ENT Emergencies

Stanford University

Division of Emergency Medicine

Overview

• Otologic Disorders

• Nasal Disorders

• Facial, Oral and Pharyngeal Infections

• Airway Obstruction

Otologic DisordersAnatomy

• Auricle

• Ear canal

• Tympanic membrane

• Middle ear and mastoid disorders

• Inner Ear

Traumatic Disorders of the Auricle• Hematoma

- cartilaginous necrosis

- drain, antibiotics, bulky ear dressing close follow up

• Lacerations - single layer closure, pick up perichondrium, bulky ear dressing

Use posterior auricular block for anesthesia

Aspiration of Auricular Hematoma

Auricle• Chondritis - Cellulitis ?- infectious, difficult to treat

because poor blood supply, cover S. Aureus and pseudomonas

- extra care in diabetics

- inflammatory causes related to seronegative arthritis at times indistinguishable from infection usually the ear lobe is spared

Otitis Externa• Infection and inflammation

caused by bacteria (pseudomonas, staph), and fungi

- treat with antibiotic-steroid drops

- use wick for tight canals

- diabetics can get malignant otitis externa (defined by the presence of granulation tissue)

Foreign Bodies in Ear Canal

• Usually put in by patient, some bugs fly in

• kill bugs with mineral oil, or lidocaine

• remove with forceps, suction or tissue adhesive

Tympanic Membrane Perforation• Hard to see – Hx of drainage• Usually from middle ear pressure

secondary to fluid or barotrauma• Sometimes from external trauma• most heal uneventfully but all need

otology follow-up • perfs with vertigo and facial nerve

involvement need immediate referral• treat with antibiotics• drops controversial but indicated for

purulent discharge (avoid gentamycin drops)

Middle Ear• Serous Otitis Media - Eustachian

tube dysfunction - treat with decongestants, decompressive maneuvers

• Otitis Media - infection of middle ear effusion - viral and bacteria

• Mastoiditis - Venous connection with brain, need aggressive treatment (can lead to brain abcess or meningitis)

Inner Ear

• peripheral vertigo (vestibulopathy)

BPV, labyrhinthitis

• - acute onset, no central signs, usually young, horizontal nystagmus

• Meniere’s - vertigo, sensorineural hearing loss, tinnitus

• Treatment

- valium, fluids, rest, manipulation for BPV

The Nose

• Vascular Supply

- Anterior - branches of internal carotid

- Posterior - distal branches of external carotid

EpistaxisAnterior

• 90% (Little’s Area) Kisselbach’s plexus - usually children, young adults

Etiologies• Trauma, epistaxis digitorum• Winter Syndrome, Allergies• Irritants - cocaine, sprays• Pregnancy

EpistaxisPosterior

• 10% of all epistaxis - usually in the elderly

• Etiologies

• Coagulopathy

• Atherosclerosis

• Neoplasm

• Hypertension (debatable)

EpistaxisManagement

• Pain meds, lower BP, calm patient

• Prepare ! (gown, mask, suction, speculum, meds and packing ready)

• Evacuate clots

• Topical vasoconstrictor and anesthetic

• Identify source

EpistaxisManagement

• Anterior Sites- Pressure +/- cautery

and/or tamponade

- all packs require antibiotic prophylaxis

EpistaxisPosterior Packing

• Need analgesia and sedation

• require admission and 02 saturation monitoring

EpistaxisComplications

• severe bleeding

• hypoxia, hypercarbia

• sinusitis, otitis media

• necrosis of the columella or nasal ala

7th Nerve Palsy• Most cases are idiopathic

- link to HSV

- no proof steroids or antivirals are effective, but many advocate

• Consider Lyme’s Disease in edemic areas

• Surgical decompression indicated in the rare patient not improving by 2 weeks and ENOG out > 90%

Facial InfectionsSinusitis

• Signs and symptoms- H/A, facial pain in sinus

distribution- purulent yellow-green

rhinorrhea- fever- CT more sensitive than plain

films• Causative Organisms- gram positives and H. flu

(acute)- anaerobes, gram neg (chronic)

Facial InfectionsSinusitis

• Treatmentacute - amoxil, septrachronic - amoxil-clavulinic acid,

clindamycin, quinolonesdecongestants, analgesia, heat

• Complicationsethmoid sinusitis - orbital cellulits and

abcessfrontal sinusitis - may erode bone

(Potts Puffy Tumor, Brain Abcess)

Facial Cellulitis

• Most common strept and staph,

• Rarely H.Flu• Can progress rapidly

Parotiditis• Usually viral

-paramyxovirus• Bacterial

- elderly, immunosuppressed

- associated with dehydration

- cover - Staph, anaerobes

Pharyngitis

• Irritants

-reflux, trauma, gases

• Viruses

- EBV, adenovirus

• Bacterial

-GABHS, mycoplasma, gonorrhea, diptheria

Peritonsillar Abcess

• Complication of suppurative tonsillitis

• Inferior - medial displacement of tonsil and uvula

• dysphagia, ear pain, muffled voice, fever, trismus

• Treatment

- Antibiotics, I&D, +/-steroids

EpiglottitisClinical Picture

• Older children and adults• decrease incidence in children

secondary to HIB vaccine• Onset rapid, patients look toxic• prefer to sit, muffled voice,

dysphagia, drooling, restlessness

Epiglottitis

• Avoid agitation

• Direct visualization if patient allows

• soft tissue of neck

- thumb print, valecula sign

• Prepare for emergent airway, best achieved in a controlled setting

• Unasyn, +/- steroids

EpiglottitisEpiglottitis

Retropharyngeal Abcess• Anterior to prevertebral space

and posterior to pharynx• Usually in children under 4

(lymphoid tissue in space)• pain, dysphagia, dyspnea, fever• swelling of retropharyngeal

space on lateral x-ray• Complications - mediastinitis

Masticator - Parapharyngeal Space Infection

• Infection of the lower molars invade masticator space

• Swelling, pain fever, TRISMUS

• Treatment

IV antibiotics (PCN or Clindamycin)

ENT admission

ANUGAcute Necrotizing Ulcerative Gingivitis

• Bacterial infection causing an acute necrotizing, destructive disease of periodontium

• Treatment

- oral rinses

- antibiotics (PCN, clindamycin, tetracycline)

Ludwigs Angina• Rapidly progressive cellulitis of the

floor of the mouth• usually in elderly debilitated

patients and precipitated by dental procedures

• massive swelling with impending airway obstruction

• Treatment

ICU, antibiotics, airway management

Angioedema• Ocassionally life

threatening• Heriditary and related

to ACE inhibitors• Antihistamines,

steroids and doxepin

Airway Obstruction

• Aphonia - complete upper airway

• Stridor - incomplete upper airway

• Wheezing - incomplete lower airway

• Loss of breath sounds- complete lower airway

Questions and Answers