1. McMaster University POS 2009
ENT EMERGENCIES
McMaster University
POS 2009

2. Overview ENT Ears = Otologic Nose = Rhinologic
Throat = Oral/Pharyngeal/Laryngeal
Infections
Facial injuries
Airway Obstruction

3. Otologic Anatomy Auricle Ear canal Tympanic membrane
Middle ear & mastoid
Inner Ear

4. 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

5. Aspiration of Auricular Hematoma

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

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

9. Nasal Septum

10. Lateral Wall

13. 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

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

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

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

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

18. 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 years old

19. Left Peritonsillar Abscess

20. Left Peritonsillar Abcess

21. Left Peritonsillar Abscess

22. CT-SCAN peritonsillar abscess

23. 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

24. 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

25. Epiglottitis Avoid agitation Direct visualization if patient allows
soft tissue of neck
Prepare for emergent airway, best achieved in a controlled setting
Unasyn, +/- steroids

26. 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

29. Epiglottitis

30. Acute epiglottitis: swan neck

31. 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.***

32. 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

33. 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.

34. Deep Neck Space Infection

36. 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

37. Ludwig Angina Infectious Spread

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

39. 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

40. Ludwig angina: swelling

41. Ludwig angina: trismus

42. 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

43. 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

44. 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

45. 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

46. 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

47. Periorbital cellulitis

48. Orbital cellulitis

50. Subperiostal orbital abscess

51. 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

52. Intracranial complications
Headache
Fever
N/V
Focal neurological deficits
Lethargy
Nuchal rigidity
Deterioration of level consciousness

53. 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)

54. Questions and Answers

55. 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

56. 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

57. 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

58. 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.

59. 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

60. 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

61. 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

62. 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

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

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

65. 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

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

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

68. 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

69. 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

70. 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.

71. 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.