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ENT Emergencies

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ENT Emergencies

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  1. ENT Emergencies Stanford University Division of Emergency Medicine

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

  3. Otologic DisordersAnatomy • Auricle • Ear canal • Tympanic membrane • Middle ear and mastoid disorders • Inner Ear

  4. 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

  5. Aspiration of Auricular Hematoma

  6. 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

  7. 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)

  8. 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

  9. 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)

  10. 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)

  11. 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

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

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

  14. EpistaxisPosterior • 10% of all epistaxis - usually in the elderly • Etiologies • Coagulopathy • Atherosclerosis • Neoplasm • Hypertension (debatable)

  15. EpistaxisManagement • Pain meds, lower BP, calm patient • Prepare ! (gown, mask, suction, speculum, meds and packing ready) • Evacuate clots • Topical vasoconstrictor and anesthetic • Identify source

  16. EpistaxisManagement • Anterior Sites - Pressure +/- cautery and/or tamponade - all packs require antibiotic prophylaxis

  17. EpistaxisPosterior Packing • Need analgesia and sedation • require admission and 02 saturation monitoring

  18. EpistaxisComplications • severe bleeding • hypoxia, hypercarbia • sinusitis, otitis media • necrosis of the columella or nasal ala

  19. 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%

  20. Facial InfectionsSinusitis • 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)

  21. Facial InfectionsSinusitis • 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)

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

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

  24. Pharyngitis • Irritants -reflux, trauma, gases • Viruses - EBV, adenovirus • Bacterial -GABHS, mycoplasma, gonorrhea, diptheria

  25. 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

  26. EpiglottitisClinical 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

  27. 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

  28. Epiglottitis

  29. 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

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

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

  32. 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

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

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

  35. Questions and Answers