pediatr Infect Dis J 13:572-575,1994 27. Mine JA, Runge JW: Management of streptococcal pharyngitis: A review of pathophysiology, diagnosis, and management. J Emerg Med 126654380, 1994 28. Koomson BK, Jaffe DM: Pharyngeal disease. In Reisdorff EJ, Roberts MR, Weigenstein JG (eds): Pediatric Emergency Medicine. Philadelphia, WB Saunders, 1993, pp 623-628 29. Krol G, Strong E: Computed tomography of head and neck malignancies. Clin Plast Surg 13475491,1986 30. Lufkin RB, Hanafee W: Magnetic resonance imaging of head and neck tumors. Cancer Metastasis Rev 7:19-38, 1988 31. May M, Klein SR Differential diagnosis of facial nerve palsy. Otolaryngol Clin North Am 24:613-645, 1991 32. Micromedex (vol 88). Englewood, CO, Micromedex 33. Moloy PJ: How to (and how not to) manage the patient with a lump in the neck. In Common Problems of the Head and Neck Region. Philadelphia, WB Saunders, 1995, pp 129-150 34. Morgan M, Nathwani D Facial palsy and infection: The unfolding story. Clin Infect Dis 14263-271, 1992 35. O’Brien JF, Meade JL, Falk JL Dexamethasone as adjuvant therapy for severe acute pharyngitis. Ann Emerg Med 22:212-215, 1993 36. Papazian MR, Campbell JH, Nabi S: Management of Bell’s Palsy. J Oral Maxillofac Surg 5k661-665, 1993 37. Paradise JL Managing otitis media: A time for change. Pediatrics 96:712-715, 1995 38. Park YW: Evaluation of neck masses in children. Am Fam Physician 51:1904-1912,1995 39. Peiterson E: The natural history of Bell’s palsy. Otolaryngol Head Neck Surg 4107111, 1982 40. Petroutsos G, Guimaraes, Giraud J, et al: Antibiotics and corneal epithelial wound healing. Arch Ophthalmol 101:1775-1778, 1983 41. Petroutsos G, Guimaraes R, Giraud J, et al: No eye pad for corneal abrasion. Eye 7468471, 1993 42. Pichichero MG: Group A streptococcal tonsillopharyngitis: Cost-effective diagnosis and treatment. Ann Emerg Med 25:390403, 1995 43. Prendergast M, Jones JS, Hartman D Racemic epinephrine in the treatment of laryngotracheitis: Can we identify children for outpatient therapy? Am J Emerg Med 12:613616, 1994 44. Puczynske MS, Stankiewicz JA, Cunningham DG, et al: Follow-up visit after acute otitis media. Br J Clin Pract 39:132-134, 1985 45. Rosenfeld RM, Vertrees JE, Carr J, et al: Clinical efficacy of antimicrobial drugs for acute otitis media: Metaanalysis of 5400 children from 5400 children form thirty three randomized trial. J Pediatr 124:355-367, 1994 46. Rosenfeld M. What to expect from medical treatment of otitis media. Pediatr Infect Dis J 14:731-738, 1995 47. Rothrock SG, Pignatiello GA, Howard RM: Radiologic diagnosis of epiglottitis: Objective criteria for all ages. Ann Emerg Med 19:978-982, 1990 48. Rothrock SG, Perkin R: Stridor: A review update and current management recommendations. Pediatric Emergency Medicine reports 1:2940, 1996 49. Selesnick SH, Patwardhan A: Acute facial paralysis: Evaluation and early management. Am J Otolaryngol 15:387408, 1994 50. Silverman S: Clinical diagnosis and early detection of oral cancer. Oral Maxillofac Surg Clin North Am 5:199-205, 1993 51. Sklar DP, Lauth JE, Johnson DR Topical anesthesia of the eye as a diagnostic test. Ann Emerg Med 18:1209-1211, 1989 52. Skolnik N Croup. J Fam Pract 378:165-170, 1993 53. Smith BA, Ferguson DB: Disposition of spontaneous pneumomediastinum. Am J Emerg Med 9:256-259, 1991 54. Stankiewicz J A Steroid and idiopathic facial paralysis. Otolaryngol Head Neck Surg 911672-677, 1983
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55. Stool SE, Berg AO, Berman S, et a1 Managing otitis media with effusion in young children. Quick reference guide for clinicians. AHCPR Publication 94-0623. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services. July 1994 56. Teele DW, Klein JO, Rosner B: Epidemiology of otitis media during the first seven years of life in greater Boston: A prospective cohort study. J Infect Dis 160:83-94, 1989 57. Waisman Y, Klein B, Boenning DA, et a1 Prospective randomized double-blind study comparing L-epinephrine and racemic epinephrine aerosols in the treatment of laryngotracheitis (croup). Pediatrics 89:302-306, 1992 58. Walton L, Masouredis C: The epidemiology of maxillofacial malignancy. Oral Maxillofac Surg Clin North Am 13:475491, 1993 59. Woollons AC, Morton RP: When does middle ear effusion signify nasopharyngeal CA? NZ Med J 107507-509, 1994 Address reprint requests to James A. Pfaff, MD, FACEP Department of Emergency Medicine Brooke Army Medical Center Building 3600 3861 Roger Brooke Drive San Antonio, TX 782344200
PEARLS, PITFALLS, AND UPDATES
+ .20
EYE, EAR, NOSE, AND THROAT James A. Pfaff, MD, FACEP, and Gregory P. Moore, MD, FACEP
UPDATE: OTITIS MEDIA Otitis media is an extremely ubiquitous disease with most children having at least one episode before age 2 years.% It is debatable whether treatment of the disease is even required. Some European practitioners have developed an expectant approach to the treatment, recognizing that over 80% of cases resolve ~pontaneously.4~ Other authors question both antibiotic efficacy6 and the wisdom of widespread antibiotic use in the face of increasing Streptococcus pneumoniae drug resi~tance.