An always popular topic is the drainage of peritonsillar abscesses. Sometimes it can be difficult to aspirate from a syringe using only one hand, especially with the awkward angle that you might encounter. I can never find syringes with the side rings to allow you to grasp the syringe more securely with one hand (see photo above).
A sister and brother, aged 7 and 14, respectively present with pharyngitis. The 7F has sore throat, cough, fever, and post-tussive vomiting for 1 day. She has posterior pharyngeal erythema, no lymphadenopathy, no exudate, no petechiae, and looks like a viral URI.
The 14M had culture confirmed GAS pharyngitis 3 weeks ago, was treated with PCN-VK and symptoms resolved. Now, he’s in the ED with signs and symptoms of pharyngitis again, including dysphagia, fever, cough, posterior pharyngeal erythema, swollen tonsils, LAD, and petechiae on his hard palate.
Peritonsillar abscess drainage in the ED continues to be one of my favorite procedures to perform. There are several tricks to increase your chances for a successful aspiration. One trick involves using a curved laryngoscope to help depress the tongue AND provide a bright light source.
What if you don’t have a laryngoscope readily available?
Performing a physical exam on frightened pediatric patients can often be challenging. I am always thrilled to add more child-whisperer techniques to my arsenal of tricks. I have written in the past about:
- Balloonimals iPhone app to grossly assess peak flow
- Candleflame iPhone app to grossly assess peak flow
- Eye Handbook iPhone app with pediatric fixation animation targets
- Casting/splinting your buddy bear
What’s your trick on performing an otoscope exam of the ears?
The Dix-Hallpike maneuver is used to help diagnose benign paroxysmal positional vertigo (BPPV).
- Place the gurney’s head of the bed down flat.
- Reposition the patient so that s/he is sitting another 12 inches or so closer towards the head of the flat gurney.
- Rotate patient’s head 45 degrees.
- Help the patient lie down backwards quickly.
- The patient’s head should be hanging off of the gurney edge in about 20 degrees extension.
- Observe for rotational nystagmus after a 5-10 second latency period, which confirms BPPV.
I find 2 things challenging in this maneuver.
- The patient often does not like to be moved AT ALL while feeling nauseously vertiginous. This even includes trying to reposition the seated patient closer to the head of the bed. This requires them to look behind them to see what where they are going, which sets off more vertigo.
- In some of our ED rooms and hallways, the head of the gurney bed is often abutting a wall, a portable monitor, or some equipment. It takes a little fancy shuffling to make room for the Dix-Hallpike maneuver.
Trick of the Trade: A modified Dix-Hallpike maneuver
The key is to maintain about 20-30 degrees of neck extension to align the posterior semicircular canals with the direction of gravity. Placing several blankets under the patients’ shoulders can accomplish this same position without having to scoot the patient close to the gurney edge. I’m sure the patient would appreciate keeping their head movement to a minimum.
One of the hardest bandages to apply well is one for auricular hematomas. After drainage, how would you apply a bandage to prevent the re-accumulation of blood in the perichondrial space?
Traditionally, one can wedge xeroform gauze or a moistened ribbon (used for I&D’s) in the antihelical fold. Behind the ear, insert several layers of gauze, which have been slit half way to allow for easier molding around the ear. Anterior to the ear, apply several layers of gauze to complete the “ear sandwich”. Finally, secure the sandwich in place with an ACE wrap, which ends up being quite challenging because of the shape of the head.
One of the most uncomfortable procedures that we do on patients is a nasogastric (NG) tube. The maximal pain comes when the NG tube has to make a right angle turn in the posterior nasopharynx. The same goes for the nasopharyngeal (NP) fiberoptic scope. There are many approaches to topical anesthesia, including using benzocaine sprays, gargling with viscous lidocaine, squirting viscous lidocaine in the nares +/- afrin spray, and nebulizing lidocaine. None, however, really apply an anesthetic directly over the most sensitive area AND test for its effectiveness.