Ent gp emergencies (edited)
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Transcript of Ent gp emergencies (edited)
Management of ENT Management of ENT EmergenciesEmergencies
Simon LloydSimon Lloyd
Consultant ENT SurgeonConsultant ENT Surgeon
Central Manchester NHS Foundation TrustCentral Manchester NHS Foundation Trust
Facial palsyFacial palsy
AnatomyAnatomy• SensorySensory
– TasteTaste– Posterior ear canalPosterior ear canal
• AutonomicAutonomic– Parasympathetic to:Parasympathetic to:
• Lacrimal glandLacrimal gland• Submandibular glandSubmandibular gland• Sublingual glandSublingual gland
• MotorMotor– Facial expressionFacial expression– StapediusStapedius– Posterior belly of digastricPosterior belly of digastric
AetiologyAetiology
• Huge differentialHuge differential• CongenitalCongenital
– Neurological eg. Moebius syndromeNeurological eg. Moebius syndrome– Traumatic eg. ForcepsTraumatic eg. Forceps
• AcquiredAcquired– Idiopathic eg. Bell’s palsyIdiopathic eg. Bell’s palsy– Traumatic eg. Temporal bone fractureTraumatic eg. Temporal bone fracture– Iatrogenic eg. SurgeryIatrogenic eg. Surgery– Infection eg. Acute otitis media, malignant otitis media, Infection eg. Acute otitis media, malignant otitis media,
Ramsey Hunt syndromeRamsey Hunt syndrome– Neoplastic eg. Parotid malignancy Neoplastic eg. Parotid malignancy
ExaminationExamination
Facial nerve grading (House Brackmann)Facial nerve grading (House Brackmann)
Other cranial nervesOther cranial nerves
Tympanic membrane/pinna for vesiclesTympanic membrane/pinna for vesicles
Parotid/mouthParotid/mouth
AssessmentAssessment
• House Brackmann Grading (I to VI)House Brackmann Grading (I to VI)II = Normal = Normal
II = Normal at rest, mild weakness on active II = Normal at rest, mild weakness on active movementmovement
III= Good eye closureIII= Good eye closure
VV = Some tone = Some tone
VI= No movementVI= No movement
Eyes open Eyes closed
Facial PalsyFacial Palsy
52 year old lady52 year old lady Rapid onset left facial Rapid onset left facial
weaknessweakness Left facial numbnessLeft facial numbness No ear symptomsNo ear symptoms Otherwise fit and wellOtherwise fit and well Grade III weaknessGrade III weakness No other abnormalitiesNo other abnormalities
Bell’s PalsyBell’s Palsy
• Idiopathic (probably viral – Herpes simplex)Idiopathic (probably viral – Herpes simplex)• Acute unilateral facial palsy (peripheral)Acute unilateral facial palsy (peripheral)• Occasionally other cranial nerve palsies eg. TrigeminalOccasionally other cranial nerve palsies eg. Trigeminal• Resolves within 3 months in 80% of casesResolves within 3 months in 80% of cases• 10% recur (including contralateral)10% recur (including contralateral)• Higher incidence in diabetesHigher incidence in diabetes• TreatmentTreatment
• Eye Care (lubrication)Eye Care (lubrication)• Oral steroidsOral steroids• No evidence for benefit from antiviralsNo evidence for benefit from antivirals
– Sullivan et al. New England Journal of Medicine 2007Sullivan et al. New England Journal of Medicine 2007
Who to referWho to refer
Additional findings (Cr. Nerves, lumps)Additional findings (Cr. Nerves, lumps)
No improvement at 3 weeksNo improvement at 3 weeks
Incomplete recoveryIncomplete recovery
ConcernsConcerns
Sudden Hearing LossSudden Hearing Loss
Normal TM with sudden hearing lossNormal TM with sudden hearing loss Aetiology unknownAetiology unknown
ViralViral VascularVascular
Rarely acoustic neuroma, perilymph leakRarely acoustic neuroma, perilymph leak May be unsteady or vertiginousMay be unsteady or vertiginous
Sudden Hearing LossSudden Hearing LossManagementManagement
Refer urgentlyRefer urgently
Treatment optionsTreatment options Oral steroidOral steroid AntiviralAntiviral
No evidence for efficacyNo evidence for efficacy CarbogenCarbogen
No evidence for efficacyNo evidence for efficacy Intratympanic steroidIntratympanic steroid
Weak evidence for efficacyWeak evidence for efficacy
Allergic response to BIPPAllergic response to BIPP
Acute Otalgia with normal TMAcute Otalgia with normal TM
Complications ofComplications ofOtitis MediaOtitis Media
MastoiditisMastoiditis Facial palsyFacial palsy LabyrinthitisLabyrinthitis MeningitisMeningitis Intracranial abscessIntracranial abscess Lateral sinus thrombosisLateral sinus thrombosis
- Long term• Tympanosclerosis
• Tympanic membrane perforation
• Ossicular damage
Acute MastoiditisAcute Mastoiditis
History of acute otitis mediaHistory of acute otitis media Infection spreads to mastoidInfection spreads to mastoid Post-auricular abscessPost-auricular abscess
TreatmentTreatment GrommetGrommet Cortical mastoidectomyCortical mastoidectomy
Complications acute otitis mediaComplications acute otitis mediamastoiditismastoiditis
Intracerebral AbscessIntracerebral Abscess
DiagnosisDiagnosis High index of suspicionHigh index of suspicion HeadacheHeadache Reduced conscious levelReduced conscious level FeverFever SeizuresSeizures
