common ent emergencies

COMMON ENT COMMON ENT EMERGENCIESEMERGENCIES

Thongchai LuxameechanpornThongchai LuxameechanpornENT departmentENT department

Ramathibodi hospitalRamathibodi hospital

Common ENT Common ENT emergenciesemergencies

Foreign bodiesForeign bodies TraumaTrauma Complications of ENT infectionsComplications of ENT infections

Foreign bodies Foreign bodies InsectsInsects Cotton, paper, Cotton, paper,

organic materialorganic material Small batteriesSmall batteries Discomfort & Discomfort &

agitationagitation Secondary Secondary

complications: complications: infection & mucosal infection & mucosal erosionerosion

Foreign bodiesForeign bodies

Kill any live insectsKill any live insects Remove foreign Remove foreign

body with micro body with micro alligator forcepsalligator forceps

Irrigation ( do not Irrigation ( do not use if organic FB )use if organic FB )

Auricular HematomaAuricular Hematoma Usually from Usually from

traumatrauma Fluctuant bluish Fluctuant bluish

swelling of auricleswelling of auricle DrainageDrainage - Needle aspiration- Needle aspiration - I & D- I & D Apply compression Apply compression

dressingdressing

Traumatic TM Traumatic TM PerforationPerforation

Compression, Compression, instrumentation & instrumentation &

blast injuriesblast injuries Hearing testHearing test Close observation Close observation

if perforation is if perforation is smallsmall

Paper patchPaper patch SurgerySurgery

Temporal bone fractureTemporal bone fracture Blunt head injuryBlunt head injury Longitudinal Fx Longitudinal Fx → →

facial n. paralysis, facial n. paralysis, CHL (ossicular CHL (ossicular chain disruption)chain disruption)

Transverse Fx Transverse Fx → → SNHL, SNHL, dysequilibrium, dysequilibrium, CN VII palsy CN VII palsy

Temporal bone fracture Temporal bone fracture Battle’s sign (bluish Battle’s sign (bluish

discoloration of discoloration of postauricular postauricular region), raccoon region), raccoon eyes, eyes, hemotympanum, hemotympanum, hearing loss, hearing loss, dizziness, CSF dizziness, CSF otorrhea, CN VII otorrhea, CN VII palsypalsy

CT temporal boneCT temporal bone

Acoustic traumaAcoustic trauma Sudden exposure (impact or blast) to Sudden exposure (impact or blast) to

noisenoise SHNL, tinnitusSHNL, tinnitus Avoidance/ ear protectionAvoidance/ ear protection Corticosteroids, carbogen, Corticosteroids, carbogen,

vasodilators, diuretics, vasodilators, diuretics, anticoagulants, plasma expandersanticoagulants, plasma expanders

Otitic BarotraumaOtitic Barotrauma Inability to Inability to

ventilate middle ventilate middle ear ear → → abnormal abnormal dysfunction of ETdysfunction of ET

Occur in rising Occur in rising ambient pressure ambient pressure (descent in flight / (descent in flight / scuba diving)scuba diving)

Can produce Can produce hemotympanumhemotympanum

BarotraumaBarotrauma

Repeated Valsalva Repeated Valsalva maneuvermaneuver

Topical nasal Topical nasal decongestantsdecongestants

Myringotomy & PE Myringotomy & PE tube insertion may tube insertion may be neededbe needed

Sudden Hearing LossSudden Hearing Loss SNHL ≥ 30 dB SNHL ≥ 30 dB

over 3 contiguous over 3 contiguous frequencies within frequencies within 3 days or less3 days or less

Etiology : Viral & Etiology : Viral & Infectious, Infectious, Vascular, Trauma, Vascular, Trauma, Autoimmune, Autoimmune, Neurologic Neurologic

Complications of ME Complications of ME infectionsinfections

ExtracranialExtracranial

Acute MastoiditisAcute Mastoiditis

preceded by AOMpreceded by AOM young childrenyoung children severe pain, fever, severe pain, fever,

edemaedema over mastoid areaover mastoid area intravenous ATBintravenous ATB Myringotomy ± PE Myringotomy ± PE

tubetube

Subperiosteal AbscessSubperiosteal Abscess

pinna pushed pinna pushed down & outward down & outward intravenous ATBintravenous ATB I&DI&D mastoidectomy mastoidectomy

