# Clinical Cases: Ophthalmologic and ENT Emergencies

## Case 1: Central Retinal Artery Occlusion - Sudden Painless Vision Loss

### Patient Demographics
- **Age:** 68 years
- **Sex:** Male
- **Occupation:** Retired banker

### Chief Complaint
"I woke up and can't see out of my right eye."

### History of Present Illness
A 68-year-old male presents with sudden, painless, complete vision loss in his right eye noticed upon waking 2 hours ago. He initially thought his eye "needed to adjust" but vision has not improved. He denies eye pain, trauma, or headache. He has a history of atrial fibrillation and hypertension but admits he ran out of his warfarin 2 weeks ago.

### Initial Assessment

**ESI Level:** 2 - Time-sensitive vision-threatening emergency

**First Impression:**
- Appearance: Anxious, well-appearing otherwise
- Work of breathing: Normal
- Circulation: Normal

**Vital Signs:**
- Heart rate: 82 bpm, irregularly irregular
- Blood pressure: 162/94 mmHg
- Respiratory rate: 14 breaths/min
- SpO2: 98% on room air
- Temperature: 37.0C
- GCS: 15

### Primary Survey

**Airway:** Patent
**Breathing:** Normal
**Circulation:** Irregular pulse (atrial fibrillation), well-perfused
**Disability:** Alert, GCS 15
**Exposure:** No abnormalities

### Time-Critical Concept

**Central Retinal Artery Occlusion (CRAO) = "Stroke of the Eye"**
- Retinal tolerance for ischemia: 90-100 minutes
- Treatment window: Best within 4-6 hours
- This patient: 2 hours from symptom onset - within treatment window!

### Ocular Examination

**Visual Acuity:**
- Right eye (OD): Hand motion only (severely decreased)
- Left eye (OS): 20/25 (normal for age)

**Pupillary Exam:**
- Right eye: Afferent pupillary defect (APD) present (Marcus Gunn pupil)
  - Direct response: Sluggish
  - Consensual response: Normal
- Left eye: Normal responses

**Extraocular Movements:** Full bilaterally

**Visual Fields:** Unable to assess OD; full OS

**External Exam:**
- No proptosis
- No injection
- No discharge

**Intraocular Pressure:** OD 14 mmHg, OS 16 mmHg (normal)

**Fundoscopic Examination:**
- Right eye:
  - Pale/opaque retina (ischemic edema)
  - **Cherry-red spot** at macula (normal choroidal flush visible through thin macula)
  - Attenuated arterioles ("boxcarring" of blood column)
  - No visible embolus
- Left eye: Normal

### Differential Diagnosis of Sudden Painless Vision Loss

| Condition | Key Features |
|-----------|--------------|
| **CRAO** | Pale retina, cherry-red spot, APD |
| CRVO | Diffuse retinal hemorrhages, "blood and thunder" |
| Vitreous hemorrhage | Can't see fundus, dark red reflex |
| Retinal detachment | "Curtain" across vision, may see detached retina |
| Optic neuritis | Pain with eye movement, younger patient |

### Secondary Survey

**SAMPLE History:**
- Symptoms: Sudden painless vision loss right eye
- Allergies: None
- Medications: Warfarin (stopped 2 weeks ago), metoprolol, lisinopril
- PMH: Atrial fibrillation, hypertension, hyperlipidemia
- Last Meal: Breakfast this morning
- Events: Noticed on waking, no improvement

**Cardiovascular Risk Assessment:**
- Atrial fibrillation (off anticoagulation!) - embolic risk
- Hypertension
- Age >50

### Management

**Immediate Interventions (within treatment window):**

1. **Ocular massage:**
   - Apply firm pressure to globe through closed lid for 10-15 seconds
   - Release for 10-15 seconds
   - Repeat x5-10
   - Goal: Dislodge embolus, increase perfusion pressure

2. **Lower intraocular pressure:**
   - Acetazolamide 500mg IV
   - Timolol 0.5% one drop
   - Goal: Improve perfusion gradient

3. **Increase oxygenation:**
   - High-flow oxygen (may increase retinal O2 delivery)
   - Consider hyperbaric oxygen if available

