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

2. THE EAR

4. 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

5. Otitis Externa - Variants
Fungal
Malignant OE
Diabetes
VII palsy

6. 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

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

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

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

12. 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

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

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

17. Cauliflower Ear

18. 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

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

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

22. 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

23. 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?

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

25. 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

26. 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

27. THE NOSE

28. 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)

29. Septal Haematoma

30. Normal Inferior TurbinateIT
Septum

31. Epistaxis

32. Little’s Area

33. 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

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

35. Nasal Packing
BIPP
MerocelTM
Rapid RhinoTM

36. How NOT to pack a nose!!!

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

39. 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

40. Subperiosteal abscess – Chandler’s grade 3

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

42. THE THROAT

43. Normal tonsils

44. Acute tonsillitis

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

46. Quinsy

49. Foreign body - throat

50. Fish Bone in Tonsil

51. 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

52. Epiglottitis

53. 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

54. 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

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

56. Emergency Trachy??

57. Cricothyroidotomy

58. 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