About Michael Sternberg, MD

Professor
Department of Emergency Medicine
University of South Alabama

SAEM Clinical Image Series: Traumatic Swollen Eye

A 53-year-old caucasian male with a history of alcohol and amphetamine abuse presents to the Emergency Department via ambulance immediately after sustaining a fist-blow injury to the right eye. The patient denies loss of consciousness and complains of eye pain with the inability to see.

Vitals: T 36.9°C; BP 181/119; HR 110

General: Alert and oriented; anxious; agitated

Ophthalmic:

OD:

  • Visual acuity – no light perception
  • Pupil 4mm, irregular shape, and fixed
  • Extraocular movement – none
  • Proptotic; Conjunctival prolapse; Subconjunctival hemorrhage
  • Anterior chamber hyphema
  • IOP 55 mmHg

OS:

  • Visual acuity – 20/20
  • Pupil 3mm round and reactive
  • Extraocular movement – intact
  • IOP 12 mmHg

Non-contributory

A lateral canthotomy and cantholysis.

This procedure is easily performed at the bedside in the ED and the transected lateral canthal tendon and inferior/superior crus can be repaired during the repair of the presenting injury. Patients report improvements in pain and sometimes vision in as little as 10 minutes after the procedure.

A CT should be ordered after performing a lateral canthotomy and cantholysis to minimize the complications associated with elevated retrobulbar pressure including ischemia and permanent loss of vision. This photograph depicts a patient who presented to the ED suffering from the effects of orbital compartment syndrome (OCS) after being punched in the eye. OCS can develop from as little as 7mL of fluid accumulation in the retro-orbital space and can rapidly lead to permanent blindness if ischemia is present for more than 100 minutes. Symptoms of OCS requiring immediate lateral canthotomy and cantholysis include: proptosis, increased intraocular pressure, Marcus-Gunn pupil, decreased acuity, or restricted ocular movements. Importantly, OCS is a clinical diagnosis, and treatment of this condition should not be delayed for further testing or diagnostic workup. While treatment may not result in the return of vision, there are many case reports of patients regaining full or partial vision up to two hours after the onset of symptoms.

Take-Home Points

  • Don’t delay! Quick action can save your patient’s vision.
  • Signs of OCS requiring immediate bedside surgical intervention include:
    • Proptosis
    • Increased intraocular pressure
    • Marcus-Gunn pupil
    • Decreased visual acuity
    • Restricted ocular movements
  1. Rowh AD, Ufberg JW, Chan TC, Vilke GM, Harrigan RA. Lateral canthotomy and cantholysis: emergency management of orbital compartment syndrome. J Emerg Med. 2015 Mar;48(3):325-30. doi: 10.1016/j.jemermed.2014.11.002. Epub 2014 Dec 16. PMID: 25524455.
  2. Jaksha AF,Justin GA, Davies BW, Ryan DS, Weichel ED, Colyer MH. Lateral Canthotomy and Cantholysis in Operations Iraqi Freedom and Enduring Freedom: 2001-2011. Ophthalmic Plast Reconstr Surg. 2019 Jan/Feb;35(1):62-66. doi: 10.1097/IOP.0000000000001168. PMID: 29979268.

 

 

By |2021-09-08T11:14:28-07:00Sep 20, 2021|Ophthalmology, SAEM Clinical Images|

SAEM Clinical Image Series: A Recurring Neck Mass

A 30-year-old female with no significant past medical history presents to the Emergency Department with a six-day history of an enlarging, tender, red “bump” on her anterior neck. She reports similar swelling during bouts of pharyngitis. She also reports a recent upper respiratory infection one week ago that was marked by fever, cough, congestion, sore throat, and myalgia. She denies shortness of breath, neck trauma, travel, or animal exposures.

Vitals: T 37°C; BP 122/78; HR 77; RR 17

General: Well-developed, well-nourished female in no acute distress

HEENT: 2cm tender, fluctuant, mobile right anterior neck mass with surrounding erythema; no drainage noted; mass does not move with swallowing

The remainder of the exam is unremarkable.

Non-contributory

Second branchial cleft cyst

Branchial cleft anomalies are the second most common type of congenital neck mass and present as cartilaginous remnants, sinuses, fistulas, or cysts due to the failure of the branchial apparatus to obliterate. The most common are second branchial cleft anomalies, representing 95% of these cases. Second branchial cleft anomalies are usually located along the anterior border of the sternocleidomastoid muscle on the left side of the neck.

Differential diagnoses include thyroglossal duct cyst, neck abscess, cystic hygroma, cervical lymphadenopathy, metastatic lymph nodes, and cat scratch disease.

The gold standard of treatment necessitates complete surgical excision of the entire branchial cleft anomaly. Branchial cleft anomalies are most commonly diagnosed with computerized tomography (CT) that shows a uniformly hypo-or-anechoic mass with well-defined margins and thin walls. Preoperative fine needle aspiration cytology can be used to view histopathological findings of the mass and help to rule out malignant disease. Ultrasound and MRI can also be helpful for diagnosis, preoperative localization, and preoperative identification of surrounding structures. However, for definitive diagnosis, surgical excision of the entire anomaly and pathology examination is required. If full resection is not achieved, recurrence is possible.

