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M2E Too! Mellick's Multimedia EduBlog by Larry Mellick, MD

​The M2E Too! blog presents important clinical pearls using multimedia. By its name, M2E Too! acknowledges that it is one of many emergency medicine blogs, but we hope this will serve as a creative commons for emergency physicians.​

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Friday, March 1, 2019

Conjunctivitis is a common condition and easy enough to treat, but several uncommon conjunctivitis syndromes require more care and should not be missed.

Conjunctivitis is either infectious (viral or bacterial) or noninfectious (allergic or nonallergic). Viral infections are more common in adults, bacterial ones in children, usually caused by Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Adults tend to have more S. aureus infections, while the other pathogens are more common in children. An adenovirus is typically responsible for viral-associated infections in conjunctivitis.

Acute Hemorrhagic Conjunctivitis

Acute hemorrhagic conjunctivitis is rare but highly contagious and often presents as an epidemic; it occurs much more commonly in developing countries. It was first described in Ghana in 1969. Its prevalence in the United States is lower than that in developing countries, but epidemics have been reported in the Southwest. When contrasted with adenoviral conjunctivitis or herpes simplex keratitis, acute hemorrhagic conjunctivitis is comparatively rare. It affects any age, race, or gender, but appears to have a predilection for adolescents between 11 and 15.

The viruses most commonly responsible for hemorrhagic conjunctivitis are members of the Picornaviridae family, most commonly the coxsackievirus group A24 (CA24) and enterovirus E70 (EV70) strains. The associated conjunctivitis is characterized by the rapid onset of a severely painful infection that quickly develops a dramatic subconjunctival hemorrhage.

The signs and symptoms of acute hemorrhagic conjunctivitis begin after 12-48 hours of incubation and include sudden onset of ocular pain, eyelid swelling, foreign body sensation, excessive tearing, eye discharge, and photophobia. Pinpoint epithelial keratitis is also sometimes described. Depending on the stage at which the patient presents, findings may include swollen lids, conjunctival follicles, chemosis, and subconjunctival hemorrhages. These hemorrhages range from petechiae to large areas of conjunctival involvement.

Despite its dramatic appearance and associated pain, acute hemorrhagic conjunctivitis is usually benign and resolves in five to seven days. A polio-like condition, however, has been reported in approximately one in 10,000 patients infected with enterovirus 70 infections. These patients are extremely contagious, and the virus is transmitted directly from person to person by fingers and fomites. EPs should use proper disinfection techniques, and patients should be warned about the potential for spreading their infection. Palliative therapy with cool compresses and ophthalmic lubricants as well as pain control measures are the available treatment options.

Conjunctivitis-Otitis Syndrome

An article titled "Conjunctivitis-Otitis Syndrome" described this syndrome for the first time. (Pediatrics 1982;69[6]:695; http://bit.ly/2UpwzIo.) It noted an association between purulent bacterial conjunctivitis, otitis media, and highly resistant, nontypeable H. influenzae. Crusted eyes frequently mean a child also has an ear infection about 75 percent of the time.

Later, I became convinced that sinusitis was also commonly associated. The original discussion of this syndrome acknowledged that "the illness started with low-grade to moderate fever, mucopurulent rhinorrhea, and cough." (Pediatrics 1982;69[6]:695; http://bit.ly/2UpwzIo.) Patients presenting with this syndrome often had a mucopurulent drainage for a week or longer. The importance of recognizing this syndrome is that it directs your treatment for the nontypeable Haemophilus influenzae. Treatment is amoxicillin-clavulanate and an appropriate ophthalmic antibiotic like trimethoprim/polymyxin (Polytrim). Others would, however, recommend no topical ophthalmic antibiotics if treating systemically.

Parinaud Oculoglandular Syndrome

Two to eight percent of patients with cat scratch disease present with parinaud oculoglandular syndrome, an atypical form of cat scratch disease characterized by tender regional lymphadenopathy of the preauricular, submandibular, or cervical lymph nodes associated with infection of the conjunctiva, eyelid, or adjacent skin surface. The conjunctivitis causes a unilateral red eye, foreign body sensation, and excessive watering of the eyes, and is described as granulomatous.

