11

Emergencies in ENTEmergencies in ENT

Mr. Guillermo Hurtado Mr. Guillermo Hurtado

B.Med, ORLB.Med, ORL (Hons), FRACS(Hons), FRACS

Ear, Nose andEar, Nose and Throat, Head and NeckThroat, Head and Neck SurgeonSurgeon

Epworth Richmond Private HospitalEpworth Richmond Private Hospital

1818thth March 2015March 2015

Epworth Healthcare

General Practitioner’s Education Session

22

Emergencies in ENTEmergencies in ENT

Bleeding EmergenciesBleeding Emergencies

Epistaxis Epistaxis

Post tonsillectomy hemorrhagePost tonsillectomy hemorrhage

Foreign Body emergenciesForeign Body emergencies

EarEar

AirwayAirway

33

EpistaxisEpistaxis

INTRODUCTIONINTRODUCTION

Very common emergencyVery common emergency

1010--12% of the population 12% of the population

•• Only 10% seek medical Only 10% seek medical attentionattention

•• Only 1.6% require admissionOnly 1.6% require admission

SeasonSeason

•• Temperature / humidityTemperature / humidity

Sex Sex

•• Equal distributionEqual distribution

Age Age

•• First 2 decadesFirst 2 decades Anterior and mild episodes Anterior and mild episodes

(90 % of epistaxis)(90 % of epistaxis)

•• > 50 yrs> 50 yrs Posterior and more severe Posterior and more severe

episodesepisodes

44

EpistaxisEpistaxis

INTRODUCTIONINTRODUCTION

Very common emergencyVery common emergency

1010--12% of the population 12% of the population

•• Only 10% seek medical Only 10% seek medical attentionattention

•• Only 1.6% require admissionOnly 1.6% require admission

SeasonSeason

•• Temperature / humidityTemperature / humidity

Sex Sex

•• Equal distributionEqual distribution

Age Age

•• First 2 decadesFirst 2 decades Anterior and mild episodes Anterior and mild episodes

(90 % of epistaxis)(90 % of epistaxis)

•• > 50 yrs> 50 yrs Posterior and more severe Posterior and more severe

episodesepisodes

55

EpistaxisEpistaxis

ANATOMYANATOMY

Rich nasal irrigationRich nasal irrigation

Internal Carotid ArtInternal Carotid Art

•• Ethmoidal ArteriesEthmoidal Arteries

External Carotid ArtExternal Carotid Art

•• Facial ArteryFacial Artery

•• Internal Maxillary ArteryInternal Maxillary Artery

PlexusPlexus KiesselbachKiesselbach’’s plexuss plexus

WoodruffWoodruff’’s plexuss plexus

66

EpistaxisEpistaxis

ANATOMYANATOMY

Rich nasal irrigationRich nasal irrigation

Internal Carotid ArtInternal Carotid Art

•• Ethmoidal ArteriesEthmoidal Arteries

External Carotid ArtExternal Carotid Art

•• Facial ArteryFacial Artery

•• Internal Maxillary ArteryInternal Maxillary Artery

PlexusPlexus KiesselbachKiesselbach’’s plexuss plexus

WoodruffWoodruff’’s plexuss plexus

77

EpistaxisEpistaxis

ANATOMYANATOMY

Rich nasal irrigationRich nasal irrigation

Internal Carotid ArtInternal Carotid Art

•• Ethmoidal ArteriesEthmoidal Arteries

External Carotid ArtExternal Carotid Art

•• Facial ArteryFacial Artery

•• Internal Maxillary ArteryInternal Maxillary Artery

PlexusPlexus KiesselbachKiesselbach’’s plexuss plexus

WoodruffWoodruff’’s plexuss plexus

88

EpistaxisEpistaxis

LOCAL CAUSESLOCAL CAUSES

TraumaTrauma

Digital / Fractures / Foreign bodyDigital / Fractures / Foreign body

Chemical irritation / desiccation / Chemical irritation / desiccation / atrophyatrophy

