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Category: Otolaryngology

AIRWAY VISUALIZATION – EXTERNAL “CEPHALIC” MANIPULATION

AIRWAY VISUALIZATION – EXTERNAL “CEPHALIC” MANIPULATION

Here is a potential airway technique that may help with visualization: hold the laryngoscope in the left hand (the usual) but the right hand, instead of being at your side, is behind the patient’s head. You then move it around until you get the best view. Then you have an assistant hold the head in that spot.   A hospital in Southern California started doing that. The technique deserves some exploration. The work of Richard Levitan reminds us that the…

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INDIRECT LARYNGOSCOPY

INDIRECT LARYNGOSCOPY

A patient presents with severe sore throat. You wonder about epiglottitis. You know that using a mirror to look at the epiglottis is a great way to check this but are not confident in your skills. What do you need?   Dental mirror – they are cheap, have your ED stock them   Light – can use a headlamp, the kind that are sold in outdoor stores. Get one with a spot beam rather than a flood light. Nice to…

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Deep Space Infection of the Neck? Check Range of Motion

Deep Space Infection of the Neck? Check Range of Motion

A young man presents with a severe sore throat. He was here yesterday and received antibiotics. Today he feels worse. You look in the throat expecting a peritonsillar abscess but the throat looks completely normal, not even erythema.   Now what?   Amidst the busy emergency department practice, sometimes we need a reason to take a second, closer look. Always trust your gut. In this case the patient had severe pain but no erythema. The concerning finding was not the…

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ACUTE OTITIS MEDIA: BULGING MORE IMPORTANT THAN COLOR

ACUTE OTITIS MEDIA: BULGING MORE IMPORTANT THAN COLOR

  A pediatric patient presents with upper respiratory symptoms. The student says there is acute otitis media. You look, and indeed there is some erythema of the tympanic membrane. But is this acute otitis media, and will the patient benefit from antibiotics?   Studies are limited by variable clinical definitions of acute otitis media (Chandler Clin Pediatr 2007) and interobserver variability (Margolis Is J Med Sci 1979). One article presents their training module as improving the accuracy of diagnosis by…

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LOCALIZE VERTIGO: LIKE IN A HEAD TURN, THE VOR PULLS THE EYE TO THE UNDERACTIVE SIDE

LOCALIZE VERTIGO: LIKE IN A HEAD TURN, THE VOR PULLS THE EYE TO THE UNDERACTIVE SIDE

You are seeing a patient with suspected vestibular neuritis. The resident is having trouble with the physical examination. Will localization help her comprehend the bedside findings?   We understand neurolgical disease by localizing it. We can often localize vertigo, though it is more difficult for 3 reasons: – the signal is tonic (there is always a basal tone which can then go up or down) – it is bilateral – Its sensory representation is space, which is not just within…

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BACTERIAL RHINOSINUSITIS

BACTERIAL RHINOSINUSITIS

A patient presents with an upper respiratory illness and wants antibiotics. She points out that she always gets antibiotics, and that she always gets better, therefore the antibiotics must be needed. Is this bacterial sinusitis?   The preferred term today is acute rhinosinusitis, which reflects the fact that the mucosa of the nasal and sinus mucosa are continuous and both affected. Upper respiratory infection is common, happening 6 times a year in children and 2-3 times per year in adults….

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BPPV WITHOUT NYSTAGMUS

BPPV WITHOUT NYSTAGMUS

The traditional teaching is that one must not diagnose benign paroxysmal positional vertigo (BPPV) unless geotropic nystagmus is seen on Dix-Hallpike maneuver. But in the emergency department, we commonly see patients with classic paroxysms of vertigo, classic positional triggers, and yet Dix-Hallpike is normal. What is the basis for the traditional view that requires for the diagnosis of BPPV a positive Dix-Hallpike maneuver?   A critically appraised review found that only one study has “tested the test,” finding a sensitivity…

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DYSPHAGIA

DYSPHAGIA

A patient presents with difficulty feeding for the past month.  Specifically, she states that she is “unable” to swallow.  How do we perform the bedside examination so as to take this presentation to the highest degree of resolution?   Swallowing can be divided into 2 processes: oropharyngeal and esophageal.   The oropharyngeal process moves the food bolus from the back of the tongue to the pharynx, where the pharynx squeezes it into the upper esophagus.  This event involves the soft…

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HEAD IMPULSE TEST FOR THE PATIENT WITH VERTIGO WHO CAN NOT WALK

HEAD IMPULSE TEST FOR THE PATIENT WITH VERTIGO WHO CAN NOT WALK

A young patient presents with nausea and spinning vertigo.  There are no focal neurologic deficits to suggest stroke, no stroke risk factors, no neck pain or neck trauma to suggest vertebral dissection. And yet, the patient has severe gait instability, which can be an indicator of a stroke.  Is this alone a reason to order an MRI? This is the exact situation where head impulse testing plays a role in the ED. The head impulse test is a test of…

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IS THE VERTIGO EPISODIC?

IS THE VERTIGO EPISODIC?

A 40 year old female presents with nausea and dizziness, with 3 recent visits to the emergency department. Could this be benign paroxysmal positional vertigo (BPPV)?   You ask the patient whether it is episodic or continuous. “Continuous.” The resident accepts that and starts to ask the next question.   “Hang on” and you gesture that you want to explore that a bit more. Patients sometimes say continuous when they mean “I get episodes all day long” or “I continue…

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