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ENT Emergencies
Mitchell Shulman MDCM FRCPC CSPQ
Attending Physician, Emerg Dept MUHC
Assistant Professor, Dept of Surgery
Copyright © 2017 by
Sea Courses Inc.
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CME Faculty Disclosure
Dr. Shulman has no affiliation with
the manufacturer of any
commercial product or provider of
any commercial service discussed
in this CME activity.
What We’ll Cover
• Otologic Disorders
• Nasal Disorders
• Facial, Oral and Pharyngeal
Infections
Rare, serious, unusual things
Anatomy
Auricle
Ear canal
Tympanic
membrane
Mastoid
Inner Ear
Traumatic Disorders of the Auricle
Traumatic Disorders of the Auricle
Hematoma
Danger: cartilage necrosis
Rx: drain, antibiotics, bulky
ear dressing, close
follow up
Lacerations
Rx: single layer closure,
pick up perichondrium,
bulky ear dressing
Aspiration of Auricular Hematoma
Foreign Bodies in Ear Canal
• By patient / Fly in / ?
• Kill bugs (mineral oil or lidocaine)
• Remove (forceps, suction or tissue
adhesive)
• Always check for damage
before and after
• Document
Tympanic Membrane Perforation
• Can be hard to see (Hx: drainage)
• Usually: middle ear pressure 2ndary to fluid / barotrauma
• Can be: external trauma
• Most heal uneventfully
• Otology follow-up
• Perforation + vertigo / facial nerve involvement need immediate referral
Middle Ear
Serous Otitis Media
eustachian tube dysfunction
Rx: decongestants
Otitis Media
viral / bacterial
Mastoiditis
Danger: aggressive Rx
(brain abscess / meningitis)
What We’ll Cover
• Otologic Disorders
• Nasal Disorders
• Facial, Oral and Pharyngeal
Infections
The Nose
Vascular Supply
Anterior: branches of
internal carotid
Posterior: distal
branches of external
carotid
EpistaxisAnterior
Little’s Area (Kisselbach’s plexus)
• 90% - usually children, young adults
Causes:
• Trauma: “epistaxis digitorum”
• Winter Syndrome, allergies
• Irritants (eg. cocaine, sprays)
• Pregnancy
EpistaxisPosterior
• 10% of all epistaxis -
usually elderly
Causes
• Coagulopathy
• Atherosclerosis
• Neoplasm
• Hypertension (debatable)
Epistaxis
Management
Anterior SitesPressure +/- cautery +/or
tamponade
All packs require
antibiotic prophylaxis ?
Epistaxis
Management
• Pain meds, lower BP, calm patient
• Prepare !
(gown, mask, suction, speculum, meds / packing ready)
• Evacuate clots
• Topical vasoconstrictor and anesthetic
• Identify source
Epistaxis
Management
Posterior Packing
Need analgesia /
sedation
Admit
02 saturation monitoring
Epistaxis
Complications
Severe bleeding
Hypoxia, hypercarbia
Sinusitis, otitis media
Necrosis of the columella or nasal ala
What We’ll Cover
• Otologic Disorders
• Nasal Disorders
• Facial, Oral and Pharyngeal
Infections
7th Nerve Palsy
Most cases:
idiopathic
- Are steroids or antivirals
effective?
• Consider: Lyme Disease;
Ramsay Hunt (herpes zoster)
Sinusitis
Signs / SymptomsH/A
Facial pain (over sinus)
Purulent yellow-green rhinorrhea
Fever
CT more sensitive than plain films
Causative Organisms
Gm + / H. flu (acute)
Anaerobes, Gm - (chronic)
Sinusitis
Treatment
Acute: amoxicillin, trimethoprim –sulfamethoxazole
Chronic: amoxicillin-clavulinic acid, clindamycin, quinolones
Decongestants, analgesia, heat
Complications of Acute Sinusitis
Preseptal:
periorbital cellulitis
Ocular pain, eyelid
swelling, erythema
Postseptal:
orbital cellulitis
Pain with eye movement,
proptosis, ophthalmoplegia
Warning: Visual impairment!!