StructuralStructural

Septal perforationSeptal perforation

99

EpistaxisEpistaxis

LOCAL CAUSESLOCAL CAUSES

Inflammatory diseaseInflammatory disease

Viral / bacterial infections Viral / bacterial infections

Granulomatous diseaseGranulomatous disease

Tumours / Vascular Tumours / Vascular malformationmalformation

Benign tumoursBenign tumours

•• Juvenile NasoJuvenile Naso--angiofibromaangiofibroma

•• Inverted papillomaInverted papilloma

Malignant tumoursMalignant tumours

•• SCC / AdenocarcinomaSCC / Adenocarcinoma

1010

EpistaxisEpistaxis

SYSTEMIC CAUSESSYSTEMIC CAUSES

CoagulopathyCoagulopathy

CongenitalCongenital

AcquiredAcquired

Anticoagulant drugsAnticoagulant drugs

Vascular diseaseVascular disease

ArteriosclerosisArteriosclerosis

CardiovascularCardiovascular

HTNHTN

1111

EpistaxisEpistaxis

DiagnosisDiagnosis Initial evaluationInitial evaluation

Hemodynamic stability Hemodynamic stability

Airway compromise Airway compromise

Airway/Breathing/CirculationAirway/Breathing/Circulation

ManagementManagement Control bleedingControl bleeding

•• Apply pressure Apply pressure

•• Definitive haemostasisDefinitive haemostasis

Intravenous resuscitationIntravenous resuscitation

Correct reversible / contributing Correct reversible / contributing factorsfactors

If possible, If possible, a complete history a complete history should be obtainedshould be obtained Side, amount, ant/post Sx?Side, amount, ant/post Sx?

Precipitants, previous tx, coPrecipitants, previous tx, co--morbidities, medicationsmorbidities, medications

1212

EpistaxisEpistaxis

Australasian Society of Thrombosis and Haemostasis

Warfarin reversal: consensus guidelines. 2004

DiagnosisDiagnosis Initial evaluationInitial evaluation

Hemodynamic stability Hemodynamic stability

Airway compromise Airway compromise

Airway/Breathing/CirculationAirway/Breathing/Circulation

ManagementManagement Control bleedingControl bleeding

•• Apply pressure Apply pressure

•• Definitive haemostasisDefinitive haemostasis

Intravenous resuscitationIntravenous resuscitation

Correct reversible / contributing Correct reversible / contributing factorsfactors

If possible take If possible take complete complete history history Side, amount, ant/post Sx?Side, amount, ant/post Sx?

Precipitants, previous tx, coPrecipitants, previous tx, co--morbidities, medicationsmorbidities, medications

