Transcript Symptoms

107 title slides
This one’s a real bitch
1.
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5.
Nose bleed anatomy
Indications for antibiotics in sinus infections
Symptoms of rhinitis medicamentosa
Treatment options for perennial rhinitis
Treatment for orbital cellulitis
1. Nose bleed anatomy
Anatomy/Physiology of Epistaxis


Anatomy

Vascular organ
 Nasal cavity
 heating
 Vascular supply
 humidification
Physiology

 Vascular nature
 Mucosa

Vasculature runs just under
mucosa (not squamous)
Arterial to venous
anastomoses
ICA and ECA blood flow
External Carotid Artery
Internal Carotid Artery

Sphenopalatine artery

Anterior Ethmoid artery

Greater palatine artery

Posterior Ethmoid artery

Ascending pharyngeal
artery

Posterior nasal artery

Superior Labial artery
Anterior vs. Posterior

Maxillary sinus ostium

Anterior: younger, usually septal vs. anterior ethmoid,
most common (>90%), typically less severe

Posterior: older population, usually from Woodruff’s
plexus, more serious.
Kesselbach’s
Plexus/Little’s Area:

Anterior Ethmoid (Opth)

Superior Labial A (Facial)

Sphenopalatine A (IMAX)

Greater Palatine (IMAX)
Woodruff’s Plexus:

Pharyngeal & Post. Nasal AA of
Sphenopalatine A (IMAX)
2. Indications for antibiotics in sinus
infections
Acute Rhinosinusitis … sinus infection

Facts:
 Viral sinusitis - 1 billion viral URIs per year
 Bacterial sinusitis – only 0.5% - 2%  secondary bacterial
infection of the sinuses.1,2

Indication for use of antibiotics
 Symptoms have not resolved after 10 days or worsen
after 5 to 7 days (see chart on next slide)
1. Gwaltney Clin Infect Dis 1996;23:1209
2. Berg et al. Rhinology 1986;24:223-5
3. Symptoms of rhinitis medicamentosa
4. Treatment options for perennial rhinitis
1st line therapy
 Avoid the offending allergen
Therapeutic options:
 Decongestants
 Mucolytic treatment
 Intranasal steroids
 Antihistamines
 Saline irrigation
 Leukotriene antagonists
 Intravenous immune globulin
http://www.medscape.com/viewarticle/560619
Adjunctive Therapy

Decongestants
no good controlled studies

Mucolytic treatment
Wawrose et al. Laryngoscope 1992;102:1225
1 double blinded study
○ 2400 mg of guaifenesin or placebo with chronic sinusitis
○ improvement in congestion and thick secretions

Topical steroids
○ Cochrane Database Syst Rev. 2013. Intranasal steroids for
acute sinusitis. Zalmanovici Trestioreanu A, Yaphe J.
Adjunctive Therapy

Antihistamines
 may play a role in allergic rhinitis patients with sinusitis

Saline irrigation
 may help mucociliary clearance
 mild vasoconstrictor of nasal blood flow
 excessive use can remove beneficial mucus

Leukotriene antagonists … allergies
 Useful in patients with CRS with nasal polyps

Intravenous immune globulin … infectious disease docs
 indicated in patients with impaired humoral immunity
5. Treatment for orbital cellulitis
http://emedicine.medscape.com/article/12178
58-treatment
Medical Therapy:
 Immediate hospitalization
 Broad-spectrum IV antibiotics – start immediately
 Identify pathogen – start narrow spectrum IV antibiotics
 IV antibiotics continued up to 1-2 weeks and then followed by Oral antibiotics for an
additional 2-3 weeks.
 Oral antibiotics (eg, ampicillin, cefpodoxime, cefuroxime, cefprozil) for aerobic infections
or to metronidazole for anaerobic infections
Surgery:
 Surgical drainage indications:
 If the response to appropriate antibiotic therapy has been poor within 48-72 hours or if
the CT scan shows the sinuses to be completely opacified.
 Ocular symptoms progress: 1) decreased vision, 2) development of afferent pupillary
defect develops, 3) progression of proptosis
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5.
Indications for tonsillectomy
Evaluation of hoarseness
Cord cysts vs. polyps vs. nodules vs. edema
Evaluation of airway foreign bodies
Tonsillectomy #1 indication
Pearls … straight from lecture 27, slide 91
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Tonsils hypertrophy due to acute and chronic infections
SDB (sleep disorder breathing) most common reason for
tonsillectomy
Paradise criteria for recurrent tonsillitis
Foreign body symptoms based on location
Vocal cord paralysis: malignancy or surgical trauma
Hoarseness 2 weeks or more needs evaluation
Etiology of hoarseness usually benign
Best test for voice- videostroboscopy
1. Indications for tonsillectomy
When is surgery appropriate?
Sleep disordered breathing (#1) – most common
 Airway compromise (unresponsive to medical Tx)
 Recurrent infections (#2)
 Chronic tonsillitis (#3)
 Peritonsillar abscess, recurrent
 Risk of malignancy

