Week 17: HEENT

Cholesteatoma is a mass of keratinized squamous epithelium that occurs in the middle ear or mastoid process occurring most frequently in teenagers. This ear-related metaplasia is not associated with cholesterol or gallbladder problems, as the name suggests. There are two types of cholesteatoma. The congenital type is less common and occurs medial to the tympanic membrane. The acquired type is more common and grows from the tympanic membrane. Conductive hearing impairment prevails, with imbalance and facial weakness being the most common associated symptoms. Examination may reveal inflammation, retrotympanic waxy appearing polyps or white-pasty discharge from the tympanic membrane. As such, this can easily be confused with chronic, suppurative otitis media. Microscopic excision surgery is required to prevent complications and to maintain or improve hearing.

Acoustic neuromas (A) present with sensorineural, not conductive, hearing impairment. Furthermore, these masses occur in the inner ear and temporal bone on the vestibular nerve and would not likely be viewable during an otoscopic examination. Otitis media (C) presents with otalgia, hearing loss, fever and tympanic membrane abnormalities like erythema, bulging, or cloudiness. Although retrotympanic masses can result from chronic suppurative middle ear infections, current infection is unlikely in the above patient. Squamous cell carcinoma (D) is an epithelial cell malignancy that typically occurs on the external, not middle, ear due to prolonged sun exposure. It has an ulcerated, erythematous appearance with or without bleeding.

The patient’s Centor Score is 1 as the patient has tonsillar exudates.

Centor criteria are as follows (each 1 point, for a total of 4 points): Temp >100.4F (38.0C); Absence of cough; Anterior cervical lymphadenopathy; Tonsillar exudates.

The modified Centor criteria factor in age: Age <15 years adds one point; Age >44 years subtracts one point.

0-1 points: no antibiotic or throat culture needed (risk of strep infection <10%)
2-3 points: obtain throat culture and treat if culture positive (risk of strep infection 15% for 2 points, 32% for 3 points)
4-5 points: empirically administer antibiotics (risk of strep infection 56%).

In adults, presence of all 4 original criteria = 40-60% positive predictive value, while absence of all 4 original criteria = 80% negative predictive value.

This patient presents with signs and symptoms concerning for a deep space infection of the neck and should have fiberoptic nasopharyngoscopy performed by a trained clinician. Deep space infections of the lower face and neck include peritnosillar abscess, Ludwig’s angina, retropharyngeal and parapharyngeal abscess. Patients with these disorders can decompensate rapidly and thus, rapid diagnosis and appropriate management is vital. Patients will often present with fever and sore throat and will be ill-appearing. Because these abscesses can compromise the airway, patients may exhibit signs of respiratory compromise including stridor and tachypnea. Trismus may be present if the infection irritates the TMJ and muscles of mastication. Airway distortion is common and intubation should not be taken lightly. The safest approach is typically awake intubation with fiberoptics. Fiberoptic nasopharyngoscopy can be beneficial for diagnosis, visualization of the airway anatomy and for intubation.

This patient is suffering from dry socket, also known as acute alveolar osteitis. Patients undergo dental extraction and after the procedure a hemostatic blood clot forms in the socket. Pain is common for 24 hours post-procedure and then improves. When the healing blood clot is lost from the socket, the patient develops acute severe pain. Most commonly, it occurs 3-4 days after the extraction and is associated with a foul odor. Pain is related to inflammation and a localized infection of the bone. Treatment includes packing the open socket with iodoform gauze. The gauze is saturated with either a medicated dental paste or eugenol (oil of cloves). Patients will require analgesia and may benefit from a nerve block.

This patient has obstructive sialoadenitis, which occurs from outflow obstruction by a stone or calculus in the salivary gland or duct. The submandibular location is most commonly involved because it is has more viscous secretions and runs an uphill course. Patients with sialolithiasis note xerostomia (dry mouth) along with increasing swelling and pain during mealtime. Most salivary stones pass spontaneously. To aid in passage, patients should be started on sialogogues (e.g., sour lozenges), which stimulate salivary secretions and help expel the stone. Palpable stones may also be “milked” from the duct, if they are distal enough, by gentle stroking in a posterior to anterior direction.

Antihistamines (A) can worsen this condition by decreasing saliva production and are contraindicated. If the sialoadenitis does not resolve with conservative therapy, dilation and incision (B) of the salivary duct is required to remove the stone. Oral antibiotics (C) are not required in simple obstructive sialoadenitis. However, when suppurative sialoadenitis is present, oral antibiotics with staphylococcal coverage are recommended.

This patient is exhibiting signs and symptoms of a peritonsillar abscess (PTA). These abscesses are typically polymicrobial in etiology. Signs and symptoms of a PTA include fever, trismus, hot potato or muffled voice, and contralateral uvular deviation. Management of a PTA is by needle aspiration or incision and drainage, and antibiotics. In order to avoid the internal carotid artery, which sits behind the peritonsillar fossa, a needle sheath should be used to control puncture depth. Aspiration should be undertaken in the soft palate at the point of maximal abscess fluctuance. Medial and superior aspiration are safer from the standpoint of avoiding injury to the carotid artery. Penicillin VK, amoxicillin and clavulanic acid, or clindamycin may be used for antibiotics. Complications of a PTA include airway obstruction, aspiration, deep space or intracranial extension, or inadvertent carotid artery injury during drainage.

The internal jugular vein (B) lies lateral to the area posterior to the peritonsillar abscess. The peritonsillar abscess typically lies superior to the tonsillar pillar (C). The vagus nerve (D) lies significantly more posterior to the peritonsillar abscess than would be reached by the needle or scalpel in draining the abscess.