~~ Conversely, the use of antibiotics has greatly decreased the incidence of complications, and it is impossible to predict which patients will develop them precluding selective management. Despite the increasing incidence of B-lactamase and S. pneumoniae resistance, amoxicillin remains an excellent first-line therapy. An alternative first-line medication includes trimethoprim-sulfamethoxazole, which is administered twice a day but may have a higher incidence of complications owing to sulfa sensitivities. Antibiotics useful as second-line therapy include amoxicillin-clavulanic acid and erythromycin-sulfisoxazole. It would be optimal for individual providers to know the drug resistance and susceptibility in their practice areas. A single dose of ceftriaxone (50 mg/kg) intramuscularly (IM)has been shown to be effective and may be useful in individuals in whom compliance may be a p r ~ b l e m . ’ ~ Traditionally, the recommendation was to follow up in 2 to 3 weeks to verify resolution of the infection. Although the acute infection may resolve in that time, it is still probable that the child will have a persistent effusion. In fact, it takes 3 months for 90% of effusions to clear.5 The child’s age is helpful in clinically determining the likelihood of resolution of otitis media. Children older than 2 years without symptoms generally have resolution of their infection.44 Parental perception of resolution and the absence of symptoms are also useful The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Departments of the Army, Air Force, or the Department of Defense. All material in this article is in the public domain. From the Department of Emergency Medicine, Brooke Army Medical Center (JAP), Methodist Hospital (GPM), and Indiana University School of Medicine (GPM), Indianapolis, Indiana
EMERGENCY MEDICINE CLINICS OF NORTH AMERICA VOLUME 1 5 . NUMBER 2 M A Y 1997
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indicators in identifying resolution of acute otitis media.I6Two-week follow-up is still important in children whose symptoms persist, children younger than 15 months old, or children with a family history of recurrent otitis media.I6 The treatment of children with persistent effusion has been problematic and controversial. A recent expert panel recommended some basic treatment guidelines." It recommended a trial of antibiotics in children with persistent effusion. The use of steroids, antihistamines, decongestants, tonsillectomy, or adenoidectomy were not believed to be statistically useful. Because there is some correlation between persistent effusion and speech and language delay,2O the use of tympanostomy tubes with persistent effusion of 4 to 6 months and a hearing loss of greater than 20 dB was recommended. PEARL: THE USE OF STEROIDS IN UPPER AIRWAY DISEASE In the past, individuals with exudative pharyngitis, regardless of the cause, have been anecdotally prescribed steroids assuming that this would reduce pharyngeal swelling. One prospective, randomized, double-blinded and placebocontrolled study, using a single IM injection of 10 mg of dexamethasone, resulted in significant improvement compared with the control group.35Although this study did not identify the cause of the pharyngitis, it seems reasonable to use steroids in patients with significant pharyngeal edema and concern for potential airway compromise. Steroids are also useful in treating croup, specifically laryngotracheobronchitis. Clearly, in severe croup where there are few other available treatment options, the use of 0.6 mg/kg has become a common practice. Several studies have evaluated the use of steroids in the inpatient setting in children with severe croup. While difficult to obtain a consensus, it has become accepted practice to use them in this manner.21,52 Whether steroids have benefit in the moderate to mild croup cases is less clear, though there are some data to support the use of dexamethasone in this setting.lo In addition, the use of nebulized budesonide has also been effective.24, 25 Nebulized budesonide has also been compared favorably with nebulized adrenaline in croup." Although most children will improve with general supportive measures, such as humidified oxygen, steroids are an additional treatment option. PEARL: NONINVASIVE NASAL FOREIGN BODY REMOVAL Nasal foreign bodies consist of a multitude of objects, most commonly food, hair beads, paper, and toy parts, and occur primarily in 2 and 3 year olds.' The child may present to the emergency department (ED) after a parent has visualized the object in the child's nose, watched the child put the object into his or her nose, or because of a unilateral foul-smelling discharge or epistaxis. Several methods have been described for removal including right angle hooks, wire loops, alligator forceps, or even small Fogarty catheter^.^ One very simple, noninvasive method that has been described is that of positive pressure rem0va1.~A vasoconstrictor may be used initially to decrease mucosal edema. The unobstructed naris is occluded, and the parent is instructed to give a puff of air, much like giving mouth-to-mouth resuscitation. For a right-sided foreign body, the parent is usually on the left side of the child, holding the mouth open
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with the left hand and occluding the unobstructed naris with the right thumb.3 Repeat attempts may be necessary to fully dislodge the foreign body. If unsuccessful or the child is uncooperative, placing the child in restraints, putting him or her in the Trendelenburg position, and repeating the mouth-to-mouth technique or Ambu bag should result in successful expulsionP PITFALLS: IDENTIFYING HEAD AND NECK MALIGNANCIES
