Ophthy and ENT - Beaumont Emergency Medicine

Ophthalmologic and ENT
William Beaumont Hospital
Department of Emergency Medicine
Sudden Loss of Vision
Central retinal artery occlusion
Central retinal vein occlusion
Retrobulbar neuritis
Amaurosis fugax
Retinal detachment
Central Retinal Artery Occlusion
Sudden monocular painless, complete
loss of vision
Fundoscopic exam: pale retina with
macular red spot
Central Retinal Artery Occlusion
STAT opthy consult
Digital massage of the globe
Increase CO2 (arteriolar dilatation) –
carbonic anhydrase inhibitor (i.e.
Definitive treatment – paracentesis of the
anterior chamber
Central Retinal Vein Occlusion
Sudden monocular
painless, and near
complete loss of
Fundoscopic exam:
chaotic, bloodstreaked retina
Stat ophthalmology
Optic Neuritis
Progressive loss of
central vision
May be painful,
scotoma, flashing
Peripheral vision
Associated with
multiple sclerosis in
25% of cases
Amaurosis Fugax
Fleeting painless loss of monocular vision
Due to minute emboli of the central retinal
Consult neurology for TIA workup
Retinal Detachment
Prodromal floaters or
flashing lights, followed
by “lowering curtain”
Opthy consult
Red Eye
Acute angle closure glaucoma
Acute iritis
Herpes simplex keratitis
Corneal ulceration
Chemical conjunctivitis
Corneal abrasions
Acute Angle Glaucoma
Sudden severe unilateral ocular pain
Decreased visual acuity
Precipitous increased IOP  blindness if
Symptoms: HA, nausea, blurred vision or
rainbow halos
Pupil dilatation is often precipitant event from
sympathomimetics, parasympatholytics, stress,
fatigue, darkness.
Acute Angle Glaucoma
Red eye
Nonreactive middilated pupil
Corneal edema
Shallow anterior
High intraocular
pressure (60-90)**
Hazy cornea
**Normal IOP <20
Glaucoma Treatment
Stat opthy consult for definitive treatment –
Timolol – beta blocker
Pilocarpine – parasympathomimetic
Acetazolamide – carbonic anhydrase inhibitor
50% glycerol – oral hyperosmotic – if patient
can tolerate PO – give in place of mannitol
Timolol Solution
Beta blocker
Decreases aqueous humor formation
0.5% solution – 1-2 drops at 10-15 min
intervals x 3, then 1 drop every 12 hours
Produces miosis
2% solution – 1 drop every 30 minutes
until the pupil constricts, then 1 drop every
6 hours
Side effects: bradycardia, hypotension,
sweating, tremors
Carbonic anhydrase inhibitor
Inhibits aqueous humor formation
500 mg IV every 12 hours or 500 mg PO
every 6 hours
Side effects: respiratory depression,
metabolic acidosis
Increases blood osmolality, creating a
gradient that draws water from the vitreous
20% 1-2 grams/kg IV over 30-60 minutes
Side effects: headache, confusion, CHF,
Acute Iritis
Blurred vision, photophobia, ocular pain
– Ciliary flush
– Anterior chamber cells and flare
– Constricted pupil
– Decreased visual acuity
– Lower IOP
– Consensual photophobia
Acute Iritis: Treatment
– i.e. Homatropine – dilates the eyes
Topical steroids
Close opthy follow up
Acute Iritis
Nonpainful red eye
Bacterial, viral, or allergic
Herpes Simplex Keratitis
Red eye with foreign
body sensation
Dendritic fluorescein
Treatment: acyclovir
drops, cycloplegics
Steroids contraindicated
Opthy consult
Corneal Ulceration
Red, painful eye
Slit lamp
– White flocculent infiltrate of the cornea
– Hypopyon
Anterior chamber exudate
May lead to corneal destruction and
?Admit, IV antibiotics
Corneal Ulceration
Chemical Conjunctivitis
Alkali burn – absolute ocular emergency
– Liquefactive necrosis
– Immediate irrigation (pH 7-7.5)
– Opthy consult
– Only opthy emergency in which visual acuity
is not checked until after therapy has begun
Alkali Burns
Chemical Conjunctivitis
Acid burn
– Coagulative necrosis
– Immediate irrigation as above
– Opthy consult
Corneal Abrasions
Foreign body sensation and photophobia
Diagnose: fluorescein uptake with slit lamp exam
– rule out foreign body with lid eversion
Suspect foreign body if “ice rink sign” – fine
linear abrasions in upper 1/3 cornea
Rule out corneal ulceration
Do not use steroid drops –may be difficult to rule
out early HS keratitis
Treatment: antibiotic ointment/drops, analgesics
Prognosis is very good
Corneal Abrasion
Traumatic Eye Injuries
Corneal laceration
Perforated globe
Intraocular foreign body
Blow-out orbital fracture
Traumatic iritis or retinal detachment
Corneal Laceration
Tear shaped pupil – prolapse of the iris
Small black fragments representing iris
pigment may be seen and initially
mistaken for a foreign body
May not see the laceration itself
Treatment: metal shield, STAT opthy
consult for surgical repair
Corneal Laceration
Perforated Globe
Suspect if penetrating wound to the eyelid
Decreased visual acuity, soft globe (do not
Fundoscopic exam may reveal vitreous
Treatment: Metal shield, STAT opthy
consult for surgical repair
Intraocular Foreign Body
