INTERNS NOTES - Otorhinolaryngology

OTORHINOLARYNGOLOGY

RADIOLOGY MASTOID SERIES (MaST – M[eyer]aS[chuller]Townes) Towne’s View Meyer’s View Projection AP projection of the skull with AP projection of the skull with the head the beam source 30°  above turned 45°  toward the side one wishes the canthomeatal line to examine & the beam source 45° above the canthomeatal line View Clear view of the foramen, Provides axial view of the external comparison of the petrous auditory meatus, mastoid, & petrous pyramid & mastoids bone

Cholesteatoma: (1) enlarged mastoid antrum, (2) round lucency usually > 1cm in size, surrounded by an area of sclerosis

Schuller’s Schuller’ s View Lateral projection of the skull with the beam source 30°  above the canthomeatal line Shows extent of pneumatization of the mastoid (1) Pneumatic – well-developed mastoid air cells (2) Diploic – with few large air cells (3) Sclerotic – with opacity due to calcification

PARANASAL SINUS SERIES

Projection

Best view

Also shows

Water’s View Occipitomental view or chin-nose view Patient’s head is tilted with the nose & the chin on the film, orbitomeatal line is 37° from the film, x-rays are directed horizontally Maxillary sinus Open mouth Water’s view – sphenoid sinus Frontal & anterior ethmoid sinuses Nasal bones, requested if suspecting nasal fractures together with Nose STL

Caldwell View Occipitofrontal view orforehead-nose view PA viewofthe skull with the beam 15-20°  from the horizontal

Skull Lateral

Frontal sinus

Sphenoid sinus

Anterior ethmoid & sphenoid sinuses, lamina papyracea

Posterior ethmoid, frontal, & maxillary sinues & sella turcica

no maxillary, no post. ethmoid

no ant. ethmoid

Basal View Submentovertical view Pt’s infraorbitomeatal line is parallel to the film, x-rays perpendicular to the infraorbitomeatal line through the sella turcica Zygomatic arch fractures Sphenoid, posterior ethmoid, maxillary & frontal sinuses

no ant. ethmoid

no post. ethmoid

Panorex View mandible • Provides the best view of the mandible fractures (most common site being the angle, having the thinnest bone), dentoalveolar dentoalveolar • Requested when suspecting mandibular fractures abscess (DAA), ameloblastoma, & oseteomyelisis of the mandible Neck soft tissue lateral (Neck STL) laryngotracheobronchitis (seen • Requested when suspecting foreign body lodged in the neck, epiglottitis (seen as “thumb sign”), laryngotracheobronchitis as “steeple sign”) CXR AP-L to include the neck and abdomen aerodigestive tract • Requested when suspecting foreign body in the aerodigestive AP-L to include the neck (or a separate STL when not possible), possible), plain abdomen • Possible for children, otherwise request for CXR AP-L Nose soft tissue lateral (Nose STL) view when suspecting nasal nasal bone fractures • Requested together with Water’s view

THE EAR IMPACTED CERUMEN Signs and Symptoms a. sense of ear fullness b. otalgia (ear pain) – usually felt after getting water into the ear, because the cerumen swells, swells, impinging on the pain receptors in the external ear. May occur with secondary otitis externa because of the clumsy efforts to remove the cerumen. c. Conductive hearing loss – usually not clinically significant. significant. On Weber’s, there is lateralization to the affected ear (may not be appreciated when impaction is not significant) never exceeds 20 dB

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Treatment Softening of cerumen with baby oil or commercially available ceruminolytics, such as Docusate Na (Otosol) 0.5% X 10mL (Lie on the side, turning the head sideways, slightly towards the surface on which you are lying. Fill the ear canal & stay in this position for 5 minutes then insert a cotton wool plug. Repeat to the other ear if necessary. Max of 2 consecutive nights.). Have the pt come back after 1 week for aural irrigation with clean lukewarm water. Aural irrigation is done with the stream directed behind the cerumen and not directly at it, which may push it further down the canal. CI to irrigation: ear pain and ear discharge (TM maybe perforated) Sample Chart Entry Apply 3 baby oil drops 3gtts TID X 7 days on affected ear Avoid ear manipulation (AEM) TCB after 7 days for aural irrigation