Paradise Criteria for Tonsillectomy
Paradise JL, Bluestone CD, Bachman RZ, et al. Efficacy of tonsillectomy for recurrent throat infection in severely affected children: results of parallel
randomized and nonrandomized clinical trials. N Engl J Med. 1984;310:674-683.
Baugh R F et al. Otolaryngology -- Head and Neck Surgery 2010;144:S1-S30
Copyright © by American Academy of Otolaryngology- Head and Neck Surgery
2. Evaluation of hoarseness
When to pursue workup?

“Any patient with hoarseness of two weeks duration
or longer must undergo visualization of the vocal
cords”
Hoarseness
Considered a symptom of a disease.
 Definition:

 Rough, abnormal harsh quality
 Rough or noisy quality of voice
 Perception of voice with breathy quality
 Abnormal quality
Evaluation of Hoarseness: HISTORY

Hoarseness persisting for more than
two weeks requires evaluation

 occupation or livelihood depends on the normal use of
the voice
 need earlier and more aggressive intervention
 often require more specialized care.
 exception: upper respiratory tract infection
 history of tobacco use
○ head and neck cancer is the first diagnosis to
consider, as hoarseness is often the only
presenting symptom.

Voice use pattern
Nature and timing of the dysphonia
 Associated symptoms

 pain, dysphagia, cough or shortness of breath
 amount and style of voice use
 gastroesophageal reflux
 recent voice use (such as screaming at a
baseball game)
 vocal environment (where the patient uses
his or her voice—such as talking while
wearing earmuffs on an assembly line)
 history of hearing loss in the patient or in a
family member
Professional voice user
 sinonasal diseases (allergic rhinitis or chronic
sinusitis)





Medications that dry the upper airway mucosa
Tobacco and ethanol use must be determined
Other irritant exposure
Surgery on the head and neck
Intubation.
Physical Exam



Head and neck exam
Cranial nerve exam
Tongue
Incisions
Hearing acuity

Visualization of larynx



http://youtu.be/ajbcJiYhFKY?t
=9s
 Mirror
 Laryngoscopy
 Videostroboscopy
○ Best test for diagnosis

EMG
Drs. Zeitels (left) and Hillman (middle) examine a voice
patient (seated) using digital videoendoscopy with
stroboscopy
3. Cord cysts vs. polyps vs. nodules vs.
edema
Benign growth on vocal cords
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Nodules – callous
Cyst
Polyps - blister
Varices
Granulomas
Papillomas
Laryngocele
Polypoid Corditis/ Reinke’s
edema
Granular cell tumor
http://fauquierent.blogspot.com/2011/10/how-do-vocalcord-cysts-polyps-and.html
3a. Cord cysts
Cyst
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
http://www.ghorayeb.com/VocalCordCyst.html
Epithelial lining covering cyst
Results from misuse or overuse
Midcord
Found in the lamina propria,
Reinke’s space
May cause fibrosis to
contralateral cord
Cyst

Treatment:
 Medical - modified voice use, vocal hygiene, steroid taper,
anti-reflux
 Surgical - vocal cysts typically do not respond to
conservative therapy
○ Goal is preservation of the mucosal cover with minimal
disruption of underlying tissue
 Lateral vs. medial flap
 Triamcinolone acetate at the end
3b. polyps
Polyp … 3rd most common
“Blister”
 Sessile or pedunculated
 Fibrotic, vascular or mixed
 Not uncommon to find
contralateral prenodule
 Not symmetric

Polyp

Treatment can be different based on type of polyp
 Sessile – microflap and resect
 Pedunculated – may retract, small flap and amputate
http://youtu.be/wrsHxE9bRzA
3c. nodules
Nodules
“calluses”
 overuse/misuse

 hard glottal attacks
females and children
 free edge

 anterior & middle third
bilateral and symmetric
 hourglass wave on strob

Nodules
Three Stages
 Inflammatory phase
 increased vascularity and protein accumulation (SP
involved early)
Localized swelling on the edge of the vocal cord that
appears as grayish, translucent thickening
 Replacement of thickening by fibrotic tissue