Failing to diagnose head and neck cancers are not high on the list of emergency medicine malpractice claims. Nonetheless, because many eye, ear, nose, and throat (ENT) problems present to the ED, it is an excellent place to identify a number of head and neck malignancies. When evaluating someone with an ENT problem, identify (in the patient history) the risk factors that may predispose a patient to these malignancies. These risk factors include alcohol and tobacco use, viruses, sunlight exposure, genetics, and a history of exposure to dust and inhalation products."R The oropharynx is obviously the most accessible area to identify ENT malignancies. Leukoplakia is a common, white oral patch that cannot be scratched off the oral surface and is considered a precancerous le~ion.~" Dental follow-up is recommended especially in patients with multiple lesions that do not resolve. Many carcinomas are painless and do not become symptomatic until an ulceration develops. The lesions may be small with an erosion or erythema that has been nonhealing. If the lesion involves the tongue, tonsil, or soft palate, the patient may additionally complain of a persistent so;e throat or dysphagia. Any nonhealing lesion should have follow-up for potential biopsy and histologic examination. Occasionally, although uncommonly, a patient may present with unilateral neck swelling, as the presenting sign of oral pharyngeal cancer.so Lesions of the nasopharynx are difficult to visualize. Presenting signs and symptoms include otitis media with effusion that is unresponsive to therapy, patients with local invasion of cranial nerves and a resulting palsy, or patients who present with unilateral effusion and a neck mass, deafness, otalgia, progressive nasal obstruction, and e p i s t a x i ~ .Some ~ ~ authors advocate the need for evaluation for any patient over 10 years old with a persistent effusion and the above-mentioned signs.5yPrompt ENT referral is recommended if these symptoms exist. Malignant lesion of the nose and sinuses are infrequent and most commonly affect men in the fifth to seventh decades of life.zyPatients that have persistent nasal obstruction, drainage, epistaxis, bloody discharge, or persistent sinus pain after treatment should be referred for suspicion of malignancy.2y Masses of the salivary glands may include the parotid, submandibular, or minor salivary glands. Most inflammatory conditions are non-neoplastic and include viral infections (most commonly mumps), bacterial infections, or salivary duct calculi. Lesions that persist after treatment should be considered suspicious for neoplasm. Most salivary gland tumors involve the parotid with 80% to 90% of these being benign. Tumors of the submandibular and minor glands are malignant in 50% and 75% of the time, respectively.2zWhen swelling of these areas persist after observation or antibiotics, suspect tumor as a cause and refer to an ENT specialist. Laryngeal tumors often present with persistent sore throat, hoarseness, or altered voice and should be considered particularly when these symptoms present in a smoker. The tumors are found predominantly in men and can be
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divided into supraglottic, glottic, and subglottic forms. Glottic tumors involve the true vocal cords and are the most common laryngeal malignancy.30They are also the most easily detected usually because of voice change. Supraglottic tumors are the next most common tumor often invading superior lymph nodes in the neck. When detected, they are often advanced.30Subglottic tumors are difficult to detect early and, fortunately, are uncommon. One problematic area in the emergency department is the evaluation of a neck mass that the patient or parent may notice and present for evaluation. There is significant difference in the appearance of a neck mass between adults and children. In adults, approximately 80% of masses are malignant, whereas in children, 80% to 90% of them are caused by benign conditions. Malignant lesions are rare in children and, when present, are usually mesothelial tumors, such as lymphomas and sarc0mas.3~In adults, most masses are metastatic, most commonly head and neck squamous cell carcinoma with metastasis to regional lymph Neck masses in children are commonly inflammatory (reactive lymphadenopathy or lymphadenitis), congenital (including thyroglossal duct, dermoid, In children, the location of the mass is and brachial cleft cysts), and neopla~tic.~~ also helpful in determining its cause. Posterior solitary nodes and supraclavicular masses have a high likelihood of malignancy, whereas anterior lymphadenopathy suggests infections from the n a s ~ p h a r y n x In . ~ ~adults, lymph nodes found in the upper and middle portions of the neck are usually affected from a primary lesion in the upper aerodigestive tract, whereas supraclavicular and lower posterior triangular lymph nodes arise from carcinoma below the clavicie.33 There are many symptoms that should increase the suspicion of head and neck disease, especially in the presence of a neck mass. These include dysphagia, odynophagia (pain on swallowing),hoarseness, stridor, otalgia, speech disorder (or "hot potato speech"), and globus (a sensation of a lump in the throat). Treating a mass in children initially as inflammatory is a reasonable course of action, but there should be improvement in 2 weeks. Adults with masses, particularly with any of the above-mentioned signs, should be referred for further evaluation. The workup of head and neck tumors is beyond the scope of the emergency department and involves direct visualization, fine-needle aspiration, endoscopy, CT, and MR imaging. In summary, there are several key points that can be made about head and neck cancers whose presence indicate the need for prompt referraP: 1. Any persistent sore throat, hoarseness, voice change, or nonhealing mouth ulcers for greater than 2 weeks duration in adults over age 40 years should be promptly referred for evaluation. 2. Solitary neck masses in adults should be considered neoplastic until proven otherwise. 3. Unilateral otitis media with effusion in patients over 10 years of age with a neck mass, deafness, otalgia, progressive nasal obstruction, and epistaxis should be evaluated for nasopharyngeal carcin0ma.5~ PEARL: DO PATIENTS GIVEN RACEMIC EPINEPHRINE NEED TO BE ADMllTED WITH CROUP?
