45 y/o male s/p tracheostomy three days ago presents with massive bleeding of bright red blood from about his trach. A tracheo-arterial fistula is suspected. What is your next move?

DON'T remove the trach; then, hyperinflate the cuff to tamponade the bleeding.   If the trach is removed the patient will aspirate blood and asphyxiate.

Fortunately, tracheo-arterial fistula after trach is a rare complication but can occur from erosion into the brachiocephalic trunk, especially with placement of a low lying trach below the third tracheal ring. 

Pressure necrosis from a trach tube can erode into the brachiocephalic artery which runs anterior to the trachea.

Sources

Praveen, CV.  "A rare case of fatal haemorrhage after tracheostomy"  Ann R Coll Surg Engl.  2007.

Image source: http://www.hawaii.edu/medicine/pediatrics/pemxray/v6c19.html

24 y/o female presents with throat pain which developed while eating chicken wings at a holiday party. Identify the abnormality, if any, on this soft tissue neck x-ray.

Click image to enlarge.

scroll down for answer 

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Arrow denotes chicken bone.

Patients with an orbital floor fracture should be given "sinus precautions." What exactly constitues these precautions?

• no blowing (nose, a wind instrument, balloons, etc)


• sneeze with mouth open 


• no sucking (straws, cigarettes, etc)


• no pushing or lifting heavy objects 

Source

"Outpatient Surgery / Procedure Instructions"  NIH.  http://www.cc.nih.gov/ccc/patient_education/postop/sinus.pdf

Which topical antibiotics should be avoided in patients with a tympanic membrane perforation? What is the antibiotic of choice?

Avoid eardrops containing gentamicin, neomycin sulfate, or tobramycin as these drugs are ototoxic when there is a tympanic membrane perforation. Ototopical fluoroquinolones are the first-line therapy of choice in this situation.


Source

Mattu, A. et al. Avoiding Common Errors in the Emergency Department.

Rosen & Barkin's 5–Minute Emergency Medicine Consult. 4th ed.

Need an ENT foreign body hook but don't have one in the ED? Try this ...

Improvised foreign body hook.  Cost: $0.01

Made from a paper clip; you can shape the tip for optimal foreign body removing power!  Perfect when you're in a bind and don't have one of these:

Bausch + Lomb Ear Hook.  Cost: $35.00

Source

http://www.bauschinstruments.com/product-details.aspx?pid=9395

What is the most common cause of spontaneous laryngospasm? Treatment?

Laryngopharyngeal reflux.  Treat with proton pump inhibitor.  For refractory symptoms, laryngeal botulinum toxin injection is a potential treatment option.


Source

Obholzer, RJ.  "An approach to the management of paroxysmal laryngospasm"  J Laryngol Otol.  1 Jan 2008. 

How to differentiate conductive and sensorineural hearing loss without a tuning fork ... (and why it matters).

Have patient hum. If sound lateralizes to ear with impaired hearing then a conductive loss is likely. If, however, sound lateralizes to ear with normal hearing, then the impaired ear may have a sensorineural problem.

Acute onset sensorineural hearing impairment warrants emergent ENT evaluation. Consider starting corticosteroids empirically if there is no clear etiology ie acoustic neuroma, stroke.


Source

Schreiber, B. et al. "Sudden sensorineural hearing loss" Lancet 2010; 375: 1203-11.

Weber, P. "Sudden sensorineural hearing loss" Up to Date. 17 Nov 2009.

Name clinical and lab features which suggest primary HIV infection.

• fever
• weight loss (average 10 lbs)
• adenopathy
• splenomegaly
• risk factors for HIV transmission within the prior 2 - 3 weeks
  
• lymphopenia
• increased transaminase levels

Diagnosis is established with an HIV viral load assay.


Source

Bartlett, J. "Evaluation of acute pharyngitis in adults" Up to Date. 13 March 2009.

Will a standard throat culture detect N gonorrhoeae?

No.

If N gonorrhoeae is suspected as the etiology of a sore throat, notify the lab so that a culture, if sent, can be plated on a special media to detect this organism.


Source

Bartlett, J. "Evaluation of acute pharyngitis in adults" Up to Date. 13 March 2009.