4. **Emergent ophthalmology consultation**

**Ophthalmology Response:**
- Anterior chamber paracentesis performed (removes aqueous to rapidly lower IOP)
- Thrombolytic therapy considered (selective intra-arterial tPA - investigational)

### Diagnostic Testing

**Labs:**
- CBC: Normal
- BMP: Normal
- ESR: 28 mm/hr (mildly elevated)
- CRP: 1.2 mg/dL
- Glucose: 118 mg/dL
- Lipid panel: LDL 142 mg/dL
- INR: 1.1 (subtherapeutic - explains embolic event)

**ECG:** Atrial fibrillation with controlled rate

**Additional Workup:**
- Carotid ultrasound: 60% stenosis right ICA
- Echocardiogram: No intracardiac thrombus, LA enlargement

**Giant Cell Arteritis Consideration:**
- Age >50: Yes
- ESR elevated: Mildly
- Headache/jaw claudication/scalp tenderness: None
- Decision: GCA less likely, but ESR monitored

### Diagnosis

**Central Retinal Artery Occlusion (CRAO)** - likely cardioembolic secondary to atrial fibrillation off anticoagulation

### Outcome

Despite aggressive treatment:
- Visual acuity at 24 hours: Count fingers at 1 foot (minimal improvement)
- Visual acuity at 1 week: 20/400 (severe permanent vision loss)
- Prognosis: Poor - most patients do not recover useful vision

### Secondary Prevention

**Essential Workup (CRAO = TIA equivalent):**
- Complete stroke workup indicated
- Evaluate for other vascular disease
- Aggressive risk factor modification

**Treatment:**
- Resume anticoagulation for atrial fibrillation
- Statin therapy (high-intensity)
- Blood pressure control
- Carotid intervention considered (vascular surgery referral)

### Disposition
- Admission for stroke workup
- Ophthalmology follow-up arranged
- Discharged on apixaban (transitioned from warfarin)
- Close follow-up for carotid disease

### Teaching Points

1. **CRAO = ocular stroke:** Same risk factors, same urgency, same workup
2. **Time is vision:** 90-100 minutes of retinal ischemia tolerance; treat immediately
3. **Cherry-red spot is pathognomonic:** Normal choroid visible through thin macula surrounded by ischemic pale retina
4. **APD confirms optic nerve/retinal pathology:** Differentiates from cortical blindness
5. **Treatment options limited:** Ocular massage, IOP lowering, hyperoxia; most don't recover
6. **Secondary prevention is critical:** Full stroke workup; treat underlying cause
7. **Consider GCA:** In patients >50 with CRAO; check ESR; temporal artery biopsy if suspected

### Clinical Image
![Cherry-Red Spot in CRAO](case_01_image.jpg)

**Image Description:** Fundoscopic photograph demonstrating central retinal artery occlusion with the characteristic "cherry-red spot" at the macula (arrow) surrounded by pale, opaque retina due to ischemic edema.

**Attribution:** Image from Wikimedia Commons, Cherry red spot CRAO. Licensed under CC BY-SA 4.0. Source: https://commons.wikimedia.org/wiki/File:Central_retinal_artery_occlusion.jpg

---

## Case 2: Peritonsillar Abscess - The Sore Throat Emergency

### Patient Demographics
- **Age:** 24 years
- **Sex:** Male
- **Occupation:** College student

### Chief Complaint
"I can barely swallow and my throat is killing me."

### History of Present Illness
A 24-year-old male presents with severe sore throat for 5 days. He was diagnosed with strep throat 4 days ago and started amoxicillin but has progressively worsened. He now has severe odynophagia (9/10), drooling, and difficulty opening his mouth fully. He reports muffled voice and pain radiating to his right ear. He has not been able to eat or drink much for the past 2 days.