Racemic epinephrine has been used in patients with moderate to severe croup who do not improve with humidification or are in extremis. Racemic
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epinephrine contains both the D and L isomers, and it was chosen because it was thought to have fewer side effects than the cheaper, more commercially available, and bioactive L is0mer.5~In a prospective randomized study, the L isomer was shown to be at least as effective as racemic epinephrine and is recommended for cr0up.5~The recommended dose is 5 mL of the 1: 1000 Lisomer aerosol.48, 57 Traditionally, the disposition of patients given racemic epinephrine has been hospitalization because of the concern for the return of the patient’s symptoms or worsening of their condition secondary to a rebound phenomena. Since the half-life of epinephrine is less than 2 hours, it seemed reasonable that patients without symptoms at this interval could be safely discharged home. Many authors have looked at outpatient management with new disposition recommendations. Patients can be safely and appropriately discharged home if they have received steroids, are observed for 2 to 3 hours, are free of stridor or 43, 47 retractions and have access to appropriate f~llow-up?~,
UPDATE: BELL’S PALSY
Seventh nerve peripheral palsy is caused by a multitude of causes. In one series of over 2800 patients, 51% of the cases were idiopathic (Bell’s). Other common causes included trauma (22%), herpes zoster (7%), and tumor (6%).31 Even though Bell’s is idiopathic, there is good clinical and serologic evidence of an infectious cause in a sizable minority of cases.% The incidence is 15 to 40 per 100,000 people, involves both sexes equally and is recurrent approximately 10% of the time. Eight percent of patients have a family history of the disorder.%In a large study of the natural course of the disease, 85% of patients had complete resolution or minimal sequelae if resolution started in the first 3 weeks.%Another favorable prognostic indicator is the occurrence in younger patients.39Patients presenting with posterior auricular pain and those over 60 years old have a worse prognosis.39 Ensuring that it is really Bell’s palsy is important once a patient presents to the emergency department. By definition, its idiopathic nature should make it a diagnosis of exclusion. Nonetheless, there are certain characteristics that make it likely to be Bell’s. These include sudden onset, unilateral presence, and the absence of other cranial nerve involvement. There is little workup required in the ED management of peripheral nerve palsy. Describing the extent of involvement to a consultant is often challenging. Table 1 identifies a facial grading system recommended by the American Academy of Otolaryngology, which is useful in describing the involvement of the seventh nerve fun~tion.’~ The need for treatment continues to be controversial because most patients improve with minimal sequelae. Eye care is very important. The use of eye drops during the day and ointment at night will prevent drying of secretions until the return of function. Though no definitive study has proved the benefit of the use of prednisone 1 mg/kg/d for 10 to 14 days followed by a taper is a recommended practice,18provided there are no contraindications. The role of surgery is very controversial with some recommending middle fossa decompression of the seventh nerve. The efficacy of surgery must be clear because of the complications of hearing loss, vertigo, and facial paralysis.49 Discussion with your consultant to arrange close follow-up and potential treatment is essential.
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Table 1. FACIAL NERVE GRADING SYSTEM Grade
Description
II
Normal Mild dysfunction
Ill
Moderate dysfunction
IV
Moderately severe dysfunction
V
Severe dysfunction
VI
Total paralysis
I
Characteristics Normal facial function in all areas Gross: slight weakness noticeable on close inspection; may have very slight synkinesis At rest: normal symmetry and tone Motion Forehead: moderate to good function Eye: complete closure with minimum effort Mouth: slight asymmetry Gross: obvious but not disfiguring difference between two sides; noticeable but not severe synkinesis, contracture, or hemifacial spasm At rest: normal symmetry and tone Motion Forehead: slight to moderate movement Eye: complete closure with effort Mouth: slightly weak with maximum effort Gross: obvious weakness and/or disfiguring asymmetry At rest: normal symmetry and tone Motion Forehead: none Eye: incomplete closure Mouth: asymmetric with maximum effort Gross: only barely perceptible motion At rest: asymmetry Motion Forehead: none Eye: incomplete closure Mouth: slight movement No movement
From House JW, Brackmann DE: Facial nerve grading system. Otolatyngol Head Neck Surg 93:146147, 1982; with permission.
PEARL: THERAPY FOR OPHTHALMOLOGIC PROBLEMS.. PATCHES AND MEDICATIONS
.
