Download ENT Emergencies - McMaster University

ENT EMERGENCIES
McMaster University
POS 2009
Overview
ENT
• Ears = Otologic
• Nose = Rhinologic
• Throat = Oral/Pharyngeal/Laryngeal
–Infections
–Facial injuries
–Airway Obstruction
Otologic Anatomy
• Auricle
• Ear canal
• Tympanic
membrane
• Middle ear &
mastoid
• Inner Ear
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
Aspiration of Auricular Hematoma
Middle Ear
• Mastoiditis
– Venous connection with brain, need
aggressive treatment (can lead to brain
abscess or meningitis)
Epistaxis
• 90% (Little’s Area) Kiesselbach’s plexus usually children, young adults
• 10% of all epistaxis - usually in the elderly
Nasal Septum
Lateral Wall
LOCALIZATION OF EPISTAXIS
POSTERIOR : LATERAL WALL
Behind the middle turbinate
Entrance of Sphenopalatine artery
Epistaxis in elderly and HBP
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
•
•
•
•
severe bleeding
hypoxia, hypercarbia
sinusitis, otitis media
necrosis of the columella or nasal ala
Parotitis
• Usually viral
-paramyxovirus
• Bacterial
- elderly, immunosuppressed
- associated with dehydration
•
-
Management
cover - Staph, anaerobes
Hydrate
Sialogogues
Warm compresses
Pain control
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 10-30 years old
Left Peritonsillar Abscess
Left Peritonsillar Abcess
Left Peritonsillar Abscess
CT-SCAN peritonsillar abscess
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
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
Epiglottitis
•
•
•
•
Avoid agitation
Direct visualization if patient allows
soft tissue of neck
Prepare for emergent airway, best achieved
in a controlled setting
• Unasyn, +/- steroids
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
Epiglottitis
Acute epiglottitis: swan neck
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.***
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
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
Deep Neck Space Infection
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
Ludwig Angina Infectious Spread
Ludwig’s Angina
• Etiology:
– typically from an odontogenic infection
• mandibular 2nd or 3rd molar
– streptococcus, oral anaerobes
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
Ludwig angina: swelling
Ludwig angina: trismus
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
Angioedema
• Ocassionally life threatening
• Acquired
-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
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
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
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
Periorbital cellulitis
Orbital cellulitis
Subperiostal orbital abscess
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
Intracranial complications
•
•
•
•
•
•
•
Headache
Fever
N/V
Focal neurological deficits
Lethargy
Nuchal rigidity
Deterioration of level consciousness
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)
Questions and Answers
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
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
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
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.
Question cont
•
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CBC
Morphine 5mg IV
Metoprolol 5mg IV
INR/PTT
Large bore IV
U/S
Serum Calcium
Serum lytes
Urine lytes
•
•
•
•
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•
•
•
•
2/3 1/3 IV solution
RL IV solution
½ NS IV solution
Stat CT scan
Cross & type 2 units
PRBC
Stat CXR
Stat ECG
Foley
Nasal packing
Question cont
•
•
•
•
•
•
•
•
•
CBC
Morphine 5mg IV
Metoprolol 5mg IV
INR/PTT
Large bore IV
U/S
Serum Calcium
Serum lytes
Urine lytes
•
•
•
•
•
•
•
•
•
2/3 1/3 IV solution
RL IV solution
½ NS IV solution
Stat CT scan
Cross & type 2 units
PRBC
Stat CXR
Stat ECG
Foley
Nasal packing
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
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
Question?
• The vessel most likely to cause significant
bleeding following tracheostomy is:
– Aorta/carotid
– innominate
– inferior thyroid
– Internal jugular
– Subclavian artery
Question?
• The vessel most likely to cause significant
bleeding following tracheostomy is:
– Aorta/carotid
– innominate
– inferior thyroid
– Internal jugular
– Subclavian artery
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
Question?
• What is the most common cause of death in
patients with tracheostomies.
– Increased aspiration
– Tube falling out
– Bleeding
– Tube becoming obstructed
– Infection
Question?
• What is the most common cause of death in
patients with tracheostomies.
– Increased aspiration
– Tube falling out
– Bleeding
– Tube becoming obstructed
– Infection
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
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
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.
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.