ENT Emergencies Flashcards
ENT emergencies of the ear (2)
foreign bodies
malignant otitis externa
ENT emergencies of the Nose/Sinus (5)
foreign bodies epistaxis nasal fracture septal hematoma complications of sinusitis
ENT emergencies of the oropharynx (2)
Ludwig’s angina
Peritonsillar abscess
ENT emergency of the salivary gland (1)
sialoadenitis
Which ENT emergency is usually visualized easily and has a primary symptoms of pain?
foreign body in the ear
If there is a live insect in the patients ear, what should you do first?
Immobilize insect with 2% Lidocaine or mineral oil
How to remove a foreign body in the ear
Alligator forceps
sometimes suction
can try irrigation
If deeply impacted FB, may need to refer to ENT
sometimes FB removal rqrs general anesthesia or conscious sedation
Cauliflower Ear: 2 sporty aliases
Wrestler’s ear, boxer’s ear
(U) cause of cauliflower ear
blunt trauma
What is cauliflower’s ear and does it need to be treated?
Cauliflower’s ear is hematoma of the pinna
if untreated, it may result in cartilage necrosis, chronic scarring & deformity
Laceration of the Pinna: characteristics, what to watch for & how to tx
(U) bleeds a lot
Make sure there is no injury to the canal & internal ear
Watch out for hemotomas
If laceration needs to be repaired, (U) a running suture is best
How can one obtain perichondritis?
- ear piercing, particularly to upper third of the pinna can result in ear infections
- cartilage is avascular, improper healing can predispose to infection (Pseudomonas and Staph)
Which two microbes are common in perichondritis?
Pseudomonas
Staph aureus
Signs/sxs of perichondritis
pain, erythema & localized warmth
Perichondritis treatment: why and what
infections can spread rapidly & lead to deformity
Antibiotics required; surgical debridement
Malignant Otitis Externa: broad 1 line definition
invasive infection that involves the temporal bone!!!!
In whom do we see Malignant Otitis Externa
IMMUNOCOMPROMISED PATIENTS (diabetics, elderly, systemic malignancy, long term steroid use)
Malignant Otitis Externa primary pathogen
Pseudomonas aeruginosa
Malignant Otitis Externa a/w which symptoms
severe, unrelenting ear pain that is worse at night
a/w purulent otorrhea
As Malignant Otitis Externa spreads, what 3 things may be seen
trismus
cervical adenompathy
CN palsies
Malignany Otitis Externa: clinical presentation & dx
ear canal edematous & erythematous w/granulation tissue
CT scan will be DIAGNOSTIC
Malignant Otitis Externa: ENT referral for which situations
admission
IV antibiotics: Imipenem or ciprofloxacin or ceftidime
Mastoiditis: definition
extension of otitis externa or acute otitis media into mastoid air cells
Mastoiditis: signs & symptoms
suspect w/slow resolution of sxs
Mastoid tenderness with edema & erythema
Deep temporal pain
Mastoiditis: diagnostic studeis
CT is BEST diagnostic study
plain x-rays might show density in mastoid airspace but may nito be discernible until 2 weeks after onset of mastoid infection
Mastoiditis: Tx & prognosis
- Hospitalize & start on IV Abx (Vancomycin or Nafcillin/Oxacillin)
- typmanocentesis for fluid to culture
- mastoidectory required if complications
prognosis is good :)
What is the most likely etiology of malignant otitis externa?
