Head, Eye, Ear, Nose, Throat Emergencies practice questions

Answer: B) Hold it by the crown and transport it covered in cow's milk

Putting an avulsed permanent tooth back in the socket is best. If that isn't possible, hold it by the crown, keep it moist (cow's milk, saliva or a storage kit), and get to care right away. Don't scrub it, dry it or disinfect it.

• AIncorrect. Touching or scrubbing the root damages the cells needed for reattachment. Hold the tooth only by the crown.
• BCorrect. When the tooth can't be put back in the socket, which is the preferred option, a container of cow's milk keeps it moist. Holding it by the crown protects the root. Keeping it in the mouth between lip and gum, or using a tooth-saving storage kit, also works. Time matters, so the patient should come in right away.
• CIncorrect. The tooth must be kept moist at all times. Letting it dry lowers the chance that reimplantation will work.
• DIncorrect. Cleaning the tooth with alcohol or peroxide damages the root surface and should be avoided.

Answer: C) Perform an immediate lateral canthotomy and cantholysis at the bedside

Post-traumatic tense proptosis with vision loss, an afferent pupillary defect and IOP of 40 mm Hg or higher means orbital compartment syndrome from a retrobulbar hematoma. Immediate lateral canthotomy and cantholysis is needed, without waiting for imaging.

• AIncorrect. When signs of optic nerve compromise are present, surgical decompression should not be delayed for imaging. Outcomes are best when treatment happens within about 2 hours.
• BIncorrect. External pressure raises orbital pressure further and makes optic nerve ischemia worse in orbital compartment syndrome.
• CCorrect. These findings suggest a retrobulbar hematoma with orbital compartment syndrome. When vision is compromised and IOP is 40 mm Hg or higher, lateral canthotomy and cantholysis is the definitive emergency treatment. It decompresses the orbit and can save vision.
• DIncorrect. Timolol, acetazolamide and mannitol can help in mild cases without optic nerve compromise, but they do not replace urgent surgical decompression when vision is threatened.

Answer: B) Branches of the sphenopalatine artery in the posterior nasal cavity

Bleeding into the posterior pharynx with no visible anterior site, despite pressure and vasoconstrictors, suggests posterior epistaxis from sphenopalatine artery branches. It often needs posterior packing or a balloon, admission, and airway monitoring.

• AIncorrect. Kiesselbach (Little's) area causes about 90% of nosebleeds. These bleeds are usually visible on exam and usually respond to direct pressure, vasoconstrictors, or cautery. That does not fit this patient.
• BCorrect. Posterior epistaxis comes from terminal branches of the sphenopalatine and posterior ethmoidal arteries (Woodruff plexus). It typically shows as bleeding into the posterior pharynx with no anterior source, and it does not respond to anterior pressure. It may need posterior packing or a balloon catheter, admission, and close airway monitoring.
• CIncorrect. Anterior ethmoidal branches feed the anterior septal blood supply, so a bleed there would usually be seen on anterior exam and controlled by anterior measures. Bleeding into the posterior pharynx that persists despite pressure points to a posterior source.
• DIncorrect. Blood from posterior epistaxis can be swallowed or coughed up and look like hemoptysis. In this patient, though, the bleeding clearly starts in the nose and drains down the posterior pharynx, which is a posterior nasal source.

Answer: B) Cover the exposed area with a calcium hydroxide dressing and arrange an expedited dental referral

A pink or bleeding center in a fractured tooth means the pulp is exposed. The ED should cover it (for example, with calcium hydroxide) to protect the pulp and arrange an expedited dental referral.

• AIncorrect. Smoothing the edges and routine follow-up are right for an enamel-only fracture. A pink, bleeding center shows that the pulp is exposed, so this fracture is deeper and more urgent.
• BCorrect. A pink or red, bleeding center means the pulp is exposed (an Ellis III–type fracture). Covering it, for example with calcium hydroxide, protects the pulp from bacteria. Any fracture with pulp exposure needs an expedited dental referral.
• CIncorrect. A fracture into dentin without pulp exposure shows yellowish dentin. A pink color or blood means the pulp is involved, which needs urgent referral, not routine follow-up.
• DIncorrect. Exposed pulp should be covered to prevent bacterial invasion and keep the tooth alive. Waiting 1 to 2 weeks for dental care raises the risk of losing the pulp.

