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ENT Emergencies January 29, 2004 Aric Storck Dr. Peter Gant Objectives • Ear injuries • Otitis externa • Nasal fractures • Epistaxis • PTA • Airway emergencies • Will not cover: OM, sore throats, sinusitis, vertigo the ear Ear Lacerations • 50 year old man • Playing hockey • • without helmet Laceration to ear from skate ?management Roberts: Clinical Procedures in Emergency Medicine, 3rd ed. Questions • Do you trim the cartilage? • How do you close the laceration? • How will you dress it? Ear Lacerations • Anatomy – auricle (pinna) – modified horn shaped structure composed of elastic cartilage covered by skin – converges onto the external auditory meatus (canal) – Cartilage is avascular and needs blood supply from overlying skin and perichondrium – earlobe • with blunt forces ensure no ruptured TM Ears Lacerations management • Debride non-viable skin and cartilage • Ensure enough skin to completely cover cartilage – • can trim up to 5 mm of cartilage while avoiding major cosmetic defect “Through and through” lacerations - 3 layer closure 1. Approximate cartilage edges • • • 4-0, 5-0 absorbable suture Include both anterior and posterior perichondrium in suture or sutures will pull through cartilage Use the folds of pinna as landmarks 2. Repair posterior skin • 5-0 non-absorbable suture 3. Repair anterior surface • • • 5-0, 6-0 non-absorbable suture Use landmarks Ensure edges of free rim are everted to avoid “notching” • NB: Some ENT’s advocate suturing all three layers together • All repaired ears should be enclosed in a compression dressing • Consider antibiotics for heavily contaminated wounds Case 2 • 16 year old wrestler – Head slammed on floor during training – Not wearing protective headgear • Diagnosis? • Management? Source: NEJM 1996: 335(6) Cauliflower Ear subchondral hematoma • Bridging vessels between perichondrium and cartilage are torn • Hematoma stimulates cartilage growth in overlying perichondrium “cauliflower” • Perfect hemostasis to prevent permanent damage • Refer all but most simple hematomas to plastics or ENT • Compression dressing Management • Small hematoma – Needle drainage (22G) and close observation • Large hematoma – I&D (use landmarks to hide incision) – Suction or curettage to remove hematoma – Compression dressing x 4-7 days – Close ENT follow-up Cauliflower Ear CASE 3 • 26 year old male – – – – Just returned from diving holiday in the Caribbean Right ear itchy x 1 week Now c/o right ear pain and moderate discharge Normal hearing • O/E – VSSA – Ear canal erythematous and edematous with some cloudy discharge. – TM moderately red, but not bulging – Patient very tender when you press on his tragus Acute Otitis Externa • What are the most common pathogens? – Pseudomonas – S. aureus • Treatment – Cleansing • Tap water, vinegar – Topical antibiotics • Generally aminoglycoside/steroid, fluoroquinolone/steroid combination – Systemic antibiotics • May be necessary in severe cases, particularly if also cellulitis • Severe cases – Wicking (cotton, gauze) – Allows medication to penetrate into the auditory canal – Should be left in 2-3 days • Suppose your patient is an elderly diabetic. What complication are you concerned about? • Malignant otitis externa – Osteomyelitis of the skull base – pseudomonas the nose Case 4 • 24 year old male – Drunk – Was minding his own business when somebody punched him in the face – Now moderate epistaxis and crooked nose Nasal Fracture diagnosis • History – “Have you broken your nose before?” – “does your nose look normal to you?” – Breathing difficulty • Physical examination – – – – – Crepitus, hypermotility, edema, tenderness, deformity Depressed, laterally angulated, comminuted if mechanism severe look for other injuries epistaxis septal hematoma Nasal anatomy Figure 1. Nasal anatomy. The relationship between the nasal bones, cartilages, and septum. From Otolaryngology–Head and Neck Surgery. 3rd ed. Copyright 1998, Mosby Figure 2. Anatomy of the nasal septum. 1, Frontal bone; 2, nasal bones; 3, perpendicular plate of the ethmoid; 4, vomer; 5, palatine bone; 6, nasal crest of maxilla; and 7, quadrangular cartilage. From Otolaryngology–Head and Neck Surgery. 