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ENT Emergencies. Stanford University Division of Emergency Medicine. Overview. Otologic Disorders Nasal Disorders Facial, Oral and Pharyngeal Infections Airway Obstruction. Otologic Disorders Anatomy. Auricle Ear canal Tympanic membrane Middle ear and mastoid disorders Inner Ear.

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ent emergencies

ENT Emergencies

Stanford University

Division of Emergency Medicine

overview
Overview
  • Otologic Disorders
  • Nasal Disorders
  • Facial, Oral and Pharyngeal Infections
  • Airway Obstruction
otologic disorders anatomy
Otologic DisordersAnatomy
  • Auricle
  • Ear canal
  • Tympanic membrane
  • Middle ear and mastoid disorders
  • Inner Ear
traumatic disorders of the auricle
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

auricle
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

otitis externa
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)

foreign bodies in ear canal
Foreign Bodies in Ear Canal
  • Usually put in by patient, some bugs fly in
  • kill bugs with mineral oil, or lidocaine
  • remove with forceps, suction or tissue adhesive
tympanic membrane perforation
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)
middle ear
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)
inner ear
Inner Ear
  • peripheral vertigo (vestibulopathy)

BPV, labyrhinthitis

  • - acute onset, no central signs, usually young, horizontal nystagmus
  • Meniere’s - vertigo, sensorineural hearing loss, tinnitus
  • Treatment

- valium, fluids, rest, manipulation for BPV

the nose
The Nose
  • Vascular Supply

- Anterior - branches of internal carotid

- Posterior - distal branches of external carotid

epistaxis anterior
EpistaxisAnterior
  • 90% (Little’s Area) Kisselbach’s plexus - usually children, young adults

Etiologies

  • Trauma, epistaxis digitorum
  • Winter Syndrome, Allergies
  • Irritants - cocaine, sprays
  • Pregnancy
epistaxis posterior
EpistaxisPosterior
  • 10% of all epistaxis - usually in the elderly
  • Etiologies
  • Coagulopathy
  • Atherosclerosis
  • Neoplasm
  • Hypertension (debatable)
epistaxis management
EpistaxisManagement
  • Pain meds, lower BP, calm patient
  • Prepare ! (gown, mask, suction, speculum, meds and packing ready)
  • Evacuate clots
  • Topical vasoconstrictor and anesthetic
  • Identify source
epistaxis management16
EpistaxisManagement
  • Anterior Sites

- Pressure +/- cautery and/or tamponade

- all packs require antibiotic prophylaxis

epistaxis posterior packing
EpistaxisPosterior Packing
  • Need analgesia and sedation
  • require admission and 02 saturation monitoring
epistaxis complications
EpistaxisComplications
  • severe bleeding
  • hypoxia, hypercarbia
  • sinusitis, otitis media
  • necrosis of the columella or nasal ala
7th nerve palsy
7th Nerve Palsy
  • Most cases are idiopathic

- link to HSV

- no proof steroids or antivirals are effective, but many advocate

  • Consider Lyme’s Disease in edemic areas
  • Surgical decompression indicated in the rare patient not improving by 2 weeks and ENOG out > 90%
facial infections sinusitis
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)

facial infections sinusitis21
Facial InfectionsSinusitis
  • Treatment

acute - amoxil, septra

chronic - amoxil-clavulinic acid, clindamycin, quinolones

decongestants, analgesia, heat

  • Complications

ethmoid sinusitis - orbital cellulits and abcess

frontal sinusitis - may erode bone (Potts Puffy Tumor, Brain Abcess)

facial cellulitis
Facial Cellulitis
  • Most common strept and staph,
  • Rarely H.Flu
  • Can progress rapidly
parotiditis
Parotiditis
  • Usually viral

-paramyxovirus

  • Bacterial

- elderly, immunosuppressed

- associated with dehydration

- cover - Staph, anaerobes

pharyngitis
Pharyngitis
  • Irritants

-reflux, trauma, gases

  • Viruses

- EBV, adenovirus

  • Bacterial

-GABHS, mycoplasma, gonorrhea, diptheria

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

- Antibiotics, I&D, +/-steroids

epiglottitis clinical picture
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
epiglottitis
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
retropharyngeal abcess
Retropharyngeal Abcess
  • Anterior to prevertebral space and posterior to pharynx
  • Usually in children under 4 (lymphoid tissue in space)
  • pain, dysphagia, dyspnea, fever
  • swelling of retropharyngeal space on lateral x-ray
  • Complications - mediastinitis
masticator parapharyngeal space infection
Masticator - Parapharyngeal Space Infection
  • Infection of the lower molars invade masticator space
  • Swelling, pain fever, TRISMUS
  • Treatment

IV antibiotics (PCN or Clindamycin)

ENT admission

anug acute necrotizing ulcerative gingivitis
ANUGAcute Necrotizing Ulcerative Gingivitis
  • Bacterial infection causing an acute necrotizing, destructive disease of periodontium
  • Treatment

- oral rinses

- antibiotics (PCN, clindamycin, tetracycline)

ludwigs angina
Ludwigs Angina
  • Rapidly progressive cellulitis of the floor of the mouth
  • usually in elderly debilitated patients and precipitated by dental procedures
  • massive swelling with impending airway obstruction
  • Treatment

ICU, antibiotics, airway management

angioedema
Angioedema
  • Ocassionally life threatening
  • Heriditary and related to ACE inhibitors
  • Antihistamines, steroids and doxepin
airway obstruction
Airway Obstruction
  • Aphonia - complete upper airway
  • Stridor - incomplete upper airway
  • Wheezing - incomplete lower airway
  • Loss of breath sounds- complete lower airway