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Transcript
ENT Emergencies By : O. Ahmadi, MD. Professor Assistant of Esfahan Medical School, Emergency Department of Al-Zahra Hospital 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 • • • • Trauma, epistaxis digitorum Winter Syndrome, Allergies Irritants - cocaine, sprays Pregnancy Epistaxis Posterior • • • • • • 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 • • • • 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 endemic 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 • • • • Aphonia - complete upper airway Stridor - incomplete upper airway Wheezing - incomplete lower airway Loss of breath sounds- complete lower airway Questions and Answers