ENT Emergencies

Mitchell Shulman MDCM FRCPC CSPQ

Attending Physician, Emerg Dept MUHC

Assistant Professor, Dept of Surgery

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What We’ll Cover

• Otologic Disorders

• Nasal Disorders

• Facial, Oral and Pharyngeal

Infections

Rare, serious, unusual things

Anatomy

Auricle

Ear canal

Tympanic

membrane

Mastoid

Inner Ear

Traumatic Disorders of the Auricle

Traumatic Disorders of the Auricle

Hematoma

Danger: cartilage necrosis

Rx: drain, antibiotics, bulky

ear dressing, close

follow up

Lacerations

Rx: single layer closure,

pick up perichondrium,

bulky ear dressing

Aspiration of Auricular Hematoma

Foreign Bodies in Ear Canal

• By patient / Fly in / ?

• Kill bugs (mineral oil or lidocaine)

• Remove (forceps, suction or tissue

adhesive)

• Always check for damage

before and after

• Document

Tympanic Membrane Perforation

• Can be hard to see (Hx: drainage)

• Usually: middle ear pressure 2ndary to fluid / barotrauma

• Can be: external trauma

• Most heal uneventfully

• Otology follow-up

• Perforation + vertigo / facial nerve involvement need immediate referral

Middle Ear

Serous Otitis Media

eustachian tube dysfunction

Rx: decongestants

Otitis Media

viral / bacterial

Mastoiditis

Danger: aggressive Rx

(brain abscess / meningitis)

What We’ll Cover

• Otologic Disorders

• Nasal Disorders

• Facial, Oral and Pharyngeal

Infections

The Nose

Vascular Supply

Anterior: branches of

internal carotid

Posterior: distal

branches of external

carotid

EpistaxisAnterior

Little’s Area (Kisselbach’s plexus)

• 90% - usually children, young adults

Causes:

• Trauma: “epistaxis digitorum”

• Winter Syndrome, allergies

• Irritants (eg. cocaine, sprays)

• Pregnancy

EpistaxisPosterior

• 10% of all epistaxis -

usually elderly

Causes

• Coagulopathy

• Atherosclerosis

• Neoplasm

• Hypertension (debatable)

Epistaxis

Management

Anterior SitesPressure +/- cautery +/or

tamponade

All packs require

antibiotic prophylaxis ?

Epistaxis

Management

• Pain meds, lower BP, calm patient

• Prepare !

(gown, mask, suction, speculum, meds / packing ready)

• Evacuate clots

• Topical vasoconstrictor and anesthetic

• Identify source

Epistaxis

Management

Posterior Packing

Need analgesia /

sedation

Admit

02 saturation monitoring

Epistaxis

Complications

Severe bleeding

Hypoxia, hypercarbia

Sinusitis, otitis media

Necrosis of the columella or nasal ala

What We’ll Cover

• Otologic Disorders

• Nasal Disorders

• Facial, Oral and Pharyngeal

Infections

7th Nerve Palsy

Most cases:

idiopathic

- Are steroids or antivirals

effective?

• Consider: Lyme Disease;

Ramsay Hunt (herpes zoster)

Sinusitis

Signs / SymptomsH/A

Facial pain (over sinus)

Purulent yellow-green rhinorrhea

Fever

CT more sensitive than plain films

Causative Organisms

Gm + / H. flu (acute)

Anaerobes, Gm - (chronic)

Sinusitis

Treatment

Acute: amoxicillin, trimethoprim –sulfamethoxazole

Chronic: amoxicillin-clavulinic acid, clindamycin, quinolones

Decongestants, analgesia, heat

Complications of Acute Sinusitis

Preseptal:

periorbital cellulitis

Ocular pain, eyelid

swelling, erythema

Postseptal:

orbital cellulitis

Pain with eye movement,

proptosis, ophthalmoplegia

Warning: Visual impairment!!