3rd ed. Copyright 1998 Pathophysiology of nasal trauma. A, Lateral nasal trauma with isolated nasal bone fracture. B, Bilateral nasal bone fractures with septal dislocation. C, Frontal trauma with dorsal widening. D, Comminuted nasal fracture. From Head and Neck Surgery–Otolaryngology. Copyright 1993, Lippincott Williams & Wilkins. To x-ray or not to x-ray …. • Clayton M, et al. The role of radiography in the management of nasal fractures. J. Laryngol Otol. 1986: 100:797-801. – 54 patients – Prospective clinical & radiological assessment & examination under anaesthesia – X-rays did not change management • Delacey et al (1977) – 100 ED patients with nasal fractures – Compared normal x-rays to those of patients with clinical fractures – No diagnostic utility of x-rays because of high incidence of “bony abnormalities” • Mayell et al (1973) – 107 patients with nasal fractures – Negative or positive x-rays did not change management or reduction decisions The bottom line If the nose looks good …and breaths good You don’t need x-rays Remember, you have a week to fix it So what are you going to do about it? Treatment • Primary goals – Restore function – Cosmetic • Consider early reduction if – patient presents before onset of soft tissue edema – or … severe fracture causing airway problems • After edema, best to wait 3-4 days for reevaluation • Closed reduction under local anaesthesia possible up to 10 days (less in kids) • F/U within a week – ENT or plastics – To ensure acceptable cosmetic result once edema subsided Closed reduction • Anaesthesia – 4% cocaine for intranasal anaesthesia – Regional blocks with 1% lidocaine with epi • Supratrochlear nerve • Infraorbital nerve • Nasal dorsum Good job with the fracture …now you look in the nose and see… Septal hematoma Septal hematoma • Bulge of nasal mucosa • Same colour as mucosa • Prone to infection – Results in abscess and cartilage necrosis • I&D with L-shaped incision • Pack nose to prevent • reaccumulation Close ENT follow-up Source: Simon, Emergency Procedures and Techniques Case 5 • 78 year old male – – – – On coumadin and ASA for cardiac disease Brisk nosebleed x 2 hours Blood mostly from right nare Some blood down back of throat • ?Diagnosis • ?Management Epistaxis: Epidemiology • Annual incidence 15% men, 9% women • More frequent from November to March • 15:10,000 seek medical care each year • 1.6:10,000 hospitalized each year Slide courtesy of Dr. Anita Hui Etiology: Local Factors • Trauma – Epistaxis digitorum • Inflammatory reactions ( allergies, infections, foreign bodies) • Tumors (juvenile nasopharyngeal angiofibroma) • Substance abuse – Cocaine, solvents Slide courtesy of Dr. Anita Hui Epistaxis: Systemic Factors • Osler-Weber-Rendu (HHT) • Von Willebrand’s disease – Bleeding time, quantitative immunoelectrophoresis or ELISA • Hemophilia • Leukemia, thrombocytopenia Slide courtesy of Dr. Anita Hui Epistaxis: Systemic Factors • MM • Hemodialysis • Nutritional deficiences • Medications: ASA, NSAIDs, warfarin, chloramphenicol, carbenicillin, dipyridamole Slide courtesy of Dr. Anita Hui Anterior Epistaxis – 90-95% • Septal wall • Kiesselbach’s area – External carotid • Sphenopalatine artery – Internal carotid • Anterior ethmoidal artery Slide courtesy of Dr. Anita Hui Posterior Epistaxis – 5-10% • Lateral wall • Both internal & external carotid • “Woodruff’s plexus” – Arterial and venous plexus – Most common site of posterior epistaxis Slide courtesy of Dr. Anita Hui Epistaxis: Management • ABC’s – Airway – Resp distress – hypotension • Correct underlying problem – CBC, coags • • • • Pressure Ice Morphine, other medications Cauterization: chemical (Ag Nitrate), electrical Slide courtesy of Dr. Anita Hui • Large clots in right nare with ++ oozing • You ask patient to blow their nose • Oozing site visualized • Now what? Nasal anaesthesia • Cocaine 4% • 2% lidocaine with epinephrine • 1:1 mixture of 4% lidocaine and 1:1000 epinephrine • Cautery – Silver nitrate – Bilateral cautery contraindicated – septal perforation • Anterior nasal packing – Absorbable packing materials • Polysporin/vaseline ointment • Gelfoam, Surgicel • Addition of hemostatic agents such as Avitene, Thrombostat, Amicar Slide courtesy of Dr. Anita Hui • Do you pack both sides? – No good evidence – Some ENT’s say to pack both sides if using vaseline-gauze pack because it relies on pressure and is likely to deviate septum – Both sides not necessary with Merocel as it functions mostly by providing matrix for clot formation • How long do you leave anterior pack in? – 48-72 hours Now suppose • Blood coming from both nares • Lots going down back of throat • No anterior source of blood seen • Diagnosis? • Management? • Disposition? Management of refractory epistaxis • Greater palatine foramen block • Laser photocoagulation (Arg, Nd:YAG) • Angiographic embolization • Surgical ligation Slide courtesy of Dr. Anita Hui the throat Case 6 • 22 year old male • 1 week history of worsening sore throat • Now talking funny – “hot potato voice” • Unable to open mouth as wide as before • Rigors, general malaise You look in his mouth … Slide courtesy of Dr. P. Park Peritonsillar Abscess Presentation • • • • • • • Sore throat Odynophagia Trismus (pterygoid muscle inflammation) Hot potato voice Fever Otalgia Unilateral swelling of the soft palate and anterior pillar with deviation of the uvula Etiology • inadequately treated tonsillitis • recurrent or chronic tonsillitis • mixed bugs – Aerobic - GABHS – Anaerobic - Fusobacterium • pus is in between the tonsillar capsule and the bed Anatomy Source: Roberts. Clinical Procedures in Emergency Medicine DDx • acute – – – – – unilateral tonsillitis peritonsillar cellulitis carotid artery aneurysm Mononucleosis Odontogenic infection • chronic – Leukemia – Carcinoma – Parapharyngeal space tumor Peritonsillar Abscess vs Cellulitis • Trismus uncommon with cellulitis • “hot potato voice” more common with abscess • Positive aspiration diagnostic – negative aspiration does not rule out abscess • Intraoral sonography – Sensitivity 91% – Specificity 80% • CT How are you going to treat it? Needle Aspiration vs Incision & Drainage • 3 RCTs 1. Spires, et al. Treatment of peritonsillar abscess. A prospective study of aspiration vs incision and drainage. Arch Otolaryngol Head Neck Surg 1987;113:984-6 – Endpoint = return to normal diet – Initial success • 95% - Needle • 100% - I&D Stringer, et al. A randomized trial for outpatient management of peritonsillar abscess. Arch Otolaryngol Head Neck Surg 1988; 114:296 • N=52 • 93% success needle aspiration • 92% success I&D • NB: No statistical analysis of P-values reported – Numbers analyzed showed insignificant result Maharaj et al. Management of peritonsillar abscess. J Laryngol Otol 1991;105:743-5. • RCT • Success – Needle = 87% – I&D = 90% • No statistical analysis done – However numbers analyzed show no significant difference Needle Aspiration • Anesthesia with topical +/- sc lidocaine • 18 - 22 gauge needle – Aspirate area of greatest fluctuance – Tonsil itself not aspirated (pus is in peritonsillar space) – Aim medially (avoid carotid) – Look for pus in superior, middle, and inferior poles Incision and Drainage • Consider I&D if aspiration positive – Guarded #11 scalpel – Aim at area of greatest fluctuance – Don’t aim laterally! – Break loculations with blunt instrument Disposition • Admission vs discharge • Abx – IV vs oral – PCN, 2nd 3rd generation cephalosporin, clindamycin • Referral for tonsillectomy – If other indications for tonsillectomy – Following 2 PTA’s Case 7 • 5 year old girl – Tonsillectomy 7 days ago for recurrent tonsillitis – Benign post-operative course thus far – Now brisk bleeding from mouth x 30 minutes – O/E: 120 85/60 pale spitting up blood Posttonsillectomy hemorrhage • 4300 cases/year in US • 1-5% of cases • When do they occur? – Primary - <24 hours • Related to surgical technique, hemostasis – Secondary - >24 hours • 5-10 days • Sloughing of surgical eschar • Tonsillar blood supply – 5 arteries • Ascending pharyngeal • Ascending palatine • Anterior tonsillar branch of lingual artery • Inferior tonsillar branch of facial artery • Superior tonsillar branch of the descending palatine artery • Tonsilloadenoidectomy (TA) – 1975 – 685,000 – 1980 – 464,000 – 1991 – 86,000 Post-tonsillectomy bleed management • The usual ABC’s • A & B – head up and forward • C – fluid resuscitation, group & screen Post-tonsillectomy bleed management • Post-tonsillectomy bleed tray • Remove clot with suction – allows vessels to contract • Pack bleeding site with epinephrine soaked pads • Bipolar cautery if bleeding site visualized • Call ENT surgeon – to OR if necessary Case 8 • December 14, 1799 – 60’s male – Sore throat – Increasing hoarseness and stridor – Did not respond to routine course of 2L bloodletting Epiglottitis • 1980 – children: adults = 2.6:1 • 1993 = 0.4:1 – Coincides with mass vaccination for HIB • Mortality rate – Children <1% – Adults 6-7% Epiglottitis – presentation • Khilanani et al. (1984) – Sore throat – 100% – Dysphagia - 76% – Fever – 88% – SOB – 78% – Pain to palpation of larynx Diagnosis • Soft tissue neck x-ray – Sensitivity 38% – Specificity 76% • Stankiewica J, Bowes A. Croup and epiglottitis. A radiologic study. Laryngoscope 1985;95:1159-1160 Diagnosis Visualization • No respiratory distress – Direct laryngoscopy – Fiberoptic laryngoscopy • Drooling, stridor, dysphonia – Direct laryngoscopy only when prepared to capture airway – Indirect laryngoscopy relatively contraindicated Epiglottitis microbiology • • • • • • H. influenzae H. parainfluenzae Pneumococcus S. aureus GABHS Viral/fungal • Abx – Intravenous – Good coverage of gram +, anaerobes • Cefoxetin, clinda Intubation vs Conservative Management • Dort J, et al. Acute Epiglottitis in Adults: Diagnosis and Treatment in 43 Patients. J of Otolaryngology 1994;23(4) – – – – Retrospective review of 43 patients X-rays – 35/40 positive for epiglotitis Immediate intubation N=14 Expectant Management N=29 • 1 developed stridor and required intubation on ward – Patients intubated more likely tachycardic and stridorous – 1 death from septic shock – No airway related deaths • Wolf m, et al. Conservative management of adult epiglottitis. Laryngoscope 1990;100:183-185. – 30 patients treated conservatively regardless of airway symptoms – No airway interventions – No deaths – advocate conservative management • Khilanani U, et al. Acute epiglottitis in adults. Am J Med Sci 1984;287:65-70. – – – – 162 patients reviewed 17.6% mortality in patients with airway symptoms Many deaths occurred while “monitoring” or during intubation Advocate aggressive approach • Friedman M, et al. A plea for uniformity in the staging and management of adult epiglottitis. ENTJ 1988;67:873-880. – Proposed staging system for management – Not validated – Stage I • No respiratory distress, RR<20 • Observation in ICU – Stage II • Some respiratory distress, RR 20-30 • Intubation in OR – Stage III-IV • RR>30, pCO2 >45, severe respiratory distress • Immediate airway intervention Case 8 • 45 year old man – – – – Seen in ER yesterday for dental pain Started on oral antibiotics and T3’s Hasn’t been able to see dentist yet Today trouble speaking, swallowing, neck swelling • OE – 105 25 120/80 38 99 – – – – Marked submental/submandibular swelling Tongue elevated in mouth Drooling “hot potato voice” Ludwig’s Angina From: Roberts: Clinical Procedures in Emergency Medicine • Cellulitis, inflammation, swelling of – Submandibular space – Submental space – Sublingual space • Usually odontogenic source of infection • Staph / Strep most common bugs Ludwig’s Angina Presentation • Rapidly progressive • Asymptomatic to respiratory compromise in hours • Sx – – – – – Chills Fever Dysphagia Stiffness of tongue movements Trismus • Signs – Elevated tongue – Edematous oral pharynx – Swollen submandibular space Source: Hartmann R. American Family Physician. 1999 Diagnosis • Primarily clinical diagnosis • Adjunct investigations – Soft tissue neck x-rays – CT – U/S Managment • • • • Sitting position ICU / ENT / Anaesthesia Broad spectrum antibiotics Awake intubation – Fiberoptic guided • Surgical airway – Difficult due to neck swelling – Can spread infection to mediastinal space • Surgery – Dental intervention of underlying cause – I&D reserved for • Not responding to Abx • Proven fluid/gas collection the end