OTITIS EXTERNA • May result from ear manipulation (e.g. sharp metal objects) or the presence of foreign objects/foreign body (FB) • Most common etiologic agent is Staphylococcus aureus , a normal flora of the external ear Classification a. Diffuse – swimmer’s ear. Swelling of the entire external auditory meatus (EAC) b. Circumscribed – furunculosis. There is only a circumscribed swelling affecting the hairy portion of the EAC Signs and Symptoms a. otalgia b. serous ear discharge c. tenderness on manipulation of pinna or tragus d. hearing loss if swelling occludes the external ear e. swelling on otoscopy Otitis Externa Otitis Media Pain Severe Not as severe Tenderness on pinna / tragus Present Absent Fever Absent Present History of URTI Usually none Usually present History of ear manipulation Present Absent Hearing Not impaired Impaired Mastoid series Normal With evidence of mastoiditis Treatment a. Systemic oral antibiotic – treat the infection. For children: Cloxacillin 50 mg/kg/day in 4 divided doses X 7 days (125mg/5mL preparation) b. Topical steroid – reduce the swelling; usually prepared with antibiotic 1. Corticosporin: Hydrocortisone + Polymyxin B + Neomycin 2. Aplosyn: Fluocinilone + Polymyxin B + Neomycin 3. Synalar: Fluocinolone + Polymyxin B + Neomycin c. Oral analgesic – for pain. 1. For the elderly or those with PUD: COX-2 Inhibitors i. Etoricoxib (Arcoxia) 120 mg OD – preferred by ENT ii. Celecoxib (Clebrex 200mg OD iii. Rofecoxib (Vioxx) 25 mg OD 2. On a full stomach: Mefenamic Acid 500mg QID prn 3. For children: Paracetamol 10 mg/kg/day prn (125mg/5mL and 250mg/5mL preparations) d. Aural toilette is done prior to application of Corticosporin. If there is no response after 1 week, then suspect Pseudomonas infection and give a quinolone with anti-Pseudomonas activity such as Ciprofloxacin 500 mg tab Sample Chart Entry Cloxacillin 500mg/cap 1 cap PO QID X 7 days (adults) Corticosporin Otic Drops 3gtts TID X 7 days Etoricoxib 120 mg/tab 1 tab OD prn for pain (adults) Aural toilette with H2O2 3 gtts TID X 7 days priorto application of Corticosporin Avoid ear manipulation TCB after after 7 days f or reassessment.

ACUTE OTITIS MEDIA • Infection of the middle ear 4 weeks; persistent ear discharge on a perforated ear >6weeks • Fever not a constitutional sign ORL DEPARTMENT GUIDELINES Classification Use TOPICAL QUINOLONES (ex. Ofloxacin) a. Active – (+) discharge Administer for 10 - 14 days b. Inactive – (-) discharge > 3 months If with no resolution, extend antibiotics for 2 more weeks c. Quiescent – (-) discharge < 3 months Treatment • Mastoid series is requested to assess pneumatization of the mastoid and aseess for cholesteatoma • Pure tone audiometry and speech test to assess severity of hearing loss • Tympanometry is requested if TM is retracted, dull or suspecting chronic infection of the middle ear

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Benign Perforation is central regardless of size or shape Mucosa lining in the middle ear is edematous

There may be granulation tissue or polyps arising from the middle ear mucosa Discharge is mucoid to purulent & non-foul smelling Hearing loss is conductive Mastoid series show no cholesteatoma

Dangerous Perforation is total or located at the margin, attic (pars flaccida) or postero-superior Mucosa around the perforation is replaced by stratified squamous epithelium. Cholesteatomatous debris may be seen around the perforation or in the attic Granulation or polyps are frequently seen in the canal obscuring the drainage Discharge is purulent & foul-smelling Hearing loss is conductive and sensorineural Mastoid series reveal cholesteatoma. On PE, there may be posterior auricular or subperiosteal abscess or fistula.