Answer: A) Keep the patient sitting upright and prepare difficult-airway and surgical-airway equipment

Ludwig angina is a fast-spreading cellulitis of the floor of the mouth, usually from a dental source, and can block the airway. Protecting the airway comes first: keep the patient upright and prepare difficult and surgical airway equipment.

• ACorrect. Ludwig angina can rapidly block the airway as the tissues and tongue swell. Protecting the airway comes first: let the patient stay upright and have advanced and surgical airway equipment ready.
• BIncorrect. Imaging is only for stable patients who can breathe comfortably and handle their secretions while lying flat. Lying a drooling patient flat can make the airway obstruction worse.
• CIncorrect. Ludwig angina needs broad-spectrum IV antibiotics and hospital care. A patient who is drooling cannot reliably swallow oral medicine, and outpatient care ignores the airway threat.
• DIncorrect. Sedating the patient before a plan to secure the airway is in place can cause sudden loss of the airway. When intubation is needed, awake fiberoptic intubation is preferred.

Answer: D) Orbital cellulitis

• AIncorrect. That doesn't cause proptosis.
• BIncorrect. That doesn't cause proptosis.
• CIncorrect. That's a localized eyelid infection.
• DCorrect. It needs IV antibiotics and imaging.

Answer: C) Keep the child calm

• AIncorrect. Let the child keep a position of comfort.
• BIncorrect. This can trigger obstruction.
• CCorrect. Avoid examining the throat; prepare for airway management.
• DIncorrect. Avoid upsetting the child.

Answer: B) Laryngeal injury; reassess the airway often and prepare for a surgical airway if it worsens

Hoarseness, pain over the thyroid cartilage, and subcutaneous emphysema after blunt anterior neck trauma suggest laryngeal injury. The priority is ongoing airway assessment and readiness for a surgical airway.

• AIncorrect. A muscle bruise does not explain hoarseness or crepitus (subcutaneous emphysema). Together, these findings point to an airway injury that needs close monitoring, not discharge.
• BCorrect. Hoarseness, anterior neck pain, and subcutaneous emphysema after blunt neck trauma are warning signs of laryngeal injury. The airway can deteriorate quickly. If it becomes unstable, a surgical airway may be needed, because intubation attempts can worsen the injury.
• CIncorrect. Blunt neck trauma can cause carotid dissection, but that usually shows up as neurological deficits. Dissection does not explain hoarseness or air in the soft tissues of the neck.
• DIncorrect. Epiglottitis is an infection, not a traumatic injury. A direct blow followed by hoarseness and crepitus points to laryngeal injury.

Answer: B) Acute mastoiditis

Swelling, redness and tenderness behind the ear with the auricle pushed forward, after otitis media, suggests acute mastoiditis. It needs prompt parenteral antibiotics, imaging, and possibly surgical drainage.

• AIncorrect. Otitis externa is an infection of the ear canal. It causes pain when the tragus or pinna is moved and swelling of the canal. It does not usually cause a fluctuant swelling over the mastoid that pushes the auricle forward.
• BCorrect. Mastoiditis is a complication of middle ear infection. Swelling behind the ear can make the ear stick out, and the child may also have fever, pain, drainage and hearing loss. Treatment usually starts with antibiotic injections. CT or MRI is used to evaluate the mastoid, and mastoidectomy or myringotomy may be needed if antibiotics fail.
• CIncorrect. An enlarged postauricular lymph node is usually a discrete, mobile lump. It does not cause diffuse boggy swelling over the mastoid bone that pushes the auricle outward after a recent otitis media.
• DIncorrect. Perichondritis is an infection of the cartilage of the outer ear. It causes a red, swollen pinna, not swelling over the mastoid bone behind the ear after a middle ear infection.

Answer: B) A Le Fort fracture

• AIncorrect. The movement suggests a fracture.
• BCorrect. Watch the airway closely.
• CIncorrect. It's a trauma finding.
• DIncorrect. It's a trauma finding.