Management of ENT

Emergencies
Simon Lloyd
Consultant ENT Surgeon
Central Manchester NHS Foundation Trust
Facial palsy
Anatomy
Sensory
Taste
Posterior ear canal
Autonomic
Parasympathetic to:
Lacrimal gland
Submandibular gland
Sublingual gland
Motor
Facial expression
Stapedius
Posterior belly of digastric
Aetiology
Huge differential
Congenital
Neurological eg. Moebius syndrome
Traumatic eg. Forceps

Acquired
Idiopathic eg. Bells palsy
Traumatic eg. Temporal bone fracture
Iatrogenic eg. Surgery
Infection eg. Acute otitis media, malignant otitis media,
Ramsey Hunt syndrome
Neoplastic eg. Parotid malignancy
Examination
Facial nerve grading (House Brackmann)

Other cranial nerves

Tympanic membrane/pinna for vesicles

Parotid/mouth
Assessment
House Brackmann Grading (I to VI)
I = Normal
II = Normal at rest, mild weakness on active
movement
III= Good eye closure
V = Some tone
VI= No movement
Eyes open Eyes closed
Facial Palsy

52 year old lady
Rapid onset left facial
weakness
Left facial numbness
No ear symptoms
Otherwise fit and well
Grade III weakness
No other abnormalities


Bells Palsy
Idiopathic (probably viral Herpes simplex)
Acute unilateral facial palsy (peripheral)
Occasionally other cranial nerve palsies eg. Trigeminal
Resolves within 3 months in 80% of cases
10% recur (including contralateral)
Higher incidence in diabetes
Treatment
Eye Care (lubrication)
Oral steroids
No evidence for benefit from antivirals

Sullivan et al. New England Journal of Medicine 2007

Who to refer
Additional findings (Cr. Nerves, lumps)

No improvement at 3 weeks

Incomplete recovery

Concerns
Sudden Hearing Loss
Normal TM with sudden hearing loss
Aetiology unknown
Viral
Vascular
Rarely acoustic neuroma, perilymph leak
May be unsteady or vertiginous

Sudden Hearing Loss
Management
Refer urgently
Treatment options
Oral steroid
Antiviral
No evidence for efficacy
Carbogen
No evidence for efficacy
Intratympanic steroid
Weak evidence for efficacy

Allergic response to BIPP
Acute Otalgia with normal TM
Complications of
Otitis Media

Mastoiditis
Facial palsy
Labyrinthitis
Meningitis
Intracranial abscess
Lateral sinus thrombosis

- Long term
Tympanosclerosis
Tympanic membrane perforation
Ossicular damage
Acute Mastoiditis
History of acute otitis media
Infection spreads to mastoid
Post-auricular abscess

Treatment
Grommet
Cortical mastoidectomy
Complications acute otitis media
mastoiditis
Intracerebral Abscess
Diagnosis
High index of suspicion
Headache
Reduced conscious level
Fever
Seizures

Requires drainage

Ring enhancement
with contract
enhanced CT
Lateral Sinus Thrombosis
Diagnosis
High index of suspicion
Headache
Decreased conscious level
Ataxia
Seizures

Treatment
Anticoagulation
?thrombectomy
Filling defect
on MRA
Epistaxis
Anatomy
Aetiology
Usually idiopathic
? atherosclerotic vessels
Predisposing factors
Anticoagulants
Hypertension
Trauma eg. Digital, fractured nose
Nasal vestibulitis eg. Staphlococcal
Topical treatment eg. Nasal steroids
Rare
HHT
Neoplasia
Septal perforation
Epistaxis First Aid

Conservative Management
Pinch soft part of nose
Lean forward and breathe
through mouth
Ten minutes

Protect yourself
Gown
Gloves
Mask

Treatment
Identifiable Vessel
Nasal cautery
Examine nose
Identify vessel
Apply 1 in 10,000
adrenaline and
1%lignocaine on
cotton wool pledget
Silver nitrate cautery
of vessel


