ENT Emergencies Paul Chatrath Consultant ENT Surgeon Barking Havering & Redbridge Hospitals NHS Trust 21st January 2009

THE EAR

Otitis Externa - Features Discharge, pain, hearing loss, itching Commonest organisms: S Aureus Ps Aeruginosa Proteus Predisposing factors: Water Cotton buds Eczema Treatment: Topical antibiotics Aural toilet Analgesia

Otitis Externa - Variants Fungal Malignant OE Diabetes VII palsy

Malignant Otitis Externa Risk factor – Diabetes Granulomatous polypoid otitis externa Disproportionately severe pain Associated features: Cranial nerve involvement – VII, IX, X, XI, XII Treatment: Topical antibiotics and aural toilet i.v. antibiotics > 6/52 Hyperbaric oxygen

Otitis Externa – when to refer Refer if: Non responsive Canal oedematous Needs aural toilet Suspicion of malignant OE

Acute Otitis Media Rx : Systemic antibiotics Analgesia Decongestants Symptoms: Pain Discharge Hearing loss Pain subsides Rx : Systemic antibiotics Analgesia Decongestants

Acute Otitis Media When to refer?: Persistent discharge Complications Failure of resolution Persistent discharge Complications VII palsy Mastoiditis

Acute Mastoiditis Rx : Systemic antibiotics Analgesia URGENT REFERRAL Features Recent URTI Ear discharge Blunting of postaural sulcus Fluctuant tender swelling Fever Rx : Systemic antibiotics Analgesia URGENT REFERRAL

Perichondrial Haematoma Rx : Systemic antibiotics Analgesia URGENT REFERRAL for incision & drainage

Perichondrial Cellulitis Rx : Systemic antibiotics Analgesia REFERRAL to ENT if no response after 24hr

Cauliflower Ear

Bead in ear Rx : one attempt at removal only. Try syringing with warm water Do not use forceps for round objects Non urgent ENT referral

Insect in Ear Rx : Kill insect with olive oil Then try syringing with warm water Urgent ENT referral

Bloody Otorrhoea Causes Otitis externa/media Trauma (local) Trauma (head injury) Postoperative

Unless VII Palsy – ENT EMERGENCY Skull Base Fracture Rx : Do not examine ears with an auriscope. Admit under the head injury team Non urgent ENT referral Unless VII Palsy – ENT EMERGENCY

Case: Facial Palsy 65yr old female 3/52 history right facial weakness What are the key points that must be established in your clinical approach?

Case: Facial Palsy Key points Establish whether UMN or LMN Try and find a cause Forehead sparing = UMN Thorough examination

Facial nerve palsy - causes UMN (forehead sparing): CVA, MS, Ca LMN (complete): Intracranial Acoustic neuroma G-Barre TB Neurosarcoid Glomus tumour Lyme disease Intratemporal Trauma Acute otitis media Malignant otitis externa Ramsey-Hunt syndrome SCC Cholesteatoma Extracranial Trauma Malignant parotid tumour Idiopathic = Bell’s Palsy

Facial Nerve Palsy (Bell’s) Rx : Prednisolone 30mg Acyclovir 200mg 5x/day Hypermellose eye drops Lacrilube ointment Red bulging ear drum = URGENT ENT review If not, Non urgent ENT review If poor eye closure = Ophthalmology review

THE NOSE

Refer if: Obvious deformity (5-7 days) Nasal Fracture Rx : Exclude other max-fax fractures Exclude CSF rhinorrhoea Analgesia Refer if: Obvious deformity (5-7 days) Septal Haematoma (URGENT)

Septal Haematoma

Normal Inferior Turbinate IT Septum

Epistaxis

Little’s Area

Epistaxis Children: Recurrent self limiting bleeds Adults: Risk factors – URTIs, digital trauma Adults: Traumatic Anterior bleed Little’s area Recurrent, self-limiting Posterior bleed Elderly Medical comorbidities (hypertension, aspirin, warfarin) More severe Admission

Epistaxis Rx : RESUSCITATE FBC, G&S, Clotting Local pressure (Cautery) Nasal Packing

Nasal Packing BIPP MerocelTM Rapid RhinoTM

How NOT to pack a nose!!!

Foreign Body in Nose Rx : one attempt at removal only. Do not use forceps for round objects Urgent ENT referral

Orbital cellulitis – Chandler’s classification Grade 1 Periorbital cellulitis (preseptal) Grade 2 Orbital cellulitis (postseptal) Grade 3 Subperiosteal abscess Grade 4 Intraorbital abscess Grade 5 Cavernous sinus thrombosis

Subperiosteal abscess – Chandler’s grade 3

Orbital Cellulitis Rx : Systemic antibiotics Decongestants Analgesia URGENT ENT referral URGENT EYE referral URGENT CT sinuses

THE THROAT

Normal tonsils

Acute tonsillitis

Tonsillitis Rx : Penicillin V/ Metronidazole Analgesia FBC, Paul Bunnel, LFT Refer if: Complete dysphagia Quinsy

Quinsy

Foreign body - throat

Fish Bone in Tonsil

Fish Bones & Xray Very Opaque: Cod, Haddock, Cole fish, Lemon sole, Gurnard Moderate Opaque: Grey Mullet, Plaice, Monkfish, Red Snapper Not Opaque: Herring (Kipper), Salmon, Mackerel, Trout, Pike

Epiglottitis

Epiglottitis Children – life threatening Adults – supraglottitis Symptoms Fever Recent URTI Sitting forwards, drooling Sore throat Plummy voice Dysphagia Causative organism: Children: H Influenzae type B Adults: Broad range of respiratory pathogens

Epiglottitis v Croup Epiglottitis Croup Cause Bacterial Viral Age Any 1-5yrs Obstruction Supraglottic Subglottic Fever High Low grade Dysphagia Marked None Drooling Present Minimal Posture Sitting Recumbent Toxaemia Mild to severe Mild Cough None Barking, brassy Voice Muffled Hoarse RR Rapid Rapid Laryngeal palpation Tender Not tender Clinical course Rapid resolution Longer resolution

Stridor Rx : Oxygen Adrenaline Nebulisers Heliox Steroids Antibiotics URGENT ENT Ref. URGENT Anaesthetic Ref. URGENT Paed. Ref.

Emergency Trachy??

Cricothyroidotomy

Paul Chatrath Consultant ENT Surgeon Queen’s/King George’s Hospitals ENT Emergencies Any Questions? Paul Chatrath Consultant ENT Surgeon Queen’s/King George’s Hospitals Email: paul.chatrath@bhrhospitals.nhs.uk paul@chatrath.com