McMaster University POS 2009 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

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 the presence of a hematoma has been found to stimulate new and often asymmetric cartilage to form

Aspiration of Auricular Hematoma

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

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

Nasal Septum

Lateral Wall

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

Epistaxis Management Anterior Sites - Pressure +/- cautery and/or tamponade - all packs require antibiotic prophylaxis

Epistaxis Posterior Packing Need analgesia and sedation require admission and 02 saturation monitoring

Epistaxis Complications severe bleeding hypoxia, hypercarbia sinusitis, otitis media necrosis of the columella or nasal ala

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

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

Left Peritonsillar Abscess

Left Peritonsillar Abcess

Left Peritonsillar Abscess

CT-SCAN peritonsillar abscess

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 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 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 Anterior-posterior view is normal Lateral view: ***THUMB PRINT*** swelling epiglottis/ary epiglottic folds fullness of the valleculae ballooned hypopharyx assess the retropharyngeal space

Epiglottitis

Acute epiglottitis: swan neck

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.***

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 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 --****Normal prevertebral soft tissue thickness at C2 is 7 mm. At C6 the thickness is 14 mm for children and 22 mm for adults. -*** soft tissue >50% of width of cervical vertebral body must be investigated -****Normal prevertebral soft tissue thickness at C2 is 7 mm. At C6 the thickness is 14 mm for children and 22 mm for adults.

Deep Neck Space Infection

Ludwig’s Angina Rapid bilaterally spreading cellulitis/inflammation with 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 Angina Infectious Spread

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

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

Ludwig angina: swelling

Ludwig angina: trismus

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 Ocassionally life threatening Acquired Hereditary -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 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 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

Periorbital cellulitis

Orbital cellulitis

Subperiostal orbital abscess

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 Headache Fever N/V Focal neurological deficits Lethargy Nuchal rigidity Deterioration of level consciousness

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)

Questions and Answers

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

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

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

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 2/3 1/3 IV solution RL IV solution CBC ½ NS IV solution Stat CT scan Cross & type 2 units PRBC Stat CXR Stat ECG Foley Nasal packing CBC Morphine 5mg IV Metoprolol 5mg IV INR/PTT Large bore IV U/S Serum Calcium Serum lytes Urine lytes

Question cont 2/3 1/3 IV solution RL IV solution CBC ½ NS IV solution Stat CT scan Cross & type 2 units PRBC Stat CXR Stat ECG Foley Nasal packing CBC Morphine 5mg IV Metoprolol 5mg IV INR/PTT Large bore IV U/S Serum Calcium Serum lytes Urine lytes

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

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

Question? The vessel most likely to cause significant bleeding following tracheostomy is: Aorta/carotid innominate inferior thyroid Internal jugular Subclavian artery

Question? The vessel most likely to cause significant bleeding following tracheostomy is: Aorta/carotid innominate inferior thyroid Internal jugular Subclavian artery

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

Question? What is the most common cause of death in patients with tracheostomies. Increased aspiration Tube falling out Bleeding Tube becoming obstructed Infection

Question? What is the most common cause of death in patients with tracheostomies. Increased aspiration Tube falling out Bleeding Tube becoming obstructed Infection

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

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

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.

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.