Patient often gives a history of striking
metal on metal
May be initially painless, but then patient
develops monocular pain and decreased
visual acuity
May not see the wound
Diagnosis: CT scan, ultrasound or x-ray of
the globe
Treatment: Opthy consult for surgical
Orbital Foreign Body
Hemorrhage in the anterior
See blood/vitreous line in
inferior iris
Bed rest
Head of bed elevation
Opthy consult
Blow-out Orbital Fracture
Blunt globe trauma (i.e. fist to eye)
transmits forces that lead to orbital floor
Inferior rectus muscle may prolapse
through the fracture
Pain and diplopia or loss of upward gaze,
enophthalmos (sunken eye), infraorbital
Treatment: OR if entrapment, opthy
Blow-out Fracture
Moving on to ENT
Ear Disorders
Auricular hematoma
Otitis externa
Malignant otitis externa
Ramsey Hunt
Foreign body
Tympanic membrane rupture
Otits media
Auricular Hematoma
Blunt trauma
Untreated, can result in cartilage necrosis
(“cauliflower ear”)
– Needle aspiration
– Compression dressing
Auricular Hematoma
Otitis Externa
Swelling of the external canal
Pain with movement of the auricula
– Abx/steroid ear drops
– Ear wick
Malignant Otitis Externa
Deep pain with movement of TMJ,
granulation tissue on the floor of the
auditory canal at bony-cartilage junction
Immunocompromised patient
Pseudomonas aeruginosa
Facial nerve paralysis  multiple CN
involvement  meningitis
Treatment: STAT ENT consult, surgical
debridement, IV abx
Malignant Otitis Externa
Ramsay Hunt Syndrome
Herpes Zoster
Vesicular rash of ext auditory canal &
Usually with sensorineural hearing loss
and facial nerve paralysis
– Admit
– IV acyclovir
– Steroids
Ramsay Hunt Syndrome
Ear Foreign Body
Tools for removal:
– Irrigation (not vegetable matter)
– Alligator forceps
– Suction
– Hook
– Cerumen loop
Live insects should be stupefied with
lidocaine or mineral oil prior to removal
Ear Disorders
Tympanic membrane rupture – ENT
Otitis media – hopefully you all know
what this is
Nasal Disorders
Foreign body
Acute sinusitis
Cavernous sinus thrombosis
Anterior most common – Kiesselbach’s
Posterior often due to uncontrolled HTN
Rule out coagulopathy
Silver nitrate or cautery
Oral antibiotics if nasal pack
Nasal Foreign Body
– Suction
– Ear curette
– Forceps
Acute Sinusitis
Treatment: nasal and oral
decongestant, antibiotics
(augmentin, macrolide, 2nd
or 3rd cephalosporin) if sxs >
1 week
– Pott’s puffy tumor – osteitis of
anterior frontal sinus wall 
frontal lobe abscess
– Meningitis
– Acute periorbital cellulitis
– Tx: admit for IV abx
– CT scan to rule out orbital
Cavernous Sinus Thrombosis
High fever
Toxic appearing
Chemosis, CN 3 & 6
palsies, papilledema
Lethargy, coma or
Diagnosis: CT, MRI
Throat Disorders
Ludwig’s Angina
Peritonsillar abscess
Retropharyngeal abscess
Group A strep
Treat to prevent complications, acute
rheumatic fever and ARHD
Glomerulonephritis not prevented by Abx
Pharyngitis, fever, cervical
Splenomegaly in 50%
Dx: monospot,  atypical lymphocytes
Treatment: fluid, rest, steroids, avoid
ampicillin (rash), contact sports/trauma
(splenic rupture)
Ludwig’s Angina
Bilateral cellulitis of the floor of the mouth
True emergency (airway obstruction)
Elderly, debilitated men (alcohol abuse)
Dx: CLINICAL – brawny edema of
submandibular area, febrile, protruding
elevated tongue, respiratory distress
Tx: IV abx (clindamycin or Unasyn or
PCN + MTZ) and airway protection
Ludwig’s Angina
Peritonsillar Abscess
Fever, trismus, dysphagia
Adolescents, young adults
Enlarged inflamed tonsil extending
Displaces uvula to opposite side
ENT consult for I & D, IV Abx (PCN or
Clindamycin or Unasyn + MTZ), IVF, IV
Peritonsillar Abscess
Retropharyngeal Abscess
Children aged 6 mos – 3 yrs
Staph aureus, Group A strep, anaerobes
Fever, neck pain, muffled voice, dysphagia
Child prefers to lie supine (do not force to sit up)
Diagnosis: prevertebral edema on lateral soft
tissue neck X-ray
Treatment: ICU admit, IV abx, ENT surgical
PCN or Clindamycin or Unasyn + MTZ
Abrupt high fever, sore throat, stridor,
Child is drooling, stridorous, muffled voice,
sitting up with chin forward and neck
Any age – children more worrisome
H. influenza, Group A strep, B. catarrhalis
Dx: thumb print sign on lateral neck x-ray
Tx: cricothyrotomy set up at bedside,
intubation by ENT in OR if possible, ICU
admit for IV antibiotics, humidified oxygen,
IV fluids
Ceftriaxone + Clindamycin or Vancomycin
OR Unasyn alone
Inflammation of the larynx and subglottic airway
Parainfluenza most common (RSV, adenovirus)
2-3 days of URI sxs, worsening to a barking
cough, hoarse voice, and stridorous
Rare after age 6
Diagnosis: steeple or pencil sign on AP soft
tissue neck x-ray
Tx: steroids (0.6 mg/kg dexamethasone),
humidifed oxygen, racemic epinephrine
Steeple/Pencil Sign
What is it?
What is it?
The End
Any Questions?