Requires drainageRequires drainage
Ring enhancement with contract enhanced CT
Lateral Sinus ThrombosisLateral Sinus Thrombosis
DiagnosisDiagnosis High index of suspicionHigh index of suspicion HeadacheHeadache Decreased conscious levelDecreased conscious level AtaxiaAtaxia SeizuresSeizures
TreatmentTreatment AnticoagulationAnticoagulation ?thrombectomy?thrombectomy Filling defect
on MRA
EpistaxisEpistaxis
AnatomyAnatomy
AetiologyAetiology Usually idiopathicUsually idiopathic
? atherosclerotic vessels? atherosclerotic vessels Predisposing factorsPredisposing factors
AnticoagulantsAnticoagulants HypertensionHypertension
Trauma eg. Digital, fractured noseTrauma eg. Digital, fractured nose Nasal vestibulitis eg. StaphlococcalNasal vestibulitis eg. Staphlococcal Topical treatment eg. Nasal steroidsTopical treatment eg. Nasal steroids RareRare
HHTHHT NeoplasiaNeoplasia Septal perforationSeptal perforation
Epistaxis First AidEpistaxis First Aid
Conservative ManagementConservative Management Pinch soft part of nosePinch soft part of nose Lean forward and breathe Lean forward and breathe
through mouththrough mouth Ten minutesTen minutes
Protect yourselfProtect yourself GownGown GlovesGloves MaskMask
TreatmentTreatment
Identifiable VesselIdentifiable Vessel Nasal cauteryNasal cautery
Examine noseExamine nose Identify vesselIdentify vessel Apply 1 in 10,000 Apply 1 in 10,000
adrenaline and adrenaline and 1%lignocaine on 1%lignocaine on cotton wool pledgetcotton wool pledget
Silver nitrate cautery Silver nitrate cautery of vesselof vessel
Silver nitrate cauterySilver nitrate cautery
TreatmentTreatment
No Identifiable VesselNo Identifiable Vessel Nasal packingNasal packing
MerocelMerocel RapidrhinoRapidrhino BIPP packingBIPP packing
Rapid RhinoRapid Rhino
BIPP PackingBIPP Packing
TreatmentTreatment
Ongoing bleedingOngoing bleeding Re-check vital signsRe-check vital signs IV access +/- fluidsIV access +/- fluids Check clottingCheck clotting Posterior packingPosterior packing
Brighton baloonBrighton baloon Foley catheter and BIPP Foley catheter and BIPP
packpack
Surgical InterventionSurgical Intervention
SeptoplastySeptoplasty Sphenopalatine artery ligationSphenopalatine artery ligation Anterior ethmoid artery ligationAnterior ethmoid artery ligation Maxillary artery ligationMaxillary artery ligation External carotid artery ligationExternal carotid artery ligation
Management AlgorithmManagement Algorithm
Nasal VestibulitisNasal Vestibulitis
PaediatricPaediatric Digital traumaDigital trauma Cautery vs NaseptinCautery vs Naseptin
Equal efficacyEqual efficacy
Bactroban tastes horrible ? Prevents digital traumaBactroban tastes horrible ? Prevents digital trauma
Fractured noseFractured nose
Fractured noseFractured nose
Ask aboutAsk about EpistaxisEpistaxis CSFCSF Diplopia on upward gazeDiplopia on upward gaze Infraorbital parasthesiaInfraorbital parasthesia Shape changeShape change Nasal obstructionNasal obstruction
FracturedFractured nosenose
ExaminationExamination Nasal bones crepitus, shapeNasal bones crepitus, shape Infraorbital parasthesiaInfraorbital parasthesia Orbital rimsOrbital rims Septum for haematomaSeptum for haematoma No need for X ray unless No need for X ray unless
medicolegalmedicolegal
Fractured noseFractured nose
ManagementManagement If no complicating factors and nose straight leave If no complicating factors and nose straight leave
alone. alone. If orbital fracture or septal haematoma refer If orbital fracture or septal haematoma refer
immediatelyimmediately If shape change with no complicating factors refer to If shape change with no complicating factors refer to
ENT about five days post injuryENT about five days post injury
Nose should be reduced within 2 weeks for Nose should be reduced within 2 weeks for best chance of good resultbest chance of good result
Complications of SinusitisComplications of Sinusitis
Intracranial complicationsIntracranial complications Brain AbscessBrain Abscess MeningitisMeningitis
Orbital complicationsOrbital complications Periorbital cellulitisPeriorbital cellulitis Periorbital abscessPeriorbital abscess Orbital abscessOrbital abscess Pott’s puffy tumourPott’s puffy tumour
Periorbital Cellulitis and AbscessPeriorbital Cellulitis and Abscess
UnwellUnwell PyrexiaPyrexia Eye closesEye closes ErythemaErythema ChemosisChemosis Colour vision goes off Colour vision goes off
firstfirst
Refer urgentlyRefer urgently
Periorbital CellulitisPeriorbital CellulitisTreatmentTreatment
NoseNose Topical decongestantsTopical decongestants
EphidrineEphidrine OtravineOtravine
SystemicSystemic IV antibioticsIV antibiotics
CT imaging to exclude CT imaging to exclude periorbital abscessperiorbital abscess
Foreign BodiesForeign Bodies MaterialMaterial
Paper, beads, watch batteries Paper, beads, watch batteries etc.etc.