Complications of ME Complications of ME infectionsinfections

IntracranialIntracranial

Foreign bodies: Foreign bodies: SymptomsSymptoms

Purulent unilateral Purulent unilateral nasal dischargenasal discharge

Usually lodge on Usually lodge on the floor of the floor of anterior or middle anterior or middle thirdthird

Foreign bodies: Foreign bodies: ManagementManagement

Good visualization: Good visualization: headlamp & nasal headlamp & nasal speculumspeculum

Alligator forceps should Alligator forceps should be used to remove cloth, be used to remove cloth, cotton, or paper cotton, or paper

Other hard FB are more Other hard FB are more easily grasped using easily grasped using bayonet forceps or Kelly bayonet forceps or Kelly clamps, or they may be clamps, or they may be rolled out by getting rolled out by getting behind it using an ear behind it using an ear curette, single skin hook, curette, single skin hook, or right angle ear hookor right angle ear hook

Nasal FractureNasal Fracture

Hx of fall or force Hx of fall or force directed to midfacedirected to midface

Deformity of noseDeformity of nose Swelling, Swelling,

ecchymosis, ecchymosis, epistaxisepistaxis

Close or open Close or open reductionreduction

Septal Septal hematoma/abscesshematoma/abscess

Trauma, surgeryTrauma, surgery Soft, fluctuant Soft, fluctuant

swelling of septumswelling of septum Needle Needle aa spiration spiration oror I&D I&D Bilateral nasal pack Bilateral nasal pack

ing for several days ing for several days Prophylactic antibio Prophylactic antibio

ticstics

Septal Septal hematoma/abscesshematoma/abscess

EpistaxisEpistaxis LocalLocalTrauma /Nose Trauma /Nose

picking or picking or blowing / surgeryblowing / surgery

Dry air / Irritants Dry air / Irritants Topical medications Topical medications

(steroids)(steroids)Foreign body Foreign body Tumor / polypTumor / polyp

SystemicSystemicBlood diseasesBlood diseasesHereditary Hereditary

hemorrhagic hemorrhagic telangiectasiatelangiectasia

Drugs Drugs (anticoagulants)(anticoagulants)

HypertensionHypertension

Epistaxis Epistaxis

EpistaxisEpistaxis Initial first-aidInitial first-aid Assessment of Assessment of

blood lossblood loss Evaluation of Evaluation of

cause cause Procedure to stop Procedure to stop

bleedingbleeding

Most common Most common → → Kiesselbach’s Kiesselbach’s Plexus Plexus

Squeeze nose 5-20 Squeeze nose 5-20 minsmins

Insert cotton Insert cotton pledget (with pledget (with decongestant)decongestant)

Cautery with silver Cautery with silver nitrate nitrate

Pope, L E R et al. Postgrad Med J 2005;81:309-314

Figure 1 Epistaxis management protocol.

Epistaxis Epistaxis

Anterior nasal packingAnterior nasal packing Local anesthetic & Local anesthetic &

decongestant decongestant Nasal packingNasal packing - - Vasaline guazeVasaline guaze - Absorbable - Absorbable

gelfoamgelfoam - Oxidized cellulose- Oxidized cellulose (Surgicel) (Surgicel) - Nasal tampon- Nasal tampon

Anterior nasal packingAnterior nasal packing

Anterior nasal packingAnterior nasal packing Nasal packingNasal packing - - Vasaline guazeVasaline guaze - - Absorbable Absorbable

gelfoamgelfoam - Oxidized - Oxidized

cellulosecellulose (Surgicel)(Surgicel) - Nasal tampon- Nasal tampon

Anterior nasal packingAnterior nasal packing Nasal packingNasal packing - - Vasaline guazeVasaline guaze - - Absorbable Absorbable


cellulosecellulose (Surgicel) (Surgicel) - Nasal tampon- Nasal tampon

Anterior nasal packingAnterior nasal packing Nasal packingNasal packing - - Vasaline guazeVasaline guaze - Absorbable - Absorbable


cellulosecellulose (Surgicel) (Surgicel) - - Nasal tamponNasal tampon

Copyright ©2005 BMJ Publishing Group Ltd.

Pope, L E R et al. Postgrad Med J 2005;81:309-314

Figure 2 Correct insertion of a nasal tampon (note that the direction is along the floor of the nasal cavity).

