EYE, EAR, NOSE, AND THROAT*

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UPDATE: OTITIS MEDIA

Otitis media is an extremely ubiquitous disease with most children having at least one episode before age 2 years.56 It is debatable whether treatment of the disease is even required. Some European practitioners have developed an expectant approach to the treatment, recognizing that over 80% of cases resolve spontaneously.45 Other authors question both antibiotic efficacy46 and the wisdom of widespread antibiotic use in the face of increasing Streptococcus pneumoniae drug resistance.37

PEARL: THE USE OF STEROIDS IN UPPER AIRWAY DISEASE

In the past, individuals with exudative pharyngitis, regardless of the cause, have been anecdotally prescribed steroids assuming that this would reduce pharyngeal swelling. One prospective, randomized, double-blinded and placebo-controlled study, using a single IM injection of 10 mg of dexamethasone, resulted in significant improvement compared with the control group.35 Although this study did not identify the cause of the pharyngitis, it seems reasonable to use steroids in patients with

PEARL: NONINVASIVE NASAL FOREIGN BODY REMOVAL

Nasal foreign bodies consist of a multitude of objects, most commonly food, hair beads, paper, and toy parts, and occur primarily in 2 and 3 year olds.4 The child may present to the emergency department (ED) after a parent has visualized the object in the child's nose, watched the child put the object into his or her nose, or because of a unilateral foul-smelling discharge or epistaxis.

Several methods have been described for removal including right angle hooks, wire loops, alligator forceps, or

PITFALLS: IDENTIFYING HEAD AND NECK MALIGNANCIES

Failing to diagnose head and neck cancers are not high on the list of emergency medicine malpractice claims. Nonetheless, because many eye, ear, nose, and throat (ENT) problems present to the ED, it is an excellent place to identify a number of head and neck malignancies.

When evaluating someone with an ENT problem, identify (in the patient history) the risk factors that may predispose a patient to these malignancies. These risk factors include alcohol and tobacco use, viruses, sunlight

PEARL: DO PATIENTS GIVEN RACEMIC EPINEPHRINE NEED TO BE ADMITTED WITH CROUP?

Racemic epinephrine has been used in patients with moderate to severe croup who do not improve with humidification or are in extremis. Racemic epinephrine contains both the d and l isomers, and it was chosen because it was thought to have fewer side effects than the cheaper, more commercially available, and bioactive l isomer.57 In a prospective randomized study, the l isomer was shown to be at least as effective as racemic epinephrine and is recommended for croup.57 The recommended dose is 5

UPDATE: BELL'S PALSY

Seventh nerve peripheral palsy is caused by a multitude of causes. In one series of over 2800 patients, 51% of the cases were idiopathic (Bell's). Other common causes included trauma (22%), herpes zoster (7%), and tumor (6%).31 Even though Bell's is idiopathic, there is good clinical and serologic evidence of an infectious cause in a sizable minority of cases.34

The incidence is 15 to 40 per 100,000 people, involves both sexes equally and is recurrent approximately 10% of the time. Eight percent

PEARL: THERAPY FOR OPHTHALMOLOGIC PROBLEMS … PATCHES AND MEDICATIONS

There are several topics in ED ophthalmologic therapy that can be a source of confusion and frustration, and these are highlighted as follows.

Antibiotics are one of the most frequent ophthalmologic medications used by emergency physicians. Two questions often arise: Which is appropriate to use?; and How should it be administered? The advantage of ointments is that they stay on the conjunctivae longer and thus require less frequent administration for higher concentrations. Thus, they are

PEARLS: KEYS TO THE DIAGNOSIS OF IRITIS

One area that emergency physicians often express insecurity about is definitively diagnosing iritis. When using the slit lamp, they relate difficulty seeing the cells and flare that accompany the condition. It is important for the instrument's beam of light to be oriented properly, or picking these features up is next to impossible. A narrow slit should be used with high intensity of light. The beam should then be shortened to almost pinpoint height and directed at a 45-degree angle to

UPDATES: HOW SHOULD I TREAT STREP THROAT?

Recent reviews confirm that penicillin is still the drug of choice for treatment of streptococcal pharyngitis.26, 27 The treatment of this disease is important to prevent rheumatic fever, glomerulonephritis, and peritonsillar abscess, and to shorten the duration of symptoms.32 Group A beta-hemolytic strep (GABHS) has shown an increasingly higher resistance rate. It is thought that the coexistent presence of beta-lactam–resistant organisms is the reason for this phenomena. These organisms are

PITFALL: THE “NORMAL” SORE THROAT (CONSIDER A LATERAL NECK RADIOGRAPH)

Scenario 1: A 40-year-old man comes in complaining of severe sore throat. He appears to be in marked pain without stridor or drooling. On pharyngeal examination, there is some injection, but no purulence or deviation in anatomy.

Scenario 2: A 2-year-old girl is brought in with a fever to 104 degrees. Her mother wants her checked for sore throat as ahe child appears to be in pain. Earlier, the mother had noted “wheezing.” On examination, the child is nontoxic, without drooling or stridor. Pharynx

PEARLS: WHAT YOUR ENT CONSULTANT WANTS TO TELL YOU ABOUT EPISTAXIS

Epistaxis is one of the most unpopular chief complaints in emergency medicine. The ENT specialists do not love them either. When they are asked about salient management advice they would pass on, the following are frequently mentioned:

  • 1

    When examining the epistaxis patient, it is important to visualize as much of the nasal vestibule as possible. It is important to keep the patient's head upright, for if he or she tilts backwards, then only the roof will be seen (Fig. 2). The nasal speculum

PITFALLS: NO COMMUNICATION WITH THE ELDERLY

There is no doubt that emergency physicians are encountering geriatric patients with increasing frequency. It is often difficult to obtain necessary historical information owing to problems in communication secondary to a natural age-related decrease in hearing ability. Elderly patients and others with decreased hearing are a source of frustration, especially in the absence of family members who are able to easily communicate, or those who know sign language. The typical physician response is

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  • Cited by (4)

    Address reprint requests to James A. Pfaff, MD, FACEP, Department of Emergency Medicine, Brooke Army Medical Center, Building 3600, 3861 Roger Brooke Drive, San Antonio, TX 78234–6200

    *

    The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Departments of the Army, Air Force, or the Department of Defense. All material in this article is in the public domain.

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