Unilateral rhinorrhoea is a Unilateral rhinorrhoea is a foreign body until proved foreign body until proved otherwiseotherwise
TreatmentTreatment Wrap up childWrap up child Assistant hold headAssistant hold head RemoveRemove
Complications of TonsillitisComplications of TonsillitisPeritonsillar abscessPeritonsillar abscess
SymptomsSymptoms Pain becomes more unilateralPain becomes more unilateral Often referred otalgiaOften referred otalgia Trismus (therefore difficult to get a good look)Trismus (therefore difficult to get a good look) DroolingDrooling Systemically unwell with pyrexiaSystemically unwell with pyrexia Normally big tender upper deep cervical nodeNormally big tender upper deep cervical node
ReferRefer
Complications of tonsillitisComplications of tonsillitisPeritonsillar abscess (quinsy)Peritonsillar abscess (quinsy)
Peritonsillar abscessPeritonsillar abscess
TreatmentTreatment Incision and drainage (needle/blade)Incision and drainage (needle/blade) Intravenous penicillin and metronidazoleIntravenous penicillin and metronidazole First quinsy and previous history of First quinsy and previous history of
tonsillitis… recommend tonsillectomytonsillitis… recommend tonsillectomy First quinsy with no prior tonsillitis First quinsy with no prior tonsillitis
history…verbal warninghistory…verbal warning
StridorStridor
Harsh, high-pitched sound indicative of airway obstruction.Harsh, high-pitched sound indicative of airway obstruction.
InspiratoryInspiratory SupraglotticSupraglottic or Glottic or Glottic
BiphasicBiphasic Subglottic or Extrathoracic Trachea Subglottic or Extrathoracic Trachea
ExpiratoryExpiratory Intrathoracic TracheaIntrathoracic Trachea
NB. Stertor – High upper airway obstructionNB. Stertor – High upper airway obstruction
Stridor - AssessmentStridor - Assessment
What level ??What level ??History – What sort of stridorHistory – What sort of stridor
How severe ??How severe ?? Accessory muscles Accessory muscles
Tracheal tug / Recession in childrenTracheal tug / Recession in childrenPulsePulse
pCOpCO22 Retention Retention
Does the airway need securing ??Does the airway need securing ?? Severe OR patient getting tired.Severe OR patient getting tired.
CausesCauses ChildrenChildren
InfectionInfection Bacterial eg. EpiglottitisBacterial eg. Epiglottitis Viral eg. CroupViral eg. Croup
Foreign bodyForeign body
AdultsAdults InfectionInfection
SupraglottitisSupraglottitis
NeoplasiaNeoplasia Squamous cell carcinoma Squamous cell carcinoma
Stridor -managementStridor -management SIT PATIENT UPSIT PATIENT UP OXYGENOXYGEN RE-HYDRATION (i.v.)RE-HYDRATION (i.v.) STEROIDS (Nebulised, i.v. or oral)STEROIDS (Nebulised, i.v. or oral) ADRENALINE NEBULISERADRENALINE NEBULISER HELIOX – Helium / oxygen mixtureHELIOX – Helium / oxygen mixture ANTI-BIOTICSANTI-BIOTICS AIRWAY INTERVENTIONAIRWAY INTERVENTION
IntubationIntubationBronchoscopyBronchoscopyTracheostomyTracheostomy
““Croup” vs EpiglottitisCroup” vs Epiglottitis
CroupCroup EpiglottitisEpiglottitis
AgeAge 1-3years1-3years 3-6 years3-6 years DurationDuration URTI (days)URTI (days) Short(hours)Short(hours) ClinicalClinical “Viral”“Viral” UnwellUnwell** StridorStridor LoudLoud QuietQuiet
* * Decreased concious level, circumoral palor, rapid deterioration.Decreased concious level, circumoral palor, rapid deterioration.
Airway Foreign BodiesAirway Foreign Bodies
RIGHT main bronchus (more vertical)RIGHT main bronchus (more vertical)
May get air trapping, distal to FB.May get air trapping, distal to FB.
Monophonic wheeze (asthma POLYphonic)Monophonic wheeze (asthma POLYphonic)
High index of suspicion - High index of suspicion - REFERREFER
Rigid bronchoscope
Bronchoscope and camera being used to assess the airway in a child with a tracheostomy