Nodules

Treatment:
 Voice rest
 Speech therapy
 Surgery (secondarily and rare)
3d. edema
Reinke's edema
Polypoid degeneration
 smoking, chronic irritation,
hormones

VC (Varices) – Reinke’s Edema

Treatment
 Smoking cessation
 Speech Therapy
 Antireflux medication
 Surgery
○ Epithelial microflap (lateral/Hirano flap) elevation with SLP
contouring and reduction using either cold instruments,
Microspot CO2 laser, or both
4. Evaluation of airway foreign bodies
Foreign Bodies

Children
 Safety pins
 Coins
 Food
○ nuts
○ seeds
○ carrot
○ beans
○ sunflower seeds
○ watermelon seeds
 Disc Batteries
 Toys
 School supplies

Adults
 Food
○ Meat
○ Vegetable matter
See a ring
- Must R/O a disc battery
- Medical emergency – eats through
whatever it touches
http://www.aaemrsa.org/communication/modernre
sident/2011/aug-sept.php
Presentation

If patient was coughing like crazy,
Not any more coughing … BE WORRIED
Initial phase
 choking and gasping, coughing, or airway obstruction

Asymptomatic phase … DANGER ZONE
 relaxation of reflexes, acute inflammation reduces
 results in a reduction or cessation of symptoms
 lasting hours to weeks

Complications phase
 erosion or obstruction leading to pneumonia, atelectasis, or
abscess
Symptoms based on location

Esophagus
 drooling, dysphagia, odynophagia, retching,
refusing po, fussy
 10 percent have airway symptoms

Larynx
 airway obstruction, hoarseness, aphonia

Trachea
 similar to laryngeal foreign bodies but
without hoarseness or aphonia
 wheezing similar to asthma

Bronchus
 cough, unilateral wheezing, and decreased
breath sounds
 65% of patients present with this classic
triad.
If FB in esophagus
(cricopharyngeus), it pushes
forward on trachea
UNILATERAL PNEUMONIA
(decrease breathe sounds,
wheezing)
Location of Ingested Foreign
Body
Cricopharyngeus
15-17 cm (C6)
Aorta
22-24 cm
Left mainstem bronchus
28-30 cm
Gastroesophageal junction
40 cm (T11)
Intrinsic narrowing
stricture, tumor
Extrinsic
tumor
Histology for Pathologists, 3rd Edition, 2007 Lippincott Williams & Wilkins
Workup at Hospital
Chest X-ray
AP & lateral
Inspiration and expiration
**Most important primary test
Flouroscopy
CT scan
virtual bronchoscopy
Bronchoscopy – definitive after
Rigid vs flexible
Foreign Bodies in the Chest: How Come They Are Seen in Adults?
Kim TJ, Goo JM, Moon MH, Im JG, Kim MY - Korean J Radiol (2001 Apr-Jun)
5. Tonsillectomy #1 indication
When is surgery appropriate?
Sleep disordered breathing (#1) – most common
 Airway compromise (unresponsive to medical Tx)
 Recurrent infections (#2)
 Chronic tonsillitis (#3)
 Peritonsillar abscess, recurrent
 Risk of malignancy

1.
2.
Symptoms, timing of symptoms and treatment of croup
Micro of epiglottitis
1. Symptoms, timing of symptoms and
treatment of croup
1a. Symptoms of croup
Larygotracheobronchitis
AKA “Croup”
•
“steeple sign” on x-ray
The most common cause of stridor outside the
neonatal period
• Peak incidence is ages 6mo – 3yrs
• Seasonal distribution: fall & early winter months
• Viral: parainfluenza, RSV, rhinovirus, and human
bocavirus
Classifying Croup by symptoms
•
•
•

