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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

Stanford University

Division of Emergency Medicine


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Overview

  • Otologic Disorders

  • Nasal Disorders

  • Facial, Oral and Pharyngeal Infections

  • Airway Obstruction


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Otologic DisordersAnatomy

  • Auricle

  • Ear canal

  • Tympanic membrane

  • Middle ear and mastoid disorders

  • Inner Ear


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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



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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


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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)


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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


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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)


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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)


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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


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The Nose

  • Vascular Supply

    - Anterior - branches of internal carotid

    - Posterior - distal branches of external carotid


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EpistaxisAnterior

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

    Etiologies

  • Trauma, epistaxis digitorum

  • Winter Syndrome, Allergies

  • Irritants - cocaine, sprays

  • Pregnancy


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EpistaxisPosterior

  • 10% of all epistaxis - usually in the elderly

  • Etiologies

  • Coagulopathy

  • Atherosclerosis

  • Neoplasm

  • Hypertension (debatable)


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EpistaxisManagement

  • Pain meds, lower BP, calm patient

  • Prepare ! (gown, mask, suction, speculum, meds and packing ready)

  • Evacuate clots

  • Topical vasoconstrictor and anesthetic

  • Identify source


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EpistaxisManagement

  • Anterior Sites

    - Pressure +/- cautery and/or tamponade

    - all packs require antibiotic prophylaxis


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EpistaxisPosterior Packing

  • Need analgesia and sedation

  • require admission and 02 saturation monitoring


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EpistaxisComplications

  • severe bleeding

  • hypoxia, hypercarbia

  • sinusitis, otitis media

  • necrosis of the columella or nasal ala


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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%


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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)


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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)


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Facial Cellulitis

  • Most common strept and staph,

  • Rarely H.Flu

  • Can progress rapidly


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Parotiditis

  • Usually viral

    -paramyxovirus

  • Bacterial

    - elderly, immunosuppressed

    - associated with dehydration

    - cover - Staph, anaerobes


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Pharyngitis

  • Irritants

    -reflux, trauma, gases

  • Viruses

    - EBV, adenovirus

  • Bacterial

    -GABHS, mycoplasma, gonorrhea, diptheria


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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


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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


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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



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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


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Masticator - Parapharyngeal Space Infection

  • Infection of the lower molars invade masticator space

  • Swelling, pain fever, TRISMUS

  • Treatment

    IV antibiotics (PCN or Clindamycin)

    ENT admission


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ANUGAcute Necrotizing Ulcerative Gingivitis

  • Bacterial infection causing an acute necrotizing, destructive disease of periodontium

  • Treatment

    - oral rinses

    - antibiotics (PCN, clindamycin, tetracycline)


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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


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Angioedema

  • Ocassionally life threatening

  • Heriditary and related to ACE inhibitors

  • Antihistamines, steroids and doxepin


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Airway Obstruction

  • Aphonia - complete upper airway

  • Stridor - incomplete upper airway

  • Wheezing - incomplete lower airway

  • Loss of breath sounds- complete lower airway



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