1313

EpistaxisEpistaxis

Assessment Assessment EquipmentEquipment

Personal protectionPersonal protection

IlluminationIllumination

InstrumentsInstruments •• SpeculumSpeculum

•• ForcepsForceps

•• Rigid suction probesRigid suction probes

•• Cotton / PledgesCotton / Pledges

•• Vasoconstrictor / anaesthetic sprayVasoconstrictor / anaesthetic spray

•• Tongue depressorsTongue depressors

CauteryCautery •• Chemical / ElectricalChemical / Electrical

Packing materials Packing materials •• MerocelMerocel

•• Rapid RhinoRapid Rhino

•• Vaseline strip gauzeVaseline strip gauze

•• SurgicelSurgicel

EndoscopesEndoscopes

1414

EpistaxisEpistaxis

Assessment Assessment EquipmentEquipment

Personal protectionPersonal protection

IlluminationIllumination

InstrumentsInstruments •• SpeculumSpeculum

•• ForcepsForceps

•• Rigid suction probesRigid suction probes

•• Cotton / PledgesCotton / Pledges

•• Vasoconstrictor / Vasoconstrictor / anaestheticanaesthetic sprayspray

•• Tongue depressorsTongue depressors

1515

EpistaxisEpistaxis

Assessment Assessment EquipmentEquipment

Personal protectionPersonal protection

IlluminationIllumination

InstrumentsInstruments •• SpeculumSpeculum

•• ForcepsForceps

•• Rigid suction probesRigid suction probes

•• Cotton / PledgesCotton / Pledges

•• Vasoconstrictor / Vasoconstrictor / anaestheticanaesthetic sprayspray

•• Tongue depressorsTongue depressors

1616

EpistaxisEpistaxis

Assessment Assessment EquipmentEquipment

Personal protectionPersonal protection

IlluminationIllumination

InstrumentsInstruments •• SpeculumSpeculum

•• ForcepsForceps

•• Rigid suction probesRigid suction probes

•• Cotton / PledgesCotton / Pledges

•• Vasoconstrictor / Vasoconstrictor / anaestheticanaesthetic sprayspray

•• Tongue depressorsTongue depressors

1717

EpistaxisEpistaxis

Assessment Assessment EquipmentEquipment

CauteryCautery •• Chemical / ElectricalChemical / Electrical

Packing materials Packing materials •• MerocelMerocel

•• Rapid RhinoRapid Rhino

•• Vaseline strip gauzeVaseline strip gauze

•• SurgicelSurgicel

EndoscopesEndoscopes

1818

EpistaxisEpistaxis

Assessment Assessment EquipmentEquipment

CauteryCautery •• Chemical / ElectricalChemical / Electrical

Packing materials Packing materials •• MerocelMerocel

•• Rapid RhinoRapid Rhino

•• Vaseline strip gauzeVaseline strip gauze

•• SurgicelSurgicel

EndoscopesEndoscopes

1919

EpistaxisEpistaxis

Physical examinationPhysical examination

Nasal examinationNasal examination

•• Evacuate, anesthetise, Evacuate, anesthetise,

decongest and inspect decongest and inspect

anterior nasal cavityanterior nasal cavity

•• If bleeding: control bleeding If bleeding: control bleeding

with nasal packingwith nasal packing

•• If not bleeding and no site is If not bleeding and no site is

identified: refer for posterior identified: refer for posterior

nasal inspectionnasal inspection

LaboratoryLaboratory

FBE, coag screen, Group RHFBE, coag screen, Group RH

ImagingImaging

Clinically guidedClinically guided

2020

EpistaxisEpistaxis

TREATMENTTREATMENT

Medical management Medical management

Humidification, lubricationHumidification, lubrication

Cautery Cautery Silver nitrateSilver nitrate

•• Proper vasoconstrictionProper vasoconstriction

•• Target paused applicationsTarget paused applications

•• Unilateral Unilateral

•• Apply ointment immediately afterApply ointment immediately after

Endoscopic electrocautery Endoscopic electrocautery

•• Bi/MonopolarBi/Monopolar

Laser cauteryLaser cautery

•• KTP laserKTP laser

2121

EpistaxisEpistaxis

TREATMENTTREATMENT

Nasal packing Nasal packing

Anterior packAnterior pack

•• Vaseline gauzeVaseline gauze

•• Expandable packs Expandable packs

RapidRhino: hydrocolloid RapidRhino: hydrocolloid

(carboxymethylcellulose)(carboxymethylcellulose)

•• Platelet aggregator, lubricant, Platelet aggregator, lubricant,

clot preserved on removalclot preserved on removal

Merocel: (polyvinyl alcohol)Merocel: (polyvinyl alcohol)

Posterior packPosterior pack

•• Will require anterior packing Will require anterior packing

Nasal balloon Nasal balloon

•• Brighton balloon, simpson plug, Brighton balloon, simpson plug, epistat nasal catheterepistat nasal catheter

2222

EpistaxisEpistaxis

TREATMENTTREATMENT

Nasal packing Nasal packing

Anterior packAnterior pack

•• Vaseline gauzeVaseline gauze

•• Expandable packs Expandable packs

RapidRhino: hydrocolloid RapidRhino: hydrocolloid

(carboxymethylcellulose)(carboxymethylcellulose)

•• Platelet aggregator, lubricant, Platelet aggregator, lubricant,

clot preserved on removalclot preserved on removal

Merocel: (polyvinyl alcohol)Merocel: (polyvinyl alcohol)

Posterior packPosterior pack

•• Will require anterior packing Will require anterior packing

Nasal balloon Nasal balloon

•• Brighton balloon, simpson plug, Brighton balloon, simpson plug, epistat nasal catheterepistat nasal catheter

