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
Anterior nasal packingNasal packing - Vasaline guaze - Absorbable gelfoam - Oxidized cellulose (Surgicel) - Nasal tampon
Anterior nasal packingNasal packing - Vasaline guaze - Absorbable gelfoam - Oxidized cellulose (Surgicel) - Nasal tampon
Copyright 2005 BMJ Publishing Group Ltd.Pope, L E R et al. Postgrad Med J 2005;81:309-314Figure 2 Correct insertion of a nasal tampon (note that the direction is along the floor of the nasal cavity).
Posterior nasal packing
Topical anesthetic & decongestantPosterior nasal packing Double balloon deviceFoley catheter
Posterior nasal packing
Topical anesthetic & decongestantPosterior nasal packing Double balloon deviceFoley catheter
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
Peritonsillar abscess
Severe, unilateral sore throatfeverHot potato voiceUvula deviates to opposite sideSwollen tonsils
Peritonsillar abscess
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
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