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ENT Emergencies
Stanford University
Division of Emergency Medicine
Overview
• Otologic Disorders
• Nasal Disorders
• Facial, Oral and Pharyngeal
Infections
• Airway Obstruction
Otologic Disorders
Anatomy
• Auricle
• Ear canal
• Tympanic
membrane
• Middle ear and
mastoid disorders
• Inner Ear
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
Aspiration of Auricular Hematoma
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
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)
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
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)
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)
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
The Nose
• Vascular Supply
- Anterior - branches of
internal carotid
- Posterior - distal
branches of external
carotid
Epistaxis
Anterior
• 90% (Little’s Area) Kisselbach’s plexus usually children, young adults
Etiologies
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Trauma, epistaxis digitorum
Winter Syndrome, Allergies
Irritants - cocaine, sprays
Pregnancy
Epistaxis
Posterior
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10% of all epistaxis - usually in the elderly
Etiologies
Coagulopathy
Atherosclerosis
Neoplasm
Hypertension (debatable)
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
Epistaxis
Management
• Anterior Sites
- Pressure +/- cautery
and/or tamponade
- all packs require antibiotic
prophylaxis
Epistaxis
Posterior Packing
• Need analgesia and
sedation
• require admission and
02 saturation
monitoring
Epistaxis
Complications
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severe bleeding
hypoxia, hypercarbia
sinusitis, otitis media
necrosis of the columella or nasal ala
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%
Facial Infections
Sinusitis
• 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)
• Treatment
Facial Infections
Sinusitis
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)
Facial Cellulitis
• Most common strept
and staph,
• Rarely H.Flu
• Can progress rapidly
Parotiditis
• Usually viral
-paramyxovirus
• Bacterial
- elderly, immunosuppressed
- associated with dehydration
- cover - Staph, anaerobes
Pharyngitis
• Irritants
-reflux, trauma, gases
• Viruses
- EBV, adenovirus
• Bacterial
-GABHS, mycoplasma, gonorrhea,
diptheria
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
Epiglottitis
Clinical 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
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
Epiglottitis
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
Masticator - Parapharyngeal
Space Infection
• Infection of the lower
molars invade masticator
space
• Swelling, pain fever,
TRISMUS
• Treatment
IV antibiotics (PCN or
Clindamycin)
ENT admission
ANUG
Acute Necrotizing Ulcerative Gingivitis
• Bacterial infection causing an
acute necrotizing, destructive
disease of periodontium
• Treatment
- oral rinses
- antibiotics (PCN, clindamycin,
tetracycline)
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
Angioedema
• Ocassionally life
threatening
• Heriditary and related
to ACE inhibitors
• Antihistamines,
steroids and doxepin
Airway Obstruction
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Aphonia - complete upper airway
Stridor - incomplete upper airway
Wheezing - incomplete lower airway
Loss of breath sounds- complete lower
airway
Questions and Answers