2323

COMPLICATIONSCOMPLICATIONS

ImmediateImmediate

•• Nasovagal reflex Nasovagal reflex –– hypotension and hypotension and bradycardiabradycardia

EarlyEarly

•• Persistent / recurrent bleedingPersistent / recurrent bleeding

•• Obstruction Obstruction

•• Nasolacrimal duct: epiphoraNasolacrimal duct: epiphora

•• OMC: sinusitisOMC: sinusitis

•• Nasal airway: hypoxia, OSANasal airway: hypoxia, OSA

•• Airway obstruction Airway obstruction

•• Toxic shock syndromeToxic shock syndrome

•• Staph aureus coverStaph aureus cover

LateLate

•• Nasal alae necrosis Nasal alae necrosis

EpistaxisEpistaxis

2424

EpistaxisEpistaxis

TREATMENTTREATMENT

Indications for surgical interventionIndications for surgical intervention

Uncontrollable bleedingUncontrollable bleeding

•• Failure of 1 Failure of 1 ––2 properly placed packs2 properly placed packs

Early intervention to reduce Early intervention to reduce

hospital stayhospital stay

2525

EpistaxisEpistaxis

TREATMENTTREATMENT

DiathermyDiathermy

Ligation Ligation

Endoscopic ligation of Endoscopic ligation of Sphenopalatine art Sphenopalatine art

Transantral ligation of the IMA Transantral ligation of the IMA

External ligation of the ethm arts.External ligation of the ethm arts.

External carotid artery ligationExternal carotid artery ligation

Other nasal surgeryOther nasal surgery

Septoplasty Septoplasty

Septal dermoplastySeptal dermoplasty

Intervention radiologyIntervention radiology

2626

DiathermyDiathermy

EndoscopicEndoscopic

TargetedTargeted

Bipolar preferable or low Bipolar preferable or low wattage monopolarwattage monopolar

Septal surgerySeptal surgery

AccessAccess

Correct spur or deviationCorrect spur or deviation

Septal dermoplasty for Septal dermoplasty for hereditary hemorrhagic hereditary hemorrhagic telangiectasiatelangiectasia

EpistaxisEpistaxis

2727

Sphenopalatine artery ligationSphenopalatine artery ligation Endoscopic dissection of Endoscopic dissection of

posterior portion of lateral nasal posterior portion of lateral nasal wallwall

SPA clipped or coagulatedSPA clipped or coagulated

Complications Complications PostPost--operativeoperative

•• EarlyEarly Palatal Palatal numbness 13% numbness 13%

•• LateLate Crusting Crusting 43%43%

Sinusitis 3%Sinusitis 3%

Septal Septal perforation 3%perforation 3%

OutcomesOutcomes Successful haemostasis in 80Successful haemostasis in 80--90% 90%

(small no. studies)(small no. studies)

EpistaxisEpistaxis

2828

Anterior/posterior ethmoidal Anterior/posterior ethmoidal artery ligationartery ligation

External ethmoidectomy External ethmoidectomy approach (Lynch incision)approach (Lynch incision)

Improve outcomes when Improve outcomes when combined with IMA ligation, combined with IMA ligation, SPA ligationSPA ligation

EpistaxisEpistaxis

2929

Maxillary artery ligationMaxillary artery ligation Rarely performedRarely performed

Modified CaldwellModified Caldwell--Luc Luc approach, through posterior approach, through posterior wall of maxillary sinus into wall of maxillary sinus into pterygopalatine fossapterygopalatine fossa

Vessel clipped or coagulatedVessel clipped or coagulated

87% effective87% effective

ComplicationsComplications

Infraorbital nerve injury, Infraorbital nerve injury, blindness, post operative blindness, post operative bleeding (15%), devitalised bleeding (15%), devitalised gums and teeth, sinusitis, gums and teeth, sinusitis, epiphoraepiphora