Sample Chart Entry Mastoid series PTA-ST Amoxicillin 500mg/cap 1 cap TID X 14 days Corticosporin otic 3 gtts TID X 14 days (only if active) Aural toilette with H2O2 3 gtts TID X 14 days (only if active) AEM, increase OFI, KED Frequent ET opening exercises TCB after 7 da s for re-assessment Cholesteatoma: (1) enlarged mastoid antrum, (2) round lucency usually > 1cm CHOLESTEATOMA in size, (3) surrounded by an area of sclerosis • Concurrent with CSOM • Seen radiographically as an enlarged mastoid antrum (>1cm). It appears as a radiolucency surrounded by areas of sclerosis with no trabeculations. Bony destruction or erosions may be seen. Clinically, there is pearly white ear discharge, very foul smelling with TM perforation. • Plain & contrast CT scan with 1mm temporal bone cuts is requested if clinically positive for cholesteatoma for OR planning prior to possible tympanomastoidectomy

Sample Chart Entry Mastoid series PTA-ST Cranial CT scan, plain & contrast, with 1m m temporal bone cuts Pen G 4 million units IV LD ( ) ANST then 2 m illion units q6h Clindamycin 600mg IV LD ( ) ANST t hen 300mg q6h Corticosporin otic 3 gtts TID (only if suppurative) Aural toilette with H2O2 3 gtts TID (only if active) AEM, increase OFI, KED Frequent ET opening exercises TCB after 7 days for re-assessment

AURAL POLYP • Squamous hypertrophy from the middle or external ear PRESBYCUSIS • Hearing loss related to aging process • Normal otoscopy Sample Chart Entry PTA-ST For possible application of hearing aid TCB once with results

SENSORINEURAL HEARING LOSS • May be due to chronic exposure to loud noise, as a complication of CSOM, as a result of infection or tumor • On Weber, there is lateralization to the unaffected ear Sample Chart Entry PTA-ST TCB once with results

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SPEECH DELAY SECONDARY TO HEARING IMPAIRMENT • First, rule out other causes such as autism Sample Chart Entry PTA-ST Refer to Pedia for evaluation and co-management TCB once with results

EXTERNAL AUDITORY CANAL BLEEDING SECONDARY TO EAR MANIPULATION • Rule out other causes • Antibiotic is given due to damage to EAC mucosa predisposing to infection Sample Chart Entry Suction Cloxacillin 500 mg/cap 1 cap QID X 7 days Etoricoxib 120 mg/tab 1 tab OD prn for pain TCB after 1 week for re-assessment

THE NOSE SINUSITIS • Most common etiologic agents: S. pneumonia , H. influenza , Moraxella catarrhalis , anaerobes Signs and Symptoms a. nasal obstruction b. mucopurulent nasal discharge c. paranasal pain d. headache e. paranasal tenderness f. congested nasal mucosa on rhinoscopy g. absent illumination(frontal / maxillary sinuses) h. fever may be present i. opacities on x-ray Classification a. Acute - < 3 months Sample Chart Entry Co-amoxiclav 625 mg/cap TID or 1g BID X 7 days Increased OFI TCB after 1 week for re-asessment b.