Posterior nasal packingPosterior nasal packing

Topical anesthetic Topical anesthetic & decongestant& decongestant

Posterior nasal Posterior nasal packingpacking

Double balloon Double balloon devicedevice

Foley catheterFoley catheter

Posterior nasal packingPosterior nasal packing

Topical anesthetic Topical anesthetic & decongestant& decongestant

Posterior nasal Posterior nasal packing packing

Double balloon Double balloon devicedevice

Foley catheterFoley catheter

Complications of Complications of sinusitissinusitis

Orbital complicationsOrbital complications Intracranial complicationsIntracranial complications

Classification of orbital Classification of orbital inflammationinflammation

StageStage II IIII IIIIII IVIV VV

InflammationInflammationInflammatory edemaInflammatory edema(periorbital cellulitis)(periorbital cellulitis)Orbital cellulitisOrbital cellulitisSubperiosteal abscessSubperiosteal abscessOrbital abscessOrbital abscessCavernous sinus Cavernous sinus

thrombosisthrombosis


Periorbital cellulitis: Periorbital cellulitis: periorbital erythema, periorbital erythema, edema, pain & feveredema, pain & fever

Purulent nasal Purulent nasal dischargedischarge

S.pneumoniae, S.pneumoniae, S.aureus, S.aureus, coagulase-coagulase-negative negative staphylococcistaphylococci

Broad-speculum Broad-speculum antibioticsantibiotics


Orbital complications Orbital complications (stages II-V)(stages II-V)

Periorbital swelling Periorbital swelling & pain, fever& pain, fever

Proptosis, chemosis, Proptosis, chemosis, restriction of ocular restriction of ocular movement & visual movement & visual disturbancedisturbance


CT scan CT scan → → subperiosteal & subperiosteal & orbital abscessorbital abscess

Admission & IV Admission & IV broad- spectrum broad- spectrum antibioticsantibiotics

Surgery (drainage) ifSurgery (drainage) if - failed medication - failed medication - develop abscess- develop abscess - visual drop- visual drop


Intracranial complicationsIntracranial complications Cavernous sinus thrombosis, Cavernous sinus thrombosis,

meningitis, extradural abscess, meningitis, extradural abscess, intracranial abscess & subdural intracranial abscess & subdural empyemaempyema

Purulent rhinorrhea, fever, Purulent rhinorrhea, fever, frontal/retro-orbital headachefrontal/retro-orbital headache

Personality change/lethargy, seizures, Personality change/lethargy, seizures, N/V, focal neurological deficits N/V, focal neurological deficits


Intracranial complicationsIntracranial complications Diagnosis Diagnosis → → MRI scan with MRI scan with

gadoliniumgadolinium Admission, IV broad-spectrum Admission, IV broad-spectrum

antibiotics & surgical drainageantibiotics & surgical drainage

Swallowed foreign bodySwallowed foreign body

Peanuts, coins, Peanuts, coins, batteries, fish batteries, fish bone, meat & bone bone, meat & bone pieces, denturespieces, dentures

Location of pain Location of pain indicates FB indicates FB locationlocation

Swallowed foreign bodySwallowed foreign body

Fish bones tend to Fish bones tend to lodge in lodge in oropharynx, oropharynx, produced ipsilateral produced ipsilateral symptomssymptoms

Esophagus FB Esophagus FB localize in midline: localize in midline: dramatic acute dramatic acute dysphagia dysphagia

Swallowed Foreign Swallowed Foreign bodiesbodies

Most FB in Most FB in oropharynx can be oropharynx can be identifiedidentified

Esophageal FB: Esophageal FB: pooling of saliva in pooling of saliva in piriformpiriform

X-rays may be X-rays may be helpful in radio-helpful in radio-paque objectspaque objects


Visualized FB can Visualized FB can be removed with be removed with angled forcepsangled forceps

Sharp FB should Sharp FB should be removed at the be removed at the earliest earliest opportunity due to opportunity due to risk of perforationrisk of perforation


Coins Coins → → removed if removed if in cervical or mid in cervical or mid esophagus esophagus → → removed within 12 removed within 12 hrs if in distal hrs if in distal esophagusesophagus

Batteries Batteries → → removed emergency removed emergency


Airway Airway compromisecompromise

- Heimlich - Heimlich maneuvermaneuver

- Emergency- Emergency cricothyrotomy/ cricothyrotomy/ tracheostomytracheostomy Endoscopy with Endoscopy with

removal in ORremoval in OR

Inhaled Foreign bodiesInhaled Foreign bodies Sudden onset of Sudden onset of

coughing, wheezing coughing, wheezing or stridor in or stridor in previously healthy previously healthy childchild