The infecting bacterium, Bartonella henselae, a small, fastidious, gram-negative bacillus, is the most common cause of this condition, but it is also seen with rodent-associated infections (tularemia or rabbit fever) by the bacterium Francisella tularensis. Sporotrichosis, caused by infections with Sporothrix schenckii, a dimorphic fungus existing in the mycelial and yeast phase, is another less common cause of parinaud oculoglandular syndrome and is seen more commonly in tropical and subtropical areas such as Brazil and Peru.

Even rarer diseases, tuberculosis, coccidioidomycosis, and syphilis, are associated with parinaud oculoglandular syndrome. Treating it when associated with cat scratch disease is different from that recommended for simple lymphadenopathy. The preferred regimen for any patient over age 8 is a combination of rifampin and doxycycline. For children under 8, the recommended treatment is rifampin plus azithromycin or rifampin plus trimethoprim-sulfamethoxazole.

Conjunctivitis is a relatively simple and routine pediatric diagnosis until it isn't. Acute hemorrhagic conjunctivitis, conjunctivitis-otitis syndrome, and parinaud oculoglandular syndrome are three conditions where pediatric conjunctivitis is not a simple diagnosis, and if missed, can have important clinical implications.


Watch this video of a patient with acute hemorrhagic conjunctivitis, a rare but highly contagious conjunctivitis.


This video shows a young boy with a purulent bacterial conjunctivitis, otitis media, and highly resistant, nontypeable H. Influenzae.

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Watch this video of a boy with neck and facial swelling as well as conjunctivitis, symptoms of cat scratch disease presenting with parinaud oculoglandular syndrome.

Friday, February 1, 2019

Tranexamic acid (TXA) was invented by a Japanese husband-and-wife research team in the 1960s. Years earlier, this same research team had discovered epsilon-aminocaproic acid, a derivative and an analogue of the amino acid lysine. In their search for a more potent antifibrinolytic agent, they discovered tranexamic acid, a synthetic analog of the amino acid lysine. Tranexamic acid is eight to 10 times more powerful than epsilon-aminocaproic acid.

The antifibrinolytic actions of TXA result from the binding of four or five lysine receptor sites on plasminogen. This binding prevents plasmin from binding to and degrading fibrin, preserving fibrin's matrix structure. Initially, marketing of the drug was for mild bleeding such as heavy menstrual periods and dental extractions. Currently, it is used in surgery to decrease the need for blood transfusions by decreasing bleeding and blood loss.

Relatively recently, respectability for this old drug dramatically increased when the 2011 CRASH-2 trial showed that TXA safely and dramatically reduced mortality in bleeding trauma patients. (Lancet 2010;376[9734]:23; http://bit.ly/2CoZJB4.) When treatment was initiated within three hours of injury, the risk of hemorrhage death was reduced by about one-third. Another piece of evidence for the respected stature of this inexpensive and highly cost-effective drug is its inclusion in the WHO list of essential medicines. (http://bit.ly/2CqEpLx.)

More recently, topical tranexamic acid has been used to successfully reduce bleeding in multiple surgical conditions. Successful treatment with topical applications has been reported for stomach bleeding with colostomies, gastrointestinal bleeding, uterine bleeding, and orthopedic and oral surgery, to name a few. Oral bleeding has been successfully managed in patients with hemophilia or Von Willebrand disease undergoing minor oral surgery or dental extractions. Topical application of tranexamic acid is considered safer because it is not absorbed systemically, reducing the risk of thromboembolic disease. Nevertheless, even with parenteral administration of TXA, the risk of thromboembolic disease appears relatively low.

More recently, the successful application of TXA for epistaxis has been reported. Additionally, case reports show success using TXA to manage epistaxis with rivaroxaban for hemophilia and hereditary hemorrhagic telangiectasia. Two studies by Zahed, et al., randomized patients with epistaxis to treatment with topical tranexamic acid or anterior nasal packing (ANP). (Am J Emerg Med 2013;31[9]:1389; Acad Emerg Med 2018;25[3]:261; http://bit.ly/2T0HKGQ.) They were markedly positive in favor of topical TXA (500 mg in 5 mL). Bleeding stopped remarkably sooner with TXA, and discharge from the ED was faster. Rebleeding in the ANP group was significantly greater: Rebleeding during the first 24 hours in the 2018 study was reported in five percent and 10 percent of patients in the TXA and ANP groups, respectively. (Acad Emerg Med 2018;25[3]:261; http://bit.ly/2T0HKGQ.) At one week, rebleeding had occurred in five percent of patients in the TXA group and 21 percent of those in the ANP group.