85 y/o male presents with black spot on hard palate. What's the diagnosis?

Patient is demented. Can't provide additional history but family states that they noted this black spot in the patient's mouth recently. "He's always wearing his dentures, even to sleep. Does this have anything to do with it?"



Biopsy is in order to evaluate for possible oral melanoma. The mouth is a rare location for melanoma and accounts for < 1% of this cancer. While cutaneous melanomas are linked to sun exposure, risk factors for mucosal melanomas are unknown.


Source

Collins, B. DDS. "Oral Malignant Melanoma" eMedicine. 21 March 2008.

Image source: http://dermatology.cdlib.org/141/case_presentations/oralmm/1.jpg

4 questions about Meniere's Disease

1. What is the cause?

Exact mechanism not completelely understood but it seems that overabundance of endolymph within the cochlea is the cause.

2. What are the classic manifestations of this disease?

Unilateral fluctuating sensorineural hearing loss, aural fullness, tinnitus and spells of disabling vertigo that typically last between 20 minutes and 24 hours (rarely longer. Longer attacks are more consistent with vestibular neuritis). The vertigo attacks are not provoked by movements as they often are with benign paroxysmal positional vertigo. Many patients have nonspecific dizziness and imbalance in between spells of vertigo as well.

3. How is Meniere's diagnosed?

In large part by clinical history and physical exam. If the diagnosis is unclear audiometry, vestibular testing and MRI can be obtained to exclude other pathology and to confirm the diagnosis.

4. How is it treated?

Decrease dietary sodium, caffeine, alcohol, tobacco use. Use diuretic. Vestibular suppressants, ie meclizine, for acute attacks. For patient who don't respond to medical treatment, surgical options (intratympanic gentamycin, endolymphatic sac decompression/shunt, vestibular nerve section, labyrinthectomy) can be considered.


Source

Rakel and Bope: Conn's Current Therapy 2008, 60th ed.

Random-Useless stat of the day: 60%

According to the New England Journal of Medicine, this is the estimated percentage of persons worldwide who have experienced epistaxis (nose bleed) during their lifetime. Is this true? It just does not seem to pass the gut check test .... I've had several episodes myself. Shouldn't the percentage be closer to 90-100%?

For fun, let's take a little informal poll of My Emergency Medicine Blog readers. If I'm proven wrong perhaps I should get checked for a coagulation disorder. :)



Source

Schlosser, R. MD. "Epistaxis" N Engl J Med 2009; 30:784-9

What causes tinnitus (ear ringing)?

Two categories of tinnitus, each with different etiologies.

1. subjective - only heard by patient

• causes of conductive hearing loss - cerumen impaction, external otititis, TM perforation, middle ear fluid, otosclerosis


• causes of sensorineural hearing loss - noise induced hearing loss, Meniere's disease, acoustic neuroma


• other - ototoxic medications (aspirin, NSAIDs, aminoglycosides, vancomycin, tetracyclcine, lasix), head trauma, metabolic disorders (hypo- hyper - thyroidism, hyperlipidemia, anemia, vit B12 or zinc deficiency)

2. objective - actual sound which may be appreciated by the examiner

• vascular abnormality - arterial bruit, venous hums, AV shunts


• neurologic disorders - brain-stem tumor, infarction, multiple sclerosis lesions which can cause repetitive rapid contractions of soft palate muscles or idiopathic stapedial muscle spasm

Source

Crummer, Richard MD and Hassan, Ghinwa MD. "Diagnostic Approach to Tinnitus." American Family Physician. v 69. 1 Jan 2004.

When is a "simple" pharyngitis just not a simple pharyngitis?

Sore throat is probably one of the most common chief complaints that we encounter during our daily practice. What historical and clinical clues do you use to distinguish the patient with a simple pharyngitis from those with more serious disease (ie epiglottis, abscess, bacterial tracheitis, etc...)?

To start ....

• toxic appearing


• tripod sitting position


• drooling


• "hot potato" voice


• trismus


• decreased neck mobility


• neck swelling

In patients with these symptoms I would consider going beyond the usual pharyngitis workup (+/- rapid strep/mono spot/pcn vk) to consider imaging and ENT consultation.

Agree?