Common ENT Emergencies Arun Badi, MD, PhD, FAAP Board Certified ENT and Sleep Medicine Dallas ENT Group

Don’t forget these medical maxims: ABCs – C also stands for Control the bleeder. First do no harm. Don’t forget that the ear, nose and throat are attached to the rest of the body If they feel better, they heal better There is a reason they call them “vital” signs Chance favors the prepared mind Know your backup, have an evaluation plan

Golden Rules 4 principle questions of ENT history you must always ask about. I call these the Golden 4  Shortness of Breath Hoarseness (Or voice change) Difficulty Swallowing (Dysphagia. Odynophagia = painful swallowing) Stridor (Noisy Breathing)

Overview Otologic Disorders Nasal Disorders Facial, Oral and Pharyngeal Infections Airway Obstruction

Otologic Disorders Anatomy Auricle Ear canal Tympanic membrane Middle ear and mastoid disorders Inner Ear

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

Auricle Chondritis - Cellulitis ? - infectious, difficult to treat because poor blood supply, cover S. Aureus and pseudomonas - extra care in diabetics - inflammatory causes related to seronegative arthritis at times indistinguishable from infection usually the ear lobe is spared

Otitis Externa Infection and inflammation caused by bacteria (pseudomonas, staph), and fungi - treat with antibiotic-steroid drops - use wick for tight canals - diabetics can get malignant otitis externa (defined by the presence of granulation tissue)

Foreign Bodies in Ear Canal Usually put in by patient, some bugs fly in kill bugs with mineral oil, or lidocaine Emergency if it is organic matter, insect or corrosive chemical or battery.

Tympanic Membrane Perforation Hard to see – Hx of drainage Usually from middle ear pressure secondary to fluid or barotrauma Sometimes from external trauma most heal uneventfully but all need otology follow-up perfs with vertigo and facial nerve involvement need immediate referral treat with antibiotics drops controversial but indicated for purulent discharge (avoid gentamycin drops)

Middle Ear Serous Otitis Media - Eustachian tube dysfunction - treat with decongestants, decompressive maneuvers Otitis Media - infection of middle ear effusion - viral and bacteria Mastoiditis - Venous connection with brain, need aggressive treatment (can lead to brain abcess or meningitis)

Inner Ear peripheral vertigo (vestibulopathy) BPV, labyrhinthitis - acute onset, no central signs, usually young, horizontal nystagmus

The Nose

Epistaxis Anterior Etiologies 90% (Little’s Area) Kisselbach’s plexus - usually children, young adults Etiologies Trauma, epistaxis digitorum Winter Syndrome, Allergies Irritants - cocaine, sprays Pregnancy

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

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

Sinusitis

Orbital Infections Sinusitis Treatment acute - amoxil, septra chronic - amoxil-clavulinic acid, clindamycin, quinolones decongestants, analgesia, heat

7th Nerve Palsy Most cases are idiopathic - link to HSV -

Facial Infections Sinusitis Signs and symptoms - H/A, facial pain in sinus distribution - purulent yellow-green rhinorrhea - fever - CT more sensitive than plain films Causative Organisms - gram positives and H. flu (acute) - anaerobes, gram neg (chronic)

Facial Cellulitis Most common strept and staph, Rarely H.Flu Can progress rapidly

Parotiditis Usually viral -paramyxovirus Bacterial - elderly, immunosuppressed - associated with dehydration - cover - Staph, anaerobes

Pharyngitis Allergies Irritants -reflux, trauma, gases Viruses - EBV, adenovirus Bacterial -GABHS, mycoplasma, gonorrhea, diptheria

Peritonsillar Abcess Complication of suppurative tonsillitis Inferior - medial displacement of tonsil and uvula dysphagia, ear pain, muffled voice, fever, trismus

Epiglottitis Clinical Picture 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 Direct visualization if patient allows soft tissue of neck - thumb print, valecula sign Prepare for emergent airway, best achieved in a controlled setting Unasyn, +/- steroids

Masticator - Parapharyngeal Space Infection Infection of the lower molars invade masticator space Swelling, pain fever, TRISMUS Treatment IV antibiotics (PCN or Clindamycin) ENT admission

Angioedema Ocassionally life threatening Heriditary and related to ACE inhibitors Antihistamines, steroids and doxepin

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

Foreign Body Airway Heimlich Heimlich Heimlich

Questions and Answers