Undoubtedly, tranexamic acid can be administered topically for epistaxis in multiple ways. Dripping TXA into the nostrils with a syringe or the shortened tubing of a butterfly needle are simple and effective delivery methods. Two other possible options are demonstrated in the videos. After insertion into the nostrils, nasal tampons can be expanded with tranexamic acid or a TXA-oxymetazoline combination. TXA can also be administered topically by using an atomizer without any form of nasal packing. About 1-2 mL (100 to 200 mg of tranexamic acid) can be nebulized in the offending nostrils. This technique appears to be highly effective at widely distributing the medication throughout the nostrils.


Watch this video to see TXA administered for recurring epitaxis.

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Watch this video to see administration of oxymetazoline and TXA for a nosebleed emergency.

Monday, December 31, 2018

Some medical conditions have signs and symptoms that significantly overlap, making a diagnosis a little more difficult. Epididymitis, testicular torsion, and torsion of the testicular appendage are examples, but orbital and preseptal cellulitis are others that can cause significant diagnostic confusion.

Both conditions are more common in children than in adults, and preseptal or periorbital cellulitis is more common in children under 5. The preseptal and orbital spaces are separated by only a thin membranous septum that originates in the orbital periosteum and inserts into the tarsal plates. It is only this thin septum that stands as a barrier against progression of the preseptal infection into the orbit.

Both conditions may present with eye pain, eyelid swelling, and erythema. The occasional bee sting or mosquito bite near the eye, with its dramatic swelling of loose areolar connective tissue, can cause similar diagnostic confusion. Several years ago I had a patient with what appeared to be a localized reaction to an insect bite that subsequently turned out to an early preseptal cellulitis. On the other hand, allergic reactions that cause periorbital swelling and conjunctival chemosis are less difficult to differentiate because of the bilateral presentation.

Preseptal cellulitis once had implications that were more serious. Haemophilus influenzae type b was one of the most frequent etiologies of these infections, and it was common practice for all of these children to undergo spinal taps as part of their evaluation. The Hib vaccine dramatically reduced the frequency of infections.

The most common antibiotic recommendations for both infections still include treatment to cover Streptococcus pneumoniae and other sinusitis-associated bacteria as well as Staphylococcus aureus. Obviously, if the preseptal or periorbital cellulitis occurred after a break in the skin and the infecting organism seems most consistent with staph, then treatment with an antibiotic such as clindamycin alone may be appropriate.

Preseptal Cellulitis Pearls

  • Preseptal cellulitis is more common in younger children and is more common than orbital cellulitis.
  • Imaging is not generally indicated, but CT imaging with contrast is entirely appropriate when in doubt about the diagnosis.
  • Eye pain often occurs with periorbital cellulitis but not with eye movement. Imaging can be justified if you cannot adequately examine the eye.
  • Chemosis rarely occurs with preseptal cellulitis, but it is much more common with orbital cellulitis.
  • Direct inoculation is more common as a cause of the infection with preseptal than orbital cellulitis.
  • Treatment as an outpatient with oral antibiotics is entirely appropriate, but the most common recommendation is to treat both with an antistaphylococcal antibiotic that you would use to treat sinusitis, such as amoxicillin-clavulanate.
  • Haemophilus influenzae type b was once a formidable agent of infection that resulted in screening lumbar punctures. The Hib vaccine has dramatically reduced the incidence of this infection.
  • Outpatient treatment is usually successful.

