ENT Emergencies

By : O. Ahmadi, MD. Professor Assistant of Esfahan Medical School,

Emergency Department of Al-Zahra Hospital

Overview

• Otologic Disorders• Nasal Disorders• Facial, Oral and Pharyngeal

Infections • Airway Obstruction

Otologic DisordersAnatomy

• Auricle • Ear canal• Tympanic

membrane• Middle ear and

mastoid disorders• Inner Ear

Traumatic Disorders of the Auricle• Hematoma - cartilaginous necrosis- drain, antibiotics, bulky ear

dressing close follow up• Lacerations - single

layer closure, pick up perichondrium, bulky ear dressing

Use posterior auricular block for anesthesia

Aspiration of Auricular Hematoma

Auricle• Chondritis - Cellulitis ?- infectious, difficult to treat

because poor blood supply, cover S. Aureus and pseudomonas

- extra care in diabetics- inflammatory causes related

to seronegative arthritis at times indistinguishable from infection usually the ear lobe is spared

Otitis Externa• Infection and inflammation

caused by bacteria (pseudomonas, staph), and fungi

- treat with antibiotic-steroid drops

- use wick for tight canals- diabetics can get malignant

otitis externa (defined by the presence of granulation tissue)

Foreign Bodies in Ear Canal• Usually put in by patient,

some bugs fly in• kill bugs with mineral oil,

or lidocaine• remove with forceps,

suction or tissue adhesive

Tympanic Membrane Perforation• Hard to see – Hx of drainage• Usually from middle ear pressure

secondary to fluid or barotrauma• Sometimes from external trauma• most heal uneventfully but all need

otology follow-up • perfs with vertigo and facial nerve

involvement need immediate referral• treat with antibiotics• drops controversial but indicated for

purulent discharge (avoid gentamycin drops)

Middle Ear• Serous Otitis Media - Eustachian

tube dysfunction - treat with decongestants, decompressive maneuvers

• Otitis Media - infection of middle ear effusion - viral and bacteria

• Mastoiditis - Venous connection with brain, need aggressive treatment (can lead to brain abcess or meningitis)

Inner Ear• peripheral vertigo (vestibulopathy)BPV, labyrhinthitis• - acute onset, no central signs, usually young,

horizontal nystagmus• Meniere’s - vertigo, sensorineural hearing loss,

tinnitus• Treatment- valium, fluids, rest, manipulation for BPV

The Nose• Vascular Supply- Anterior - branches of

internal carotid- Posterior - distal

branches of external carotid

EpistaxisAnterior

• 90% (Little’s Area) Kisselbach’s plexus - usually children, young adults

Etiologies• Trauma, epistaxis digitorum• Winter Syndrome, Allergies• Irritants - cocaine, sprays• Pregnancy

EpistaxisPosterior

• 10% of all epistaxis - usually in the elderly• Etiologies• Coagulopathy• Atherosclerosis• Neoplasm• Hypertension (debatable)

EpistaxisManagement

• Pain meds, lower BP, calm patient• Prepare ! (gown, mask, suction, speculum,

meds and packing ready)• Evacuate clots• Topical vasoconstrictor and anesthetic• Identify source

EpistaxisManagement

• Anterior Sites- Pressure +/- cautery

and/or tamponade - all packs require antibiotic

prophylaxis

EpistaxisPosterior Packing

• Need analgesia and sedation

• require admission and 02 saturation monitoring

EpistaxisComplications

• severe bleeding• hypoxia, hypercarbia• sinusitis, otitis media• necrosis of the columella or nasal ala

7th Nerve Palsy• Most cases are idiopathic - link to HSV- no proof steroids or antivirals are

effective, but many advocate• Consider Lyme’s Disease in

endemic areas• Surgical decompression indicated

in the rare patient not improving by 2 weeks and ENOG out > 90%

Facial InfectionsSinusitis

• Signs and symptoms- H/A, facial pain in sinus

distribution- purulent yellow-green

rhinorrhea- fever- CT more sensitive than plain

films• Causative Organisms- gram positives and H. flu

(acute)- anaerobes, gram neg (chronic)

Facial InfectionsSinusitis• Treatment

acute - amoxil, septrachronic - amoxil-clavulinic acid,

clindamycin, quinolonesdecongestants, analgesia, heat• Complicationsethmoid sinusitis - orbital cellulits and

abcessfrontal sinusitis - may erode bone (Potts

Puffy Tumor, Brain Abcess)

Facial Cellulitis

• Most common strept and staph,

• Rarely H.Flu• Can progress rapidly

Parotiditis• Usually viral-paramyxovirus• Bacterial- elderly, immunosuppressed- associated with dehydration- cover - Staph, anaerobes

Pharyngitis

• Irritants-reflux, trauma, gases• Viruses- EBV, adenovirus• Bacterial-GABHS, mycoplasma, gonorrhea,

diptheria

Peritonsillar Abcess

• Complication of suppurative tonsillitis• Inferior - medial displacement of tonsil and

uvula• dysphagia, ear pain, muffled voice, fever,

trismus• Treatment - Antibiotics, I&D, +/-steroids

EpiglottitisClinical Picture

• Older children and adults• decrease incidence in children

secondary to HIB vaccine• Onset rapid, patients look toxic• prefer to sit, muffled voice,

dysphagia, drooling, restlessness

Epiglottitis

• Avoid agitation• Direct visualization if patient allows• soft tissue of neck- thumb print, valecula sign• Prepare for emergent airway, best achieved

in a controlled setting• Unasyn, +/- steroids

EpiglottitisEpiglottitis

Retropharyngeal Abcess• Anterior to prevertebral space

and posterior to pharynx• Usually in children under 4

(lymphoid tissue in space)• pain, dysphagia, dyspnea, fever• swelling of retropharyngeal

space on lateral x-ray• Complications - mediastinitis

Masticator - Parapharyngeal Space Infection

• Infection of the lower molars invade masticator space

• Swelling, pain fever, TRISMUS

• TreatmentIV antibiotics (PCN or

Clindamycin)ENT admission

ANUGAcute Necrotizing Ulcerative Gingivitis

• Bacterial infection causing an acute necrotizing, destructive disease of periodontium

• Treatment- oral rinses- antibiotics (PCN, clindamycin,

tetracycline)

Ludwigs Angina• Rapidly progressive cellulitis of the

floor of the mouth• usually in elderly debilitated

patients and precipitated by dental procedures

• massive swelling with impending airway obstruction

• TreatmentICU, antibiotics, airway management

Angioedema• Ocassionally life

threatening• Heriditary and related

to ACE inhibitors• Antihistamines,

steroids and doxepin

Airway Obstruction

• Aphonia - complete upper airway• Stridor - incomplete upper airway• Wheezing - incomplete lower airway• Loss of breath sounds- complete lower

airway

Questions and Answers