There are several topics in ED ophthalmologic therapy that can be a source of confusion and frustration, and these are highlighted as follows. Antibiotics are one of the most frequent ophthalmologic medications used by emergency physicians. Two questions often arise: Which is appropriate to use?; and How should it be administered? The advantage of ointments is that they stay on the conjunctivae longer and thus require less frequent administration for higher concentrations. Thus, they are especially useful in children who may be difficult to elicit compliance with these medications. A negative aspect of ointments is that they interfere with vision of adults who desire to remain visually active (i.e., drive, read). They should be avoided in cases of large or deep corneal abrasions as they may fill in and be incorporated into the defect
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as the epithelium heels over it. Antibiotic drops do not impair vision but dissolute quickly via the lacrimal apparatus. One way to increase local effect, absorption, and concentration is to have the patient squeeze the bridge of his or her nose or simply squeeze his or her eyes shut for 5 minutes after administration. This blocks the outflow tract. Drops may be difficult to administer to a combative child with forcefully closed eyes. A way around this is to place a couple drops on the outside lid in the sulcus of the medial eye with the patient in a reclining position. Eventually, the child will voluntarily open his or her eye and the medicine will flow in. When prescribing ophthalmologic antibiotics it would seem natural to prescribe the highest concentration available. This may not be true, especially if there is a corneal defect or abrasion. It has been shown in several animal studies that when higher concentrations of antibiotics are used, there is slower healing of the corneal epithelium. So, for example, when the choice is between using 30% sulfacetamide or lo%, the latter is probably preferredPo Neomycin is notorious for causing sensitization and redness in 15% of cases, and should be avoided for this reason. Gentamicin may also do this in a lower percentage, and when faced with a patient who has “worse” conjunctivitis, the cause may not be resistance but iatrogenic medication effect. When treating corneal abrasions or foreign bodies, classically antibiotics are instilled and an eyepatch is applied. The traditional teaching has been the eyepatch prevents movement of the lids over the defect and thus prevents further injury and promotes healing. This is also promoted to decrease discomfort. Recent literature has questioned this practice. One controlled randomized study of 30 patients with corneal defects after foreign body removal compared treatment with or without an eyepad. There was no difference in rate of healing, and 75% of patients treated with eyepads reported discomfort at 24 hours ’~ prospective, controlled, randomcompared with 29% of those w i t h o ~ t .Another ized study of 44 patients with corneal abrasions used a similar design and found that the epithelial defects healed significantly quicker without use of an eyepad. There was no difference between the groups when they rated their pain by a visual analog These and other studies have recommended treatment of corneal abrasions should not include an eyepatch. There is one clinical situation in which the use of a corneal eyepad in treatment of an abrasion may be considered malpractice. The eyepad should not be used when a corneal abrasion is secondary to contact lenses. These wounds are extremely prone to pseudomonas, and patching predisposes to corneal ulceration.8 PEARLS: KEYS TO THE DIAGNOSIS OF IRlTlS
One area that emergency physicians often express insecurity about is definitively diagnosing iritis. When using the slit lamp, they relate difficulty seeing the cells and flare that accompany the condition. It is important for the instrument’s beam of light to be oriented properly, or picking these features up is next to impossible. A narrow slit should be used with high intensity of light. The beam should then be shortened to almost pinpoint height and directed at a 45-degree angle to disappear into the posterior part of the globe. This allows minimization of reflection of light, and the cells and flare can be searched for in the normally dark anterior chamber (appearing as small flashes of light). Many physicians will adjust the beam to maximum height thinking they need to visualize the entire height of the anterior chamber. This causes more light
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Figure 1. Proper orientation of slit-
lamp beam to detect cells and flare.
scattering and reflection back at the examiner, making subtle cells and flare more difficult to see (Fig. 1). If you still feel uncertain with the slit lamp, there are shortcuts that you can rely on to make or rule out this diagnosis in patients with a painful eye. One study looked at 71 patients with corneal abrasions versus other causes of eye pain in a prospective, controlled fashion. Pain was assessed using visual analogue scales before and after administration of the topical anesthetic proparacaine. When pain reduction was used as a diagnostic tool, it had a sensitivity of 80% and a specificity of 86% in determining whether a simple corneal injury was present. So, if putting anesthetic in the eye relieves the pain, you can be fairly sure that the diagnosis is not iriti~.~l There are two easy findings that help me determine that there is likely iritis present before doing a slit-lamp examination. These patients will present with a red, painful eye. In iritis, there is inflammation of the iris, so naturally the injection will be localized predominantly around the iris and not diffusely over the conjunctiva. Second, the consensual light reflex can be used to make the diagnosis. Of course, shining a light in the affected eye will cause pain, but in iritis shining a light in the normal, unaffected eye (by causing consensual movement of the other affected iris) will cause pain if iritis is present. A study found this physical finding to be reliable and actually more sensitive than the slit-lamp examination.2 UPDATES: HOW SHOULD I TREAT STREP THROAT?
Recent reviews confirm that penicillin is still the drug of choice for treatment of streptococcal pharyngitis.z6,27 The treatment of this disease is important to prevent rheumatic fever, glomerulonephritis, and peritonsillar abscess, and to shorten the duration of symptoms.3z Group A beta-hemolytic strep (GABHS) has shown an increasingly higher resistance rate. It is thought that the coexistent presence of beta-lactam-resistant organisms is the reason for this phenomena.