Chronic - > 3 months, most common cause is untreated acute sinusitis; usually mized flora

Sample Chart Entry PNS series Co-amoxiclav 625 mg/cap TID or 1g BID X 7 days Increased OFI Nasal douche BID on each nostril, increased OFI TCB after 1 week for re-asessment

Treatment Nasal douche is prepared by mixing 1 tsp rock salt, 1 tsp baking soda, and 1L of boiled tap water made to cool. ALLERGIC RHINITIS Signs and Symptoms a. rhinorrhea b. sneezing (>4x/day, usually in the morning) c. nasal obstruction d. nasal pruritus e. congested nasal mucosa on rhinoscopy f. allergic salute (crease near the tip of the nose due to frequent rubbing) g. allergic shiners (skin hyperpigmentation below the lower eyelid) h. triggers – may be present; most common allergens are household dust mite, cockroach, grass pollen, molds i. family history of allergy  j. personal history of bronchial asthma or eczema

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Treatment a. Topical steroid – relieve the inflammation 1. Fluticasone (Flixotide) Fluticasone nasal spray 2 puffs / nostril BID X 14 days & prn – Usually prescribed by ENT 2. Budesonide (Budecort) nasal spray 64 mcg/dose [X 120 doses] Initially 2 puffs in each nostril daily. Maintenance: 1 puff in each nostril daily. b. Oral anti-pruritus 1. Cetirizine (Virlix) 10 mg/tab 1tab OD at HS X 14 days & prn 2. Loratidine (Claritin) 10 mg/tab 1tab OD at HS X 14 days & prn c. Decongestant are not of proven benefit and may cause rebound rhinitis (rhinitis medicamentosa) if used for more than 5 days Sample Chart Entry Fluticasone nasal spray 2 puffs / nostril BID X 14 days & prn Cetirizine (Virlix) 10 mg/tab 1tab OD at HS X 14 days & prn Avoid exposure to allergen Refer to Allergy Clinic Re: Skin testing TCB after 2 weeks for re-assessment

NASAL POLYPOSIS •  Usually arises from the osteomeatal complex (MIM HUBAd: Middle meatus, Infundibulum, Maxillary sinus ostium, Hiatus semilunaris, Uncinate process, Bulla ethmoidalis, Agger nasi) Signs and Symptoms a. Nasal obstruction – may cause sinusitis due to obstruction of the drainage of frontal and maxillary sinuses b. Anosmia c. Rhinorrhea (watery to mucoid) d. Smooth, gelatinous, semitransparent to pale white mass on anterior rhinoscopy Grading 0 No polyps I Polyps do not prolapse beyond the middle turbinate & may require endoscopy for visualization II Polyps extend below the middle turbinate. Visible with nasal speculum. III Polyps touching the nasal floor. May occlude the entire nasal cavity. May be seen through the vestibule without the aid of a nasal speculum Comparison of Nasal Polyp & Turbinates Nasal Polyps Turbinates Color “skinned grapes” Pink to red Decongestant effect (-) (+) Mobility Mobile Fixed Sensation (-) (+) Location Usually at osteomeatal complex Along entire lateral nasal wall Consistency Soft Hard Treatment a. Surgery: (PEA) Polypectomy, Ethmoidectomy, Anthrostomy. Done under LA if middle-aged. Done under GA in children & elderly. b. Steroids – given 1 week prior to OR to decrease the swelling & minimize bleeding intraop 1. Prednisone 10mg/kg OD X 1 week prior to OR 2. Methylprednisolone 16 mg 2 tab OD every other day for 1 week c. SAPOD clearance: CBC with PC & DC, BUN/Crea, RBS/FBS, Na, K, Cl, U/A, 12L ECG, CXR Sample Chart Entry PEA/LA c/o minor OR Prednisone 10mg/kg OD X 1 week prior to OR SAPOD clearance: CBC with PC & DC, BUN/Crea, RBS/FBS, Na, K, Cl, U/A, 12L ECG, CXR TCB once with results for OR scheduling

NASAL FOREIGN BODY • Usually presents as a unilateral, foul-smelling, purulent nasal discharge, usually in children & handicapped • Removal may be done with theuse of Hartmann forceps, alligator forceps, or a blunt right-angled hook. Done in office setting with the use of restraints for uncooperative patients, especially children. INVERTING PAPILLOMA • Most common benign neoplasm in the nose & sinuses • Pre-malignant lesion usually unilateral • 10% develops SCCA • Complete excision