EpistaxisEpistaxis

3030

External carotid artery External carotid artery

ligationligation

Last resort in profound Last resort in profound

uncontrollable uncontrollable

haemorrhagehaemorrhage

LongLong--term failure rate 45%term failure rate 45%

•• Watershed areas supplied Watershed areas supplied

by contralateral external by contralateral external

carotidcarotid

EpistaxisEpistaxis

3131

Intervention radiologyIntervention radiology Embolisation with coils or Embolisation with coils or

gelfoamgelfoam •• AngiographyAngiography

•• Cannulation of external Cannulation of external carotidcarotid

•• Up to 87% effectiveUp to 87% effective

ComplicationsComplications •• BlindnessBlindness

•• Neurological deficit Neurological deficit

•• CVA CVA

•• False aneurysmFalse aneurysm

EpistaxisEpistaxis

3232

PostPost--tonsillectomy tonsillectomy

haemorrhagehaemorrhage CLASSIFICATIONCLASSIFICATION

PrimaryPrimary •• At time of surgeryAt time of surgery

•• ReactiveReactive First 6 hrs post opFirst 6 hrs post op

SecondarySecondary •• During recovery periodDuring recovery period

Very serious conditionVery serious condition Death riskDeath risk

ChildrenChildren •• Occult blood loss Occult blood loss

(swallowed)(swallowed)

•• Excellent autoregulationExcellent autoregulation Normal vital signs until Normal vital signs until

potentially fatal blood losspotentially fatal blood loss

3333

PostPost--tonsillectomy tonsillectomy

haemorrhagehaemorrhage TONSILS IRRIGATIONTONSILS IRRIGATION

Facial art.Facial art. Tonsillar branchTonsillar branch

Ascending palatine art.Ascending palatine art.

•• Tonsillar branchTonsillar branch

Lingual art. Lingual art. Dorsal lingualDorsal lingual

•• Tonsillar branchTonsillar branch

Ascending pharyngeal art. Ascending pharyngeal art. Tonsillar branchTonsillar branch

Intern Max art.Intern Max art. Lesser descending palatineLesser descending palatine

•• Tonsillar branchTonsillar branch

3434

PostPost--tonsillectomy tonsillectomy

haemorrhagehaemorrhage Ascending Pharyngeal a.

Lesser palantine a.

Tonsillar branch of

lesser palantine

Tonsillar branch of ascending

Pharyngeal a.

Tonsillar branch of facial a.

Tonsillar branch of

ascending palatine a.

Tonsillar branch of

dorsal lingual a.

TONSILS IRRIGATIONTONSILS IRRIGATION

Facial art.Facial art. Tonsillar branchTonsillar branch

Ascending palatine art.Ascending palatine art.

•• Tonsillar branchTonsillar branch

Lingual art. Lingual art. Dorsal lingualDorsal lingual

•• Tonsillar branchTonsillar branch

Ascending pharyngeal art. Ascending pharyngeal art. Tonsillar branchTonsillar branch

Intern Max art.Intern Max art. Lesser descending palatineLesser descending palatine

•• Tonsillar branchTonsillar branch

3535

SURGICAL TECHSURGICAL TECH

Cold steel vs diathermy Cold steel vs diathermy (O(O’’Leary & Vorrath 2005)Leary & Vorrath 2005)

Bleed rate 1.85% vs 2.35% Bleed rate 1.85% vs 2.35% (p<0.05)(p<0.05)

More reactive bleeds in More reactive bleeds in cold steel groupcold steel group

More secondary bleeds in More secondary bleeds in dissection group dissection group

•• Day 4Day 4--77

Bleeds > 500mL more Bleeds > 500mL more common in diathermy common in diathermy groupgroup

PostPost--tonsillectomy tonsillectomy

haemorrhagehaemorrhage

3636

DIAGNOSISDIAGNOSIS

Initial evaluationInitial evaluation

Hemodynamic stability and Hemodynamic stability and potential airway compromise potential airway compromise

Airway/Breathing/CirculationAirway/Breathing/Circulation

If possible, If possible, a complete a complete

history should be obtainedhistory should be obtained

Time of onset, how many days Time of onset, how many days post surgery, type of procedure, post surgery, type of procedure, type of bleeding (+/type of bleeding (+/-- epistaxis)epistaxis)

