Emergencies in ENT

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Information about Emergencies in ENT
Health & Medicine

Published on March 5, 2014

Author: crisbertc

Source: slideshare.net


Emergencies in ENT

Topics: Nasal Fracture Haemorrhage - Epistaxis, Post-op Bleed Ear Emergencies Head & Neck Infections Ingested Foreign Body

Nasal Fracture Exclude intra-cranial, orbital and other facial injuries If epistaxis present, apply first-aid measures Need to exclude septal haematoma (requires urgent drainage) Isolated nasal fractures can be managed as outpatient

Nasal Fracture Investigation Request for ‘Nasal Bone Xray’ Nasal XR - medicolegal reason In more serious injury - skull and facial XR CT scan - useful for maxillofacial fractures and to exclude other injuries

Nasal Fracture Management Refer to ENT urgently if: Uncontrolled epistaxis Presence of septal haematoma

Nasal Fracture Management Need for M&R within 14 days of injury Refer to ENT outpatient to await reduction of oedema to enable assessment of nasal bone alignment If epistaxis stops and no other significant injuries, provide outpatient ENT follow-up within 1 week of nasal injury

A. Epistaxis Local causes Idiopathic (90%) Traumatic ( fracture, foreign body, nose picking ) Infection Inflammatory ( rhinitits, sinusitis ) Tumour ( rare ) Iatrogenic (Nasal Surgery)

Epistaxis General causes Coagulopathy (Dengue, anticoagulant) Hypertension Hereditary Haemorrhagic telangiectasia Raised venous pressure (whooping cough, pneumonia)

Epistaxis Majority are self limiting, esp. in children 90% bleed from Kiesselbach’s plexus (Little’s area)

Epistaxis Kiesselbach plexus Located on exposed anterior part of septum Upper portion ICA ( anterior and posterior ethmoidal arteries ) Lower portion ECA ( Greater palatine, sphenopalatine, superior labial arteries )

Epistaxis - First Aid Sit up with head forward Pinch the nose firmly with thumb and fingers for > 5min (Cartilaginous part) Breathe through mouth Ice pack on forehead Ice cubes to suck

Epistaxis - Management Assess blood loss Resuscitation, i.v. access Base line blood investigation GXM Medication - sedative or anti-hypertensive

Epistaxis - Management Treat underlying cause Reverse coagulopathy Control hypertension Allergic rhinitis Sinusitis Nasal hygiene Haemostasis

Epistaxis - Haemostasis 1) Cautery Silver Nitrate Electrocautery 2) Anterior Nasal Pack No clear bleeding point or Failed cautery BIPP or Merocel Antibiotic cover

Epistaxis – Admission Criteria Uncontrolled bleeding Nasal packing done Post-operative cases Haemodynamically unstable Poor premorbid conditions Severe bleeds

B. Post-Tonsillectomy bleed Resuscitation! & i.v. access Assess for symptoms/signs of shock Baseline blood including coagulation profile GXM NBM

Post-Tonsillectomy bleed Management First aid measures, e.g. ice gargle Pressure (adrenaline gauze) Silver nitrate Electrocautery Ligation of local bleeder

Post-Tonsillectomy bleed Management& small clot evident If no active bleed observe If large clot, need to remove clot to access if bleeding If active bleeding: Attempt haemostasis at A&E/Clinic Haemostasis under G.A.

Admission Criteria All post-operative haemorrhage should be admitted If bleeding stopped, offer admission for observation

Ear Emergencies Admission Criteria Most ear cases can be reviewed in the next ENT outpatient clinic Following needs urgent admission: Acute Mastoiditis Acute perichondritis of the pinna Any ear infection/trauma with facial nerve palsy

Ear Cases Seen at A&E 1. 2. 3. 4. 5. 6. 7. Impacted ear wax Traumatic TM Perforation Otitis Externa Otitis Media Sudden Sensorineural Hearing Loss Foreign Body Ear Miscellaneous

Impacted Ear Wax Prescribe wax softeners (e.g. olive oil ear drops) Obtain outpatient referral for review

Traumatic TM Perforation If no other serious head injuries, can be followed up as outpatient 1 week TCU Keep ears dry Antibiotics not required Obtain outpatient referral for review

Otitis Externa Treatment : Aural toilet Topical antibiotic ± steroid ear drops Oral antibiotic for severe cases Obtain outpatient referral for review

Acute Otitis Media Common in children Fever, ear- pain TM - red & bulging Otitis media can only be diagnosed if the TM is visualised!

Acute Otitis Media Treatment Topical nasal decongestant Analgesia Oral anti-histamine Antibiotics if patient toxic Obtain outpatient referral for review

Chronic Otitis Media (effusion) Oral antibiotics to prevent infection If nasal symptoms present, treat with nasal decongestants Valsalva manouvre

Chronic Otitis Media (effusion) Need to exclude NPC If persist for more than 2 months, may need myringotomy and ventilation tube insertion Can be managed in ENT outpatient clinic

Chronic Suppurative Otitis Media (CSOM) Aural toilet Topical ± oral antiobiotics Keep ears dry Elective Myringoplasty if perforation does not heal Can be managed in ENT outpatient clinic

Sudden Sensorineural Hearing Loss Loss of hearing of > 30 dB over 3 days, over at least 3 frequencies Sudden onset of hearing loss Normal ear examination Diagnose SNHL with tuning fork tests or puretone audiogram