Mild: occasional barking cough, no stridor, mild to no
retractions, no agitation or distress
Moderate: frequent barking cough, easily audible
stridor at rest, +chest wall retractions at rest, little
agitation or distress
Severe: frequent barking cough, prominent inspiratory
stridor and occasional expiratory stridor, marked
sternal retractions, +agitation and distress
CLINICAL JUDGEMENT / ASSESSMENT SKILLS!
1b. Timing of croup symptoms
Larygotracheobronchitis
AKA “Croup”
•
The most common cause of stridor outside the
neonatal period
• Peak incidence is ages 6mo – 3yrs
• Seasonal distribution: fall & early winter months
• Viral: parainfluenza, RSV, rhinovirus, and human
bocavirus
1c. Treatment of croup
Treating Croup
RACEMIC EPINEPHRINE
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For moderate to severe croup
Do not use Albuterol as β-agonists cause
vasodilatation and can increase airway edema
Observe for approx 3hrs
Studies have shown that approx 38% of patients
with Croup refractory to treatment expressed this in
the 2nd-3rd hours of observation
Treating Croup
CORTICOSTEROIDS
 Dexamethasone 0.6mg/kg IM or PO
 Reduces severity & duration of symptoms
HELIOX (mix of 70%helium & 30%oxygen): may improve
laminar gas flow / ventilation but not definitively proven
The majority of children w/ Croup are readily managed with
Dexamethasone and anti-pyretics / cough & cold
preparations.
2. Micro of epiglottitis
Epiglottitis
•
•
•
“thumbprint sign” on x-ray
An ACUTE inflammatory process of the epiglottis
which can lead to a life-threatening airway obstruction
Primary causative agent is H.influenzae type B;
which, has been largely eradicated due to
immunization
Other potential causative agents: Staph & Strep,
Candida (immunocomp.), thermal injury/burns, direct
trauma
1.
2.
3.
Rash causes after amoxicillin
Symptoms of peritonsillar abscess
Retropharygeal vs. peritonsillar vs. Ludwigs
1. Rash causes after amoxicillin
If a patient is placed on antibiotic (PCN) for a
presumed pharyngitis and a scattered, faint,
morbilliform rash occurs….what is another
possible diagnosis?
Amoxicillin rash, differential dx
1.
2.
PCN Allergy
Infectious mononucleosis secondary to EBV
2. Symptoms of peritonsillar abscess
Retropharyngeal Abscess (RPA)
•
•
Believed to be due to suppuration of lymph nodes found
within/between the anatomical space between the post.
pharyngeal wall & prevertebral fascia
These nodes tend to regress by age 4; hence, increased
potential in children <4yo
Also can be due to trauma/penetration into the space
•
Symptoms:
•
• Lack of or very mild URI
• Neck pain & swelling
• Increased drooling
• Tripoding
RPA
• Pleuritic chest pain (ominous sign of extension into the thoracic
cavity/mediastinum)
“tripoding”
3. Retropharygeal vs. peritonsillar vs.
Ludwigs
3a. Retropharygeal Abscess (RPA)
Retropharyngeal Abscess (RPA)
•
•
•
•
Believed to be due to suppuration of lymph nodes found
within/between the anatomical space between the post.
pharyngeal wall & prevertebral fascia
These nodes tend to regress by age 4; hence, increased
potential in children <4yo
Also can be due to trauma/penetration into the space
Symptoms: lack of or very mild URI, neck pain & swelling,
increased drooling, tripoding, pleuritic chest pain is an
ominous sign of extension into the thoracic
cavity/mediastinum
RPA Anatomically speaking
RPA Diagnosis
•
Lateral neck X-ray
 Retropharyngeal space at C2 is 2x diameter of the
vertebral body width OR > ½ width of C4 vertebral body
 CT scan is near 100% sensitive
•
Need to be clinically astute as this can cause
severe airway compromise – be prepared, airway
equipment, steroids to reduce inflammation
RPA on X-Ray
(L) normal
(R) abnormal
RPA on CT
RPA Treatment
•
•
•
•
Airway management!
ENT consultation for possible Incision & Drainage
Often mixed flora: S.aureus, S.pyogenes,
S.viridans, gram-negative rods, oral anaerobes
Ampicillin/sulbactam or Clindamycin
3b. Peritonsillar Abscess
Peritonsillar Abscess (PTA)
•
•
•
•
Deep OROPHARYNGEAL infection/abscess
Can occur at ANY age; however, most common in
adolescents & young adults
Typically is the propagation of a superficial infection
that progresses to an accumulation of pus between
the tonsillar capsule the superior constrictor
muscle
Most are UNI-lateral (<10% BI-lateral)
Trismus – cannot open mouth d/t pain
PTA Diagnosis & Treatment
•
•
•
•
•
Sore throat, fever / chills, trismus, voice
change (“hot potato”), increased salivation
Exam reveals UNI-lateral peritonsillar edema,
deviation of the uvula away from the side of
infection
Abscess vs. Cellulitis can often be difficult to
discern: more ill appearing = ?PTA, CT scan
can identify
Antibiotic for polymicrobial coverage:
Amoxicillin/clavulanic acid or Clindamycin
Needle Aspiration
PTA Aspiration
Complications:
Compliance of patient to
participate
 Hemorrhage
 Puncture of the Carotid artery;
needle should not penetrate
>1cm as the Carotid lies
lateral & posterior
 Aspiration of purulent material

