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Otolaryngological Emergencies AHD Jan 31, 2013

Otolaryngological Emergencies AHD Jan 31, 2013. Hans Rosenberg MD CCFP(EM). Objectives . Ear Anatomy Otitis Media Otitis Externa Mastoiditis. Anatomy. Clinical Examination. Start with External: helix, antihelix, tragus, outer ear canal Otoscope: external auditory canal, TM Syringing

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Otolaryngological Emergencies AHD Jan 31, 2013

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  1. Otolaryngological EmergenciesAHD Jan 31, 2013 Hans Rosenberg MD CCFP(EM)

  2. Objectives • Ear Anatomy • Otitis Media • Otitis Externa • Mastoiditis

  3. Anatomy

  4. Clinical Examination • Start with External: helix, antihelix, tragus, outer ear canal • Otoscope: external auditory canal, TM • Syringing • Pneumatoscopy

  5. Question 4 • What is the DDx of Ear pain, list 5 primary causes and 5 non-ear causes? (10)

  6. DDx for Ear Pain Ear Non-Ear Pharyngitis Sinusitis Upper Respiratory Tract Infection Dental pain Bell’s Palsy Foreign bodies • Otitis Media • Otitis Externa • Otitis Media with Effusion • Mastoiditis • Labyrinthitis • Dysbarism • Ramsay Hunt Syndrome • Malignant External Otitis

  7. Case 6 • 4 year old brought in by mom because he has pain in his right ear, fever and coryza

  8. Otitis Media • #1 diagnosis in patients <15 yo • #1 reason for Rx of antimicrobials • Definitions: • Inflammationof the middle ear • AOM: signs and symptoms of an acute infection with an effusion • OM with Effusion: effusion without symptoms and signs of acute infection • Recurrent AOM: 3 episodes in 6/12 or 4 in 1 year

  9. Question 5 • What are the 5 most common bacteria that cause AOM?

  10. Otitis Media • Bacteriology • S. pneumoniae, H. influenzae (primarily nontypeable), and M. catarrhalis. • Streptococcus pyogenes, Staphylococcus aureus, and gram-negative bacteria are much less common • Virology • RSV, parainfluenza, influenza, enterovirus, rhinovirus, and adenovirus

  11. Clinical • Hx • otalgia, fever, ear pulling, coryza, cough, anorexia, vomiting, diarrhea • Risk Factors • 6m-3y, male, daycare, smoking, pacifier, cleft palate, Downs • Sequelae • mastoiditis, bacterial meningitis, H/L, labyrinthitis, CN VII palsy

  12. TM Anatomy • P/E • TM • Normal: pars flaccida, malleus, light reflex, moves with insufflation

  13. Clinical • P/E • TM • AOM: bulging/retracted, erythematous*, effusion, A/F level, dull (loss of anterior light reflex), no movement

  14. Otitis Media

  15. Otitis Media - Guidelines • 1. Recent, usually abrupt, onset of signs and symptoms of middle-ear inflammation and MEE. • 2. The presence of MEE that is indicated by any of the following: • a. Bulging of the tympanic membrane • b. Limited or absent mobility of the tympanic membrane • c. Air fluid level behind the tympanic membrane • d. Otorrhea

  16. Otitis Media • 3. Signs or symptoms of middle-ear inflammation as indicated by either • a. Distinct erythema of the tympanic membrane OR • b. Distinct otalgia (discomfort clearly referable to the ear[s] that results in interference with or precludes normal activity or sleep)

  17. Management • Pain Control • Tylenol • Advil • Narcotic Analgesics • Benzocaine-Antipyrenegtts (Auralgan)

  18. Management • Note:Nonsevere illness is mild otalgia and fever <39C in the past 24 hours. Severe illness is moderate to severe otalgia or fever >39C.

  19. Management <2yr old or complex case use 10 day course, otherwise may use 7 day course

  20. Management • Recurrent AOM • If > 6 weeks since last AOM use first line agents • If < 6 weeks since last AOM use second line agents • Consider ENT referral • OME for ≥ 3 months with bilateral hearing loss ≥ 20 dB. • ≥ 3 episodes in 6 months • ≥ 4 episodes in 12 months • Retracted tympanic membrane • Cleft plate or craniofacial malformations.

  21. Management Controversies

  22. Management Controversies • Primary Outcome – not statistically significant • Changed protocol, from single Primary Outcome to four primary outcomes • Lead author has received multiple honoraria from makers of Amox-Clav ES • Make little to no mention of secondary outcome which was statistically significant - Diarrhea

  23. Mastoiditis • Inflammation of mastoid air cells • commonly associated with AOM • Bacteriology • S. pneumoniae, group A streptococci, S. aureus, S. epidermidis, M. catarrhalis, H. flu

  24. Clinical • Hx • PAIN, Fever, h/a, erythema posterior to auricle, AOM symptoms for >2 weeks • P/E • tenderness, erythema • displaced auricle • TM  erythema/bulging/fluid • Complications • SubperiostialAbscess • BezoldAbscess – below pinna, behind SCM • Petrositis/Osteomyelitis • Diagnostic Imaging • CT (Sens 87-100%)/MRI

  25. Management • Antibiotics: Ceftriaxone, Clindamycin + Gentamycin, Pip-Tazo • ENT for possible myringotomy, tympanostomy tubes, mastoidectomy

  26. Case 7 • 23 year old male returns from his weekend at his cottage early due to unbearable pain in his right ear. His vital signs are all stable but when you touch his helix he screams out in pain.