Pseudomonas
Epistaxis: most common etiology
& other causes of epistaxis
TRAUMA is most common
others: FB, irritants (cig smoke), HTN, nose picking,
meds (ASA, NSAIDS, anticoagulants)
hematologic disorders; hemophilia, leukemia, platelet dysfunction, thrombocytopenia
Epistaxis physical exam (3 management elements)
- sitting position preferable to supine
- initial management: direct pressure for a minimum of 5 mins
- ensure hemodynamic stability & airway patency
Epistaxis: equipment used is in physical exam
- bright light source (headlight)
- nasal speculum
- adequate suction
- adequate protection against blood exposure (goggles, apron, gloves)
- adjustable chair (ENT or dental chair)
Epistaxis: usual source of bleeding in kids
Kiesselbach’s Plexus
anteriorly on the nasal septum branch of the labial artery
Epistaxis: adult usual source of bleeding
in septum, but more posterior than kids
Epistaxis: elderly usual source of bleeding
elderly (U) most difficult to identify & control
branch of the MAXILLARY ARTERY
POSTERIOR, harder to visualize
more bleeding, more systemic factors
Anterior nose bleed tx
Topical vasoconstrictors: 2%Neo-synephrine spray, 4% cocaine spray or solution on cotton pledgets
Cautery: chemical (silver nitrate), hemostatic packing material-Gelfoam or Surgicel, electrocautery
Anterior packing: petrolatum-impregnated gauze packed firmly in the anterior nares with forceps, leave for 48 hours (preformed nasal tampon may be used)
Posterior nose bleed tx and complications
Vasoconstrictor: pledgets saturated in 4-5% cocaine
Anterior packing
Posterior packing:
-posterior pack + anterior nares bilaterally
-balloon catheter: left in place for 2-5 days
-HOSPITALIZE if posterior pack or balloon catheter
Complications: septal hematoma, sinusitis, toxic shock syndrome
Nasal fracture: (U) cause, may be a/w what
very common injury, (U) from blunt trauma
-may have associated epistaxis (need to evaluate for septal hematoma)
non-displaced nasal fracture: immediate needs
generally don’t require immediate intervention
ENT referral in 3-5 days
BLOOD w/surrounding STRAW-COLORED FLUID OR SEROUS FLUID->think other facial fractures, need URGENT NEUROSURGICAL consultation
Septal hematoma: When seen, (C) in whom
seen following trauma
more common in pediatric patients
Septal hematoma: symptoms (3), Physical exam (3)
sxs: increased nasal obstruction, pain, tenderness
PE: soft, tender, swelling
Nasal Hematoma tx
-incision & drainage of hematoma to prevent avascular necrosis
[untx hematomas complicated by “saddle nose” deformity]
after drainage, pack nose and cover w/antibiotics
When do you avoid irrigation of the nose
if foreign body is vegetable matter
What can you have a parent do if their child has a foreign body in his mose?
can have parent try to blow it out
What is necessary for nose foreign body removal in a child
child must be adequately restrained and you must have good visualization
When do you refer nasal FB to ENT
if more than 2 unsuccessful attempts, refer to ENT
Foreign body in nose: when to re-examine
ALWAYS re-examine after 1 FB removed
4 potentially life-threatening complications of sinusitis
[result from extension of a bacterial infection into the orbital or intracranial spaces]
- Periorbital cellulitis
- Orbital cellulitis
- Cavernous sinus thrombosis
- Frontal osteomyelitis
Periorbital Cellulitis def & may be a complication of what
infection confined to the eyelids, may be a complication of sinusitis or local disruption of skin
Periorbital cellulitis: 2 most common pathogens
S. pneumo
S. aureus
Periorbital cellulitis: ddx includes (3)
trauma, contact allergy, dacryocystitis
Periorbital cellulitis: symptoms (4)
unilateral periorbital edema with erythema, warmth, tenderness, fever
Physical exam findings suggestive of ORBITAL cellulitis
VISION LOSS, DIPLOPIA, & PROPTOSIS suggest intraorbital involvement consistent with orbital cellulitis
[on exam, assess visual acuity & EOMs)
Perioribital Cellulitis: dx & tx
-CT scan most helpful to dx
-hospitalize anyone who is febrile & appears acutely ill
-IV Abx
-consult ophthamologist and/or ENT
prognosis is good if tx started early
Orbital cellulitis can lead to what
TRUE EMERGENCY, can lead to: vision loss meningitis cavernous sinus thrombosis frontal abcess