3c. Ludwig’s Angina
Ludwig’s Angina
•
•
•
•
•
•
Infection of the submental, sublingual, and submandibular
spaces
Clinical findings: 1) poor dentition/dental hygiene, 2) dysphagia,
odynophagia, 3) trismus, 4) edema of the upper midline neck and
floor of the mouth
85% of cases arise from an odontogenic source (abscess)
Need to consider in patients with recent dental
instrumentation/procedures
Rapidly progressing Infection/inflammation  cause the
posterior displacement of the tongue  airway compromise
Treatment: airway management, steroids, IV antibiotics,
ENT/surgical consultation
Ludwig’s Angina
Ludwig’s Angina on the Inside
Tongue can fall posterior and can block airway
1.
2.
3.
4.
5.
Promoter and synergistic agents of head/neck cancers
What to do with hoarseness > 2 weeks
Sinus cancer presentation
Why do supraomohyoid dissection
Etiology of sinus cancers
Conclusions
Head and neck cancer is the 8th leading cause of death
worldwide
 Tobacco use is the most significant risk factor for developing a
head and neck cancer
 Most common sites include





Tongue
Floor of mouth
Tonsil
Vocal cord
Early detection and smoking cessation lead to the best longterm outcomes
 Cancer of the nose and sinuses are very rare and require a
high index of suspicion for diagnosis

Conclusions
Status of cervical lymph nodes is an important
prognostic indicator
 The benefit of elective therapy outweighs the risks, if the
prevalence of micrometastases is >20% … neck
dissection (early removal can prevent mets)
 Neck dissections are divided into 3 main categories
(RND, MRND, SND)
 Selective neck dissection is based on lymphatic
drainage of the primary site
 Recurrence rates are comparable in appropriately
selected patients

1. Promoter and synergistic agents of
head/neck cancers
Head and Neck Cancer
All tobacco products –
cigarettes, pipes,
cigars, smokeless
tobacco, betel quids
(nut), reverse smoking,
secondhand smoke
Tobacco and alcohol are considered the most
common factors associated with the development of
head and neck cancer
 This relationship is synergistic

 Alcohol serves as a promoter for the carcinogenic
effects of tobacco
Head and Neck Cancer

Tobacco
 1.9 fold risk for males
 3.0 fold risk for females
 Risk directly proportional to the number of cigarettes smoked and
number of years smoked (dose dependant relationship)

Alcohol
 Alone confers a 1.7 fold risk

Combination
 At least 15 fold risk
 35 fold risk for 2 pack per day and 4 drinks per day
2. What to do with hoarseness > 2 weeks
Hoarseness (side note)


Hoarseness lasting >2 weeks
with little or no improvement
needs laryngeal exam
URI is most common cause of
hoarseness
 Often lasts several weeks
 Rarely lasts 6 weeks


Hoarseness lasting >6 weeks in
an adult should be considered
cancer until proven otherwise
Acute Hoarseness in any
smoker should be considered
cancer until proven otherwise
Evaluation (laryngeal exam)
Complete history and physical
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Laryngosocpy
Videostroboscopy
CT neck with contrast
CXR
Labs including LFTs
FNA neck mass
Biopsy / Exam under
anesthesia

Consultations
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
Head and neck surgeon
Radiation oncologist
Medical oncologist
Internal medicine
Dentist / Oral surgeon
Speech pathologist
Nutritionist
Psychologist
Tobacco cessation
Evaluation
Flexible fiberoptic nasopharyngoscope
Videostroboscopy
3. Sinus cancer presentation
Cancer of the Paranasal Sinuses
Very rare: 3% of Head and Neck Cancers
 Delay in diagnosis due to similarity to benign conditions (i.e.
usually present in advanced stages [88% at T3/T4])
 Nasal cavity neoplasms

 ½ benign
 ½ malignant

Paranasal Sinuses
 Malignant
Presentation

Oral symptoms: 25-35%
 Pain, trismus, alveolar ridge fullness, erosion

Nasal findings: 50%
 Obstruction, epistaxis, rhinorrhea

Ocular findings: 25%
 Epiphora, diplopia, proptosis

Facial signs
 Paresthesias, asymmetry
Epidemiology
Predominately disease of older males
 Exposure:

 Wood working, nickel-refining processes
 Industrial fumes, leather tanning

Cigarette and Alcohol consumption
 No significant association has been shown

HPV may play role in malignant degeneration of inverting
papillomas
Location

Maxillary sinus
 70%

Ethmoid sinus
 20%

Sphenoid
 3%

Frontal
 1%
Inverted Papilloma
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



UNILATERAL “SINUS INFECTION”
- Think inverting papilloma
- Will turn into SCC 10% if untreated
4% of sinonasal tumors
Site of Origin: lateral nasal wall
Unilateral
Malignant degeneration in 2-13% (avg 10%)
Must rule out IP for any CT showing unilateral sinusitis
4. Why do supraomohyoid dissection
Introduction
One of the most important prognostic indicators for patients
with squamous carcinomas of the upper aerodigestive tract
is the status of the cervical lymph nodes
 Local metastatic disease (spread to cervical lymph nodes)
can be managed with surgery, radiation, or both

 i.e. Goal is to remove cancer that may have spread to the neck
Supraomohyoid Type
Used for oral cavity cancer: lip, buccal mucosa,
upper & lower alveolar ridge, RMT, hard palate,
anterior 2/3 tongue, FOM
 Tumors in this region, especially oral tongue & FOM,
metastasize early
 20% risk occult disease
 >90% of occult metastatic disease in oral cavity
cancer involves Levels I, II, and III

Supraomohyoid Type



En bloc removal of node
levels I-III
Posterior limit: posterior
border SCM
Inferior limit: superior belly
of omohyoid m. where it
crosses the IJ
5. Etiology of sinus cancers
Epidemiology
Predominately disease of older males
 Exposure:

 Wood working, nickel-refining processes
 Industrial fumes, leather tanning

Cigarette and Alcohol consumption
 No significant association has been shown

HPV may play role in malignant degeneration of inverting
papillomas
1.
2.
3.
4.
5.
Injuries with associated internal injuries
Clavicle injuries with Surgical repair required
When to intubate a trauma
Most easily seen injuries on plain x-ray
Define flail chest
1. Injuries with associated internal injuries
Blunt Chest Trauma

Chest Wall Injuries
○ Rib, clavicle, sternal fractures
○ Chest wall contusions

Cardiac Injuries
○ Cardiac Tamponade*
○ Myocardial Contusions*

Pulmonary Injuries
○ Pulmonary contusion
○ Pneumothorax*/Hemothorax*
○ Flail Chest

Vascular Injuries
○ Aortic Rupture*



Esophageal Rupture*
Tracheal/Bronchial Injuries*
Diaphragmatic Rupture*
2. Clavicle injuries with Surgical repair
required
Clavicle Fractures


Most common newborn/childhood fracture
Mechanisms
 Force directly to clavicle or to outer end
 Most pts have history of direct fall onto shoulder
 Football, bike accidents, wrestling, hockey, MVC

Classification of fractures
 Based on dividing clavicle into thirds
 Proximal (5%), Middle (80%), Distal (15%)

Presentations
 swelling, loss of normal contour, skin tenting, head turned towards affected
side, open fx possible

Complications
 Brachial plexus injury, pneumothorax, non-union (0.1-15%)
 Vascular Injury: subclavian artery/vein, internal jugular, axillary artery
Lateral (Distal) Third Fractures



15% of clavicle fractures
Mechanism – direct blow to top of shoulder
Fracture lateral to the coracoclavicular ligament
Integrity of
CC Ligament
Fx Displaced?
Treatment
Type I
Intact
No
Non-operative: sling, ice, pain control, early
ROM exercise
Type II
Torn
YES
Medial fragment pulled
superiorly
Ortho consult within 72 hrs -possible
surgical repair
Risk of non-union
Type III
Intact
What type of fracture
is this?
No
Fx through articular
surface of AC joint
Non-operative: sling, ice, pain control, early
ROM exercise
Risk of OA of joint
3. When to intubate a trauma
Pulmonary Contusion

Treatment
 Maintenance of adequate oxygenation & ventilation
○ Endotracheal intubation may be necessary
 Pain control, encourage deep breaths, incentive spirometry
 Generally require admission – contusions tend to worsen
over 24 hrs
 Avoid excessive IV fluid - may worsen contusions