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THE THYROID GLAND Hyperthyroidism Hypothyroidism Nervousness Fatigue, lethargy Weight loss Weight gain Excessive sweating Cool, dry, coarse skin; loss of hair Warm, smooth, moist skin Swelling of the face, hands, legs, non-pitting edema Heat intolerance Cold intolerance Muscular weakness, tremor Weakness, muscle cramps, arthralgia, paresthesia Lid lag, exophthalmos, stare Peri-orbital puffiness Palpitations, hyperdynamic cardiac pulsations, accentuated S1 Decreased intensity of heart sounds Tachycardia Bradycardia ↑ SBP, ↓ DBP ↓ SBP, ↑ DBP Frequent bowel movements Constipation Toxic SSx: Heat intolerance, palpitations, dysphagia/dyspnea, finger tremors

NODULAR NON-TOXIC GOITER (NTNG) • Present as an asymmetric anterior neck mass (ANM) that moves with deglutition and usually nodular on palpation; no or minimal symptoms of hypo/hyperthyroidism Sample Chart Entry FNAB FT4, TSH TCB once with results

DIFFUSE TOXIC GOITER (DTG) • Presents as symmetric ANM which moves with deglutition and smooth on palpation; with symptoms of hyperthyroidism • FT4 is requested and not total T4 because it is the active form. Free T3 is only requested when both FT4 & TSH are normal and the pt is clinically hyperthyroid. Between the two, TSH is more diagnostic of hyperthyroidism. Sample Chart Entry FT4, TSH CBC with PC & DC 12L ECG PTU 50mg/tab 2 tabs TID (Maximum of 600mg/day) Propranolol 10mg/tab 1 tab BID (for tachycardia, palpitations, and anxiety) Refer to ENDO re: DTG

NODULAR TOXIC GOITER • Not very common; presents as an asymmetric ANM which moves with deglutition and nodular on palpation, but presents with symptoms of hyperthyroidism Treatment FNAB is done because of higher rate of occurrence of CA in nodular goiter Sample Chart Entry FNAB FT4, TSH PTU 50mg/tab 2 tabs TID (Maximum of 600mg/day) Propranolol 10mg/tab 1 tab BID (for tachycardia, palpitations, and anxiety) Refer to ENDO re: NTG

DIFFUSE NONTOXIC GOITER • Not very common, presents with symmetric ANM which moves with deglutition and smooth on palpation but has no symptoms of hyperthyroidism Treatment FNAB is not done due to low incidence of CA in DNTG. Thyroid scan is requested to determine the size and activity of the ANM. Sample Chart Entry Thyroid scan FT4. TSH TCB once with results

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Most common complications of thyroid surgery a. Hemorrhage – if this occurs post-op, remove the sutures immediately to protect the airway b. Hypocalcemia – occurs if all parathyroid glands are inadvertently removed or if ischemia occurs c. Recurrent laryngeal nerve transaction – Pt would present with hoarseness

THE UPPER AERODIGESTIVE TRACT BELL’S PALSY • Facial nerve paralysis (CN VII) usually following viral infection Grading of Facial Nerve Involvement 1-2 risorius involved; can’t smile 3-4 cheeks involved 5 orbicularis involved; can’t close eyes 6 frontalis involved; can’t wrinkle forehead Sample Chart Entry EMG-NCV Prednisone 5mg/tab 4 tabs AM, 3 t abs lunch, 2 tabs PM X 2 weeks Etoricoxib 120 mg/tab for pain Refer to Neuro Refer to Ophtha re: Exposure keratitis

