common ent emergencies
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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
gelfoamgelfoam - Oxidized - Oxidized
cellulosecellulose (Surgicel) (Surgicel) - Nasal tampon- Nasal tampon
Anterior nasal packingAnterior nasal packing Nasal packingNasal packing - - Vasaline guazeVasaline guaze - Absorbable - Absorbable
gelfoamgelfoam - Oxidized - Oxidized
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
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
Complications of Complications of sinusitissinusitis
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
Complications of Complications of sinusitissinusitis
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
Complications of Complications of sinusitissinusitis
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
Complications of Complications of sinusitissinusitis
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
Complications of Complications of sinusitissinusitis
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
Swallowed Foreign Swallowed Foreign bodiesbodies
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
Swallowed Foreign Swallowed Foreign bodiesbodies
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
Swallowed Foreign Swallowed Foreign bodiesbodies
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
Peritonsillar abscessPeritonsillar abscess
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
Peritonsillar abscessPeritonsillar abscess
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
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