Complications of Sinusitis

Periorbital Cellulitis

• Preseptal (doesn’t involve orbit,

infection of structures anterior to the orbital septum)

• Pain, eyelid swelling, erythema

• More common; Less serious

• Source: ethmoidal sinus; local trauma; insect bites;

foreign body

• Intracranial extension

• Investigation: CT scan (contrast)

• Outpt Rx: clavulin; clindamycin 300 mg Q8H

(30-40 mg/kg IV QID do not exceed 1.8 gms / 24 hrs)

• If no improvement in 24 hrs, admit and get CT.

• Postseptal

• Eyelid swelling; eye pain; pain with eye

movement; proptosis;

ophthalmoplegia/diplopia; vision impairment

• Complications: abscess; vision loss; death!

• Can develop rapidly

• Daily visual acuity and pupillary light reflex

checks

• IV Abx: Vancomycin + Piperacillin-tazobactam

Complications of Sinusitis

Orbital Cellulitis

Complications of acute sinusitis

Cavernous sinus thrombosis

• From orbital veins: blood can flow to the cavernous sinus (?no valves)

• High fever; toxic

• Severe headache, protracted vomiting, mental status changes; unilateral CN palsies (III; IV; V; VI)

• Rapidly progressive chemosis

• Severe retinal engorgement

• May progress to vision loss, meningitis, death

• IV Abx: Vancomycin + Piperacillin - tazobactam

Facial Cellulitis

Most common organisms:

streptococcus,

staphylococcus

rarely H.flu

• Can progress rapidly

ParotitisViral / Autoimmune

Bacterial:

Elderly, immunosuppressed

Associated with dehydration

Rx:

Abx: Cloxacillin; Vancomycin;

Clindamycin

Warm compresses

Pain control

Pharyngitis

Irritants

reflux, trauma, gases

Viruses

EBV, adenovirus

Bacterial

GABHS, mycoplasma, gonorrhea,

diptheria

Peritonsillar AbcessComplication of suppurative

tonsillitis

(Group A strep, Strep

pyogenes, Staph aureus, H.

influenzae, anaerobes)

Infero - medial

displacement of tonsil and

uvula

Dysphagia, ear pain,

muffled voice, fever, trismus

Rx: Antibiotics (clindamycin),

I&D

EpiglottitisClinical Picture

• Acute inflammation causing

swelling of the supraglottic

structures of the larynx

• Children vs adults

• Decrease incidence in children (HIB vaccine)

• Onset rapid, pts toxic

• Prefer to sit, muffled voice,

dysphagia, drooling, restless

Epiglottitis

• Avoid agitation

• Direct visualization if

patient allows

• Soft tissue X-rays of

neck

• Prepare for emergent

airway

(best achieved in a

controlled setting)

Epiglotitis

ManagementChildren:

To operating room

Be ready to intubate

Have backup ready including surgical airway

Adults:Admitted (ICU or Step-down Unit)

Intubation (if airway at risk)

Continuous O2 sat monitoring

Daily examination of larynx

Retropharyngeal Abcess

• Anterior to prevertebral space

and posterior to pharynx

• Pain, dysphagia, dyspnea, fever

• Swelling of retropharyngeal

space on lateral x-ray

• Complications – mediastinitis;

internal jugular thrombosis,

carotid artery erosion, etc…

• IV Abx: Vancomycin + Pip-Taz

C2 > 7 mm*

C6 > 22 mm**

*

**

Ludwigs Angina

Rapidly progressive cellulitis of the

floor of the mouth

Usually: elderly debilitated

patients, precipitated by dental

procedures / infection (2nd or 3rd

molar)

Organisms: streptococcus,

oral anaerobes

Danger: Massive swelling with

impending airway obstruction

Ludwig Angina Spread

Ludwig Angina

Presentation• Fever, chills, malaise

• Tender swelling under mandible + floor mouth

• Usually little or no fluctuance

• Muffled voice

• Severe trismus?, drooling of saliva, dysphagia

• Gross swelling, elevation, displacement of tongue

• Tachypnea / dyspnea Stridor / cyanosis

Danger of upper airway obstruction + death!

Ludwig Angina

Management

• ABC’s

Awake intubation (fiberoptic) vs surgical airway

• Admit

ICU / stepdown (unless airway is totally safe)

02 sat monitoring

• Drain abscess

• I.V. Antibiotics: Clindamycin + Vancomycin;

Pip/Taz + Vancomycin