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
Menieres - 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% (Littles Area) Kisselbachs 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 Lymes 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

Aphonia - complete upper airway

Stridor - incomplete upper airway
Wheezing - incomplete lower airway
Loss of breath sounds- complete lower
airway

Questions and Answers