TEMPOROMANDIBULAR JOINT DYSFUNCTION •  Most common: Myofascial pain and dysfunction, usually the result of bruxism or jaw clenching, related to stress/ anxiety/ depression/ chronic pain. • Less commonly due to mechanical problem or OA. Or primary internal derangement of joint (has clicking during open/close) leading to disc displacement, due to m any causes. Etiology a. Traumatic (OA, condylar fx, TMJ subluxation, whiplash, capsulitis synovitis) b. Dental (malocclusion, reconstruction, poor fitting prosthesis/ dentures/ orthodontics) c. Iatrogenic (ETT intubation, surgical) d. Systemic (RA, gout, Pagets, psoriasis) e. Infectious (GC, syphilis, TB, actinomycosis, RF, Lyme dz --> cyclic pain q1-3mo lasting 7-14d) f. Congenital (aplasia, hyperplasia, hypoplasia, bifid condyle) g. Others: stress, bruxism, idiopathic, myofascial pain. 3 Cardinal features a. orofacial pain – Classic: pain in front of tragus with radiation to ear/ lower jaw/ cheek/ temple. Preauricular, temporal, ear that may radiates to head/face/eye. Pt also may c/o pain in the neck/ shoulder, tinnitus, H-A, insomnia. Pain worse in AM, may occur in cyclical episodes b. restricted jaw function - Jaw movement is described as a tightness/ sticking/ catching/locking. c. noise in the joint (crunch-pop-grind). Physical Examination a. Clicking TMJ b. Check ROM 1. Open & close, 6x/year) Sample Chart Entry For tonsillectomy/GA SAPOD clearance: CBC with PC & DC, BUN/Crea, RBS/FBS, Na, K, Cl, U/A, 12L ECG, CXR TCB once with results for OR scheduling

LARYNGITIS • Acute if 4 weeks. Sample Chart Entry Lonazolac 200mg/tab 1 tab BID X 2 weeks Voice rest Increased OFI Warm saline gargle TCB after 2 weeks once with results

LARYNGOPHARYNGEAL REFLUX • Characterized by foreign body sensation in the throat • Treated with Omeprazole 20mg/tab 1 tab OD X 2 weeks GASTROESOPHAGEAL REFLUX DISEASE (GERD) • Characterized by retrosternal chest pain • Treated with Omeprazole 20mg/tab 1 tab OD X 2 weeks • Diet modification: No spicy & sour food, eat small-portioned meals • Sleep at 30° angle and rest the voice FOREIGN BODY INGESTION • Pt may feel pain on the anatomic location where the FB was lodged (cricopharynx, notch on esophagus, arch of the aorta, L bronchus, lower esophageal sphincter) • Diagnostics is through radiographic studies which may be repeated every 12 hours. FB appears slit-like when in the esophagus on lateral x-rays. If FB is in the stomach, refer to Surgery. If it is in the airway but beyond the main bronchi, refer to TCVS. ENT manages FB in the esophagus and upper airway (trachea & main bronchi) • Barium swallow is done when plain radiographs are non-diagnostics. It is not requested if FB is metallic. Sample Chart Entry NPO now IVF: D5 0.9 NaCl 1L X 8 CXR-APL to include neck and abdomen (in children) CXR-APL to include the neck, plain abdomen (in adults, a separate neck STL may be requested when not possible)

SOFT TISSUE INFECTIONS CELLULITIS Sample Chart Entry Cloxacillin 500mg/cap 1 cap QID X 7 days Etoricoxib 120 mg/tab 1 tab OD prn for pain TCB after 1 week for re-assessment