  27. Otitis Externa • Infection of the external auditory canal • DDx • AOM • Otomycosis – Aspergillosis • Furunculosis – infection of cartilagenous portion of ext. canal • Herpes Zoster Oticus – Ramsay Hunt Syndrome • Bacteriology • P. aeruginosa, S. aureus, and other gram-negative organisms often occurring as polymicrobial infection.

  28. Clinical • Hx • otalgia, ear fullness, H/L, redness, swelling, jaw pain, discharge, pruritis • Risks • moisture, maceration, trauma • P/E • erythema, edema, narrowing of canal, discomfort with pulling on the auricle or tragus

  29. Otitis Externa • Analgesia – NSAID’s, opiates • Ear Wick • Antifungals • Thimerosolgtts • Gentian Violet gtts • Antimicrobials • Ciprodex 4gtts bid • Cortisporin 4gtts qid

  30. Necrotizing (Malignant) External Otitis • Osteomyelitis of temporal bone secondary to OE • potentially life threatening • almost exclusively in immunocompromised • Pseudomonas • 50 % mortality if left untreated • Hx: severe pain, h/a, discharge • P/E: erythema, tenderness, edema of external ear or adjacent structures, POOP, granulation tissue

  31. Malignant External Otitis • Oral Ciprofloxacin 750mg po bid if uncomplicated • IV Ceftazidime 1-2g IV q8h • Hyperbaric • ENT consultation • Treatment length guided by bone scan

  32. Case 8 • http://www.youtube.com/watch?v=S3Mrh52-pzs

  33. Epistaxis

  34. Epistaxis • Nasal Anatomy • Etiology • Management of Anterior Bleeds • Management of Posterior Bleeds

  35. Question • What are the arteries which are involved in anterior epistaxis (ie. Kiesselbach’s Plexus)?(5)

  36. Epistaxis • Most cases in children although bimodal distribution • Anterior ~90% of cases in Kiesselbach’s Plexus • ant. ethmoid, sphenopalatine, greater palatine, superior labial arteries • Posterior Epistaxis from posterior branch sphenopalatine artery

  37. Nasal Anatomy

  38. Epistaxis • Causes • TRAUMA – self, assault, surgical • Mucosal – URTI, allergies, cold/dry weather • Bleeding diatheses • Etc. • Hypertension – NOT a cause of bleeding but may worsen active bleeding

  39. Epistaxis • Preparation, proper equipment and an organized step-wise approach will be the key to success or…

  40. Management - Anterior • Clear clots • Apply pressure for 15-20 min with clips – over septum!!! • With nose parallel to ground use nasal speculum • Use headlight or assistant for light source • Suction as necessary • Check  if continued bleeding…

  41. Management - Anterior • Apply pledgets soaked in: • Lidocaine w/ Epi • Cocaine • Xylometazoline (Otrivin) • Re-examine  if bleeding persists…

  42. Management - Anterior • If light or no bleeding but identify source • Silver Nitrate • Outside to inside • Avoid on both sides of septum • Re-examine  if bleeding persists…

  43. Management - Anterior • Nasal Packing • Nasal Packing with Vaseline gauze • Nasal Tampon/Rhino-Rocket – 8 or 10cm sizes • May need bilateral packs *warn patient that Nasal tampon insertion will be painful for about 10 seconds

  44. Management - Anterior • If success leave packing in for 48hrs, consider antibiotic prophylaxis • Prevention: avoid blowing nose, picking, closed mouth sneezing, apply Polysporin cream • If STILL bleeding • Consider posterior bleed

  45. Management - Posterior • Commercial Balloon Cather – Epistat • Foley Catheter • Prophylaxis with Keflex/Clavulin • ENT consultation

  46. Management • If all of above fails time to call ENT • In case of massive, life threatening bleed • ABC’s • Establish Advanced A/W • Nasal Packing • Fluids/Blood Products – PRBC’s, FFP, Plts, PCC • call ENT/IR/Vascular

  47. Summary • AOM is common – be aware of treatment guidelines and rare complications including mastoiditis • OE is very painful but quite benign, be aware of NOE as a complication • Have an approach to the patient with epistaxis, consider posterior bleed if unable to achieve hemostasis with above techniques

  48. References • American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media: Diagnosis and management of acute otitis media. Pediatrics 113:1451, 2004 • eMedicine: Otitis Externa, Otitis Media • Guidelines for the Diagnosis and Management of Acute Otitis Media. Towards Optimized Practice. Alberta Medical Association. 2008 • Treatment of Acute Otitis Media in Children under 2 Years of Age. Alejandro Hoberman, M.D. et al. NEJM January 13, 2011

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