Complications of Sinusitis
Periorbital Cellulitis
• Preseptal (doesn’t involve orbit,
infection of structures anterior to the orbital septum)
• Pain, eyelid swelling, erythema
• More common; Less serious
• Source: ethmoidal sinus; local trauma; insect bites;
foreign body
• Intracranial extension
• Investigation: CT scan (contrast)
• Outpt Rx: clavulin; clindamycin 300 mg Q8H
(30-40 mg/kg IV QID do not exceed 1.8 gms / 24 hrs)
• If no improvement in 24 hrs, admit and get CT.
• Postseptal
• Eyelid swelling; eye pain; pain with eye
movement; proptosis;
ophthalmoplegia/diplopia; vision impairment
• Complications: abscess; vision loss; death!
• Can develop rapidly
• Daily visual acuity and pupillary light reflex
checks
• IV Abx: Vancomycin + Piperacillin-tazobactam
Complications of Sinusitis
Orbital Cellulitis
Complications of acute sinusitis
Cavernous sinus thrombosis
• From orbital veins: blood can flow to the cavernous sinus (?no valves)
• High fever; toxic
• Severe headache, protracted vomiting, mental status changes; unilateral CN palsies (III; IV; V; VI)
• Rapidly progressive chemosis
• Severe retinal engorgement
• May progress to vision loss, meningitis, death
• IV Abx: Vancomycin + Piperacillin - tazobactam
Facial Cellulitis
Most common organisms:
streptococcus,
staphylococcus
rarely H.flu
• Can progress rapidly
ParotitisViral / Autoimmune
Bacterial:
Elderly, immunosuppressed
Associated with dehydration
Rx:
Abx: Cloxacillin; Vancomycin;
Clindamycin
Warm compresses
Pain control
Pharyngitis
Irritants
reflux, trauma, gases
Viruses
EBV, adenovirus
Bacterial
GABHS, mycoplasma, gonorrhea,
diptheria
Peritonsillar AbcessComplication of suppurative
tonsillitis
(Group A strep, Strep
pyogenes, Staph aureus, H.
influenzae, anaerobes)
Infero - medial
displacement of tonsil and
uvula
Dysphagia, ear pain,
muffled voice, fever, trismus
Rx: Antibiotics (clindamycin),
I&D
EpiglottitisClinical Picture
• Acute inflammation causing
swelling of the supraglottic
structures of the larynx
• Children vs adults
• Decrease incidence in children (HIB vaccine)
• Onset rapid, pts toxic
• Prefer to sit, muffled voice,
dysphagia, drooling, restless
Epiglottitis
• Avoid agitation
• Direct visualization if
patient allows
• Soft tissue X-rays of
neck
• Prepare for emergent
airway
(best achieved in a
controlled setting)
Epiglotitis
ManagementChildren:
To operating room
Be ready to intubate
Have backup ready including surgical airway
Adults:Admitted (ICU or Step-down Unit)
Intubation (if airway at risk)
Continuous O2 sat monitoring
Daily examination of larynx
Retropharyngeal Abcess
• Anterior to prevertebral space
and posterior to pharynx
• Pain, dysphagia, dyspnea, fever
• Swelling of retropharyngeal
space on lateral x-ray
• Complications – mediastinitis;
internal jugular thrombosis,
carotid artery erosion, etc…
• IV Abx: Vancomycin + Pip-Taz
C2 > 7 mm*
C6 > 22 mm**
*
**
Ludwigs Angina
Rapidly progressive cellulitis of the
floor of the mouth
Usually: elderly debilitated
patients, precipitated by dental
procedures / infection (2nd or 3rd
molar)
Organisms: streptococcus,
oral anaerobes
Danger: Massive swelling with
impending airway obstruction
Ludwig Angina Spread
Ludwig Angina
Presentation• Fever, chills, malaise
• Tender swelling under mandible + floor mouth
• Usually little or no fluctuance
• Muffled voice
• Severe trismus?, drooling of saliva, dysphagia
• Gross swelling, elevation, displacement of tongue
• Tachypnea / dyspnea Stridor / cyanosis
Danger of upper airway obstruction + death!
Ludwig Angina
Management
• ABC’s
Awake intubation (fiberoptic) vs surgical airway
• Admit
ICU / stepdown (unless airway is totally safe)
02 sat monitoring
• Drain abscess
• I.V. Antibiotics: Clindamycin + Vancomycin;
Pip/Taz + Vancomycin