Silver nitrate cautery

Treatment
No Identifiable Vessel
Nasal packing
Merocel
Rapidrhino
BIPP packing
Rapid Rhino
BIPP Packing
Treatment
Ongoing bleeding
Re-check vital signs
IV access +/- fluids
Check clotting
Posterior packing
Brighton baloon
Foley catheter and BIPP
pack
Surgical Intervention
Septoplasty
Sphenopalatine artery ligation
Anterior ethmoid artery ligation
Maxillary artery ligation
External carotid artery ligation
Management Algorithm
Nose bleed
Digital
pressure
Bleeding stops:
discharge with
relevant information
Ongoing bleeding
Nasal preparation
Visualise bleeding point
Able to
visualise
Cauterise
Cautery fails
Unable to
visualise
Packing
Packing fails
Surgery
Nasal Vestibulitis
Paediatric
Digital trauma
Cautery vs Naseptin
Equal efficacy

Bactroban tastes horrible ? Prevents digital trauma
Fractured nose

Fractured nose
Ask about
Epistaxis
CSF
Diplopia on upward gaze
Infraorbital parasthesia
Shape change
Nasal obstruction
Fractured nose
Examination
Nasal bones crepitus, shape
Infraorbital parasthesia
Orbital rims
Septum for haematoma
No need for X ray unless
medicolegal
Fractured nose
Management
If no complicating factors and nose straight leave
alone.
If orbital fracture or septal haematoma refer
immediately
If shape change with no complicating factors refer to
ENT about five days post injury

Nose should be reduced within 2 weeks for
best chance of good result

Complications of Sinusitis
Intracranial complications
Brain Abscess
Meningitis
Orbital complications
Periorbital cellulitis
Periorbital abscess
Orbital abscess
Potts puffy tumour
Periorbital Cellulitis and Abscess

Unwell
Pyrexia
Eye closes
Erythema
Chemosis
Colour vision goes off
first
Refer urgently

Periorbital Cellulitis
Treatment
Nose
Topical decongestants
Ephidrine
Otravine
Systemic
IV antibiotics

CT imaging to exclude
periorbital abscess
Foreign Bodies
Material
Paper, beads, watch batteries
etc.

Unilateral rhinorrhoea is a
foreign body until proved
otherwise

Treatment
Wrap up child
Assistant hold head
Remove
Complications of Tonsillitis
Peritonsillar abscess

Symptoms
Pain becomes more unilateral
Often referred otalgia
Trismus (therefore difficult to get a good look)
Drooling
Systemically unwell with pyrexia
Normally big tender upper deep cervical node
Refer
Complications of tonsillitis
Peritonsillar abscess (quinsy)
Peritonsillar abscess
Treatment
Incision and drainage (needle/blade)
Intravenous penicillin and metronidazole
First quinsy and previous history of
tonsillitis recommend tonsillectomy
First quinsy with no prior tonsillitis
historyverbal warning

Stridor
Harsh, high-pitched sound indicative of airway obstruction.

Inspiratory Supraglottic or Glottic

Biphasic Subglottic or Extrathoracic Trachea

Expiratory Intrathoracic Trachea

NB. Stertor High upper airway obstruction

Stridor - Assessment
What level ??
History What sort of stridor

How severe ??
Accessory muscles
Tracheal tug / Recession in children
Pulse
pCO
2
Retention

Does the airway need securing ??
Severe OR patient getting tired.
Causes
Children
Infection
Bacterial eg. Epiglottitis
Viral eg. Croup
Foreign body

Adults
Infection
Supraglottitis
Neoplasia
Squamous cell carcinoma

Stridor -management
SIT PATIENT UP
OXYGEN
RE-HYDRATION (i.v.)
STEROIDS (Nebulised, i.v. or oral)
ADRENALINE NEBULISER
HELIOX Helium / oxygen mixture
ANTI-BIOTICS
AIRWAY INTERVENTION
Intubation
Bronchoscopy
Tracheostomy


Croup vs Epiglottitis

Croup Epiglottitis

Age 1-3years 3-6 years
Duration URTI (days) Short(hours)
Clinical Viral Unwell*
Stridor Loud Quiet

* Decreased concious level, circumoral palor, rapid deterioration.

Airway Foreign Bodies
RIGHT main bronchus (more vertical)

May get air trapping, distal to FB.

Monophonic wheeze (asthma POLYphonic)

High index of suspicion - REFER
Rigid bronchoscope
Bronchoscope and camera being used to assess the airway in a child with a
tracheostomy