Senior Report 8.6

seniorreport

Case Presentation by Katherine Shulman, MD

Chief Complaint: Difficulty swallowing

History of Present Illness: This is a 66-year-old male with no significant medical history who comes in to emergency department complaining of difficulty in swallowing beginning 3 months ago. He further describes it as a foreign body sensation in his throat and has started eating a soft diet, which he tolerates well. He reports only mild discomfort with swallowing. Also, three months ago he noticed a change in his voice. He reports a “very mild” baseline shortness of breath over the same timeframe. He denies any neck pain, chest pain, fevers, night sweats, or headaches. No recent dental procedures. Denies any URI symptoms in the past several months.

Past Medical History: none

Medications: None

Social History: Denies tobacco, alcohol, or illicit drug use.

Family History: His brother just died of laryngeal cancer two months ago.

 

Physical Exam:

Vital Signs: BP 145/82; HR 98; RR 16; Temp 36.8; 98% RA

General: Patient sitting semi-fowler in stretcher in no acute apparent distress, with no acute respiratory distress. Handling oral secretions well. Speaking in full sentences with a muffled voice. Resting comfortably.

Head: normocepahlic; atraumatic

Eyes: EOMI; PERRL; pink conjunctiva

Mouth: moist mucous membranes, no tongue or submandiblar swelling, good overall dental hygiene, uvula midline; significant area of swelling in the right oropharynx just posterior to the tonsil with normal appearing overlying mucosa; no erythema, exudates, ulcerations in the anterior or posterior pharynx.

Neck: Supple; trachea midline; no palpable lymphadenopathy

Cardiovascular: s1, s2; regular rate and rhythm; no murmur

Respiratory: no stridor, lungs clear to auscultation bilaterally; symmetrical chest rise and fall; no accessory muscle use

 

Workup: We obtained laboratory tests and a CT – Neck w/ contrast.

 

8.62

8.63

8.61

 

Questions:

1. What is the most likely diagnosis?

A. Peritonsillar Abscess

B. Nasopharyngeal Carcinoma

C. Diphtheria

D. Ludwig’s Angina

 

2. What is the most likely causative organism?

A. Streptococcus Species

B. Staphylococcus Aureus

C. Haemophilus Influenzae

D. Fusobacterium

 

3. What are the next steps in management?

A. Initial dose IV Clindamycin, discharge home w/ PO Clindamycin, and ENT f/u

B. IV Unasyn, consult ENT, medicine admit

C. IV Zosyn, consult ENT, ICU admit for compromised airway

D. Consult ENT, obtain blood cultures, medicine admit

 

ANSWERS:

1) A

2) A

3) B

1. A. The diagnosis is right peritonsillar abscess. The CT scan shows a large peripherally enhancing complex cystic mass arising from the right peritonsillar region (best seen in the first image) causing significant mass effect. The structure measures 5.4 centimeters in the greatest dimension, and the airway measures 1 centimeter at the narrowest dimension. This is a relatively uncommon presentation of peritonsillar abscess. Usually, the progression of disease occurs within a week, signs and symptoms include: odynophagia, dysphagia, drooling, trismus, muffled voice. Additionally, fever, malaise, and dehydration are common systemic symptoms.

B. Nasopharyngeal carcinoma is uncommon in the US, difficult to detect early, and usually presents with the following: cervical lymphadenopathy, sore throat, nasal discharge or bleeding, bloody saliva, ear infection or pain, changes in hearing, tinnitus, headaches.

C. Diphtheria usually presents with an upper respiratory tract illness with sore throat, low-grade fever, and an adherent grey pseudomembrane covering the posterior aspect of the pharynx. Due to vaccinations, there has been only one case in the US in the past ten years.

D. Ludwig’s Angina is a fulminant disease process that may lead to death within hours or days. It generally occurs secondary to a dental infection, causing progressive cellulitis of the submandibular space extending to the deep tissues of the floor and mouth.

 

2. A. Common organisms associated with peritonsillar abscess include the following: Streptococcus pyogenes (most common aerobic), Staphylococcus aureus, Haemophilus influenzae, Neisseria species, Fusobacterium (the most common anaerobic), Peptostreptococcus, Prevotella, and Bacteroides. For most abscesses, a mixed profile of both aerobic and anaerobic organisms proliferates. The final culture in the case above was positive for Streptococcus viridans, negative for anaerobic organisms.