Amount of blood lossAmount of blood loss

MedicationsMedications

•• NSAIDNSAID’’s s

•• AnticoagulantsAnticoagulants

PostPost--tonsillectomy tonsillectomy

haemorrhagehaemorrhage

3737

ACTIVE BLEEDING ACTIVE BLEEDING MANAGEMENTMANAGEMENT

Intravenous resuscitationIntravenous resuscitation

•• Blood tests (FBE, coag), group and holdBlood tests (FBE, coag), group and hold

CALL ENTCALL ENT Control bleedingControl bleeding

•• Do not remove the clotsDo not remove the clots

•• May attempt with May attempt with

Ccophenylcaine soaked swab or H202 Ccophenylcaine soaked swab or H202

Correct reversible / contributing Correct reversible / contributing factorsfactors

Bleeding continues Bleeding continues OTOT

PostPost--tonsillectomy tonsillectomy

haemorrhagehaemorrhage

3838

INACTIVE MANAGEMENTINACTIVE MANAGEMENT

Do not remove the clotDo not remove the clot

REFER TO ENTREFER TO ENT

Bleeding stops Bleeding stops bed rest bed rest (admission), IV antibiotics, NBM(admission), IV antibiotics, NBM

Patient to be admitted for Patient to be admitted for observationobservation

PostPost--tonsillectomy tonsillectomy

haemorrhagehaemorrhage

3939

INACTIVE MANAGEMENTINACTIVE MANAGEMENT

Do not remove the clotDo not remove the clot

REFER TO ENTREFER TO ENT

Bleeding stops Bleeding stops bed rest bed rest (admission), IV antibiotics, NBM(admission), IV antibiotics, NBM

Patient to be admitted for Patient to be admitted for observationobservation

PostPost--tonsillectomy tonsillectomy

haemorrhagehaemorrhage

4040

Foreign Body in ENTForeign Body in ENT

EAREAR

SymptomsSymptoms

•• Hypoacusia, otalgia, Hypoacusia, otalgia, dischargedischarge

ClassificationClassification

•• Animated Animated vsvs InertInert

•• AnimatedAnimated EmergencyEmergency

•• Kill insect with Oil Kill insect with Oil

4141

Foreign Body in ENTForeign Body in ENT

EAREAR

SymptomsSymptoms

•• Hypoacusia, otalgia, Hypoacusia, otalgia, dischargedischarge

ClassificationClassification

•• InertInert UrgencyUrgency

•• Irrigation (NOT for Irrigation (NOT for seeds)seeds)

Removal under visionRemoval under vision

•• ONLY with proper ONLY with proper equipment, conditions equipment, conditions and trainingand training

DO not remove if there is DO not remove if there is already blood in EACalready blood in EAC

•• EUA under microscopeEUA under microscope

REFER TO ENTREFER TO ENT

4242

Foreign Body in ENTForeign Body in ENT

NOSENOSE •• Unilateral offensive Unilateral offensive

rinorrhearinorrhea/epistaxis/epistaxis

ManagementManagement •• Ask patient to blow noseAsk patient to blow nose

Can be further aspirated!Can be further aspirated!

•• Spray topic Spray topic anaesthanaesth//vasoconstricvasoconstric

•• Removal under visionRemoval under vision ONLY with proper equipment, ONLY with proper equipment,

conditions and trainingconditions and training

DO not remove if there is DO not remove if there is already blood in nostril or already blood in nostril or it is too deepit is too deep

•• Batteries need to come out Batteries need to come out fastfast

REFER TO ENTREFER TO ENT

4343

Foreign Body in ENTForeign Body in ENT

Upper airwayUpper airway PHARYNXPHARYNX •• HistoryHistory

Recent choking/gagging episode Recent choking/gagging episode while feedingwhile feeding