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These organisms are proposed to "eat up" the penicillin, which leaves none left to work on the primary GABHS infection. Many are now advocating cephalosporin (or other beta-lactam agents, such as amoxicillin-clavulinic acid and azithromycin) play a more prominent role in the primary treatment of streptococcal p h a r y n g i t i ~Meta-analysis .~~ of 19 studies showed streptococcal cure and eradication rates are higher with these agents than with penicillin.6 The increased cost must be balanced against the true likelihood of the disease being present, as well as the financial and time impact as a result of increased physician visits owing to treatment failure. Cephalosporins that have proved effective include cefaclor, cefixime, cephalexin, cefuroxime, cefpodoxime, loracarbef, cefadroxil, and cefpodoxime.6,32 In the near future, these agents may replace penicillin as the drug of choice. PITFALL: THE "NORMAL" SORE THROAT (CONSIDER A LATERAL NECK RADIOGRAPH) Scenario 1: A 40-year-old man comes in complaining of severe sore throat. He appears to be in marked pain without stridor or drooling. On pharyngeal examination, there is some injection, but no purulence or deviation in anatomy. Scenario 2: A 2-year-old girl is brought in with a fever to 104 degrees. Her mother wants her checked for sore throat as ahe child appears to be in pain. Earlier, the mother had noted "wheezing." On examination, the child is nontoxic, without drooling or stridor. Pharynx is mildly injected without deviation in anatomy or purulence. The remainder of the physical examination and a chest radiograph result is normal. Infrequently, but not rarely, patients will present with a symptom complex suggestive of pharyngitis; however, on examination, the findings are surprisingly unimpressive. In these situations, it is important to step back and think of the diagnosis below. All can be easily diagnosed with a lateral neck radiograph. In the first scenario, adult epiglottitis and pneumomediastinum should be considered. With the advent of Hib vaccine, childhood epiglottitis has decreased while the adult form of the disease is more common than previously recognized and usually occurs in middle age.I2 Lack of suspicion and delayed diagnosis leads to overall mortality of 7y0.'~ Adults often present with a nontoxic appearance and normal or low grade temperature.'2 Because the upper airway diameter is larger than in children, stridor is a late finding and adults can often be managed without active airway intervention. The diagnosis should be suspected whenever there is dysphagia out of proportion to the examination. In adults, the lateral neck radiograph may be helpful. Epiglottic width over 50% of third vertebrae or greater than 60% of the height of epiglottis are very sensitive and specific parameter^.^^ If suspicion is high, than direct laryngoscopy can also be safely used in adults.' Responsible organisms are Hemopkilus influenzae, Streptococcus pneumoniae, and beta-hemolytic streptococcus, and treatment should cover these. In adults, observation without intubation in an intensive care unit setting is acceptable if clinical situation allows it.' Another important consideration in the first scenario is pneumomediastinum. Patients may present with neck pain and more commonly with chest pain.53The disease primarily occurs when air from ruptured alveoli (usually caused by Valsalva mechanism) coalesces and tracks back into the mediastinum and up into the subcutaneous tissues of the neck. Other causes are iatrogenic airway trauma and rupture of the esophagus (Booerhaves's). The feared complications are mediastinitis and tension pneumomediastinum, and for this reason,
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patients were previously universally admitted. Recent literature has shown that recreational drug use accounts for most cases and have a benign clinical course. Once the more morbid causes are ruled out by history and, if indicated, by esophagram, patients may be discharged. The way to make the diagnosis on physical examination is to palpate subcutaneous emphysema in the neck (the neck should be palpated in all ”sore throats”), or to auscultate a mediastinal crunch over the heart (sounds like crackling cereal), which is referred to as Hamman’s crunch. The diagnosis can be confirmed radiographically with neck or chest films. It is important to get lateral films of the chest as up to 50% of cases may be missed otherwise.53 The pediatric scenario is based on an actual case seen recently in our ED. What the mother interpreted as wheezing was actually stridor, and the child was diagnosed on lateral neck radiograph as having a retropharyngeal abscess. It primarily occurs in infants to age 3 years (an uncommon age for strep throat). The most common organism is group A streptococcus, but anaerobes are also frequent. It is thought that children may puncture their retropharynx with objects (i.e., popsicle sticks, toys) thus seeding the infection. Presentation is usually with fever, stiff neck, and ”sore throat.” Airway compromise is the lifethreatening complication. Most patients can be successfully managed using IV antibiotics without surgical drainage.z8 PEARLS: WHAT YOUR ENT CONSULTANT WANTS TO TELL YOU ABOUT EPlSTAXlS
Epistaxis is one of the most unpopular chief complaints in emergency medicine. The ENT specialists do not love them either. When they are asked about salient management advice they would pass on, the following are frequently mentioned:
1. When examining the epistaxis patient, it is important to visualize as much of the nasal vestibule as possible. It is important to keep the patient’s head upright, for if he or she tilts backwards, then only the roof will be seen (Fig. 2). The nasal speculum should be held in a horizontal position to allow an optimum view of the nasal septum, which is the site of most bleeding. 2. When using silver nitrate sticks to cauterize a bleeding vessel, the attempt is often unsuccessful because every attempt to contact the site inactivates the cautery because of moisture. A way to avoid this is to cauterize concentrically in a circle around the vessel from the outside in. This sequentially decreases collateral flow and allows for a drier field. 3. When a nasal tampon or anterior pack is used, patients will often return with oozing. Rather than immediately removing the product of your previous hard work, try injecting a vasoconstrictive solution into the material with a needle and syringe. It often works! 4. If using a balloon device for nasal packing, water or saline should be used to inflate rather than air. Air tends to escape in an unnoticed fashion, rendering the pack ineffective. 5 . Antibiotics should be strongly considered whenever a nose is packed. Not only does obstruction increase the likelihood of iatrogenic sinusitis, but toxic shock is a real and known complication of nasal packing. Upper respiratory and skin organisms should be covered. 6. Patients with coagulopathies (i.e., hemophilia, thrombocytopenia) should
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A Figure 2. Proper (A) and improper (6) head orientation the nasal cavity.