Orbital Cellulitis Pearls

  • Orbital cellulitis is more common in children, but occurs more frequently in older children than preseptal cellulitis.
  • The ethmoid sinuses, the most common location of orbital infections, are separated from the orbit by only the paper-thin lamina papyracea.
  • The main three examination findings that confirm the diagnosis are ophthalmoplegia (and often diplopia), eye pain with movement, and proptosis.
  • Three percent to 11 percent of those with infections can have vision loss. One percent to two percent can be fatal.
  • If fever, chemosis, and leukocytosis are present, orbital cellulitis should be a strong consideration.
  • Most cases of orbital cellulitis can be treated with antibiotics alone, but surgical drainage of a subperiosteal abscess is occasionally needed.
  • CT imaging with contrast is the tool most commonly used to make the diagnosis.
  • Hospital admission for administration of parenteral antibiotics is required for this condition.
  • Use parenteral antibiotics targeting Staphylococcus and sinusitis-causing bacteria such as Streptococcus pneumoniae and Haemophilus influenzae, nontypable, such as vancomycin and ceftriaxone.
  • Treatment with metronidazole is recommended if intracranial infection is suspected.
  • The valveless superior and inferior orbital veins increase the risk of an intracranial spread of infection because they drain directly into the cavernous sinus.
  • Consider a cavernous sinus infection or other intracranial spread of infection if vision complaints and pain develop in both eyes.
  • Lateral canthotomy and cantholysis are emergently required on rare occasions.

CT imaging may at times be the only way to differentiate between preseptal and orbital cellulitis. Close follow-up is strongly recommended because of the risks associated with failure to diagnose orbital cellulitis.

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Watch this video to learn about treating orbital cellulitis.

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Watch this video to see the management of a patient with preseptal cellulitis.

Tuesday, December 4, 2018

I recently met with a group from our children's hospital to standardize the hospital management of bronchiolitis according to the latest American Academy of Pediatrics guidelines. (Pediatrics 2014;134[5]:e1474; http://bit.ly/2QIGbMX.) Unfortunately, these guidelines seem to cause confusion for experienced and inexperienced emergency physicians alike.

This confusion comes from the guidelines raising unaddressed issues and new questions, most importantly not tackling important aspects of frontline clinical practice. These guidelines were developed with the best evidence currently available, and their application mostly causes confusion with our undifferentiated patients. In fact, the guidelines may potentially create unnecessary vulnerabilities in our clinical practice by minimalizing our approach to these wheezing infants. Clinical evaluations, workups, and treatments seem to be discouraged.

Diagnosis under the AAP Guidelines

  • 1a. Clinicians should diagnose bronchiolitis and assess disease severity based on history and physical examination. (Evidence Quality: B; Recommendation Strength: Strong Recommendation.)
  • 1b. Clinicians should assess risk factors for severe disease, such as age under 12 weeks, a history of prematurity, underlying cardiopulmonary disease, or immunodeficiency, when making decisions about the evaluation and management of children with bronchiolitis. (Evidence Quality: B; Recommendation Strength: Moderate Recommendation.)
  • 1c. Radiographic or laboratory studies should not be obtained routinely when clinicians diagnose bronchiolitis based on history and physical examination. (Evidence Quality: B; Recommendation Strength: Moderate Recommendation.)

Treatment under the AAP Guidelines

  • 2. Clinicians should not administer albuterol (or salbutamol) to infants and children with a bronchiolitis diagnosis. (Evidence Quality: B; Recommendation Strength: Strong Recommendation.)
  • 3. Clinicians should not administer epinephrine to infants and children with a bronchiolitis diagnosis. (Evidence Quality: B; Recommendation Strength: Strong Recommendation.)
  • 4a. Nebulized hypertonic saline should not be administered to infants with a bronchiolitis diagnosis in the emergency department. (Evidence Quality: B; Recommendation Strength: Moderate Recommendation.)
  • 4b. Clinicians may administer nebulized hypertonic saline to infants and children hospitalized for bronchiolitis. (Evidence Quality: B; Recommendation Strength: Weak Recommendation [based on randomized controlled trials with inconsistent findings].)
  • 5. Clinicians should not administer systemic corticosteroids to infants with a diagnosis of bronchiolitis in any setting. (Evidence Quality: A; Recommendation Strength: Strong Recommendation.)
  • 6a. Clinicians may choose not to administer supplemental oxygen if the oxyhemoglobin saturation exceeds 90% in infants and children with a bronchiolitis diagnosis. (Evidence Quality: D; Recommendation Strength: Weak Recommendation [based on low-level evidence and reasoning from first principles].)
  • 6b. Clinicians may choose not to use continuous pulse oximetry for infants and children with a bronchiolitis diagnosis. (Evidence Quality: D; Recommendation Strength: Weak Recommendation [based on low-level evidence and reasoning from first principles].)
  • 7. Clinicians should not use chest physiotherapy for infants and children with a bronchiolitis diagnosis. (Evidence Quality: B; Recommendation Strength: Moderate Recommendation.)
  • 8. Clinicians should not administer antibacterial medications to infants and children with a bronchiolitis diagnosis unless there is a concomitant bacterial infection or a strong suspicion of one. (Evidence Quality: B; Recommendation Strength: Strong Recommendation.)
  • 9. Clinicians should administer nasogastric or intravenous fluids for infants with a bronchiolitis diagnosis who cannot maintain hydration orally. (Evidence Quality: X; Recommendation Strength: Strong Recommendation.)