•• SymptomsSymptoms Odinophagia, globus a/dysphagia, Odinophagia, globus a/dysphagia,

sialorrheasialorrhea Localized pain, haemoptisisLocalized pain, haemoptisis

•• Airway compromiseAirway compromise Dyspnea, WOB, stridorDyspnea, WOB, stridor

•• IF complicatedIF complicated Fever, otalgia, torticolis, trismusFever, otalgia, torticolis, trismus Chest pain, tachypnea, tachycardia, Chest pain, tachypnea, tachycardia,

hypotensionhypotension

4444

Foreign Body in ENTForeign Body in ENT

Upper airwayUpper airway PHARYNXPHARYNX •• HistoryHistory

Recent choking/gagging episode Recent choking/gagging episode while feedingwhile feeding

•• SymptomsSymptoms Odinophagia, globus a/dysphagia, Odinophagia, globus a/dysphagia,

sialorrheasialorrhea Localized pain, haemoptisisLocalized pain, haemoptisis

•• Airway compromiseAirway compromise Dyspnea, WOB, stridorDyspnea, WOB, stridor

•• IF complicatedIF complicated Fever, otalgia, torticolis, trismusFever, otalgia, torticolis, trismus Chest pain, tachypnea, tachycardia, Chest pain, tachypnea, tachycardia,

hypotensionhypotension

4545

Foreign Body in ENTForeign Body in ENT

Upper airwayUpper airway

PHARYNXPHARYNX

ManagementManagement

•• Adequate inspectionAdequate inspection

•• Imaging may be necessaryImaging may be necessary

•• DO NOTDO NOT Rely on local anaesthetic effect. Rely on local anaesthetic effect.

Attempt blind removal from the Attempt blind removal from the

throat with a finger or instrumentthroat with a finger or instrument

•• Removal under visionRemoval under vision

ONLY with proper ONLY with proper

equipment, conditions and equipment, conditions and

trainingtraining

POTENTIAL AIRWAY POTENTIAL AIRWAY COMPROMISECOMPROMISE

REFER TO ENTREFER TO ENT

•• Keep NBM Keep NBM

x

4646

Foreign Body in ENTForeign Body in ENT

AirwayAirway Larynx / Trachea / BronchusLarynx / Trachea / Bronchus Challenging diagnosis and treatment Challenging diagnosis and treatment

A high index of suspicionA high index of suspicion

3000 deaths / year from foreign body 3000 deaths / year from foreign body

aspirationaspiration •• Most deaths occurring before hospitalMost deaths occurring before hospital

Treatment Treatment

Open approach Open approach Bronchotomy (1800Bronchotomy (1800’’s)s)

Endoscopic removal Endoscopic removal •• From 1897. From 1897. •• Chevalier Jackson developed rodChevalier Jackson developed rod--

lens telescope lens telescope •• Improvements in anesthetic Improvements in anesthetic

techniques made a safer techniques made a safer procedure.procedure.

4747

Foreign Body in ENTForeign Body in ENT

AirwayAirway Larynx / Trachea / BronchusLarynx / Trachea / Bronchus

FrequencyFrequency

Most of aspirations occur in children Most of aspirations occur in children 11--3 yrs. 3 yrs.

•• Predisposing factorsPredisposing factors

•• Lack of molars for grinding Lack of molars for grinding •• Lack coordination of swallowing and Lack coordination of swallowing and

glottic closureglottic closure •• They tend to be running or playing and They tend to be running or playing and

put objects in their mouth more put objects in their mouth more frequently.frequently.

Vegetable matter the most commonVegetable matter the most common SeedsSeeds

4848

Foreign Body in ENTForeign Body in ENT

AirwayAirway Larynx / Trachea / BronchusLarynx / Trachea / Bronchus

PathophysiologyPathophysiology

•• 8080--90% become lodged in the bronchi.90% become lodged in the bronchi.

•• In adults: Right main bronchus (lesser angle In adults: Right main bronchus (lesser angle

of convergence carina location left of the of convergence carina location left of the midline.midline.

•• Equal frequency of right and left bronchial Equal frequency of right and left bronchial foreign bodies in children.foreign bodies in children.

•• Larger objects tend to become lodged in the Larger objects tend to become lodged in the

larynx or trachealarynx or trachea..

4949

Foreign Body in ENTForeign Body in ENT

ImagingImaging

HighHigh--kilovolt AP and Lateral chest films kilovolt AP and Lateral chest films

Greater definition of the airway while reducing the Greater definition of the airway while reducing the effect of the surrounding bony structures.effect of the surrounding bony structures.