for maximal visual examination of
never have cautery or anterior packs placed. The former will cause increased bleeding, and the latter induces bleeding when removed in these patients, which leaves you where you started. These patients are best treated with topical agents that induce clot formation, such as gelfoam or surgicel (this author uses this as a primary treatment in all patients not easily managed with cautery, as it also avoids the discomfort of obstruction of the nares and the pack itself). Correcting the underlying medical problem may also be required. PITFALLS: NO COMMUNICATION WITH THE ELDERLY
There is no doubt that emergency physicians are encountering geriatric patients with increasing frequency. It is often difficult to obtain necessary historical information owing to problems in communication secondary to a natural age-related decrease in hearing ability. Elderly patients and others with decreased hearing are a source of frustration, especially in the absence of family members who are able to easily communicate, or those who know sign language. The typical physician response is to ask questions extremely loudly or give up. One technique that can be used in this situation is to put the stethoscope in the patient’s ears and speak into the bell. This serves two functions: the first is amplification of the sound and the second is elimination of extraneous distracting noises present in the environment (by the obstructive seal of the ear attachments). Elderly, who have decreased hearing, usually compensate by picking up on visual clues from the environment. They will depend more on gestures and expressions. Very importantly, however, they will rely on lip reading. If someone begins to speak quicker and louder to “get their message through,” the interaction may deteriorate. An extremely effective technique in this situation is to present yourself directly in the patient’s sight so they may receive these important clues. Yelling from above the patient’s head or behind the bed deprives them of important visual clues. Then talk slowly to facilitate this process, not louder. You will be amazed at the immediate reward and sudden under-
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standing and communication you will achieve by simply moving around in front of the patient and speaking slower, not louder. Try these two techniques, and you will frequently be pleasantly surprised with an easily obtained history. References 1. Andreassen UK, Baer S, Nielsen TG, et al: Acute epiglottitis-25 years' experience with nasotracheal intubation, current management policy and future trends. J Laryngol Otol 106:1072-1075, 1992 2. Au YK, Henkind P: Pain elicited by consensual pupillary reflex: A diagnostic test for acute iritis. Lancet 2:1254-1255, 1981 3. Backlin SA: Positive-pressure technique for nasal foreign body removal in children. Ann Emerg Med 25:554555, 1995 4. Baker M D Foreign bodies of the ear and nose in childhood. Pediatr Emerg Care 3:67-70, 1987 5. Bluestone CD, Klein JO: Otitis media, atelectasis and eustachian tube dysfunction. In Bluestone CD, Stool SE (eds): Pediatric Otolaryngology. Philadelphia, WB Saunders, 1990, pp 3 2 M 8 6 6. Blumer JL, Goldfarb J: Meta-analysis in the evaluation treatment for streptococcal pharyngitis: A review. Clin Ther 16:604-620, 1994 7. Brownstein DR, Hodge D: Foreign bodies of the eye, ear, and nose. Pediatr Emerg Care 4:215--218, 1988 8. Clemons CS, Cohen EJ, Arentsen JJ, et al: Pseudomonas ulcers following patching of corneal abrasions associated with contact lens wear. CLAO 13:161-164, 1987 9. Cohen HA, Goldberg E, Horev Z : Removal of nasal foreign bodies in children. Clin Pediatr 32:192, 1993 10. Cruz MN, Stewart G, Rosenberg N: Use of dexamethasone in the outpatient management of acute laryngotracheitis. Pediatrics 96:220-223, 1995 11. Fitzgerald D, Mellis C, Johnson M, et al: Nebulized Budesonide is as effective as nebulized adrenaline in moderately severe croup. Pediatrics 97722-725, 1996 12. Fontanarosa PB, Polsky SS, Goldman GE: Adult epiglottitis. J Emerg Med 7223-231, 1989 13. Garlington JC, Neminoff P M Emergency aspects of head and neck neoplasms. In Harwood-Ness AL (ed): The Clinical Practice of Emergency Medicine. Philadelphia, Lippincott-Raven, 1996, pp 124-128 14. Glock JL, Morales W: Acute epiglottitis during pregnancy. South Med J 865336-838, 1993 15. Green SM, Rothrock SG: Single dose intramuscular ceftriaxone for acute otitis media in children. Pediatrics 91:23-30, 1993 16. Hathaway TJ, Katz HP, Dershewitz RA, et al: Acute otitis media: Who needs posttreatment follow-up? Pediatrics 94143-147, 1994 17. House JW, Brackmann DE: Facial nerve grading system. Otolaryngol Head Neck Surg 93:146-147, 1982 18. Hughes GB: Practical management of Bell's palsy. Otolaryngol Head Neck Surg 102:658-663, 1990 19. Hulbert MFG: Efficacy of eyepad in corneal healing after corneal foreign body removal. Lancet 337643, 1991 20. Infante-Rivard C, Fernandez A: Otitis media in children: Frequency, risk factors and research avenues. Epidemiol Rev 153444463, 1993 21. Kairys SW, Olmstead EM, OConnor G T Steroid treatment of laryngotracheitis: A meta-analysis of the evidence form randomized trials. Pediatrics 83:683-693, 1989 22. Keiner DJ: Disorders of salivary glands. Zn Common Problems of the Head and Neck Region. Philadelphia, WB Saunders, 1995, pp 167-186 23. Kelley PB, Simon JE: Racemic epinephrine use in croup and disposition. Am J Emerg Med 10:181-183, 1992 24. Klassen TI', Feldman ME, Watters LK, et al: Nebulized budesonide for children with mild to moderate croup. N Engl J Med 331:285-289, 1994