The Undifferentiated Patient

Wheezing patients presenting to the ED and outpatient clinic will often be undifferentiated patients in contrast to the patients admitted and treated in the hospital. This is where there seems to be a disconnect between the guidelines and the clinical practice of emergency medicine. Unfortunately, the undifferentiated febrile or afebrile patient who presents with varying degrees of respiratory distress may not have bronchiolitis.

Bronchiolitis must be distinguished from a variety of acute and chronic conditions that affect the respiratory tract. The differential to consider includes a number of life-threatening conditions. Whether or not the guidelines acknowledge it, many patients may require further testing and treatment to differentiate better the etiology of the wheezing and adventitial sounds.

Bronchiolitis Lookalikes

  • Asthma
  • Recurrent viral-triggered wheezing
  • Pneumonia
  • Chronic pulmonary disease
  • Foreign body aspiration
  • Aspiration pneumonia
  • Congenital heart disease
  • Congestive heart failure
  • Myocarditis

The Differential Diagnosis

Bronchiolitis is at best a syndrome or collection of signs and symptoms. RSV predominates, but multiple other viruses and some atypical bacteria can present with the syndrome. In fact, at least four viruses are commonly associated with wheezing in children: the respiratory syncytial virus, the rhinovirus, the human metapneumovirus, and the influenza viruses. It helps to know that coinfection with viral and bacterial pathogens such as Haemophilus influenza type b or Streptococcus pneumoniae is uncommon because of the widespread use of conjugate polysaccharide vaccines, Bordetella pertussis, Chlamydia trachomatis, or Mycoplasma pneumoniae must be included in the differential diagnosis of a lower respiratory tract infection in a young child. In fact, one of the videos below shows an infant acutely ill and co-infected with both RSV and pertussis.

The Fallacy of 'Do Less, Not More'

It is possible for seasoned providers in pediatric care to make a bronchiolitis diagnosis without further testing, but it might not be realistic to expect everyone to do the same. And it might be unrealistic to expect learners to be able to confirm the diagnosis without additional steps to differentiate the patient. (Many of my undifferentiated wheezing patients respond to nebulized albuterol and epinephrine.) Furthermore, the overall message of "do less, not more" in the current guidelines may be the predominant message heard by learners or non-pediatricians, inadvertently resulting in sicker patients not being evaluated and treated aggressively when appropriate.

The 2014 AAP guidelines seem to personify therapeutic nihilism, but more optimistic and current evidence should be incorporated into the next revision of these guidelines in 2019. It is not possible to dive deeply into the evidence, but my analysis of the current literature suggests that the following treatment options have now sufficiently matured to allow their routine application in treating the bronchiolitis syndrome:

  • Hypertonic saline (3%) nebulization (Cochrane Database Syst Rev 2017;12:CD006458)
  • Nebulized epinephrine (Cochrane Database Syst Rev 2011;[2]:CD006619 and several other studies)
  • High-flow nasal cannula (multiple studies)
  • Heliox therapy (Cochrane Database Syst Rev 2015;[9]:CD006915)

The undifferentiated patient presenting with bronchiolitis syndrome and the health care provider's experience or comfort level pose challenges that are not sufficiently addressed in the guidelines. I am convinced that there is a mismatch between ivory tower recommendations and frontline care. In fact, it is common to hear clinicians sounding like guilty schoolchildren feeling obligated to justify why they are not following these clinical guidelines. Thankfully, there is less to feel guilty about because we now have growing evidence-based treatment options for our bronchiolitis syndrome patients.

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This video shows apnea in a child infected with RSV and swine flu.

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This video shows two infants with RSV presenting to the ED.

Thursday, November 1, 2018

Pediatric patients frequently put foreign bodies into their mouths, noses, and ears. The spectrum of foreign bodies that children place into their facial orifices are impressive. Paper, vegetable matter (such as peanuts), toys, beads, metal screws, and Play-Doh are just a few examples.