Sudden Sensorineural Hearing Loss Refer to next ENT outpatient clinic Cover with oral prednisolone 1mg/kg if no contraindication Acyclovir 800mg 5x/day for 5 days, if onset within 1 week

Sudden Sensorineural Hearing Loss Causes  Idiopathic – 85%  Meniere’s disease  Acoustic Neuroma  Cerebellar-pointine angle tumours  Ototoxicity  Noise-induced  Trauma  Viral infection  Vascular - impairment of cochlear blood supply  Syphillis  Immunological disorders

FB - Ear Crocodile forceps- cotton,paper,foam , sponge Blunt hook – round objects Suction – fluid

FB - Ear Syringing – C/I organic material Insects Killed by alcohol/lignocaine/olive oil Removed Can be managed in ENT outpatient clinic


Perichondritis Admission for i.v. antibiotics Risk of cauliflower ear deformity

Pseudocyst of the Pinna

Pseudocyst of the Pinna TCU next ENT outpatient clinic Elective excision of pseudocyst Do not aspirate Do not perform I & D

Giddiness ≠ ENT Referral Always exclude central causes first Peripheral causes not life-threatening

Head & Neck Infections Acute Tonsillitis Peritonsillar Abscess (Quinsy) Sinusitis Epiglottitis Deep Neck Infection

Acute Tonsillitis Sorethroat, Fever, Odynophagia Bilateral tonsils - enlarged, injected, swollen, purulent exudates Diptheria, Infectious Mononucleosis

Acute Tonsillitis Treatment : antibiotic, gargles, lozenges, analgesia, anti-pyretic Antibiotics of choice: Penicillin Augmentin Clindamycin Erythromycin

Acute Tonsillitis – Admission Criteria Inadequate oral intake of fluids/food Signs of peritonsillar abscess (quinsy)

Peritonsillar Abscess Quinsy Trismus Unilateral Swollen soft palate, uvula displaced Treatment : Aspiration Incision and drainage

Sinusitis Symptoms : Purulent nasal discharge nasal congestion Facial pain Headache

Sinusitis - Diagnosis Clinical History Sinus X-ray - not reliable, not necessary Mucopus seen on nasal endoscopy

Sinusitis - Treatment Goal : Relieve obstruction of the sinus ostia Nasal decongestant (oxymetazoline nose drop) Systemic decongestant (pseudoephedrine) Antibiotic (at least 10 days)

Sinusitis - Treatment Nasal douche Hypertonic saline Sodium bicarbonate Functional Endoscopic Sinus Surgery (FESS) Failed medical treatment for chronic cases

Sinusitis – Admission Criteria Complicated sinusitis Orbital cellulitis/abscess Intracranial abscess

Epiglottitis Adult and Children Organism - S. pneumoniae, H.Influenze, Beta- Haemolytic strep

Epiglottitis Severe sore throat, odynophagia, high fever Muffled voice, Difficulty in breathing Sit erect and bend forward Salivating

Epiglottitis Indirect Laryngoscopy Flexible Fiberoptic nasopharyngoscope Lateral neck X-ray - thumb sign

Normal epiglottis

Swollen epiglottis

Epiglottitis - Treatment Airway management Monitor Closely Intubation, Cricothyroidectomy, Tracheostomy Oxygen Antibiotic Epinephrine, steroids

Deep Neck Infection Neck swelling Sore throat, odynophagia, trismus Immunocompromised Fever, unwell Lateral neck XR Airway control Admission for CT, KIV I&D

Deep Neck Infection •Normal retropharyngeal space on lateral neck XR is up to 1 vertebral body width from C5 and below. Widened retropharyngeal space on lateral neck XR •Up to half a vertebral body width from C1 to C4 is normal

FB - Throat History Localised Below post-cricoid region - midline Mouth/ oropharynx – localised to side Time of ingestion

FB - Throat History High risk Sensory deprivation eg dentures (adults ) Otalgia, neck tenderness, fever, chest or back pain, haemetamesis

FB - Throat Examination Distress Unable to swallow saliva Tracheal rock positive Swallow test positive

Common Sites of impaction of FB Tonsils Base of tongue Vallecula Pyriform fossa Cricopharynx Oesophagus

Common Sites of impaction of FB Tonsils Base of tongue Vallecula Pyriform fossa Cricopharynx Oesophagus

Common Sites of impaction of FB Tonsils Base of tongue Vallecula Pyriform fossa Cricopharynx Oesophagus

Equipment Head mirror/ head light Tongue depressor Laryngeal mirror Forceps Direct laryngoscopy* Flexible Nasopharyngoscope*

Tongue depressors to allow examination of tonsils

Dental mirrors to allow examination of base of tongue and hypopharynx

For removal of FB in pharynx

Nagashima forceps: For removal of FB from base of tongue, vallecula and hypopharynx

FB Throat - Investigations Lateral neck XR CXR Barium swallow CT scan – without contrast Rigid oesophagoscopy



Hyoid bone Thyroid cartilage Cricoid cartilage FB Osteophyte






FB Throat >50% of ingested FB cannot be found! Discharge with symptomatic treatment Cover with antibiotics if diabetic patient or immunocompromised FB advice Chest pain, fever, increasing symptoms

FB Throat Can be seen in next ENT clinic if: No FB found on detailed examination No chest pain Symptoms mild

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