### Initial Assessment

**ESI Level:** 2 - Potential airway emergency

**First Impression:**
- Appearance: Ill-appearing, drooling, "hot potato" muffled voice
- Work of breathing: Slightly labored, mild stridor noted
- Circulation: Flushed

**Vital Signs:**
- Heart rate: 112 bpm
- Blood pressure: 128/78 mmHg
- Respiratory rate: 18 breaths/min
- SpO2: 96% on room air
- Temperature: 38.9C (102.0F)
- GCS: 15

### Airway Assessment

**Critical Question: Is the airway threatened?**

**Warning Signs:**
- Stridor: Mild inspiratory stridor - CONCERNING
- Drooling: Present - unable to swallow secretions
- Voice: Muffled "hot potato" voice
- Trismus: Present - limited mouth opening
- Position: Sitting forward, reluctant to lie flat

**Decision:** Airway currently stable but at risk; avoid any intervention that might obstruct airway (no blind nasopharyngeal procedures)

### Primary Survey

**Airway:** Patent but potentially compromised; prepare for difficult airway
**Breathing:** Mild increased work, audible stridor
**Circulation:** Tachycardic, well-perfused
**Disability:** Alert, anxious
**Exposure:** No external abnormalities

### Physical Examination

**Oropharyngeal Exam (performed carefully):**
- Severe trismus (inter-incisal distance 2cm)
- Muffled voice
- Deviation of uvula to the LEFT
- Right tonsillar bulging and erythema
- Right soft palate fullness
- Right anterior pillar displacement
- Purulent exudate on right tonsil
- Tender right submandibular lymphadenopathy

**Classic PTA Findings:**
- Unilateral tonsillar bulge
- Uvula deviation AWAY from affected side
- Trismus
- "Hot potato" voice

### Diagnosis

**Right Peritonsillar Abscess (PTA)**

### Secondary Survey

**SAMPLE History:**
- Symptoms: Severe sore throat, odynophagia, trismus, fever, ear pain
- Allergies: None
- Medications: Amoxicillin (started 4 days ago)
- PMH: Prior tonsillitis x2, otherwise healthy
- Last Meal: Yesterday (unable to eat)
- Events: Progressive worsening despite antibiotics

### Management

**Preparation:**
- Difficult airway equipment at bedside
- ENT consultation requested
- IV access obtained (hydration, antibiotics)

**Imaging:**
- CT neck with contrast (if diagnosis uncertain or concern for deep space infection)
- This patient: Clinical diagnosis clear; CT to assess for extension to parapharyngeal space

**CT Findings:**
- 2.5cm right peritonsillar abscess
- No extension to parapharyngeal or retropharyngeal space
- Airway patent but narrowed

### Treatment Options

| Procedure | Description | Success Rate |
|-----------|-------------|--------------|
| Needle aspiration | 18g needle into abscess | 85-90% |
| Incision and drainage | Scalpel incision, drainage | 90-95% |
| Tonsillectomy | Definitive (quinsy tonsillectomy) | 100% |

**This Patient:**
- ENT performed needle aspiration at bedside
- 8mL of purulent material aspirated
- Immediate relief of symptoms

### Procedure: Needle Aspiration

**Technique:**
1. Position patient upright
2. Topical anesthesia (lidocaine spray + pledget)
3. 18g needle on 10mL syringe
4. Insert at point of maximal fluctuance
5. Aspirate while withdrawing
6. May require multiple passes

**Results:**
- 8mL thick purulent drainage
- Sent for culture

### Antibiotic Therapy

**IV Antibiotics (initially):**
- Ampicillin-sulbactam 3g IV q6h OR
- Clindamycin 900mg IV q8h (if penicillin allergic)

**Oral Antibiotics (discharge):**
- Amoxicillin-clavulanate 875mg PO BID x 10 days

**Why amoxicillin alone failed:**
- PTA often has mixed flora including anaerobes
- Anaerobes produce beta-lactamases
- Need beta-lactamase inhibitor coverage

### Culture Results

**Aspirate culture:**
- Streptococcus pyogenes (Group A Strep)
- Fusobacterium necrophorum
- Prevotella (anaerobe)

**Polymicrobial infection typical of PTA**

### Clinical Course

**After Drainage:**
- Immediate improvement in pain
- Trismus resolved within 24 hours
- Able to drink fluids
- Fever resolved

**Observation:**
- Observed for 6 hours in ED
- Tolerated oral intake
- Discharged with oral antibiotics

### Disposition
- Discharged home after observation
- Oral antibiotics x 10 days
- ENT follow-up in 1 week
- Return if worsening symptoms
- Discussion of elective tonsillectomy (given history of recurrent tonsillitis)

### Complications to Consider

1. **Airway obstruction** - most immediate concern
2. **Parapharyngeal/retropharyngeal extension** - deep space infection
3. **Lemierre syndrome** - septic thrombophlebitis of internal jugular vein (F. necrophorum)
4. **Mediastinitis** - descending infection
5. **Aspiration of abscess contents**

