Diagnosis At A Glance

1. Diagnosis At A Glance Harry Kopolovich

2. 31 y/o female presents with tooth pain and a swollen neck

4. Ludwig's Angina • Submandibular space is primary site of infection • Subdivided by mylohyloid muscle • Sublingual space superiorly • Submandibular space inferiorly • Odontogenic source in >90% cases • Others include: Trauma, tongue piercing, sialedenitis, neoplasm, other parapharnygeal infections

5. - Definitive Airway Management is Key • Direct vs. fiber optic visualization • No blind nasotracheal attempts • May rupture abscess - Empiric antibiotics • Primary flora: Strep, Staph, Bacteroides • 3rd Generation Cephalosporins plus clindamycin • No definite role of steroids

6. Definitive management is surgical • Prior to antibiotics: Mortality >50% • Currently: Antibiotics + Surgery Mortality 8%

7. 75 y/o white man presents with 5 days of rash and pain to forehead

9. Herpes Zoster Opthalmicus • VZV causative agent • Reactivation produces typical dermatomal distribution • Dissemination occurs in immunocompromised patients • Anterior horn cells Muscular weakness, diaphragmatic paralysis, colon pseudo obstruction • Spinal cord  GBS like syndrome, Transverse myelitis

10. Phases of Presentation • Three phases • Pre-eruptive • Pain or dysesthesia occurs 48-72 hours prior • Eruptive • Heralded by emergence of skin lesion • Erythematous macules Vesicles  Ruptured Vesicles  Ulcers  Crusted lesions • Lesions can last 10-15 days • Not considered healed until lesion are crusted • Considered a TORCH infection • Post-Eruptive • Post-herpetic neuralgia is pain lasting or recurring >30 days • Most t frequent complication: Occurs in 9-45% of cases • Higher incidence in elderly males

11. Herpes Zoster Opthalmicus • Reactivation of VZV in trigeminal nerve CN V • Usually V1 affected • Hutchinson’s Sign • Lesion on tip of nose • Indicates higher likelihood of ocular involvement (76% vs. 34%) • Pseudo-dendrites • Peripherally located, poorly stain with fluorescein • Partial thickness (can be wiped clean as compared to dendrites in herpes keratitis which are full thickness and cannot be wiped clean) • Ophthalmology Consult

12. Complications • Post-herpetic neuralgia • Corneal Anesthesia or hypoesthesia • Secondary Infection • Treatment • Anti-virals • Proven benefit when instituted within 48-72 hours • Reduces viral shedding and accelerated resolution of symptoms

13. Corticosteroids • Controversial at best • Two studies conducted using steroids + acyclovir only • Current indications • Only in moderate to severe pain • Or in severe CNS symptoms or paralysis exist • Use of steroid contraindicated in isolation • Concern exists for promotion of viral replication • Optimal Duration uncertain • Should not exceed duration of anti-viral agent

14. 24 year old man presents with pain to nose after being hit in the head with a soccer ball • Examination reveals the following

16. Nasal Septal Hematoma • Uncommon complication following direct nasal trauma • Associate with fracture of septal cartilage • Nasal septum composed of a thin cartilaginous plate with a closely adherent perichondrirum and mucosa

17. Septal Hematoma • Occurs as perichondrium separated from septum • Accumulation of blood results • Avascular necrosis  Septal perforation, saddle nose deformity • Abscess • Possible meningitis, encephalitis, cavernous sinus thrombosis

18. Make sure to examine nostril on all patients with facial trauma • Visual inspection with otoscope or nasal speculum • Nasal septum 2-4mm thick (possible bilateral hematomas) • Digital inspection • Treatment is I & D

19. 70 year old Asian woman present with headache, nausea and eye pain while watching a movie at a local movie theater

21. Acute Angle Closure Glaucoma • Aqueous humor produced in ciliary body in the posterior chamber • It diffuses through the pupil into the anterior chamber • Drains into the vascular system through the canal of Schlemm

22. Acute Angle Closure Glaucoma (AACG) • Defined by the presence of 2 of the following symptoms • Ocular pain, nausea/vomiting, hx of intermittent blurring of vision with halos • And 3 of the following signs • IOP >21mmHg (Usually >50), conjunctival injection, corneal epithelial edema, mid-dilated non-reactive pupil, shallow anterior chamber • End result is sustained production of aqueous humor which is unable to pass from posterior to anterior chamber, resulting in an increased IOP, culminating ultimately in retinal damage, and visual loss • Risk Factors • Older age, female, Asian descent, shallow anterior angle, excessive sympathetic tone, thin iris, darkened environment • Essentially, any condition which cause the iris to heap up, and become closer to pupil, thus preventing egress of aqueous humor • Or any condition that disrupts the egress of aqueous from the anterior chamber