Orbital Cellulitis: what will you see
periorbital edema, erythema PLUS proptosis, chemosis, impaired EOMs & evidence of vision loss
Orbital cellulitis dx
CT WILL DISTINGUISH between periorbital cellulitis and orbital cellulitis
Orbital cellulitis tx
Admit for IV Abx:
Nafcillin + Ceftriaxone + Metronidazole
Cavernous Sinus Thrombosis Sxs
sxs develop acutely, w/in 1 week after infection
- severe unilateral, retro-orbital headache
- bilateral proptosis
- ophthalmoplegia
- vision loss
- SENSORY DYSFUNCTION: hypo-/hyperesthesia of cranial nerve V, 1st branch
Sensory nerve dysfunction on Cavernous Sinus Thrombosis is due to
hypo-/hyperesthesia of Cranial Nerve V, 1st branch
Cavernous Sinus Thrombosis appearance on exam
Febrile, toxic appearing pt
Periorbital edema
Cranial Nerve dysfunction (III, IV, VI)
Papilledema (late)
Cavernous Sinus Thrombosis: dx and tx
need URGENT head CT
IV Abx: Vancomycin + Ceftriaxone
Frontal Osteomyelitis aka & a/q
Pott’s Puffy Tumor
is a complication a/w frontal sinusitis
Frontal Osteomyelitis most common microbes
S. aureus & anaerobes
Frontal Osteomyelitis: patient presentation
patient presents w/HA & progressive swelling of the forehead
Frontal Osteomyelitis dx
CT or MRI will be dx
Frontal Osteomyelitis tx
drainage of abscess & debridement of infected bone
IC Abx: Vancomycin or Nafcillin
Tongue laceration: cause & what is the problem
(U) related to injury, frequently involving the teeth
Great potential for INFECTION & HEMATOMA
Tongue Laceration tx
almost never sutured, exception: tip of tongue (forked tongue)
- may need to suture if more than 1/3 of the width of the tongue involved
- absorbable suture material, Abxs
Puncture wounds in the mouth: etiology, description
common but rarely serious
running with something in mouth or run into something
almost always small
bleeding resolves spontaneously
Puncture wounds in mouth tx
- start on Abx (possibly only when more serious?)
- rinse w/ warm water after every meal
- will resolve without tx
- topical anesthesia for pain control
- can use orabase dental paste to prevent irritation, but doesn’t speed healing
- solution of Maalox & liquid Benadryl (1:1)
What ENT condition presents with uvula displacement?
Peritonsilar abscess
Ludwig’s Angina: what is this?
infection involving the submandibular space
potential spread can compromise oral cavity, airway & deep neck spaces
85% cases of Ludwig’s Angina are the result of what
-can also see with what?
85% are the result of a dental infection
-can also see with a peritonsillar abscess, oral malignancy or mandibular fracture
Ludwig’s Angina: 3 common pathogens
Streptococcus, Staphylococcus & Bacteroides
Ludwig’s Angina sxs and associated conditions
- rapidly progressive infection a/w neck swelling, tongue protrusion & severe pain
- also see malaise, trismus & bad breath
Ludwig Angina: tx
- ENT consultation for potential airway compromise & surgical debridement
- IV Abx
Most common abscess of the head and neck
peritonsillar abscess
“hot potato” voice seen in
peritonsilar abscess
Signs and symptoms of peritonsilar abscess
fever, severe sore throat, drooling odynophagia & otalgia
signs: trismus, unilateral erythema & swelling, displaced uvula
Peritonsillar Abscess tx
drainage of abscess and Abx
Sialoadenitis: definition, etiology, 2 types
- inflammation of any of the salivary glands (parotid, submandibular, sublingual)
- viral or bacterial etiology
Forms:
Suppurative-most(C)cause:Staphylococcous aureus
Obstructive-occurs fro a stone or calculus in salivary gland or duct
Sialoadenitis presentation
pts are: elderly, diabetic, poor oral hygiene, dehydration
-enlarged, swollen, painful mass
w/stone: xerostomia & worsening pain & swelling during mealtime
Bilateral swelling of a gland may be due to
VIRAL sialoadenitis
Bacterial Sialoadenitis presents: (Uni or bi-laterally)
UNILATERAL
Viral Sialoadenitis presents (uni- or bi-laterally)
BILATERAL
Unilateral swelling of a gland may be due to
bacterial sialoadenitis
Tx of sialoadenitis
Suppurative: Abx tx to cover Staph
Rehydration, proper oral hygiene
surgical irrigation & drainage
Obstructive: most stones pass spontaneously without complication
lozenges to stimulate salivary secretions
Serum amylase will be elevated in which ENT Emergency lecture condition?
Sialodenitis