 

3. B. IV antibiotics should be started. Unasyn, Zosyn, clindamycin, a combination of penicillin G and metronidazole, are all good options for treatment of inpatient peritonsillar abscess. Mainstay of therapy is needle aspiration or incision and drainage, which in this case should be performed by ENT. The patient has a large peritonsillar abscess and an airway measuring 1 cm in diameter at the narrowest point, thus, the patient should be admitted. A medicine floor admission is an appropriate disposition. ICU is not indicated at this time, as the patient is stable and not showing signs of respiratory distress. He is neither hypoxic nor tachypneic. Physical exam demonstrates a comfortable, well appearing male. In general, peritonsillar abscesses do not take such an indolent course as described in the case above.

References:

Steyer, Terrence E. Peritonsillar Abscess: Diagnosis and Treatment. Am Fam Physician. 2002; Jan 65(1):93-97.
Marx, John A, et al. Rosen’s Emergency Medicine, 7th Ed. Philadelphia: Mosby Elsevier, 2010. Print.

Senior Report 6.21

Case Presentation by Dr. Deepa Japra

Questions:

1.) A 19 year old female presents with decreased hearing from her right ear since going diving earlier today. Otoscopic exam reveals the findings in the picture, which of the following is an acceptable treatment?

6.21-1

a) oral ciprofloxacin

b) topical neomycin

c) hydrogen peroxide

d) ciprofloxacin otic solution

2.) Your next patient arrives with a chief complaint of ear pain and with 45 minutes left in your shift, you know it’s bad form to push it off for the next resident to see. You are dreading having to see yet another cerumen impaction, and are startled to observe the following findings on physical exam. Which of the following is central to management of this condition?

6.21-2

a) admission for IV antibiotics

b) emergent bedside incision and drainage

c) ENT consult for emergency mastoidectomy

d) outpatient antibiotics with urgent ENT follow up

3) Your next patient presents with a foreign body in the ear. You grab your alligator forceps with 10 minutes left in your shift, but which of the following findings should prompt an ENT evaluation instead of attempted removal by the ED physician?

a) disk-shaped battery

b) live insect

c) cotton ball

d) object present more than 8 hours

Answers & Discussion

1) d

2) a

3) b

Question 1 –  d

The picture above is of a perforated tympanic membrane. This can occur through various mechanisms, including a direct blow to the ear, blast injury, scuba diving, air travel while having an upper respiratory infection, and more commonly from the traumatic usage of cotton swabs to clean the ear. In the case of this patient, TM perforation occurred during a diving injury. Topical antibiotics, such as d) ciprofloxacin otic solution, can be safely prescribed, especially in this case since the perforation likely occurred in a contaminated setting while the patient was in water. It is important to note, however, that usage of topical anitbiotics in TM perforation is not proven by evidence, but can also be given in cases of external puncture or canals occluded with blood or drainage.  Most cases of tympanic membrane perforation heal spontaneously. Larger, more central lesions such as those greater than 25% of the total drum surface area may require operative repair, especially in patients that do not heal spontaneously in 4 weeks. Lesions in elderly patients are also less likely to heal on their own. Topical ototoxic agents should be avoided in perforated TM and includes aminoglycosides like, b) neomycin, and antiseptics and compounds with low pH including c) hydrogen peroxide and acetic acid. Alcohol is also ototoxic and should not be applied.  If the clinician cannot fully visualize the tympanic membrane and is unsure of whether it is disrupted and there is an index of suspicion for perforation, it is best to avoid these ototoxic agents. After the diagnosis is made, patients with small isolated tympanic membrane perforation with minimal hearing loss can be managed with avoidance of water exposure for 4 to 6 weeks, possible topical antibiotics in contaminated settings as described above, the recommendation for audiometry within 24 hours, and follow up with ENT within 4 weeks to ensure the perforation is closed and the hearing deficit has resolved. There is no indication for oral antibiotics, a), in a perforated TM with no signs of infection.  Patients with more marked hearing loss, vestibular signs such as nystagmus, vomiting, and ataxia, or those with findings consistent with facial nerve injury should have emergent ENT evaluation if possible or within 48 hours of injury.