23. Diagnosis • Clinical suspicion: Anyone with headache and eye pain, make sure to examine eye • Tono pen • If not working or stolen, use your finger • Treatment • Lie patient flat: May cause separation of Iris from lens • Analgesia • Topical β- blockers or α- agonists • Decreases aqueous humor production (Timolol 0.5% 1 drop) • Topical Steroids • Reduce inflammation (Prednisolone 1 drop Q15min • Hyperosmotic agents • Decrease fluid volume in eye (Mannitol 1-2 g/kg IV over 30-60min) • Topical Miotics • Pulls the iris back away from pupil (Pilocarpine ½% 1 drop Q6hr) • Will not work unless IOP <40mmg

24. 50 year old female presents with headache and blurry vision

26. CN III Palsy • Anatomy • Originates in the brainstem continues within sub-arachnoid space  traverses the cavernous sinus  terminates within the orbit after exiting the superior orbital ridge • Contains voluntary muscle fibers and parasympathetic control • Responsible for majority of EOM • Pupillary Constriction • Raises eyebrow (Levator palpebrae superiorus has dual innervation) • Presentation • Typically down and out pupil, which doesn't’t constrict or accommodate • Ptosis

27. Why is the anatomy important? • Disposition • Because of the origin and course CN III, deficits can indicate • PCA Aneurysm • Uncal Herniation • Compressive Neoplasms • Inflammatory Conditions • Trauma • Cavernous sinus neoplasm • Cavernous sinus thrombosis • Carotid-Cavernous fistula • MRI/MRA Imaging and neurology consult strongly recommended • It is possible to have isolated CNIII deficits affecting primarily the EOM and rarely the pupil • Adjunct indicator for micro vascular disease in HTN and DM • Usually a painful condition • Low threshold for neurology involvement

28. 20 year old wrestler presents with ear pain

30. Auricular Hematoma • Develop when the ear sustains blunt trauma • Causing auricular perichondrium to separate from underlying cartilage • Tearing of the perichondrial blood vessels results in subsequent hematoma • Chronic presence of blood stimulates new cartilage deposition and subsequent cauliflower ear

32. Auricular Hematoma • Treatment • >7 days • Referral to ENT • <7 days • I & D • Needle aspiration no longer recommended as hematoma tends to re-accumulate • Pressure dressing • Follow-up in 24 hours • Most pressure dressing are inadequate, tend to allow hematoma to re-accumulate

33. 18 year old woman presents with ear pain and fever • Examination reveals a tender, erythematous bulge posterior to ear

35. Mastoiditis • Mastoid bone is directly contiguous to and is an extension of the middle ear cleft • Mastoidits is the result of an extension of purulent otitis media • Medial wall erosion can result in • Cavernous sinus thrombosis, CN VII palsy, Meningitis, Brain abscess

36. Treatment • Flora is similar to causes of AOM • Strep Pneumo most common • Risk Factors • Likely multifactorial • Invasive species vs. host anatomy (Eg. Congenitally narrow mastoid antrum)

37. Disposition • Broad spectrum antibiotics: Semi-synthetic PCN’s, 3rd generation cephalosporins, Vanco • Imaging • Admission • Surgery in refractory cases

38. 20 year old man presents with eye pain and fever after being scratched by his cats claws 2 days ago

41. Orbital Cellulitis • Orbital septum is a fascial layer which extends vertically from the periosteum of the orbital rim to the inferior border of the tarsal plate in the lower eyelid • Orbital cellulitis is an infection posterior to the septum

42. Etiology • 1) Extension of an infection from the periorbital structures • Usually ethmoid sinusitis • 2) Direct inoculation from trauma or surgery • 3) Hematogenous spread from bacteremia • Veins in this region are valveless allowing retrograde and anterograde flow

43. Presentation • Pain, fever, chemosis • Important findings are proptosis, painful EOM’s • Disposition • Imaging: CT with contrast • Broad spectrum abx (MRSA becoming common) • Admission

44. Complications • Visual Loss • Cavernous sinus thrombosis • Meningitis • Abscess • Osteomyelitis

45. 7 year old boy is brought in by mom for evaluation of a bump next to his eye

47. Dacrocystitis • Lacrimal excretory system • Drain tears from the medial aspect of the eye through a series of canal which ultimately terminate in the nose • Prone to infection as system is contiguous with conjunctiva proximally and nasal mucosa distally • Infection usually develops when stagnation occurs secondary to obstructed lacrimal sac

48. Microbiology • Usual nasal and skin flora • Management • Most case are self limited • Warm compresses, massage lacrimal sac, oral anti-biotic (β- lactamase resistant) • Consider imaging for recurrent causes • Obstruction caused by malignancy

49. 25 year old brought to ER screaming. • Pain began while yawning when trying to fall asleep