Common Ent Emergencies 24126

COMMON ENT EMERGENCIES

Thongchai LuxameechanpornENT departmentRamathibodi hospital

Common ENT emergenciesForeign bodiesTraumaComplications of ENT infections

Foreign bodies InsectsCotton, paper, organic materialSmall batteriesDiscomfort & agitationSecondary complications: infection & mucosal erosion

Foreign bodies

Kill any live insectsRemove foreign body with micro alligator forcepsIrrigation ( do not use if organic FB )

Auricular HematomaUsually from traumaFluctuant bluish swelling of auricleDrainage - Needle aspiration - I & DApply compression dressing

Traumatic TM PerforationCompression, instrumentation & blast injuriesHearing testClose observation if perforation is smallPaper patchSurgery

Temporal bone fractureBlunt head injuryLongitudinal Fx facial n. paralysis, CHL (ossicular chain disruption)Transverse Fx SNHL, dysequilibrium, CN VII palsy

Temporal bone fracture Battles sign (bluish discoloration of postauricular region), raccoon eyes, hemotympanum, hearing loss, dizziness, CSF otorrhea, CN VII palsyCT temporal bone

Acoustic traumaSudden exposure (impact or blast) to noiseSHNL, tinnitusAvoidance/ ear protectionCorticosteroids, carbogen, vasodilators, diuretics, anticoagulants, plasma expanders

Otitic BarotraumaInability to ventilate middle ear abnormal dysfunction of ETOccur in rising ambient pressure (descent in flight / scuba diving)Can produce hemotympanum

Barotrauma

Repeated Valsalva maneuverTopical nasal decongestantsMyringotomy & PE tube insertion may be needed

Sudden Hearing LossSNHL 30 dB over 3 contiguous frequencies within 3 days or lessEtiology : Viral & Infectious, Vascular, Trauma, Autoimmune, Neurologic

Complications of ME infectionsExtracranial

Acute Mastoiditis

preceded by AOMyoung childrensevere pain, fever, edema over mastoid areaintravenous ATBMyringotomy PE tube

Subperiosteal Abscess

pinna pushed down & outward intravenous ATBI&Dmastoidectomy

Complications of ME infectionsIntracranial

Foreign bodies: Symptoms

Purulent unilateral nasal dischargeUsually lodge on the floor of anterior or middle third

Foreign bodies: ManagementGood visualization: headlamp & nasal speculumAlligator forceps should be used to remove cloth, cotton, or paper Other hard FB are more easily grasped using bayonet forceps or Kelly clamps, or they may be rolled out by getting behind it using an ear curette, single skin hook, or right angle ear hook

Nasal Fracture

Hx of fall or force directed to midfaceDeformity of noseSwelling, ecchymosis, epistaxisClose or open reduction

Septal hematoma/abscessTrauma, surgerySoft, fluctuant swelling of septumNeedle aspiration or I&D Bilateral nasal packing for several days Prophylactic antibiotics

Septal hematoma/abscess

EpistaxisLocalTrauma /Nose picking or blowing / surgeryDry air / Irritants Topical medications (steroids)Foreign body Tumor / polyp

SystemicBlood diseasesHereditary hemorrhagic telangiectasiaDrugs (anticoagulants)Hypertension

Epistaxis

EpistaxisInitial first-aidAssessment of blood lossEvaluation of cause Procedure to stop bleedingMost common Kiesselbachs Plexus Squeeze nose 5-20 minsInsert cotton pledget (with decongestant)Cautery with silver nitrate

Pope, L E R et al. Postgrad Med J 2005;81:309-314Figure 1 Epistaxis management protocol.