If the mechanism for perforation is secondary to barotrauma, such as air travel with a URI, diving, or blast injury, making the diagnosis of perforated TM can give insight to other injuries. The tympanic membrane is sensitive to changes in pressure and more likely to be injured at lower pressures than any other organ. Some studies suggest that it can be used as a triage tool in blasts with multiple victims, especially with patients that are initially healthy appearing, in order to identify patients that have a higher risk of delayed sequelae including pulmonary or gastrointestinal injury.

Question 2 – a

The picture represents acute mastoiditis, which occurs most likely as a complication of acute otitis media. Acute mastoiditis is more common in children than adults, and the incidence has declined with the use of antibiotics for the treatment of otitis media, and is now relatively rare. The mastoid air cells are connected to the distal end of the middle ear through the antrum. While most episodes of acute otitis media are associated with some inflammation of the mastoid, mastoiditis occurs when the mucous lining of the middle ear lining the mastoid becomes persistently inflamed and purulent material accumulates in the mastoid air cells.

The clinical presentation of mastoiditis can include fever, posterior ear pain, local erythema and tenderness over the mastoid bone, edema of the pinna, and posterior and downward displacement of the auricle. If mastoiditis is suspected, the patient should be a) admitted for IV antibiotics and a CT scan of the temporal bone should be performed.  CT scan can demonstrate air-fluid levels and identifies the extent of the disease, but it is important to note that the isolated or incidental finding of mastoid air-fluid levels on CT should not prompt a change in treatment in a well appearing patient without other clinical signs of mastoiditis. IV antibiotics should be directed against streptococcus pneumoniae, the most common pathogen, with consideration for broader coverage against pseudomonas, staphylococcus aureus, and enteric gram negative rods when mastoiditis presents as a complication of a more chronic disease. A third-generation cephalosporin is acceptable as an initial antibiotic choice, and other recommendations include vancomycin, clindamycin, or imipenem. Answer d) outpatient antibiotics with ENT follow up is inappropriate as acute mastoiditis can lead to further intracranial spread and neurological sequelae if not appropriately diagnosed and treated. Choice b) emergency bedside incision and drainage is not an appropriate treatment option for acute mastoiditis. Though an emergency ENT consult is warranted, choice c), an emergency mastoidectomy for debridement of necrotic bone, is not an initial intervention performed and is sometimes indicated if the patient does not respond to conservative therapy with IV antibiotics. A myringotomy by ENT for aspirate and fluid cultures is an appropriate initial treatment choice in order to guide antibiotic therapy and may include placement of a tympanostomy tube for drainage.

Question 3 – a

When removing a foreign body in the ear in the emergency department, the clinician should remember that smaller instruments are more likely to cause damage to the canal so one should use the largest, bluntest instrument that has the capacity to grasp the object or pass a hook behind it.  Choice b) live insect, can be safely removed by the ED physician, and the insect should be killed first with solutions such as lidocaine (2% gel or liquid) or mineral oil prior to removal. Though some studies suggest that ethanol causes the most rapid killing of insects, this should not be routinely used because alcohol is ototoxic and contraindicated unless the TM is intact, which is difficult to assess with an insect blocking visualization.

Choice a) disk-shaped battery should prompt an ENT evaluation because of its ability to cause burns or liquefactive necrosis of the external auditory canal. The battery’s electrical potential is damaging and does not need to leak or rupture in order to cause damage. Choice c) cotton ball, can be safely removed as long as the object is easily visualized and accessible. Choice d) object present more than 8 hours, is not a definite ENT referral. Some studies suggest that primary ENT referral should be performed for any sharp-edged or spherical object, any vegetable matter or disk-shaped battery, location adjacent o the TM, age less than 4 years, previous unsuccessful removal attempts, and time in ear exceeding 24 hours, all of which were associated with increased complications. Other studies suggest that there is no increase in complication rates related to patient age or the time object is present in the ear.

After removal of any foreign body, the physician should perform appropriate inspection of the ear canal for signs of damage to the external canal, TM perforation, or infection, and treat these conditions appropriately.