ENT Emergencies

Otologic Disorders Anatomy Auricle Tympanic Membrane Ear Canal Mastoid Inner Ear

External auditory Meatus Concha Helix Anti-helical fold Triangular Fossa External auditory Meatus Tragus Anti-tragus Lobe

Embedded Earrings

15 year old after a boxing match! What has happened? What is the treatment? What is the risk?

Traumatic Disorders of the Auricle Haematoma cartilaginous necrosis drain, antibiotics Pressure dressing close follow up Lacerations single layer closure pick up perichondrium, bulky ear dressing Use posterior auricular block for anesthesia

Aspiration of Auricular Haematoma

This child is going nuts!

Foreign Bodies in Ear Canal Usually put in by patient, some bugs fly in Kill bugs with mineral oil, or lignocaine Remove with forceps or suction

Itchy painful ear with discharge

Otitis Externa Painful ++ Preceded by itching Debris ++ Clean out Topical antibiotics and steroids Wick? ENT F/U

Otitis Externa Usually mixed infections Bacteria (pseudomonas, staph) Fungi More common in swimmers and diabetics Complications malignant otitis externa (defined by the presence of granulation tissue) Temporal osteomyelitis

Furuncle Extreme Pain Warm compresses and systemic antibiotics Analgesia

Otoscopy

5 year old with acute ear ache

Acute Otitis Media Children 3-6 Most follow viral URTI May discharge if TM perforates Analgesia Antibiotics? Amoxicillin Complications TM perforation Mastoiditis Facial paralysis Meningitis/ Cerebral Abscess

Tympanic Membrane Perforation Hard to see – Hx of drainage Usually increased middle ear pressure secondary to fluid or barotrauma Sometimes from external trauma Most heal uneventfully but all need ENT follow-up Perfs with vertigo and facial nerve involvement need immediate referral Debate about topical antibiotics

Mastoiditis Post Otitis Media Localised tenderness and red Persistent discharge after OM Direct venous drainage into the head

EPISTAXIS

Frequent presentation to the PED Often traumatic but usually minor Parents often anxious Can affect all age groups Can be massive and rapidly fatal (rare) Often self-limiting, should approach all in a systematic way – no matter what the degree of severity.

Aetiology 90% occur from Little’s area/Kiesselbach’s plexus Area of rich vascular supply formed by end arteries. Causes may be divided into local or general.

The Nose Vascular Supply - Anterior - branches of internal carotid - Posterior - distal branches of external carotid

Local Causes Idiopathic. Trauma Infection Foreign body. epistaxis digitorum Infection Foreign body.

General Causes Drugs (i.e. Anticoagulants). Blood diseases (leukaemia etc). Inherited coagulopathies. Hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu disease) Hypertension not a cause

Management in the ED Four stage process: Resuscitation & Initial fist-aid measures. Assessment of blood loss. Assessment of the cause. Procedures to stop continual bleeding.

First-aid measures The nostril pinch Invariably done incorrectly by patients The soft flared part of the nose should be pinched Breath through the mouth Sit upright (Lowers BP) Lean slightly forward (Allows blood to run out of mouth) Compression of the bony part of the nose is a waste of time.

…..should look like this: Pressure must be applied CONTINUOSLY for twenty minutes. NO “CHECKING”!!!!

Assessment of Blood Loss Assess physiological parameters to determine degree of blood loss. i.e. Pulse, Pulse Pressure, BP. If any signs of shock then: X2 Large IV access Bloods for FBC, U&E, CS and G&S IV fluid resuscitation.

Simple or Complex Epistaxis? Patient under 50 Not hypertensive Not Anticoagulated Potentially Complex Patient over 50 Hypertensive Anticoagulated

Simple Epistaxis Most of Paediatric cases If stopped spontaneously Protect yourself Try to visualise bleeding point Cauterise or Naseptin Discharge with written advice Fails to stop – Cause requires evaluation.

Potentially Complex Epistaxis Rare in children IV access and bloods sent Protect yourself (Gowns, Gloves, Masks) Attempt to visualise bleeding site Remove clot Suction Pressure Ice Lignocaine/Adrenaline Good light and speculum

Why Examine? May reveal a bleeding point in Little’s area amenable to silver nitrate cautery. May reveal a cause such as a neoplastic growth or a foreign body.

Anterior bleed

Anterior Epistaxis Following use of LA haemostasis Silver nitrate cautery. possible to cause septal perforation if over enthusiastic). If haemostasis is achieved the patient may be discharged home with advice. If unable to achieve haemostasis then a nasal pack will be required…..

Cautery Very stimulating Not both sides Use paraffin ointment on skin

Uncontrolled Epistaxis Requires insertion of a “Nasal Tampon” Lubricate with aquagel. Insert in an AP direction. Saline may help to expand Aid with BP, atherosclerotic elderly patients Warfarin Check coagn Refer to ENT

Epistaxis Posterior 10% of all epistaxis - usually in the elderly Etiologies Coagulopathy Atherosclerosis Neoplasm Hypertension (debatable)

Epistaxis Complications Severe bleeding Hypoxia, hypercarbia Sinusitis, otitis media Necrosis of the columella or nasal ala

What will ENT do? Haemorrhage control with nasal packing. Balloons available which tamponade both the anterior and posterior nasal space. Continued bleeding may require GA examination and diathermy. Rarely it is necessary to ligate the offending vessel (anterior ethmoid artery or maxillary artery). Very rarely the external carotid artery in the neck may be ligated!

This child has a screw loose!

Nasal Foreign bodies Pain and discharge Organic material = inflammatory response Try hook, forceps or suction Jobson-Horne Probe ‘Kiss’ method Never pursue in un cooperative child Can be done semi-electively under GA Beware the persistent foul smelling nasal discharge

Nasal trauma Unusual to get # nose in children Cartilage Clinical Diagnosis Assess Deviation ?Septal haematoma Saddle defomity Septal necrosis/abscess ENT with photo 5/7

Bell’s palsy LMN Palsy Full examination Treatment ENT Look for vesicles Ramsay-Hunt Check Parotid Treatment Prednisolone Acyclovir Eye care ENT

Tonsillitis

Tonsillitis Bacterial v Viral Abscess formation Penicillin V 500 qds DM, valvular disease Analgesia

Quinsy

Bilateral Quinsy

Peritonsillar Abcess Complication of suppurative tonsillitis Medial displacement of tonsil and uvula Dysphagia, ear pain, muffled voice, fever, trismus Treatment Aspiration or I&D Antibiotics Analgesia

Epiglottitis 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 Avoid agitation Soft tissue x-ray of neck (doubtful help) Thumb print, valecula sign Prepare for emergent airway Best achieved in a controlled setting

4-year old presents with fever, sore throat and dysphagia progressing over the past three days. He has no stridor but has torticollis of his neck. You elect to perform a soft tissue neck x-ray

Retropharyngeal Abcess Anterior to prevertebral space and posterior to pharynx Usually in children under 4 (lymphoid tissue in space) Complications Mediastinitis Airway obstruction Spinal infection

A 3 year old girl has been positing money into her little brother

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

Any Questions?