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ENT EMERGENCIES. McMaster University POS 2009. Overview. ENT Ears = Otologic Nose = Rhinologic Throat = Oral/Pharyngeal/Laryngeal Infections Facial injuries Airway Obstruction. Otologic Anatomy. Auricle Ear canal Tympanic membrane Middle ear & mastoid Inner Ear.

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ent emergencies

ENT EMERGENCIES

McMaster University

POS 2009

overview
Overview

ENT

  • Ears = Otologic
  • Nose = Rhinologic
  • Throat = Oral/Pharyngeal/Laryngeal
    • Infections
    • Facial injuries
    • Airway Obstruction
otologic anatomy
Otologic Anatomy
  • Auricle
  • Ear canal
  • Tympanic membrane
  • Middle ear & mastoid
  • Inner Ear
trauma of the auricle
Trauma of the Auricle
  • Subperichondrial Hematoma
    • Shear force trauma
    • Perichondrium lifted & bleeds
    • Drain before cartilaginous necrosis
    • Leave drain, Abx, bolster dressing, monitor/24hrs
    • “Cauliflower” ear  asymmetric cartilage formation
middle ear
Middle Ear
  • Mastoiditis
    • Venous connection with brain, need aggressive treatment (can lead to brain abscess or meningitis)
epistaxis
Epistaxis
  • 90% (Little’s Area) Kiesselbach’s plexus - usually children, young adults
  • 10% of all epistaxis - usually in the elderly
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 management1
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
parotitis
Parotitis
  • Usually viral

-paramyxovirus

  • Bacterial

- elderly, immunosuppressed

  • associated with dehydration
  • Management
  • cover - Staph, anaerobes
  • Hydrate
  • Sialogogues
  • Warm compresses
  • Pain control
peritonsillar abscess
Peritonsillar Abscess
  • Cellulitis of the space behind tonsillar capsule extending onto soft palate leading to abscess. The pus is located between the tonsillar bed and the capsule anterosuperior to the anterior pillar.
  • Complication from acute/chronic tonsillitis vs. Weber’s gland
  • Unilateral
  • Most common 10-30 years old
peritonsillar abcess
Peritonsillar Abcess
  • Inferior - medial displacement of tonsil and uvula
  • dysphagia, ear pain, muffled voice, fever, trismus
  • Group A strep, Strep pyogenes, Staph aureus, H. influenzae, Anaerobes
  • Treatment

- Antibiotics (clinda), I&D, +/-steroids

epiglottitis clinical picture
EpiglottitisClinical Picture
  • Acute inflammation causing swelling of the SupraGlottic structures of the larynx
  • Older children & 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
  • Prepare for emergent airway, best achieved in a controlled setting
  • Unasyn, +/- steroids
soft tissue x ray of neck
Soft tissue X-ray of neck
  • Anterior-posterior view is normal
  • Lateral view: ***THUMB PRINT***
    • swelling epiglottis/ary epiglottic folds
    • fullness of the valleculae
    • ballooned hypopharyx
    • assess the retropharyngeal space
management
Management
  • In Children:
    • Brought in the operating room
    • Be ready to Intubate
    • Have a rigid Bronchoscope ready
    • Have the Tracheostomy tray opened
  • ***All need to be intubated to secure the airway due to the smaller airway in the child.***
management1
Management
  • In Adult:
    • All need to be admitted
    • ICU or Step-down Unit
    • Intubation only if compromise airway
    • Continuous O2 sat monitoring
    • Daily examination of their larynx
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
ludwig s angina
Ludwig’s Angina
  • Rapid bilaterally spreading cellulitis/inflammationwith possible abscess formation of superior compartment of the suprahyoid space:
    • Submandibular, sublingual, submental spaces
  • usually in elderly debilitated patients and precipitated by dental procedures
  • massive swelling with impending airway obstruction
ludwig s angina1
Ludwig’s Angina
  • Etiology:
    • typically from an odontogenic infection
      • mandibular 2nd or 3rd molar
    • streptococcus, oral anaerobes
clinical presentation
Clinical presentation
  • Very tender swelling under mandible + floor mouth
  • Usually little or no fluctuance
  • Severe trismus, drooling of saliva
  • Gross swelling, elevation, displacement of tongue
  • Tachypnea and dyspnea may happen
  • Danger of upper airway obstruction + death
management2
Management
  • ABC’s
    • Awake intubation vs tracheostomy if needed
  • Admit ICU or stepdown unless the airway is totally safe (02 sat monitoring)
  • Drain the abscess
  • I.V. ATB: penicillin, clindamycin, flagyl
angioedema
Angioedema
  • Ocassionally life threatening
  • Acquired

