Rosen & Barkin's 5-Minute Emergency Medicine Consult (617 page)

TREATMENT

• ABCs
  
• Pre-hospital lateral canthotomy very controversial
  

• ABCs
  
• Immediate transfer to Level 1 Trauma Center
  
• If past window of 90–120 min, lateral canthotomy & inferior cantholysis may be attempted by competent physician provider
  

Surgical therapy:

• Indication: IOP >40, proptosis in unconscious patient
  
• Contraindication: Ruptured globe.
  
• The only definitive treatment
  

Lateral canthotomy and inferior cantholysis:

• Prep site with 5% Betadine
  
• Local anesthesia of cutaneous and deep tissues lateral to angle of the eye. Take caution to avoid the globe and orbit
  
• Clamp across the lateral canthus with hemostats for ∼1 min
  
• With blunt scissors cut in lateral fashion along clamp marks from lateral angle of eyelid to the orbital rim
  
• Expose the inferior and superior crus of the lateral canthal tendon by pulling down the lateral aspect of the lower lid
  
• Ligate the inferior crus at its insertion into the lower lid with blunt scissors. The lower lid should relax downward
  

• Methylprednisolone
  
  • 30 mg/kg loading dose
    
  • 15 mg/kg q6h
    
• Mannitol
  
  • 1.5–2 g/kg over 30 min, with the 1st 12.5 g over 3 min
    
• Acetazolamide: 500 mg intravenously (do not use if allergic to sulfa or sickle cell pts)
  
• Hyperbaric oxygen
  

FOLLOW-UP

• All patients with suspected ROH should be admitted for definitive treatment in the OR and observation
  
• All patients need to be followed by an ophthalmologist
  
• All patients need to be worked up for other significant trauma
  

Patients should not be discharged

• STAT ophthalmology consultation in the ED
  
• Do not delay decompression procedure due to consultation delay
  
• Emergency lateral canthotomy is within the scope of practice for emergency physicians
  

• Delayed diagnosis of retro-orbital hematoma due to:
  
  • Poor physical exam
    
• Lack of suspicion
  
• Lack of equipment such as a Tono-Pen:
  
  • Unconscious patient
    
• Waiting for CT/imaging thereby delays sight saving procedure
  
• Delayed consultation arrival
  

• Allen M, Perry M, Burns F. When is retrobulbar haemorrhage not a retrobulbar haemorrhage?
  Int J Oral Maxillofac Surg
  . 2010;39:1045–1049.
  
• Ballard SR, Enzenauer RW, O’Donnell T, et al. Emergency lateral canthotomy and cantholysis: A simple procedure to preserve vision from sight threatening orbital hemorrhage.
  J Spec Oper Med
  . 2009;9(3):26–32.
  
• Chen YA, Singhal D, Chen YR, et al. Management of acute traumatic retrobulbar haematomas: A 10-year retrospective review.
  J Plast Reconstr Aesthet Surg
  . 2012;65(10):1325–1330.
  
• Colletti G, Valassina D, Rabbiosi D, et al. Traumatic and iatrogenic retrobulbar hemorrhage: An 8-patient series.
  J Oral Maxillofac Surg
  . 2012;70(8):e464–468.
  
• Lewis CD, Perry JD. Retrobulbar hemorrhage.
  Expert Rev Ophthalmol
  . 2007;2(4):557–570.
  

CODES

376.89 Other orbital disorders

BASICS

• Deep tissue infection of the retropharyngeal space:
  
  • Potential space bound anteriorly by buccopharyngeal fascia, posteriorly by alar fascia, superiorly by skull base, inferiorly by fusion of fascial layers at T2
    
  • Space fused by raphe at midline with chains of lymph nodes extending down each side
    
  • Alar fascia is poor barrier and allows retropharyngeal infections to spread into “danger” space and posterior mediastinum
    
• Primarily a disease of children, but increasing frequency in adults:
  
  • Peak incidence at 3–5 yr when retropharyngeal nodes most prominent
    
• Prognosis is good when promptly diagnosed and aggressively managed with IV antibiotics and/or surgical drainage
  
• Complications due to mass effect, rupture, or spread are the major source of morbidity and include:
  
  • Airway compromise (most common)
    
  • Aspiration pneumonia due to rupture
    
  • Sepsis
    
  • Spontaneous perforation
    
  • Necrotizing fasciitis
    
  • Mediastinitis
    
  • Thrombosis of the internal jugular vein
    
  • Jugular vein suppurative thrombophlebitis (Lemierre syndrome)
    
  • Erosion into carotid artery (primarily adults)
    
  • Atlantoaxial dislocation from erosion of ligaments
    
  • Cranial nerve palsies (typically IX–XII)
    
  • Epidural abscess
    
  • Recurrent abscess formation (1–5%)
    

• Causes:
  
  • Most often arises from infection of nasopharynx, paranasal sinuses, or middle ear
    
  • Infection then spreads to lymph nodes between posterior pharyngeal wall and alar fascia
    
  • Trauma, foreign bodies, and iatrogenic introduction of infection from instrumentation also common cause, especially in adults
    
  • Diabetes and other immunosuppressed states may predispose to this infection
    
• Bacteriology: Predominately polymicrobial with anaerobes and aerobes
  
• Most common organisms are:
  
  • Streptococcus pyogenes
    and
    Streptococcus viridans
    
  • Staphylococcus aureus
    (including MRSA)
    
  • Respiratory anaerobes (including
    Prevotella
    ,
    Fusobacterium,
    and
    Veillonella
    )
    
• Less common organisms are:
  
  • Haemophilus
    species
    
  • Acid-fast bacilli
    
  • Klebsiella pneumoniae
    
  • Escherichia coli
    
  • Mycobacterium
    tuberculosis
    
  • Aspergillus
    and
    Candida
    species
    

DIAGNOSIS

May differ between adults and children

• Most common:
  
  • Sore throat
    
  • Neck pain/stiffness
    
  • Odynophagia
    
  • Dysphagia
    
  • Fever
    
• Additional presenting symptoms:
  
  • Stridor, dyspnea
    
  • Muffled voice
    
  • Trismus
    

Young children may present with only:

• Poor oral intake
  
• Lethargy or irritability
  
• Cough
  

• Adults:
  
  • Posterior pharyngeal edema
    
  • Nuchal rigidity
    
  • Cervical adenopathy
    
  • Fever (67%)
    
  • Drooling
    
  • Stridor
    
  • Dysphonia (cri du canard)
    
  • Tracheal “rock” sign: Tenderness on moving the larynx and trachea side to side
    
• Children and infants:
  
  • Cervical adenopathy
    
  • Fever
    
  • Neck stiffness with extension most frequently limited
    
  • Retropharyngeal bulge
    
  • Trismus
    
  • Torticollis
    
  • Drooling
    
  • Agitation
    
  • Respiratory distress
    

Rapid assessment of airway and respiratory status:

• Normal exam does not rule out diagnosis
  
• No lab tests make the diagnosis
  
• When suspicious, obtain lateral neck x-ray or CT of neck with IV contrast