Take-Home Points

  • A branchial cleft anomaly is the second most common type of congenital neck mass.
  • Branchial cleft anomalies are due to failure of the branchial apparatus to obliterate and can present as cartilaginous remnants, sinuses, fistulas, or cysts.
  • The gold standard of treatment requires complete surgical excision of the entire branchial cleft anomaly to prevent recurrence.
  1. Muller S, Aiken A, Magliocca K, Chen AY. Second Branchial Cleft Cyst. Head Neck Pathol.2015;9(3):379-383. doi:10.1007/s12105-014-0592-y Zaifullah S, YunusMR, See GB. Diagnosis and treatment of branchial cleft anomalies in UKMMC: a 10-year retrospective study. Eur Arch  2013;270(4):1501-1506. doi:10.1007/s00405-012-2200-7

 

By |2021-08-20T09:57:47-07:00Aug 23, 2021|HEENT, SAEM Clinical Images|

SAEM Clinical Image Series: Facial Edema

facial edema

A 44-year-old female presents to the emergency department after noticing swelling of her tongue and face, specifically the cheeks and periorbital area. She states the swelling began two weeks ago and has progressively worsened. She also complains of redness.

Vitals: T 38.6°C; BP 135/78; HR 90; RR 18

General: Lying in bed, somewhat anxious appearing

HEENT:

  • Significant edema of bilateral cheeks and periorbital areas
  • Thinning of hair along scalp and lateral aspect of eyebrows
  • Mild macroglossia

Skin:

  • Yellow tinge to patient’s skin
  • Horizontal scar noted on the anterior aspect of the neck

TSH: 31.27 mU/L

Free T4: 0.20 pmol/L

Myxedema facies

This patient has a history of thyroidectomy, as indicated by her neck scar, and a history of noncompliance with levothyroxine.

Myxedema is a term used to describe the appearance of nonpitting edema in patients with severe hypothyroidism. While the exact mechanism is not completely understood, this edema is thought to be secondary to increased deposition of dermal hyaluronic acid, a glycosaminoglycan that can grow up to 1000x its normal size when hydrated. Carotenemia is another possible manifestation of hypothyroidism and is secondary to impaired conversion of carotenoids to retinol in the setting of low levels of thyroid hormone. Additionally, patients may exhibit patchy alopecia, fatigue, cold intolerance, goiter, coarsening of the skin, and macroglossia.

Take-Home Points

  • The presentation of hypothyroidism is widely variable and may be subtle or atypical. Classically, hypothyroidism presents with pretibial myxedema, hyporeflexia, and cold intolerance. In some cases, facial edema may be the predominant feature, as seen in this patient.
  • Brittle, thinning hair on the scalp and eyebrows is a common feature. Thinning of the hair along the lateral eyebrows is called madarosis, also known as “Queen Anne’s Sign.”
  • In a patient with Grave’s disease, maintain a high index of suspicion for hypothyroidism, either as part of the natural history of the disease or as a sequela of treatment.
  1. Safer JD. Thyroid hormone action on skin. Dermatoendocrinol. 2011 Jul;3(3):211-5. doi: 10.4161/derm.3.3.17027. Epub 2011 Jul 1. PMID: 22110782; PMCID: PMC3219173.
  2. Wiersinga WM. Adult Hypothyroidism. 2014 Mar 28. In: Feingold KR, Anawalt B, Boyce A, Chrousos G, de Herder WW, Dhatariya K, Dungan K, Grossman A, Hershman JM, Hofland J, Kalra S, Kaltsas G, Koch C, Kopp P, Korbonits M, Kovacs CS, Kuohung W, Laferrère B, McGee EA, McLachlan R, Morley JE, New M, Purnell J, Sahay R, Singer F, Stratakis CA, Trence DL, Wilson DP, editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000–. PMID: 25905416.

 

 

SAEM Clinical Image Series: Sun-burnt Hands and Lips

blistering

A 44-year-old Caucasian male with a past medical history of hepatitis C presents with a complaint of pain, swelling, and skin blistering of his hands. He also notes skin sores on his nose, lower lip, and the tops of his ears. The patient claims that these have become progressively worse since starting work a month ago in outdoor construction. The patient denies the use of medications or illicit drugs and denies any medical allergies. He admits to tobacco use and daily alcohol use. The patient denies any other symptoms.

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SAEM Clinical Image Series: The Insidious Rash

rash

A 60-year-old African American female with a history of hypertension presents to the emergency department for an itchy, diffuse rash. She first noticed the lesions a few years prior, and they have progressively become larger and more inflamed. The lesions have become severely pruritic over the last couple of months. Steroid creams did not appear to improve symptoms. Currently, the lesions on her arm have become painful with yellow drainage. The patient denies nausea, vomiting, and fever.

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SAEM Clinical Image Series: Distended Bowels

Distended Bowels Ogilvie syndrome

[Click for larger view]

Chief Complaint: Abdominal distention

History of Present Illness: A 36-year-old male with a history of cerebral palsy, gastrointestinal dysmotility, epilepsy, hypertension, gastroesophageal reflux disease, and insomnia presents to the ED after referral by his family physician for a 3-day history of abdominal distention. Due to the patient’s neurological disorder, he is unable to communicate but is accompanied by his mother who provides his medical history. The patient’s mother states that he had a loose bowel movement this morning, which is normal for him. He has had a history of bowel problems since the age of 14. Two months previously the patient was admitted for abdominal distention and had a rectal tube placed which relieved his symptoms. The patient has not experienced nausea, vomiting, or changes in bowel movements.

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