Conference Notes 12-9-2015

Sherman   Joint Pediatric and EM Conference           ENT Emergencies       


Case 1. We discussed a case of a 1.5-year-old child who had stridor after eating some food.    Inspiratory stridor indicates an upper airway obstruction.  With inspiratory stridor, CXR is not indicated.  Dr. Sherman recommended also not placing an IV in the ER in such a child.  He recommended keeping the child calm and getting the child to the OR ASAP.   The management of upper airway foreign body is best performed by ENT and Anesthesia in the OR.


*The pediatric airway is more anterior and superior than the adult airway.   The epiglottis is more floppy.   The occiput is larger.   The vocal cords are higher in a child than an adult.  Based on these differences a straight blade is usually thought to be a better choice than a curved blade to intubate in children.  Dr. Sherman felt whatever blade you are most comfortable with is optimal.  There is also the option of the pediatric glidescope.


If you have to intubate in the ER use a sedative (Ketamine) to keep respirations spontaneous.  Avoid positive pressure ventilation if possible as it may move a FB to a more problematic location.


Case 2.  We discussed periorbital/orbital cellulitis. 


*Orbital Cellulitis


*Chandler Classification of Orbital Infections.  Classes 2-5 require ENT/Ophthomology Consultation



*Pictures of Chandler Classes 1-4.


Case 3.   We discussed neutropenic patients with mucormycosis.   The inferior nasal turbinate is the most common site of findings indicating mucormycosis.   CT is not sensitive or specific for invasive fungal sinus disease.


Case 4.   We discussed a teenage patient who had persistent headache.   There was no improvement of a course of 2-3 weeks despite oral antibiotics.  CT showed mass in the ethmoid sinus and sphenoid sinus.  Patient had chronic allergic fungal sinusitis.


*Chronic allergic fungal sinusitis.  This is usually due to aspergillis.  Patients usually improve with oral steroids and surgery.  They do well in general.


Case 5.    Potts Puffy Tumor is more common in patients that have had prior frontal skull surgery.   We saw six cases at ACMC this year.   One ID specialist feels the increased incidence is due to vaccines selecting out more invasive bacteria in the nose.


*Potts Puffy Tumor


*Potts Puffy Tumor CT


Case 6.  Nasopharyngeal Angio Fibroma is a disease of boys.  They can’t breath thru their nose and have epistaxis.


*Juvenile Nasalpharyngeal Angio Fibroma



Juvenile Nasalpharyngeal Angio FibromaCT


Jamieson/Marynowski        Oral Boards

Case 1.  Adult with drooling and stridor and difficulty breathing.  Diagnosis was adult epiglottitis.   Patient could not be intubated and required cricothyrotomy.   Patient also required IV antibiotics.    Fiberoptic nasal intubation is the preferred approach for intubation in the patient with epiglottitis.


Case 2.   52 yo male hit in the face with a falling tree limb. Patient has left eye pain.  Exam was consistent with retrobulbar hematoma with orbital compartment syndrome  (Elevated intra-occular pressure, loss of vision, and non-reactive pupil) requiring lateral canthotomy.


*Retrobulbar hematoma


*Retrobulbar Hematoma with Orbital Compartment Syndrome

*Lateral canthotomy.  If IOP is above 40 following cutting the superior tendon, the next step is to cut the inferior tendon. 


Steve immobilized the patient’s C-spine appropriately.   He consulted ophthomology and obtained serial IOP measurements.  

Adjunctive therapy for retrobulbar hematoma with orbital compartment syndrome is osmotic therapy with mannitol and carbonic anhydrase inhibitor in addition to lateral canthotomy.

Case 3.  43 yo male injured his right upper extremity when he fell from step stool at work.   Patient has forearm deformity and a small laceration of the distal forearm.   Xrays show a Galeazzi Fracture/DLX.   With laceration you have to consider open fracture and give antibiotics.  Galeazzi fractures need surgical reduction and internal fixation.


*Galeazzi FX/DLX


 Town Hall Meeting

We discussed a number of issues affecting our residents.



The workshop featured multiple stations covering common ENT topics such as epistaxis treatment, FB removal, and peritonsilar abscess management, and much more.