POTD: Foreign Body of the Nose

Foreign body of the Nose

•        Most common age range: 2-5 yo

•        Most common FB: beads, beans, peanuts, toy parts

•        Beware of: button batteries and two magnets, as always.

•        Can lead to septal perforation/necrosis of tissue.

•        Be suspicious of nasal FB when you see unilateral discharge, often malodorous

•        Complications: infection, aspiration, epistaxis

To remove:

•        Topical lidocaine or afrin?

• Pro: improve tolerance of/cooperation with the procedure

• Con: risks displacement of the FB

How to remove

1) Mechanical extraction: You need a cooperative child and good visualization.

2) Suction: must exercise extreme caution not to push further back and aspirated into the trachea

3) Positive Pressure: Parent’s kiss, bag mask, continuous pressure

• Start by asking the child to blow their nose, occluding the unaffected nostril as they do this. Sometimes, this alone may expel the foreign body.

• Parent’s Kiss: One of my preferred methods. Has a 50 % success rate.

Kissing parent: The technique is performed by a parent by placing their mouth over the child’s (giving a ‘big kiss’), while they occlude the unaffected nostril. The parent then exhales into the child’s mouth, generating positive pressure, similar to that of nose blowing. See picture below for demonstration.

Nothing working? You may need an ENT consult because the FB is so posterior that above methods are futile.

Now that it’s removed:

·       Don’t forget to inspect for trauma or retained FB

References:

•        PEM playbook foreign bodies: excellent peds podcast by Dr. T Horeczko - ‎2015

•        Wiki EM: Nose foreign body

Look at this retro parent’s kiss!

POTD: Foreign bodies, Ears!

This is a two part series for POTD. Foreign bodies: Ears and Nose! Today, Ears!

Quick Anatomy review to help locate that FB:

•        Anatomy

–       medial 2/3 is fixed in temporal bone –where many FBs are lodged and/or where trauma

•        Ask yourself: is it graspable or non-graspable?

–       Graspable: 64% success rate, 14% complication rate

–       Non-graspable: 45% success rate, 70% complication rate

•        What instrument/method should I use for what?

–       Alligator forceps: think something graspable like paper, foam

–       Suction tip: think something non graspable like a round object such as a bead

–       Irrigation: think something non graspable like a bead (note: do not irrigate organic material as will swell or break apart)

–       Glue: something non graspable like a bead or organic material that might swell or break if irrigated

Pearls on insect FB:

·       Kill it first. They will fight.

-        What to use? Lidocaine jelly, viscous lidocaine (2%), lidocaine solution, isopropyl alcohol, or mineral oil.

-        After they are dead, you can remove or can send to ENT for removal (most patients will want it out, can you blame them?)

o    An ENT friend of mine says to keep the insect in the ear and let them remove because we tend to cause trauma. Something to keep in mind.

What if I caused or the FB (like that insect fighting for their life) caused local trauma?

•        TM rupture?

–       Keep dry

•        When to use otic abx drops

–       Any trauma or dirty FB injury (think: that insect crawling around) or canal lacerations/abrasions.

–       What to give? Ofloxacin drops or the very expensive ciprodex.

•        ENT f/u

Pitfalls

•        Inspect after removal

–       Something else in there? Abrasions/trauma and need prophylactic antibiotic ear drops

•        If at first you don’t succeed, try again. But consider changing the technique of removal. Remember the law of diminishing returns.

References:

Pem playbook: excellent peds podcast by Dr.  T Horeczko - ‎2015

Wiki EM: Ear foreign body

POTD: Cavernous sinus thrombosis (CST)

Clinical Scenario:

A 30-year-old woman presents with headache, fever, and decreased vision in her right eye over the past 24 hours. Examination reveals exophthalmos of the right eye and no pupillary reflex and a clear anterior chamber. When asked, she denies weakness and numbness.

What is the most likely diagnosis?

Last week we talked about cerebral venous sinus thrombosis (CVST), today let’s talk about cavernous sinus thrombosis (CST), or the infected subset of cerebral venous sinus thrombosis.

What is it?

• Cavernous sinus thrombosis (CST) is a rare condition, defined as a septic thrombophlebitis of the cavernous sinus. It is caused by a bacterial infection that typically originates in the face, sinuses, ears, or orbits. Most infectious etiologies in cavernous sinus thrombosis are from Staphylococcus or Streptococcus species. 

• The two cavernous sinuses are located on both sides of the sella turcica. Important structures are located in, or run through, the cavernous sinus, including the pituitary gland, cranial nerves III, IV, V and VI, and the internal carotid arteries (ICA). 

• It causes significant morbidity and the mortality rate is at 20-30%.

Risk Factors

• Sphenoid and ethmoid sinusitis are the most common causes of CST. 

• Other risk factors include dental infections, facial cutaneous infections, otitis media, maxillofacial surgery, and trauma.

Presentation

• Most patients will have fever, headache, and vision changes/ocular complaints (proptosis, periorbital edema and/or chemosis). 

• Most will also have external ophthalmoplegia, due to venous congestion of orbital tissues, extra-ocular muscle inflammation and/or inflammation of cranial nerves III, IV and VI. 

• Other symptoms include eyelid erythema, autonomic dysfunction, sensory changes in the ophthalmic and maxillary trigeminal nerve distributions, pupillary abnormalities, and papilledema. 

• Vision loss is rare as the orbital nerve lies outside the cavernous sinus. 

• CST commonly spreads from one eye to both within 24 to 48 hours.

Evaluation

Blood cultures, CBC, and coagulation studies (PT and PTT) should be ordered, as well as CT of the head and orbits with contrast.

Treatment

• Parenteral antibiotic treatment should be started with gram-positive coverage (nafcillin plus a third-generation cephalosporin or vancomycin if concerned for MRSA). The patient should be admitted with neurology and ophthalmology consultations

• Anticoagulation and steroids, remain controversial.

  • Steroids may confer improved cranial nerve function.

  • Anticoagulation may confer a risk of systemic and intracranial bleeding and may result in dissemination of septic emboli. Consider anticoagulation only if there is no evidence of severe bleeding risk or current hemorrhage.

Differences between CVST and CST

References

PEER IX

http://www.emdocs.net/cavernous-sinus-thrombosis/