Radiopaque objects are visible, but Radiopaque objects are visible, but radiolucent objects (eg, plastic) are not.radiolucent objects (eg, plastic) are not.

Chest radiographs may reveal obstructive Chest radiographs may reveal obstructive emphysema or hyperinflation, atelectasis, emphysema or hyperinflation, atelectasis, and consolidation.and consolidation.

Lateral decubitus chest Lateral decubitus chest

•• In childrenIn children

•• Obstructed dependent lung remains Obstructed dependent lung remains inflatedinflated

Chest inspiratory and expiratory Chest inspiratory and expiratory radiographs radiographs

•• Atelectasis on inspiration and Atelectasis on inspiration and hyperinflation on expiration with a foreign hyperinflation on expiration with a foreign body obstructing the bronchus.body obstructing the bronchus.

..

5050

Foreign Body in ENTForeign Body in ENT

AirwayAirway

Laryngeal Foreign Bodies Laryngeal Foreign Bodies

•• Typically dysphonia and Typically dysphonia and stridor. stridor.

Can mimic CROUPCan mimic CROUP

•• Airway emergency that Airway emergency that requires lifesaving first aid requires lifesaving first aid before transport to the before transport to the hospital. hospital.

•• Partial obstruction Partial obstruction

Irregular foreign bodies Irregular foreign bodies

Sagittal orientationSagittal orientation

•• Laryngeal edema can lead to Laryngeal edema can lead to complete obstruction. complete obstruction.

5151

Foreign Body in ENTForeign Body in ENT

AirwayAirway

Tracheal Foreign Bodies Tracheal Foreign Bodies

•• Typically do not have Typically do not have hoarseness. hoarseness.

"asthmatoid wheeze," the "asthmatoid wheeze," the "audible slap"audible slap”” and the and the "palpable thud" over the "palpable thud" over the trachea.trachea.

As with laryngeal foreign As with laryngeal foreign bodies, edema can bodies, edema can progress to complete progress to complete obstruction.obstruction.

•• Stridor featuresStridor features Inspiratory / Expiratory Inspiratory / Expiratory

5252

Foreign Body in ENTForeign Body in ENT

AirwayAirway Bronchial FBBronchial FB

Initial phaseInitial phase •• At the moment of aspirationAt the moment of aspiration •• Choking, gagging, and paroxysms of Choking, gagging, and paroxysms of

coughing or airway obstruction coughing or airway obstruction

Asymptomatic phaseAsymptomatic phase •• FB lodged and reflexes fatigue. FB lodged and reflexes fatigue. •• Hours to weeks. Hours to weeks.

Third phase with complicationsThird phase with complications •• Obstruction, erosion, or infection Obstruction, erosion, or infection

causes hemoptysis, pneumonia, causes hemoptysis, pneumonia, atelectasis, abscess, or fever. atelectasis, abscess, or fever.

Sudden Sudden ““asthmaasthma”” onsetonset Persistent LRIPersistent LRI

5353

Foreign Body in ENTForeign Body in ENT

AirwayAirway Bronchial FBBronchial FB

CAREFUL history and examinationCAREFUL history and examination

Typical triadTypical triad •• Cough, unilateral wheezing, and Cough, unilateral wheezing, and

decreased breath sounds decreased breath sounds •• Only present in 65% of patientsOnly present in 65% of patients

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Foreign Body in ENTForeign Body in ENT

AirwayAirway

Esophageal foreign body Esophageal foreign body impaction impaction

•• Vomiting, odynophagia, Vomiting, odynophagia, dysphagia, and ptyalism.dysphagia, and ptyalism.

If the ingestion is witnessed, If the ingestion is witnessed, gagging or choking may be gagging or choking may be reported. reported.

A large foreign body may A large foreign body may cause symptoms of airway cause symptoms of airway obstruction and cough caused obstruction and cough caused by compression or irritation of by compression or irritation of the upper airway / left the upper airway / left bronchus.bronchus.

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Thanks for your attentionThanks for your attention