-IgE mediated: vasodilation and increased vascular permeability (ie. insect bites, food, etc)

-not IgE mediated (ie. ace inhibitors)

  • Hereditary
  • Tx: O2, anti-histamine, steroids, epinephrine
  • Consider intubation/trach
airway obstruction
Airway Obstruction
  • All the previously mentioned airway issues can eventually obstruct the patient:
  • Note:
    • Aphonia - complete upper airway
    • Stridor - incomplete upper airway
    • Wheezing - incomplete lower airway
    • Loss of breath sounds- complete lower airway
airway management
Airway Management
  • A good rule of thumb about a tracheotomy is if you think about it, you probably should do it.
  • If you need a surgical airway then a cricothyrotomy is the way to go
complications of acute sinusitis
Orbital:

preseptal:periorbital cellulitis

postseptal: orbital cellulitis

subperiosteal abscess

orbital abscess

Intracranial:

meningitis

brain abscess

cavernous sinus thrombosis

Osteomyelitis frontal bone:

Pott’s Puffy tumor

Complications of acute sinusitis
cavernous sinus thrombosis
Cavernous sinus thrombosis
  • Absence of valves in the orbital veins allows the blood to flow to the cavernous sinus
  • Rapidly progressive chemosis, ophthalmoplegia
  • Severe retinal engorgement
  • High fever
  • Prostation
  • May progress to vision loss, meningitis, death
intracranial complications
Intracranial complications
  • Headache
  • Fever
  • N/V
  • Focal neurological deficits
  • Lethargy
  • Nuchal rigidity
  • Deterioration of level consciousness
management of complications of acute sinusitis
Management of Complications of Acute Sinusitis
  • ENT, opht, ID, & neurosx consult
  • CT , MRI
  • I.V. ATB usually prolonged course
  • Drainage of any abscess
  • Orbital decompression if visual acuity decreased
  • Heparinization (Cavernous Sinus Thrombosis)
question
Question?
  • You are seeing a 50 yr old male in the ER for query epiglottitis? During your physical exam the patient stops making any airway sounds, turns blue, grasping at neck & collapses in bed. How do you manage this patient?
  • A) immediately place a chest tube b/c patient most likely has a tension pnemothorax
  • B) immediately place an oxygen mask on patient at fi02 100%
  • C) immediately call for surgeon on call to come place a tracheostomy tube
  • D) immediately perform a cricothyrotomy
  • E) immediately call for a CXR and place a central line
question1
Question?
  • What is the name of the sign for epiglottitis seen on soft tissue neck X-ray?
  • A) Steeple sign on AP neck films
  • B) Birds beak sign on Lat neck films
  • C) Thumb printing sign on AP neck films
  • D) Hour glass sign on Lat neck films
  • E) Thumb printing sign on Lat neck films
question2
Question?
  • What is the name of the sign for epiglottitis seen on soft tissue neck X-ray?
  • A) Steeple sign on AP neck films
  • B) Birds beak sign on Lat neck films
  • C) Thumb printing sign on AP neck films
  • D) Hour glass sign on Lat neck films
  • E) Thumb printing sign on Lat neck films
question3
Question?
  • A 65 yr old male patient presents to the ER with severe epistaxis. He has a significant cardiac Hx and is currently taking coumadin and aspirin. He states that it began 6 hrs ago and he has soaked through 3 towels and has vomited what looks like dark blood twice. HR is 125 and BP is 90/70. Manage this patient! What tests/medications should you order? Pick 6 from the following list.
question cont
CBC

