ENT EMERGENCIES

1. ENT EMERGENCIES McMaster University POS 2009

2. Overview ENT • Ears = Otologic • Nose = Rhinologic • Throat = Oral/Pharyngeal/Laryngeal • Infections • Facial injuries • Airway Obstruction

3. Otologic Anatomy • Auricle • Ear canal • Tympanic membrane • Middle ear & mastoid • Inner Ear

4. 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

5. Aspiration of Auricular Hematoma

7. Middle Ear • Mastoiditis • Venous connection with brain, need aggressive treatment (can lead to brain abscess or meningitis)

8. Epistaxis • 90% (Little’s Area) Kiesselbach’s plexus - usually children, young adults • 10% of all epistaxis - usually in the elderly

9. Nasal Septum

10. Lateral Wall

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

14. EpistaxisManagement • Anterior Sites - Pressure +/- cautery and/or tamponade - all packs require antibiotic prophylaxis

15. EpistaxisPosterior Packing • Need analgesia and sedation • require admission and 02 saturation monitoring

16. EpistaxisComplications • severe bleeding • hypoxia, hypercarbia • sinusitis, otitis media • necrosis of the columella or nasal ala

17. Parotitis • Usually viral -paramyxovirus • Bacterial - elderly, immunosuppressed • associated with dehydration • Management • cover - Staph, anaerobes • Hydrate • Sialogogues • Warm compresses • Pain control

18. 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

19. Left Peritonsillar Abscess

20. Left Peritonsillar Abcess

21. Left Peritonsillar Abscess

22. CT-SCAN peritonsillar abscess

23. 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

24. 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

25. Epiglottitis • Avoid agitation • Direct visualization if patient allows • soft tissue of neck • Prepare for emergent airway, best achieved in a controlled setting • Unasyn, +/- steroids

26. 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

29. Epiglottitis

30. Acute epiglottitis: swan neck

31. 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.***

32. 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

33. 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

34. Deep Neck Space Infection

36. 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

37. Ludwig Angina Infectious Spread

38. Ludwig’s Angina • Etiology: • typically from an odontogenic infection • mandibular 2nd or 3rd molar • streptococcus, oral anaerobes

39. 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

40. Ludwig angina: swelling

41. Ludwig angina: trismus

42. 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

43. 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

44. 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

45. 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

46. 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

47. Periorbital cellulitis

48. Orbital cellulitis

50. Subperiostal orbital abscess