Management of ENT Management of ENT EmergenciesEmergencies

Simon LloydSimon Lloyd

Consultant ENT SurgeonConsultant ENT Surgeon

Central Manchester NHS Foundation TrustCentral Manchester NHS Foundation Trust

Facial palsyFacial palsy

AnatomyAnatomy• SensorySensory

– TasteTaste– Posterior ear canalPosterior ear canal

• AutonomicAutonomic– Parasympathetic to:Parasympathetic to:

• Lacrimal glandLacrimal gland• Submandibular glandSubmandibular gland• Sublingual glandSublingual gland

• MotorMotor– Facial expressionFacial expression– StapediusStapedius– Posterior belly of digastricPosterior belly of digastric

AetiologyAetiology

• Huge differentialHuge differential• CongenitalCongenital

– Neurological eg. Moebius syndromeNeurological eg. Moebius syndrome– Traumatic eg. ForcepsTraumatic eg. Forceps

• AcquiredAcquired– Idiopathic eg. Bell’s palsyIdiopathic eg. Bell’s palsy– Traumatic eg. Temporal bone fractureTraumatic eg. Temporal bone fracture– Iatrogenic eg. SurgeryIatrogenic eg. Surgery– Infection eg. Acute otitis media, malignant otitis media, Infection eg. Acute otitis media, malignant otitis media,

Ramsey Hunt syndromeRamsey Hunt syndrome– Neoplastic eg. Parotid malignancy Neoplastic eg. Parotid malignancy

ExaminationExamination

Facial nerve grading (House Brackmann)Facial nerve grading (House Brackmann)

Other cranial nervesOther cranial nerves

Tympanic membrane/pinna for vesiclesTympanic membrane/pinna for vesicles

Parotid/mouthParotid/mouth

AssessmentAssessment

• House Brackmann Grading (I to VI)House Brackmann Grading (I to VI)II = Normal = Normal

II = Normal at rest, mild weakness on active II = Normal at rest, mild weakness on active movementmovement

III= Good eye closureIII= Good eye closure

VV = Some tone = Some tone

VI= No movementVI= No movement

Eyes open Eyes closed

Facial PalsyFacial Palsy

52 year old lady52 year old lady Rapid onset left facial Rapid onset left facial

weaknessweakness Left facial numbnessLeft facial numbness No ear symptomsNo ear symptoms Otherwise fit and wellOtherwise fit and well Grade III weaknessGrade III weakness No other abnormalitiesNo other abnormalities

Bell’s PalsyBell’s Palsy

• Idiopathic (probably viral – Herpes simplex)Idiopathic (probably viral – Herpes simplex)• Acute unilateral facial palsy (peripheral)Acute unilateral facial palsy (peripheral)• Occasionally other cranial nerve palsies eg. TrigeminalOccasionally other cranial nerve palsies eg. Trigeminal• Resolves within 3 months in 80% of casesResolves within 3 months in 80% of cases• 10% recur (including contralateral)10% recur (including contralateral)• Higher incidence in diabetesHigher incidence in diabetes• TreatmentTreatment

• Eye Care (lubrication)Eye Care (lubrication)• Oral steroidsOral steroids• No evidence for benefit from antiviralsNo evidence for benefit from antivirals

– Sullivan et al. New England Journal of Medicine 2007Sullivan et al. New England Journal of Medicine 2007

Who to referWho to refer

Additional findings (Cr. Nerves, lumps)Additional findings (Cr. Nerves, lumps)

No improvement at 3 weeksNo improvement at 3 weeks

Incomplete recoveryIncomplete recovery

ConcernsConcerns

Sudden Hearing LossSudden Hearing Loss

Normal TM with sudden hearing lossNormal TM with sudden hearing loss Aetiology unknownAetiology unknown

ViralViral VascularVascular

Rarely acoustic neuroma, perilymph leakRarely acoustic neuroma, perilymph leak May be unsteady or vertiginousMay be unsteady or vertiginous

Sudden Hearing LossSudden Hearing LossManagementManagement

Refer urgentlyRefer urgently

Treatment optionsTreatment options Oral steroidOral steroid AntiviralAntiviral

No evidence for efficacyNo evidence for efficacy CarbogenCarbogen

No evidence for efficacyNo evidence for efficacy Intratympanic steroidIntratympanic steroid

Weak evidence for efficacyWeak evidence for efficacy

Allergic response to BIPPAllergic response to BIPP

Acute Otalgia with normal TMAcute Otalgia with normal TM

Complications ofComplications ofOtitis MediaOtitis Media

MastoiditisMastoiditis Facial palsyFacial palsy LabyrinthitisLabyrinthitis MeningitisMeningitis Intracranial abscessIntracranial abscess Lateral sinus thrombosisLateral sinus thrombosis

- Long term• Tympanosclerosis

• Tympanic membrane perforation

• Ossicular damage

Acute MastoiditisAcute Mastoiditis

History of acute otitis mediaHistory of acute otitis media Infection spreads to mastoidInfection spreads to mastoid Post-auricular abscessPost-auricular abscess