### Teaching Points

1. **PTA is a clinical diagnosis:** Uvular deviation, tonsillar bulge, trismus, hot potato voice
2. **Airway first:** Prepare for difficult airway; avoid interventions that may worsen obstruction
3. **Needle aspiration is first-line:** Effective, can be done at bedside, avoids incision
4. **Antibiotics need anaerobic coverage:** Amoxicillin-clavulanate, ampicillin-sulbactam, or clindamycin
5. **Consider Lemierre syndrome:** If F. necrophorum isolated or patient has neck pain/swelling
6. **Recurrent PTA:** Consider tonsillectomy; 10-15% recurrence rate
7. **Trismus may limit exam:** CT useful if unable to adequately visualize oropharynx

### Clinical Image
![Peritonsillar Abscess](case_02_image.jpg)

**Image Description:** Intraoral photograph demonstrating a right peritonsillar abscess with uvular deviation to the left, right soft palate and tonsillar bulge, and erythema consistent with PTA.

**Attribution:** Image from Wikimedia Commons, Peritonsillar abscess. Licensed under CC BY-SA 3.0. Source: https://commons.wikimedia.org/wiki/File:PeriijTomsillitis.jpg

---

## Case 3: Posterior Epistaxis - The Bleeding That Won't Stop

### Patient Demographics
- **Age:** 72 years
- **Sex:** Female
- **Occupation:** Retired nurse

### Chief Complaint
"My nose won't stop bleeding and I'm swallowing a lot of blood."

### History of Present Illness
A 72-year-old female presents with profuse epistaxis for 2 hours that has not responded to home measures (pinching nose, ice). She reports swallowing significant amounts of blood and has vomited once (bloody emesis). She has a history of hypertension and takes aspirin daily for cardiovascular protection. The bleeding began spontaneously while watching television.

### Initial Assessment

**ESI Level:** 2 - Potential significant hemorrhage

**First Impression:**
- Appearance: Anxious, blood around mouth and in basin
- Work of breathing: Normal
- Circulation: Pale, tachycardic

**Vital Signs:**
- Heart rate: 104 bpm
- Blood pressure: 188/102 mmHg
- Respiratory rate: 18 breaths/min
- SpO2: 96% on room air
- Temperature: 36.8C
- GCS: 15

### Primary Survey

**Airway:**
- Patent but active bleeding with swallowing
- Position patient leaning forward to prevent aspiration

**Breathing:** Normal effort
**Circulation:** Tachycardic, pale, active hemorrhage
**Disability:** Alert
**Exposure:** Blood on clothing, in basin

### Classification of Epistaxis

| Type | Location | Features | Management |
|------|----------|----------|------------|
| Anterior | Kiesselbach's plexus | Visible bleeding from septum | Direct pressure, cautery, anterior packing |
| **Posterior** | **Sphenopalatine artery** | **Blood in pharynx, bilateral bleeding, profuse** | **Posterior packing, admission, possible IR/surgery** |

**This Patient - Features Suggesting POSTERIOR Epistaxis:**
- Bilateral bleeding
- Blood draining into pharynx
- Profuse, not stopping with pressure
- Elderly with hypertension on anticoagulant

### Immediate Management

**Initial Steps:**
1. Universal precautions (blood exposure risk)
2. Position: Sitting upright, leaning forward
3. Have patient blow nose (clear clots)
4. Suction equipment ready
5. IV access, type and screen
6. Apply topical vasoconstrictor

**Topical Vasoconstriction:**
- Oxymetazoline (Afrin) soaked cotton pledgets
- Place in nasal cavity, apply direct pressure x 15 minutes
- Alternative: Cocaine 4% or lidocaine with epinephrine

### Nasal Examination

**After vasoconstriction and suctioning:**
- Anterior rhinoscopy performed
- No clear anterior source identified
- Blood seen trickling posteriorly
- Bilateral bleeding (posterior source likely)