The insertions are often done surreptitiously, only to be discovered days or sometimes weeks later. Occasionally, the retained foreign nasal bodies will ferment and present with a purulent, unilateral nasal drainage, accompanied by an unrelentingly repulsive odor. Sometimes an occasional cockroach wanders into the external auditory canal looking for a dark, moist cavity for sleeping or laying eggs. There appears to be a preference for the right nostrils or right external auditory canal, which correlates with a higher percentage of right-handed children.

Classic Techniques

The classic techniques for removing foreign bodies from the nose and ears include using the following:

  • Alligator forceps
  • Balloon-tipped catheters
  • Frazier suction tips
  • Ear curettes
  • Nose-blowing
  • Bulb syringe
  • Bag-valve-mask
  • Mother's breath

Tension with ENT Colleagues

An ongoing low-grade tension between otolaryngologists and emergency physicians always seems to be brewing about attempts to remove foreign bodies. It is understandable because our ENT colleagues only see our failures and our failures often slightly traumatize our patients and their orifices. If every patient with a foreign body required an otolaryngologist, however, the demand would probably outstrip the specialty's availability.

Thankfully, emergency physicians are increasingly experienced at managing these cases. And, in MacGyver fashion, we do a good job of developing our own tools for removing foreign bodies like the right-angled hook, improvised suction catheters, the application of topical skin adhesive, and the use of rare earth magnets.

Procedure Risks

Many of the classic techniques are not easily reproduced, and often fail in my hands. Besides failures, other risks include trauma-induced bleeding of the orifice's skin or mucosa, pain, perforated tympanic membranes, and unwanted displacement of the foreign body. Dislodgement may include pushing the foreign body deeper into the orifice, making access and removal even more difficult. It can also result in aspiration or ingestion of the foreign body.

My most memorable case was one where I had to remove two small screws from a child's nose with forceps. Just as I was transporting the screws across the open mouth of the crying child, I dropped both screws directly into his mouth. A subsequent x-ray demonstrated the two screws sitting safely in his stomach. Thankfully, our patient had no complications and passed the two screws uneventfully several days later.

Pain is another risk. The external auditory canal is a sensitive area containing multiple nerves that are notoriously difficult to anesthetize. Topical anesthesia has only a partial effect, and four quadrant injections for local anesthesia are difficult and painful. The nose, notorious for bleeding from the slightest trauma, can also hide foreign bodies behind and under the turbinates.

Procedure Adjuncts

Thankfully, a number of adjuncts can make removing a foreign body from the nose or ears go more smoothly, including:

  • Child life specialists
  • Atomized intranasal midazolam
  • Papoose boards or burrito sheets
  • Atomized intranasal lidocaine
  • Topical tetracaine to the external auditory canal
  • Oxymetazoline hydrochloride nasal spray
  • Ketamine procedural sedation
  • Nasal speculums
  • Otoscopes

Insects, most often cockroaches, are occasionally still moving. Besides being unnerving to the patient, insects desperately clawing during the extraction process can be uncomfortable, but several substances are reportedly excellent at humanely euthanizing cockroaches: microscope oil, 2% to 4% lidocaine, viscous lidocaine, mineral oil, EMLA cream, and ethanol.

Post-procedure Interventions

A number of interventions are often recommended following extraction. First, always check the orifice for additional foreign bodies. Many clinicians will use topical antibiotic drops for the external ear canals or a topical antibiotic ointment for the nostrils. Their reasoning is that trauma to the mucosa or skin is not uncommon after orifice instrumentation. Systemic antibiotics may be necessary to treat sinusitis from a chronically retained nasal foreign body. Pain control with ibuprofen or acetaminophen is also helpful. Post-procedure epistaxis can be treated with an oxymetazoline nasal spray. The emergency department visit may also be an appropriate time for counseling the parents on child safety.

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Watch a video of using a suction catheter to remove a bead stuck in child's nose.


Two medical students help Dr. Mellick experiment using suction to remove a hearing aid from the ear in this video.

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EPs first tried a bulb syringe, direct removal, and bag-valve-mask to remove a nasal foreign body, but sometimes you just have to call for ENT consult, as shown in this video.