TreatmentTreatment GrommetGrommet Cortical mastoidectomyCortical mastoidectomy

Complications acute otitis mediaComplications acute otitis mediamastoiditismastoiditis

Intracerebral AbscessIntracerebral Abscess

DiagnosisDiagnosis High index of suspicionHigh index of suspicion HeadacheHeadache Reduced conscious levelReduced conscious level FeverFever SeizuresSeizures

Requires drainageRequires drainage

Ring enhancement with contract enhanced CT

Lateral Sinus ThrombosisLateral Sinus Thrombosis

DiagnosisDiagnosis High index of suspicionHigh index of suspicion HeadacheHeadache Decreased conscious levelDecreased conscious level AtaxiaAtaxia SeizuresSeizures

TreatmentTreatment AnticoagulationAnticoagulation ?thrombectomy?thrombectomy Filling defect

on MRA

EpistaxisEpistaxis

AnatomyAnatomy

AetiologyAetiology Usually idiopathicUsually idiopathic

? atherosclerotic vessels? atherosclerotic vessels Predisposing factorsPredisposing factors

AnticoagulantsAnticoagulants HypertensionHypertension

Trauma eg. Digital, fractured noseTrauma eg. Digital, fractured nose Nasal vestibulitis eg. StaphlococcalNasal vestibulitis eg. Staphlococcal Topical treatment eg. Nasal steroidsTopical treatment eg. Nasal steroids RareRare

HHTHHT NeoplasiaNeoplasia Septal perforationSeptal perforation

Epistaxis First AidEpistaxis First Aid

Conservative ManagementConservative Management Pinch soft part of nosePinch soft part of nose Lean forward and breathe Lean forward and breathe

through mouththrough mouth Ten minutesTen minutes

Protect yourselfProtect yourself GownGown GlovesGloves MaskMask

TreatmentTreatment

Identifiable VesselIdentifiable Vessel Nasal cauteryNasal cautery

Examine noseExamine nose Identify vesselIdentify vessel Apply 1 in 10,000 Apply 1 in 10,000

adrenaline and adrenaline and 1%lignocaine on 1%lignocaine on cotton wool pledgetcotton wool pledget

Silver nitrate cautery Silver nitrate cautery of vesselof vessel

Silver nitrate cauterySilver nitrate cautery

TreatmentTreatment

No Identifiable VesselNo Identifiable Vessel Nasal packingNasal packing

MerocelMerocel RapidrhinoRapidrhino BIPP packingBIPP packing

Rapid RhinoRapid Rhino

BIPP PackingBIPP Packing

TreatmentTreatment

Ongoing bleedingOngoing bleeding Re-check vital signsRe-check vital signs IV access +/- fluidsIV access +/- fluids Check clottingCheck clotting Posterior packingPosterior packing

Brighton baloonBrighton baloon Foley catheter and BIPP Foley catheter and BIPP

packpack

Surgical InterventionSurgical Intervention

SeptoplastySeptoplasty Sphenopalatine artery ligationSphenopalatine artery ligation Anterior ethmoid artery ligationAnterior ethmoid artery ligation Maxillary artery ligationMaxillary artery ligation External carotid artery ligationExternal carotid artery ligation

Management AlgorithmManagement Algorithm

Nasal VestibulitisNasal Vestibulitis

PaediatricPaediatric Digital traumaDigital trauma Cautery vs NaseptinCautery vs Naseptin

Equal efficacyEqual efficacy

Bactroban tastes horrible ? Prevents digital traumaBactroban tastes horrible ? Prevents digital trauma

Fractured noseFractured nose

Fractured noseFractured nose

Ask aboutAsk about EpistaxisEpistaxis CSFCSF Diplopia on upward gazeDiplopia on upward gaze Infraorbital parasthesiaInfraorbital parasthesia Shape changeShape change Nasal obstructionNasal obstruction

FracturedFractured nosenose

ExaminationExamination Nasal bones crepitus, shapeNasal bones crepitus, shape Infraorbital parasthesiaInfraorbital parasthesia Orbital rimsOrbital rims Septum for haematomaSeptum for haematoma No need for X ray unless No need for X ray unless

medicolegalmedicolegal

Fractured noseFractured nose

ManagementManagement If no complicating factors and nose straight leave If no complicating factors and nose straight leave

alone. alone. If orbital fracture or septal haematoma refer If orbital fracture or septal haematoma refer

immediatelyimmediately If shape change with no complicating factors refer to If shape change with no complicating factors refer to

ENT about five days post injuryENT about five days post injury

Nose should be reduced within 2 weeks for Nose should be reduced within 2 weeks for best chance of good resultbest chance of good result

Complications of SinusitisComplications of Sinusitis

Intracranial complicationsIntracranial complications Brain AbscessBrain Abscess MeningitisMeningitis

Orbital complicationsOrbital complications Periorbital cellulitisPeriorbital cellulitis Periorbital abscessPeriorbital abscess Orbital abscessOrbital abscess Pott’s puffy tumourPott’s puffy tumour

