Common ENT Emergencies

1. Common ENT Emergencies Arun Badi, MD, PhD, FAAP Board Certified ENT and Sleep Medicine Dallas ENT Group

2. Don’t forget these medical maxims: • ABCs – C also stands for Control the bleeder. • First do no harm. • Don’t forget that the ear, nose and throat are attached to the rest of the body • If they feel better, they heal better • There is a reason they call them “vital” signs • Chance favors the prepared mind • Know your backup, have an evaluation plan

3. Golden Rules • 4 principle questions of ENT history you must always ask about. • I call these the Golden 4 • Shortness of Breath • Hoarseness (Or voice change) • Difficulty Swallowing (Dysphagia. Odynophagia = painful swallowing) • Stridor (Noisy Breathing)

4. Overview • Otologic Disorders • Nasal Disorders • Facial, Oral and Pharyngeal Infections • Airway Obstruction

5. Otologic DisordersAnatomy • Auricle • Ear canal • Tympanic membrane • Middle ear and mastoid disorders • Inner Ear

6. 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

7. 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

9. 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)

11. Foreign Bodies in Ear Canal • Usually put in by patient, some bugs fly in • kill bugs with mineral oil, or lidocaine • Emergency if it is organic matter, insect or corrosive chemical or battery.

14. 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)

16. 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)

18. Inner Ear • peripheral vertigo (vestibulopathy) BPV, labyrhinthitis • - acute onset, no central signs, usually young, horizontal nystagmus

19. The Nose

20. EpistaxisAnterior • 90% (Little’s Area) Kisselbach’s plexus - usually children, young adults Etiologies • Trauma, epistaxis digitorum • Winter Syndrome, Allergies • Irritants - cocaine, sprays • Pregnancy

21. EpistaxisPosterior • 10% of all epistaxis - usually in the elderly • Etiologies • Coagulopathy • Atherosclerosis • Neoplasm • Hypertension (debatable)

22. EpistaxisManagement • Pain meds, lower BP, calm patient • Prepare ! (gown, mask, suction, speculum, meds and packing ready) • Evacuate clots • Topical vasoconstrictor and anesthetic • Identify source

23. Sinusitis

25. Orbital InfectionsSinusitis • Treatment acute - amoxil, septra chronic - amoxil-clavulinic acid, clindamycin, quinolones decongestants, analgesia, heat

26. 7th Nerve Palsy • Most cases are idiopathic - link to HSV -

27. 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)

28. Facial Cellulitis • Most common strept and staph, • Rarely H.Flu • Can progress rapidly

29. Parotiditis • Usually viral -paramyxovirus • Bacterial - elderly, immunosuppressed - associated with dehydration - cover - Staph, anaerobes

30. Pharyngitis • Allergies • Irritants -reflux, trauma, gases • Viruses - EBV, adenovirus • Bacterial -GABHS, mycoplasma, gonorrhea, diptheria

33. Peritonsillar Abcess • Complication of suppurative tonsillitis • Inferior - medial displacement of tonsil and uvula • dysphagia, ear pain, muffled voice, fever, trismus

34. 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

35. 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

37. Masticator - Parapharyngeal Space Infection • Infection of the lower molars invade masticator space • Swelling, pain fever, TRISMUS • Treatment IV antibiotics (PCN or Clindamycin) ENT admission

38. Angioedema • Ocassionally life threatening • Heriditary and related to ACE inhibitors • Antihistamines, steroids and doxepin

39. Airway Obstruction • Aphonia - complete upper airway • Stridor - incomplete upper airway • Wheezing - incomplete lower airway • Loss of breath sounds- complete lower airway

40. Foreign Body Airway • Heimlich Heimlich • Heimlich • Heimlich • Heimlich

41. Questions and Answers