**Finding:** No anterior source identified = POSTERIOR EPISTAXIS

### Secondary Survey

**SAMPLE History:**
- Symptoms: Profuse epistaxis 2 hours, swallowing blood
- Allergies: Sulfa
- Medications: Aspirin 81mg daily, lisinopril, hydrochlorothiazide
- PMH: Hypertension, hyperlipidemia, no bleeding disorders
- Last Meal: 3 hours ago
- Events: Spontaneous onset

**Risk Factors:**
- Hypertension (uncontrolled)
- Aspirin use
- Elderly (fragile vessels)

### Management Progression

**Step 1: Anterior Packing (if posterior suspected, may bridge to posterior)**
- Merocel (expandable sponge) or Rapid Rhino placed
- Bleeding continued despite bilateral anterior packing

**Step 2: Posterior Packing Required**

**Posterior Packing Options:**
1. **Posterior epistaxis balloon catheter** (Epistat, Rapid Rhino posterior)
2. Foley catheter technique
3. Formal posterior gauze packing (requires sedation)

**This Patient:**
- Bilateral posterior packing with balloon catheters placed
- Posterior balloon inflated with 7-10mL saline
- Anterior cuff inflated
- Bleeding controlled

### Diagnostic Testing

**Labs:**
- CBC: Hgb 10.2 (likely hemodiluted, check baseline was 12.8)
- Platelets: 234,000
- PT/INR: 1.0
- PTT: 32 seconds
- Type and screen: O positive

**Hemoglobin concerning for significant blood loss** - baseline was 12.8 (per patient's knowledge)

### Additional Management

**Blood Pressure Control:**
- Epistaxis and hypertension: Control BP, but avoid hypotension
- Goal: <160 systolic
- Labetalol 10mg IV given
- BP improved to 152/88

**Aspirin:**
- Held during acute bleeding
- Discussion with cardiology re: resumption

**Transfusion:**
- Hemoglobin 10.2 in asymptomatic patient with controlled bleeding
- Not transfused; serial monitoring

### Admission Criteria for Posterior Epistaxis

**ALL patients with posterior packing should be admitted:**
- Airway monitoring (packing can dislodge, cause obstruction)
- Hypoxia risk (nasopulmonary reflex)
- Rebleeding risk
- Cardiac monitoring (vagal response)

**Additional Indications:**
- Hemodynamic instability
- Significant blood loss
- Failed outpatient management
- Need for blood transfusion

### Hospital Course

**Day 1:**
- Posterior packing in place
- No rebleeding
- Hemoglobin stable

**Day 2:**
- Packing removed by ENT
- No rebleeding after removal
- Observed for 6 hours

**Day 3:**
- Discharged home
- Blood pressure medications adjusted
- Held aspirin x 1 week (cardiology approved)
- Saline nasal spray
- Avoid nose blowing, straining
- ENT follow-up in 1 week

### When to Involve ENT/IR

**ENT Consultation:**
- All posterior epistaxis
- Failed anterior packing
- Recurrent epistaxis
- Suspected nasal mass
- Need for examination under anesthesia

**Interventional Radiology:**
- Refractory posterior epistaxis
- Sphenopalatine artery embolization highly effective
- Alternative: Surgical ligation

### Teaching Points

1. **Position matters:** Sit upright, lean forward to prevent aspiration
2. **Anterior vs. posterior:** Posterior = blood in pharynx, bilateral, elderly with HTN/anticoagulation
3. **Vasoconstriction first:** Oxymetazoline or topical epinephrine
4. **Step-wise escalation:** Direct pressure → anterior packing → posterior packing → ENT/IR
5. **Admit all posterior packing:** Airway risk, hypoxia risk, rebleeding risk
6. **Control blood pressure:** But avoid hypotension; SBP <160 reasonable target
7. **Check hemoglobin:** Epistaxis can cause significant blood loss
8. **Anticoagulation management:** Hold if possible; discuss risk/benefit with cardiology

### Clinical Image
![Posterior Nasal Packing](case_03_image.jpg)

**Image Description:** Illustration demonstrating placement of a posterior epistaxis balloon catheter with the posterior balloon inflated in the nasopharynx and anterior balloon inflated in the nasal cavity to tamponade posterior bleeding sources.

**Attribution:** Image from Wikimedia Commons, Nasal packing for epistaxis. Licensed under CC BY-SA 4.0. Source: https://commons.wikimedia.org/wiki/File:Blausen_0061_AnteriorNosePacking.png