Periorbital Cellulitis and AbscessPeriorbital Cellulitis and Abscess

UnwellUnwell PyrexiaPyrexia Eye closesEye closes ErythemaErythema ChemosisChemosis Colour vision goes off Colour vision goes off

firstfirst

Refer urgentlyRefer urgently

Periorbital CellulitisPeriorbital CellulitisTreatmentTreatment

NoseNose Topical decongestantsTopical decongestants

EphidrineEphidrine OtravineOtravine

SystemicSystemic IV antibioticsIV antibiotics

CT imaging to exclude CT imaging to exclude periorbital abscessperiorbital abscess

Foreign BodiesForeign Bodies MaterialMaterial

Paper, beads, watch batteries Paper, beads, watch batteries etc.etc.

Unilateral rhinorrhoea is a Unilateral rhinorrhoea is a foreign body until proved foreign body until proved otherwiseotherwise

TreatmentTreatment Wrap up childWrap up child Assistant hold headAssistant hold head RemoveRemove

Complications of TonsillitisComplications of TonsillitisPeritonsillar abscessPeritonsillar abscess

SymptomsSymptoms Pain becomes more unilateralPain becomes more unilateral Often referred otalgiaOften referred otalgia Trismus (therefore difficult to get a good look)Trismus (therefore difficult to get a good look) DroolingDrooling Systemically unwell with pyrexiaSystemically unwell with pyrexia Normally big tender upper deep cervical nodeNormally big tender upper deep cervical node

ReferRefer

Complications of tonsillitisComplications of tonsillitisPeritonsillar abscess (quinsy)Peritonsillar abscess (quinsy)

Peritonsillar abscessPeritonsillar abscess

TreatmentTreatment Incision and drainage (needle/blade)Incision and drainage (needle/blade) Intravenous penicillin and metronidazoleIntravenous penicillin and metronidazole First quinsy and previous history of First quinsy and previous history of

tonsillitis… recommend tonsillectomytonsillitis… recommend tonsillectomy First quinsy with no prior tonsillitis First quinsy with no prior tonsillitis

history…verbal warninghistory…verbal warning

StridorStridor

Harsh, high-pitched sound indicative of airway obstruction.Harsh, high-pitched sound indicative of airway obstruction.

InspiratoryInspiratory SupraglotticSupraglottic or Glottic or Glottic

BiphasicBiphasic Subglottic or Extrathoracic Trachea Subglottic or Extrathoracic Trachea

ExpiratoryExpiratory Intrathoracic TracheaIntrathoracic Trachea

NB. Stertor – High upper airway obstructionNB. Stertor – High upper airway obstruction

Stridor - AssessmentStridor - Assessment

What level ??What level ??History – What sort of stridorHistory – What sort of stridor

How severe ??How severe ?? Accessory muscles Accessory muscles

Tracheal tug / Recession in childrenTracheal tug / Recession in childrenPulsePulse

pCOpCO22 Retention Retention

Does the airway need securing ??Does the airway need securing ?? Severe OR patient getting tired.Severe OR patient getting tired.

CausesCauses ChildrenChildren

InfectionInfection Bacterial eg. EpiglottitisBacterial eg. Epiglottitis Viral eg. CroupViral eg. Croup

Foreign bodyForeign body

AdultsAdults InfectionInfection

SupraglottitisSupraglottitis

NeoplasiaNeoplasia Squamous cell carcinoma Squamous cell carcinoma

Stridor -managementStridor -management SIT PATIENT UPSIT PATIENT UP OXYGENOXYGEN RE-HYDRATION (i.v.)RE-HYDRATION (i.v.) STEROIDS (Nebulised, i.v. or oral)STEROIDS (Nebulised, i.v. or oral) ADRENALINE NEBULISERADRENALINE NEBULISER HELIOX – Helium / oxygen mixtureHELIOX – Helium / oxygen mixture ANTI-BIOTICSANTI-BIOTICS AIRWAY INTERVENTIONAIRWAY INTERVENTION

IntubationIntubationBronchoscopyBronchoscopyTracheostomyTracheostomy

““Croup” vs EpiglottitisCroup” vs Epiglottitis

CroupCroup EpiglottitisEpiglottitis

AgeAge 1-3years1-3years 3-6 years3-6 years DurationDuration URTI (days)URTI (days) Short(hours)Short(hours) ClinicalClinical “Viral”“Viral” UnwellUnwell** StridorStridor LoudLoud QuietQuiet

* * Decreased concious level, circumoral palor, rapid deterioration.Decreased concious level, circumoral palor, rapid deterioration.

Airway Foreign BodiesAirway Foreign Bodies

RIGHT main bronchus (more vertical)RIGHT main bronchus (more vertical)

May get air trapping, distal to FB.May get air trapping, distal to FB.

Monophonic wheeze (asthma POLYphonic)Monophonic wheeze (asthma POLYphonic)

High index of suspicion - High index of suspicion - REFERREFER

Rigid bronchoscope

Bronchoscope and camera being used to assess the airway in a child with a tracheostomy