Morphine 5mg IV

Metoprolol 5mg IV

INR/PTT

Large bore IV

U/S

Serum Calcium

Serum lytes

Urine lytes

2/3 1/3 IV solution

RL IV solution

½ NS IV solution

Stat CT scan

Cross & type 2 units PRBC

Stat CXR

Stat ECG

Foley

Nasal packing

Question cont
question cont1
CBC

Morphine 5mg IV

Metoprolol 5mg IV

INR/PTT

Large bore IV

U/S

Serum Calcium

Serum lytes

Urine lytes

2/3 1/3 IV solution

RL IV solution

½ NS IV solution

Stat CT scan

Cross & type 2 units PRBC

Stat CXR

Stat ECG

Foley

Nasal packing

Question cont
question4
Question?
  • A patient with a peritonsillar abscess usually has:
    • A) trismus
    • B) upper airway obstruction
    • C) dysphagia
    • D) Hemoptysis
    • E) Mononucleolus

Ans: A only, or A&C, or A&C&E, or D only

question5
Question?
  • A patient with a peritonsillar abscess usually has:
    • A) trismus
    • B) upper airway obstruction
    • C) dysphagia
    • D) Hemoptysis
    • E) Mononucleolus

Ans: A only, or A&C, or A&C&E, or D only

question6
Question?
  • The vessel most likely to cause significant bleeding following tracheostomy is:
    • Aorta/carotid
    • innominate
    • inferior thyroid
    • Internal jugular
    • Subclavian artery
question7
Question?
  • The vessel most likely to cause significant bleeding following tracheostomy is:
    • Aorta/carotid
    • innominate
    • inferior thyroid
    • Internal jugular
    • Subclavian artery
question8
Question?
  • Regarding tracheostomies, the following facts are true except:
    • tracheostomies are commonly indicated for long term ventilation or airway protection
    • swallowing problems are fairly common in patients with tracheostomies
    • an appropriately placed tracheostomy with its cuff inflated virtually eliminates the risk of aspiration
    • tracheostomies should be placed at the level of the second or third cartilaginous ring
    • a tracheo-innominate fistula may occur with tracheostomies placed too low in the trachea
question9
Question?
  • What is the most common cause of death in patients with tracheostomies.
    • Increased aspiration
    • Tube falling out
    • Bleeding
    • Tube becoming obstructed
    • Infection
question10
Question?
  • What is the most common cause of death in patients with tracheostomies.
    • Increased aspiration
    • Tube falling out
    • Bleeding
    • Tube becoming obstructed
    • Infection
question11
Question?
  • To avoid the complications of tracheostomy: Which of the following are True?
    • a tracheostomy tube of appropriate size, length and curvature must be used
    • two tracheal rings must be removed
    • judicious suctioning to avoid aspiration of blood during the procedure
    • the skin must be closed tightly around the tracheostomy tube
question12
Question?
  • To avoid the complications of tracheostomy: Which of the following are True?
    • a tracheostomy tube of appropriate size, length and curvature must be used
    • two tracheal rings must be removed
    • judicious suctioning to avoid aspiration of blood during the procedure
    • the skin must be closed tightly around the tracheostomy tube
question13
Question?
  • In a patient requiring a cuffed tracheostomy tube for prolonged closed ventilation, tracheal injury can be best prevented by?
    • Frequent cuff deflation.
    • Use of a non-reactive cuff.
    • Use of an alternating double cuff tube.
    • Use of a wide cuff.
    • Use of a minimal cuff volume to effect adequate seal.
question14
Question?
  • In a patient requiring a cuffed tracheostomy tube for prolonged closed ventilation, tracheal injury can be best prevented by?
    • Frequent cuff deflation.
    • Use of a non-reactive cuff.
    • Use of an alternating double cuff tube.
    • Use of a wide cuff.
    • Use of a minimal cuff volume to effect adequate seal.