Stanford University Division of Emergency Medicine ENT Emergencies Stanford University Division of Emergency Medicine

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

Aspiration of Auricular Hematoma

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 remove with forceps, suction or tissue adhesive

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 Meniere’s - vertigo, sensorineural hearing loss, tinnitus Treatment - valium, fluids, rest, manipulation for BPV

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

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

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

7th Nerve Palsy Most cases are idiopathic - link to HSV - no proof steroids or antivirals are effective, but many advocate Consider Lyme’s Disease in edemic areas Surgical decompression indicated in the rare patient not improving by 2 weeks and ENOG out > 90%

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 Infections Sinusitis Treatment acute - amoxil, septra chronic - amoxil-clavulinic acid, clindamycin, quinolones decongestants, analgesia, heat Complications ethmoid sinusitis - orbital cellulits and abcess frontal sinusitis - may erode bone (Potts Puffy Tumor, Brain Abcess)

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 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 Treatment - Antibiotics, I&D, +/-steroids

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

Epiglottitis

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

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

ANUG Acute Necrotizing Ulcerative Gingivitis Bacterial infection causing an acute necrotizing, destructive disease of periodontium Treatment - oral rinses - antibiotics (PCN, clindamycin, tetracycline)

Ludwigs Angina Rapidly progressive cellulitis of the floor of the mouth usually in elderly debilitated patients and precipitated by dental procedures massive swelling with impending airway obstruction Treatment ICU, antibiotics, airway management

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

Questions and Answers