Epistaxis

Anterior nasal packingLocal anesthetic & decongestant Nasal packing - Vasaline guaze - Absorbable gelfoam - Oxidized cellulose (Surgicel) - Nasal tampon

Anterior nasal packing

Anterior nasal packingNasal packing - Vasaline guaze - Absorbable gelfoam - Oxidized cellulose (Surgicel) - Nasal tampon

Posterior nasal packing

Topical anesthetic & decongestantPosterior nasal packing Double balloon deviceFoley catheter

Complications of sinusitisOrbital complicationsIntracranial complications

Classification of orbital inflammation Stage I II III IV VInflammationInflammatory edema(periorbital cellulitis)Orbital cellulitisSubperiosteal abscessOrbital abscessCavernous sinus thrombosis

Complications of sinusitisPeriorbital cellulitis: periorbital erythema, edema, pain & feverPurulent nasal dischargeS.pneumoniae, S.aureus, coagulase-negative staphylococciBroad-speculum antibiotics

Complications of sinusitisOrbital complications (stages II-V)Periorbital swelling & pain, feverProptosis, chemosis, restriction of ocular movement & visual disturbance

Complications of sinusitisCT scan subperiosteal & orbital abscessAdmission & IV broad- spectrum antibioticsSurgery (drainage) if - failed medication - develop abscess - visual drop

Complications of sinusitisIntracranial complicationsCavernous sinus thrombosis, meningitis, extradural abscess, intracranial abscess & subdural empyemaPurulent rhinorrhea, fever, frontal/retro-orbital headachePersonality change/lethargy, seizures, N/V, focal neurological deficits

Complications of sinusitisIntracranial complicationsDiagnosis MRI scan with gadoliniumAdmission, IV broad-spectrum antibiotics & surgical drainage

Swallowed foreign body

Peanuts, coins, batteries, fish bone, meat & bone pieces, denturesLocation of pain indicates FB location

Swallowed foreign body

Fish bones tend to lodge in oropharynx, produced ipsilateral symptomsEsophagus FB localize in midline: dramatic acute dysphagia

Swallowed Foreign bodies

Most FB in oropharynx can be identifiedEsophageal FB: pooling of saliva in piriformX-rays may be helpful in radio-paque objects

Swallowed Foreign bodiesVisualized FB can be removed with angled forcepsSharp FB should be removed at the earliest opportunity due to risk of perforation

Swallowed Foreign bodies

Coins removed if in cervical or mid esophagus removed within 12 hrs if in distal esophagusBatteries removed emergency

Swallowed Foreign bodiesAirway compromise - Heimlich maneuver - Emergency cricothyrotomy/ tracheostomyEndoscopy with removal in OR

Inhaled Foreign bodiesSudden onset of coughing, wheezing or stridor in previously healthy childUnilateral wheezing, poor chest movement & reduced breath soundCXR: hyperinflate, infection, collapse

Inhaled Foreign bodies

Heimlich manuverSecure airway Endoscopic removal under general anesthesia

Airway ObstructionNeonatal : Congenital tumors, cysts, webs : Laryngomalacia : Subglottic stenosisChildren : Laryngotracheobronchitis : Supraglottitis (epiglottitis) : Foreign body : Retropharyngeal abscess : Respiratory papillomaAdults : Laryngeal cancer : Laryngeal trauma : Epiglottis & deep neck infection

Deep neck infections

Peritonsillar abscess

Pus forms between tonsils capsule & superior constrictorGroup A Streptococcus


Severe, unilateral sore throatfeverHot potato voiceUvula deviates to opposite sideSwollen tonsils


CBC, throat C/SAntibiotics - Oral - Parenteral needle aspiration or I&D

Ludwigs AnginaRapid swelling cellulitis of sublingual & submaxillary spacesDental infection, floor of mouth, salivary glandFever, edema & erythema of neck under chin & floor of mouth

Ludwigs AnginaOpen mouth, Tongue upward & backward airway obstructionStreptococci, Bacteroides, S.aeruesTracheostomyIV antibioticI&D, tooth extraction

EpiglottitisAge 3-7 yrs oldH. influenzae type B, Group A Streptococcus severe sore throat & fever, dysphagia, drooling StridorBreathing with raised chin & open mouth

Epiglottitis

CBC: leukocytosisFilm lateral neck thumb shaped epiglottisAvoid tongue depressorControlled intubationIntravenous ATB

Retropharyngeal AbscessInfants & childrenSecondary to oropharyngeal infectionSevere dysphagia & respiratory distressairway observationIV antibioticSurgical drainage ( prevent pus aspiration)

TracheostomyEmergency tracheostomyin the case of upper airways obstruction1. Tumor in the larynx2. Trauma of the larynx3. Bilateral vocal cord paralysis4. F.B. in the larynx after failure of Heimlichs manuver

Common Ent Emergencies 24126

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