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25. Klassen TP, Walters LK, Feldman, et al: The efficacy of nebulized budesonide in dexamethasone treated outpatients with croup. Pediatrics 97:463466, 1996 26. Lein J O Management of streptococcal pharyngitis. Pediatr Infect Dis J 13:572-575,1994 27. Mine JA, Runge JW: Management of streptococcal pharyngitis: A review of pathophysiology, diagnosis, and management. J Emerg Med 126654380, 1994 28. Koomson BK, Jaffe DM: Pharyngeal disease. In Reisdorff EJ, Roberts MR, Weigenstein JG (eds): Pediatric Emergency Medicine. Philadelphia, WB Saunders, 1993, pp 623-628 29. Krol G, Strong E: Computed tomography of head and neck malignancies. Clin Plast Surg 13475491,1986 30. Lufkin RB, Hanafee W: Magnetic resonance imaging of head and neck tumors. Cancer Metastasis Rev 7:19-38, 1988 31. May M, Klein SR Differential diagnosis of facial nerve palsy. Otolaryngol Clin North Am 24:613-645, 1991 32. Micromedex (vol 88). Englewood, CO, Micromedex 33. Moloy PJ: How to (and how not to) manage the patient with a lump in the neck. In Common Problems of the Head and Neck Region. Philadelphia, WB Saunders, 1995, pp 129-150 34. Morgan M, Nathwani D Facial palsy and infection: The unfolding story. Clin Infect Dis 14263-271, 1992 35. O’Brien JF, Meade JL, Falk JL Dexamethasone as adjuvant therapy for severe acute pharyngitis. Ann Emerg Med 22:212-215, 1993 36. Papazian MR, Campbell JH, Nabi S: Management of Bell’s Palsy. J Oral Maxillofac Surg 5k661-665, 1993 37. Paradise JL Managing otitis media: A time for change. Pediatrics 96:712-715, 1995 38. Park YW: Evaluation of neck masses in children. Am Fam Physician 51:1904-1912,1995 39. Peiterson E: The natural history of Bell’s palsy. Otolaryngol Head Neck Surg 4107111, 1982 40. Petroutsos G, Guimaraes, Giraud J, et al: Antibiotics and corneal epithelial wound healing. Arch Ophthalmol 101:1775-1778, 1983 41. Petroutsos G, Guimaraes R, Giraud J, et al: No eye pad for corneal abrasion. Eye 7468471, 1993 42. Pichichero MG: Group A streptococcal tonsillopharyngitis: Cost-effective diagnosis and treatment. Ann Emerg Med 25:390403, 1995 43. Prendergast M, Jones JS, Hartman D Racemic epinephrine in the treatment of laryngotracheitis: Can we identify children for outpatient therapy? Am J Emerg Med 12:613616, 1994 44. Puczynske MS, Stankiewicz JA, Cunningham DG, et al: Follow-up visit after acute otitis media. Br J Clin Pract 39:132-134, 1985 45. Rosenfeld RM, Vertrees JE, Carr J, et al: Clinical efficacy of antimicrobial drugs for acute otitis media: Metaanalysis of 5400 children from 5400 children form thirty three randomized trial. J Pediatr 124:355-367, 1994 46. Rosenfeld M. What to expect from medical treatment of otitis media. Pediatr Infect Dis J 14:731-738, 1995 47. Rothrock SG, Pignatiello GA, Howard RM: Radiologic diagnosis of epiglottitis: Objective criteria for all ages. Ann Emerg Med 19:978-982, 1990 48. Rothrock SG, Perkin R: Stridor: A review update and current management recommendations. Pediatric Emergency Medicine reports 1:2940, 1996 49. Selesnick SH, Patwardhan A: Acute facial paralysis: Evaluation and early management. Am J Otolaryngol 15:387408, 1994 50. Silverman S: Clinical diagnosis and early detection of oral cancer. Oral Maxillofac Surg Clin North Am 5:199-205, 1993 51. Sklar DP, Lauth JE, Johnson DR Topical anesthesia of the eye as a diagnostic test. Ann Emerg Med 18:1209-1211, 1989 52. Skolnik N Croup. J Fam Pract 378:165-170, 1993 53. Smith BA, Ferguson DB: Disposition of spontaneous pneumomediastinum. Am J Emerg Med 9:256-259, 1991 54. Stankiewicz J A Steroid and idiopathic facial paralysis. Otolaryngol Head Neck Surg 911672-677, 1983
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55. Stool SE, Berg AO, Berman S, et a1 Managing otitis media with effusion in young children. Quick reference guide for clinicians. AHCPR Publication 94-0623. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services. July 1994 56. Teele DW, Klein JO, Rosner B: Epidemiology of otitis media during the first seven years of life in greater Boston: A prospective cohort study. J Infect Dis 160:83-94, 1989 57. Waisman Y, Klein B, Boenning DA, et a1 Prospective randomized double-blind study comparing L-epinephrine and racemic epinephrine aerosols in the treatment of laryngotracheitis (croup). Pediatrics 89:302-306, 1992 58. Walton L, Masouredis C: The epidemiology of maxillofacial malignancy. Oral Maxillofac Surg Clin North Am 13:475491, 1993 59. Woollons AC, Morton RP: When does middle ear effusion signify nasopharyngeal CA? NZ Med J 107507-509, 1994 Address reprint requests to James A. Pfaff, MD, FACEP Department of Emergency Medicine Brooke Army Medical Center Building 3600 3861 Roger Brooke Drive San Antonio, TX 782344200