ABSCESSES

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• Include dentoalveolar abscess (DAA), tonsillar abscess, parotid abscess, and parapharyngeal abscess Treatment a. Incision and Drainage. Local analgesic is not used since it is not effective in the presence of an abscess. b. Antibiotics. To cover for G (+) & (-), Pen G is given. To cover for anaerobes, Clindamycin or Metronidazole. 1. For adults: i. Pen G 4 mill ion units IV LD ( ) ANST then 2 million units q6h ii. Clindamycin 600mg IV LD ( ) ANST then 300 mg q6h OR Metronidazole 500mg IV LD ( ) ANST then 250 mg q6h 2. For children: i. PenG 50,000 units/kg IV LD ( )ANST then 25,000 units/kg q6h ii. Clindamycin 20 mg/kg IV LD ( ) ANST then 10 mg/kg q6h OR Metronidazole 15 mg/kg IV LD ( ) ANST then 7.5 mg/kg q6h 3. Preparations i. Pen G is available in 1 million units/amp preparation ii. Clindamycin is available in 1,600 mg/ amp preparation 4. After IV loading and I&D, the pt may be sent home with the following meds: i. Pen G 250 mg/t ab 1 tab QID to complete 7days (40,000 units = 250mg) ii. Clindamycin 300mg/tab 1 tab QID to complete 7 days

Sample Chart Entry S/P I & D Pen G 4 million units IV LD ( ) ANST then 2 m illion units q6h Clindamycin 600mg IV LD ( ) ANST t hen 300 mg q6h OR Etoricoxib 120mg/tab 1 tab OD prn for pain MGH Advised

LUDWIG’S ANGINA • Abscess dissecting the muscle planes of the chin which pushes the floor of the mouth upwards • Palpated as a board-like mass in the floor of the mouth • Usually originates forma DAA • Commonly caused by Borrelia  or spirochete which is responsive to Pen G / Metronidazole / Clindamycin Sample Chart Entry S/P I & D Pen G 4 million units IV LD ( ) ANST then 2 m illion units q6h Clindamycin 600mg IV LD ( ) ANST t hen 300 mg q6h OR Etoricoxib 120mg/tab 1 tab OD prn for pain MGH Advised TCB after 1 week for re-assessment

REACTIVE LYMPHADENOPATHY • Usually has a focus of infection • Commonly due to dental carries, hair lice, skin infection in the head and neck • Should rule out TB adenitis Sample Chart Entry FNAB Co-amoxiclav 625 mg/tab TID or 1 g/t ab BID X 7 days -

TB ADENITIS • May or may not present with chronic cough (>2 weeks), weight loss, failure to gain weight, anorexia • Should rule out reactive LAD Sample Chart Entry FNAB CXR AP-L Sputum AFB X 3 TCB once with results

PAROTIDITS

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• If viral (mumps), treatment is supportive with Etoricoxib 120 mg/tab 1 tab OD prin for pain, bed rest, increased OFI, and avoidance of close contact with household members • If bacterial, treat with Co-amoxiclav 625 mg/tab TID or 1 g/tab BID X 7 days

MAXILLO-FACIAL TRAUMA NASAL BONE FRACTURE • Common due to its midline location on the face • Most common mechanism of injury is mauling, followed by vehicular accidents • Usually associated with a history of impact to the midfacial area • Said to be “neglected” if fracture >14 days post-injury Signs and Symptoms a. crepitation b. step-down deformity c. nasal speculum deviation d. shortening of the nose e. increased mobility of the nose f. anosmia g. epistaxis h. CSF rhinorrhea Treatment a. Imaging – Radiographic studies cannot distinguish between recent and old fractures. Therefore, these are not useful for medico-legal cases, with a high rate of false negatives and false positives. 1. Water’s view – information regarding lateral displacement 2. Nose STL – demonstrates fracture in the anterior nasal bone b. Packing – control bleeding using antibiotic impregnated nasal pack for 2-5 days. Antibiotics are given as prophylaxis because nasal bone fractures are usually associated with lacerations of the nasal mucosa or skin. c. Antibiotics – Penicillin (Cloxacillin) and first generation cephalosporin (Cefalexin – Cefalexin 500mg cap or 125mg/5mL suspension) are usually given as prophylactic antibiotics. d. Pain Medications e. Closed reduction is done when swelling has subsided to allow for better assessment of the deformity. In children, swelling usually subsides in