Unilateral wheezing, Unilateral wheezing, poor chest movement poor chest movement & reduced breath & reduced breath soundsound

CXR: hyperinflate, CXR: hyperinflate, infection, collapseinfection, collapse

Inhaled Foreign bodiesInhaled Foreign bodies

Heimlich manuverHeimlich manuver Secure airway Secure airway Endoscopic Endoscopic

removal under removal under general anesthesiageneral anesthesia

Airway ObstructionAirway Obstruction Neonatal Neonatal :: Congenital tumors, cysts, webs Congenital tumors, cysts, webs

: Laryngomalacia: Laryngomalacia : Subglottic stenosis: Subglottic stenosis Children : LaryngotracheobronchitisChildren : Laryngotracheobronchitis : Supraglottitis (epiglottitis): Supraglottitis (epiglottitis) : Foreign body: Foreign body : Retropharyngeal abscess: Retropharyngeal abscess : Respiratory papilloma: Respiratory papilloma Adults : Laryngeal cancer Adults : Laryngeal cancer : Laryngeal trauma: Laryngeal trauma : Epiglottis & deep neck infection: Epiglottis & deep neck infection

Deep neck infectionsDeep neck infections

Peritonsillar abscessPeritonsillar abscess

Pus forms between Pus forms between tonsils capsule & tonsils capsule & superior superior constrictorconstrictor

Group A Group A StreptococcusStreptococcus


Severe, unilateral Severe, unilateral sore throatsore throat

feverfever Hot potato voiceHot potato voice Uvula deviates to Uvula deviates to

opposite sideopposite side Swollen tonsilsSwollen tonsils


CBC, throat C/SCBC, throat C/S Antibiotics Antibiotics - Oral - Oral - Parenteral - Parenteral needle aspiration needle aspiration

or I&Dor I&D

Ludwig’s AnginaLudwig’s Angina Rapid swelling Rapid swelling

cellulitis of cellulitis of sublingual & sublingual & submaxillary spacessubmaxillary spaces

Dental infection, Dental infection, floor of mouth, floor of mouth, salivary glandsalivary gland

Fever, edema & Fever, edema & erythema of neck erythema of neck under chin & floor of under chin & floor of mouthmouth

Ludwig’s AnginaLudwig’s Angina Open mouth, Open mouth, Tongue Tongue → → upward & upward &

backwardbackward →→ airway airway obstructionobstruction

Streptococci, Streptococci, Bacteroides, Bacteroides, S.aeruesS.aerues

TracheostomyTracheostomy IV antibioticIV antibiotic I&D, tooth extractionI&D, tooth extraction

EpiglottitisEpiglottitis Age 3-7 yrs oldAge 3-7 yrs old H. influenzae H. influenzae type B, type B,

Group A Group A Streptococcus Streptococcus

severe sore throat & severe sore throat & fever, dysphagia, fever, dysphagia, drooling drooling

StridorStridor Breathing with raised Breathing with raised

chin & open mouthchin & open mouth

EpiglottitisEpiglottitis

CBC: leukocytosisCBC: leukocytosis Film lateral neck Film lateral neck → →

thumb shaped thumb shaped epiglottisepiglottis

Avoid tongue Avoid tongue depressordepressor

Controlled Controlled intubationintubation

Intravenous ATBIntravenous ATB

Retropharyngeal AbscessRetropharyngeal Abscess Infants & childrenInfants & children Secondary to Secondary to

oropharyngeal oropharyngeal infectioninfection

Severe dysphagia & Severe dysphagia & respiratory distressrespiratory distress

airway observationairway observation IV antibioticIV antibiotic Surgical drainageSurgical drainage ( prevent pus ( prevent pus

aspiration)aspiration)

TracheostomyTracheostomyEmergency Emergency

tracheostomytracheostomyin the case of upper in the case of upper

airways obstructionairways obstruction1. Tumor in the larynx1. Tumor in the larynx2. Trauma of the larynx2. Trauma of the larynx3. Bilateral vocal cord 3. Bilateral vocal cord

paralysisparalysis4. F.B. in the larynx 4. F.B. in the larynx

after failure of after failure of Heimlich’s manuver Heimlich’s manuver

common ent emergencies

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