1. ENT Emergencies

2. Otologic Disorders Anatomy
Auricle
Tympanic Membrane
Ear Canal
Mastoid
Inner Ear

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

4. Embedded Earrings

5. 15 year old after a boxing match!
What has happened?
What is the treatment?
What is the risk?

6. 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

7. Aspiration of Auricular Haematoma

8. This child is going nuts!

9. 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

10. Itchy painful ear with discharge

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

12. 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

13. Furuncle Extreme Pain Warm compresses and systemic antibiotics
Analgesia

14. Otoscopy

15. 5 year old with acute ear ache

16. 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

17. 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

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

20. EPISTAXIS

21. 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.

22. 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.

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

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

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

26. 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.

27. 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.

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

29. 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.

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

31. 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.

32. 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

33. 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.

34. Anterior bleed

35. 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…..

36. Cautery
Very stimulating
Not both sides
Use paraffin ointment on skin

37. 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

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

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

40. 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!

41. This child has a screw loose!

42. 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

43. 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

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

46. Tonsillitis

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

48. Quinsy

49. Bilateral Quinsy

50. 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

51. 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

52. 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

54. 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

55. 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

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

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

58. Any Questions?