Avulsed permanent teeth are true dental emergencies. The majority of patients with an avulsed tooth will lose the tooth, so the expectations of patients should be managed accordingly. Time is an important consideration with dental avulsion. Periodontal ligament cells generally die after 60 minutes outside the oral cavity if not replanted or placed in the proper transport media. The ideal transport media is Hank’s solution, but this is not usually available in most homes. Therefore, milk is an alternative and has a compatible osmolality to tooth root cells. However, like normal saline, it lacks the necessary metabolites and glucose to maintain normal cell metabolism of the tooth root cells. The cells on the avulsed periodontal ligament in milk do not die immediately, and is the best alternative to Hank’s solution. Patients should be reminded to avoid touching the periodontal ligament and hold the tooth by the crown. In the ED, temporary replantation should be performed. The tooth should be gently rinsed (not wiped) with care not to traumatize the periodontal ligament cells. The dental socket should be carefully rinsed and suctioned to remove any debris or clot. The tooth can be replanted gently into the socket and then splinted with periodontal dressing material. Dental follow-up should be arranged for the following day.

Hydrogen peroxide (A) is not an appropriate transport solution because it will damage the periodontal ligament cells. Normal saline (C) has a fairly compatible osmolality and will not cause cellular swelling, but it lacks the metabolites and glucose necessary for maintenance of normal cell metabolism. The different pH and osmolality of water (D) has been shown to damage the periodontal root cells.

The coin is in the esophagus and will need to be removed endoscopically. Flat objects (coins) will be oriented in the coronal plane if it is located in the esophagus. An AP or PA radiograph will reveal the flat surface of the coin (as seen in the above radiograph). If it is in the trachea, the coin will be oriented in the sagittal plane (reflecting the angle of the coin required to pass through the vocal cords). The AP or PA radiograph will reveal the coin on edge. The esophageal epithelium can rapidly necrose and perforate with a lodged foreign body; therefore, endoscopy is necessary to remove a foreign body. The patient also is noted to be drooling, which is indicative of partial or complete obstruction.

The patient exhibits signs (drooling) of partial or complete obstruction, thus, intervention rather than observation is necessary. Most foreign bodies tend to lodge at sites where esophageal narrowing occurs. This occurs at the level of the cricopharyngeus muscle (C6) in kids < 4 years old. Once lodged, it is uncommon for the foreign body to pass. Lodged esophageal foreign bodies can cause esophageal necrosis and lead to perforation. Objects lodged in the esophagus that are causing obstruction (A) should be removed emergently. Tracheal foreign bodies (C and D) are oriented in the sagittal plane and appear round on the lateral view, not the AP view, as seen in the above radiograph. All tracheal foreign bodies need emergent removal in the operating room under anesthesia by laryngoscopy or bronchoscopy. Most patients will also exhibit some form of respiratory distress with a tracheal foreign body.

This patient is suffering from a retropharyngeal abscess and will need advanced imaging (CT scan of the neck with IV contrast) to further delineate the extent of the disorder along with emergent ENT consultation for possible operative intervention. Historically, this was a disease of children under 6 years of age but adults are increasingly affected. A number of infectious processes including nasopharyngitis, otitis media, peritonsillar abscess, dental infections as well as iatrogenic procedures including endoscopy and dental instrumentation have been associated with retropharyngeal abscess formation. The infection is most commonly polymicrobial with both aerobes and anaerobes requiring broad antibiotic coverage. Patients typically present with sore throat, odynophagia, dysphagia, drooling, muffled voice, neck stiffness, fever and trismus. In severe cases, the patient may hold the neck in extension in order to increase airway diameter by distracting the posterior pharynx from the airway. CT scan and MRI are diagnostic but in unstable patients, lateral neck X-ray can demonstrate retropharyngeal swelling supporting the diagnosis. Additionally, if the patient is unable to lie flat for advanced imaging, direct visualization with an upper airway scope can be diagnostic.

Oral antibiotics (C) alone are insufficient for treatment of retropharyngeal abscess in the majority of cases. In addition, the patient should not be discharged home as she is at risk to develop a compromised airway. Ibuprofen, dexamethasone, and a Rapid strep test (B) is the standard treatment for simple pharyngitis. However, this patient has a deep space infection and requires imaging, intravenous antibiotics, ENT consultation and possible surgery. In this patient, there is no swelling of the tonsils to suggest a peritonsillar abscess (D) as the cause of the patient’s symptoms.

A. This patient has a dental fracture with exposed pulp. This is a dental emergency requiring dental follow-up within the next 24 hours. The most superficial dental fractures involve only the enamel on the surface and treatment is mostly cosmetic and aimed at dulling any sharp edges. Fractures that expose dentin will have an ivory-yellow appearance. In younger patients, there is less dentin relative to the pulp and treatment is aimed at protecting any pulp contamination with placement of a calcium-hydroxide dressing. Younger patients need more urgent follow-up with a dentist. The most significant dental fractures involve the pulp as in this clinical scenario. The tooth should be gently wiped clean with gauze and inspected for a drop of blood or pink blush which represents pulp exposures. The area is usually exquisitely painful. Timely follow-up (within 24 hours) is required for evaluation and possible root canal and extraction of the pulp. If dental follow-up will be delayed, the tooth should be covered with moist cotton and sealed with dry foil or a temporary commercial sealant. In order to clean the tooth, a clean gauze should be used to wipe off the surface, not irrigation of the tooth (B) as the patient will be extremely sensitive to that and all efforts should be maintained to avoid pulp contamination. Hank’s solution (C) is a physiologic solution in which an avulsed tooth may be placed while waiting for reimplantation into the socket. There is no role in a partial tooth fracture. Viscous lidocaine (D) is not an appropriate analgesic for a dental fracture. Oral analgesics or dental block should be provided for pain control.