May lead to ARDS, pneumonia, respiratory failure
http://www.trauma.org/index.php/main/image/1002/
Flail Chest

Management
 Oxygenation, ventilation, pain control
 Manual stabilization initially
 Detection & treatment of underlying injuries
○ CT scan indicated
○ Chest tube if PTX of hemothorax
 Positive pressure ventilation - endotracheal intubation often
required
○ Provides splinting
 Pain Control - IV narcotics, regional nerve blocks, epidural
anesthesia
 If no hypotension, hypovolemia, blood loss limit IV fluids
4. Most easily seen injuries on plain x-ray
Hemothorax
 Pneumothorax
 Pulmonary contusion
 Vascular injury

5. Define flail chest
Flail Chest

Three or more adjacent ribs, each fractured in 2 or more places
 Chest wall unstable & segment lacks continuity with rest of thoracic cage

Paradoxical motion of chest wall
 Segment moves IN during Inspiration & OUT during Exhalation
 May not be obvious initially (splinting, muscle spasm)
1.
2.
3.
Secondary pneumothorax causes
Symptoms (it’s not shortness of breath),Tx and imaging of simple PNX
Treatment of tension PNX
Summary Points - PTX







Primary ptx occurs in pts without lung disease
Pain, not dyspnea may be the chief complaint in primary ptx
Secondary ptx occurs in pts with underlying lung disease - COPD
most common
Tension pneumothorax is an immediate life threat and if suspected
must be treated emergently before x-ray confirmation.
A CXR is the initial test to detect ptx in a stable patient.
An open ptx must be sealed and then a chest tube placed
A needle decompression may be performed in an emergent
situation as a temporizing measure in suspected tension
pneumothorax. A chest tube must be placed following needle
decompression.
1. Secondary pneumothorax causes
Secondary Pneumothorax

PTX in setting of underlying
lung disease
 1/3 – 1/2 of all spontaneous ptx
(o)

Most common risk factor?
 COPD
Peak age is 60-65 years; male
to female 3:1
 More likely to present with
dyspnea & more severe
symptoms . Why?
 Much higher mortality than
PSP


Don’t
Memorize!
Other diseases associated
with SSP
 HIV
 Other Airway Disease – asthma;




CF
Infections - necrotizing
bacterialpneumonia/ abscess; TB
Interstitial lung disease –
sarcoidosis; idiopathic pulmonary
fibrosis
Neoplasms - primary lung ca;
pulmonary/pleural metastasis
Miscellaneous - connective tissue
dx; pulmonary infarction
2. Symptoms (it’s not shortness of
breath),Tx and imaging of simple PNX
Simple pneumothorax is a non-expanding collection of
air around the lung. The lung is collapsed, to a variable
extent. Diagnosis on physical examination may be very
difficult.
2a Symptoms (it’s not shortness of breath)
simple PNX
Primary Pneumothorax

Clinical Manifestations - Chest pain & dyspnea
 Chest pain
○ Acute onset, ipsilateral
○ Often pleuritic
 Symptoms often mild – rarely life threatening (l) Why?

Physical Exam Findings
 Vital signs often normal (l)
 Most common physical finding - tachycardia (o)
 Ipsilateral Chest findings
○ \/ movement with respiratory cycle
○ Hyperresonant to percussion
○ \/ Breath sounds
○ \/ fremitus
 Chest exam findings may be absent in small ptx

Symptoms of PTX
 Sudden onset of ipsilateral chest
or shoulder pain
 Dyspnea - variable
 Cough



Reduced air entry
Resonance to percussion are
often difficult or impossible to
appreciate.
Careful palpation of the chest
wall and apices may reveal
 Subcutaneous emphysema
 Rib fractures as the only sign of
an underlying pneumothorax.

Signs of PTX
 Mild resting tachycardia
 Tachypnea
 Unilateral \/ breath sounds
○ Caution: Often normal with small
ptx
 Other possible findings
○ Hyperresonance to percussion
○ Unilateral enlargement of
hemithorax
○ \/ chest excursion with
respiration
2b. Tx simple PNX
Observation
 Oxygen

2c. Imaging of simple PNX
Summary Points - PTX







Primary ptx occurs in pts without lung disease
Pain, not dyspnea may be the chief complaint in primary ptx
Secondary ptx occurs in pts with underlying lung disease - COPD most common
Tension pneumothorax is an immediate life threat and if suspected must be
treated emergently before x-ray confirmation.
A CXR is the initial test to detect ptx in a stable patient.
An open ptx must be sealed and then a chest tube placed
A needle decompression may be performed in an emergent situation as a
temporizing measure in suspected tension pneumothorax. A chest tube must be
placed following needle decompression.
3. Treatment of tension PNX
EXAM … Management – Tension Pneumothorax



