ENT case

ENT Case PresentationRunal Shah

PGY-2Masters in Emergency Medicine

KDAH

45/ Female, walks to A&E Triage at 10.45pm on Sunday

Complaints – sudden onset pain, swelling of right cheek for 2 hours.

A, B, C, D – all correct

Vitals◦ T- Afebrile◦ P- 84/min◦ R- 16/min◦ BP- 120/70 mmHg◦ SpO2- 97% on room air

Pain Score – 5/10

So, what is the problem we are dealing with ??

What should be done ?

Consider resources and act wisely !

Triage category ???

Interventions – ◦ IV access – scalp vein◦ Inj Dynapar 75mg in 20ml NS iv

Investigate –◦ CBC

◦ Imaging – CT scan / USG soft parts ??

S – Pain and swelling of the right cheek, for approx 2 hours, following dinner, No fever, similar complaints in the past

A – no allergiesM – no meds on routine basisL – dinner at 8.30pmE – none

Secondary survey –

HEENT –

Inspection – ◦ vague swelling of right cheek, comparable increase in

size as to left cheek◦ asymmetry of face !◦ Oral mucosa healthy, no purulent discharge.

Palpation – ◦ mild tenderness over right cheek◦ on per-oral palpation no stones palpable

Rest of the systems – unremarkable

Reassessment

Pain score 1/10 – discomfort onlySwelling was sameDiscussed with pt regarding need of imaging for

the same to rule out sialolithiasis

USG soft parts – ◦ right parotid gland duct stone of 1.7mm !◦ No obvious inflammatory changes within right parotid

gland

CBC◦ 13.2 / 40 / 7800 / 2,90,000

Disposition

Explained the condition to the patient, discharged with ENT follow up in OPD.

On discharge Rx◦ Tab Voveran-SR 75mg 1—0—0 x 3 days◦ Tab Pantocid 40mg 1—0—0 x 3 days, 30min before

breakfast◦ Warm compresses over right cheek

Concrements (stones) formed in the salivary gland parenchyma or duct due to increased viscosity or stasis.

1% populationM > FAge group : 30-50Submandibular gland (80-90%) >> Sublingual >

Parotid

Case Discussion – Sialolithiasis

Differentials :

1) Infections – Bacterial

(Staphylococcus, Strep Viridans, Pneumococcus, H influenza)

Viral – Mumps

2) Inflammation3) Granulamtous4) Neoplastic

Commonly forms around an organic nidus.

Clinical presentation

Pain, swelling, tenderness overlying the gland, Purulent discharge from the duct

Difficult to differentiate between parotitis and sialolithiasis clinically as they may co-exist or may be causative of each other !!

Features favoring Sialolithiasis :◦ Typically Unilateral◦ Pain, swelling aggravated post meals

Management in ED

Diagnosis is clinicalPer-oral palpation with gland massage may

reveal stone or purulent discharge

Imaging – ◦ X-ray◦ USG◦ CT◦ MRI◦ Sialography

Pain relief by NSAIDs

Ultrasound appearance

Small High Frequency probes (Vascular probe)

DispositionIf palpable stone is removed in ED – f/up with ENT

in 3-4 days

If not, ENT f/up within 24 hours

Discharge treatment – 1) Hydration2) Moist heat3) Massage

4) Analgesics5) Sialogogues (Lemon

drops)6) Antibiotics

Thank You…

Ref :

◦Rosen 8/e◦Tintinalli 7/e

◦http://radiopaedia.org/articles/sialolithiasis

Health & Medicine

ENT case