Emergency!
Clinical diagnosis – don’t wait for cxr!
Immediate needle decompression
 Must follow w/ chest tube

Needle Decompression





Temporizing measure
Insert 14-16 gauge IV catheter over rib at 2nd ICS, midclavicular line
Advance catheter & remove needle
Rush of air is confirmatory
Tube Thoracostomy




28-36F in Trauma
16-20F for Spontaneous
4th-5th ICS (about nipple level)
Mid to anterior axillary line
Case – Patient A Resolution
Occlusive dressing placed over wound
Needle decompression followed by 36 F chest tube
Pt dramatically improved after chest tube and was taken to the OR for exploration of his abdomen due to a
GSW to the abdomen
1.
2.
3.
4.
5.
Dermoid vs. 1st branchial cleft cyst
Symptoms of thyroglossal duct cyst
Tx of thyroglossal duct cyst
Anatomy of 3rd branchial cleft cyst
Micro / appearance of scrofula
1. Dermoid vs. 1st branchial cleft cyst
1a. Dermoid
1b. 1st branchial cleft cyst
2. Symptoms of thyroglossal duct cyst
3. Tx of thyroglossal duct cyst
4. Anatomy of 3rd branchial cleft cyst
5. Micro / appearance of scrofula
1.
2.
Distinguish metabolic acidosis / alkalosis / respiratory acidosis /
alkalosis / gapped
Treatment for high CO2
1. Distinguish metabolic acidosis / alkalosis
/ respiratory acidosis / alkalosis /
gapped
1a. metabolic acidosis
1b. alkalosis
1c. respiratory acidosis
1d. alkalosis
1e. gapped
2. Treatment for high CO2
1.
2.
3.
4.
5.
Inspiratory cough anatomy
Treatment of epiglottitis
Diagnosing laryngomalacia
Diagnosing croup with imaging
Diagnosing vocal cord dysfunction
1. Inspiratory cough anatomy
2. Treatment of epiglottitis
3. Diagnosing laryngomalacia
4. Diagnosing croup with imaging
5. Diagnosing vocal cord dysfunction
1.
2.
3.
4.
5.
Etiology of VTE
Origin of PE clots
EKG findings in PE
Definitively diagnosing PE
Length of tx for PE
1. Etiology of VTE
2. Origin of PE clots
3. EKG findings in PE
4. Definitively diagnosing PE
5. Length of tx for PE
1.
2.
3.
4.
5.
Define pulmonary hypertension
pulmonary function tests of pulmonary hypertension
treatment plans for pulmonary hypertension
diagnose Goodpasture syndrome
lab findings of Goodpasture syndrome
1. Define pulmonary hypertension
2. pulmonary function tests of pulmonary
hypertension
3. treatment plans for pulmonary
hypertension
4. diagnose Goodpasture syndrome
5. lab findings of Goodpasture syndrome
1.
2.
3.
4.
Management of CF hemoptysis
Differential Newborn with no poop
Lab findings in CF
Testing for CF
1. Management of CF hemoptysis
2. Differential Newborn with no poop
3. Lab findings in CF
4. Testing for CF
1.
2.
3.
4.
5.
6.
Preventing and treating pertussis
Micro of bronchiolitis
When to hospitalize bronchiolitis
Define RDS
Etiology of RDS
Symptoms of primary ciliary dyskinesia
1. Preventing and treating pertussis
1a. Preventing pertussis
1b. treating pertussis
2. Micro of bronchiolitis
3. When to hospitalize bronchiolitis
4. Define RDS
5. Etiology of RDS
6. Symptoms of primary ciliary dyskinesia
1.
2.
3.
Intrinsic vs. Extrinsic causes of restrictive lung
PFTs in restrictive dz
Asbestosis vs. sarcoid vs. hypersensitivity vs. pneumonia
1. Intrinsic vs. Extrinsic causes of restrictive
lung
1a. Intrinsic causes of restrictive lung
1b. Extrinsic causes of restrictive lung
2. PFTs in restrictive dz
3. Asbestosis vs. sarcoid vs. hypersensitivity
vs. pneumonia
3a. Asbestosis
3b. sarcoid
3c. hypersensitivity
3d. pneumonia