ENT emergenies Flashcards
Primary concern with facial, head or neck trauma?
- maintain airway
- avoid nasal tracheal intubation
- consider: endotracheal intubation, laryngeal mask airway, cricothyroidotomy
- avoid NG tubes (or any tube in the nose) until the extent of the injury is determined (don’t want to lose tubes in the brain!!)
Hemorrhage control?
- shock rarely develops from facial bleeding alone
- apply direct pressure
- may need nasal packing for epistaxis
What PE findings are you looking for with ENT fractures - nose specifically?
- CSF rhinorrhea
- septal hematoma
- nasal fracture
Significance of CSF rhinorrhea?
- how do you distinguish b/t clear nasal d/c and CSF?
- direct communication with CNS exists due to disruption of bony barrier and tear in dura
- significant risk for CNS infection
- distinguish:
clinical hx
filter paper - look for halo sign - test for glucose with glucose oxidase paper
When can a septal hematoma occur in adults, children?
- occur from trauma to anterior nasal septum
- adults: sig trauma and nasal fracture
- children: can occur with simple falls or minor altercations
Tx of septal hematomas?
- drain and pack
- abxs (augmentin) - if abscess suspected IV clindamycin and admission
- cartilage fracture: can result in formation of bilateral hematomas
Complications from not draining a septal hematoma?
- saddle nose deformity
- septal perforation
- septal abscess: may spread to paranasal and intracranial structures resulting in intracranial abscess, orbital cellulitis, cavernous sinous thrombosis
Nasal fracture:
dx, what to look for on PE?
- most commonly fractured bone in the face
- dx usually based on PE
- nose usually edematous and tender
- look for displacement, crepitus, and epistaxis
- inspection with nasal speculum mandatory to rule out septal hematoma
- manage (closed reduction) 2-10 days post injury to allow for reduction of swelling
In an ENT trauma - what should you look for in and around the ears?
- auricular hematoma
- hemotympanum
- battle sign
What is auricular hematoma?
Tx?
- direct trauma to auricle
- caused by separation of cartilage from perichondrium resulting in avascular necrosis
- drain within 7 days, compression dressing, daily follow up for few days, abx to cover staph
Etiologies of cauliflower ear?
- failure to drain hematoma
- stimulation of cartilage growth
- laceration through cartilage
- infection
- high piercings
- prevention with protective head gear for wrestling, boxing, rugby, and martial arts is key
Tx of ear laceration?
- can do single layer closure through skin and perichondrium but not cartilage (risk of hyperstim. cartilage)
- pressure dressing to prevent hematoma
- close f/u
- can use posterior auricular block for anesthesia
Findings of middle ear injury?
- hemotympanum
- amber or clear middle ear effusion
- otorrhea (clear or bloody ear canal drainage)
- hearing deficit by Weber and rinne tuning fork tests
- nystagmus
- ataxia
- retroauricular hematoma (battle sign)
- facial nerve deficit may be sign of basilar skull fracture or assoc with middle ear injury
Basilar skull fracures - what bones are involved?
- can be secondary to fracture in temporal, occipital, sphenoid, or ethmoid bones
- temporal bone: involved in 75% of basilar skull fractures
What is a hemotympanum indicative of?
- basilar skull fracture and middle ear injury
What is Battle sign indicative of?
- basilar skull fracture
- occurs 6-12 hrs after injury
Ottorhea - examination?
- eval for blood or CSF
- may have hemorrhagic ottorhea from TM rupture or other middle ear injury
- leave penetrating fbs there until further eval with imaging
- leave clots in EAC if other signs of middle ear injury (ENT to eval)
- eval for further injury - skull fracture
What would you look for in trauma pt while doing the oral and mandibular exam?
- mandibular deviation, malocclusion of teeth, paresthesia, tongue blade test
Eval of mandibular fracture?
- 2nd most common facial fracture
- eval the bite - tongue blade test
- tooth fractures or avulsions
- look for trauma of tongue and sublingual ecchymosis
Management and workup of mandibular fracture?
- management: airway management, hemostasis, surgical consult
- workup: hx, PE, xray, or CT scan
First thing you need to do with pt that has blunt trauma to the neck?
- pt may deteriorate rapidly: leading to impending airway obstruction
- first thing - determine if airway and pt are stable or unstable!
Most common etiologies of blunt trauma to neck?
- MVA
- sports
- GSW
- assault
- bicycle
mechanism of injury: forward thrust
(in MVA - seat belts and air bags decrease incidence)
Initial eval of pt with blunt trauma to neck
- ATLS principles
- intubation hazardous
- respiratory distress: tracheotomy under local anesthesia
- avoid cricothyroidotomies: worsen injury
- if no acute breathing difficulties: get detailed hx and careful PE
History ?s in dx laryngeal injury?
- change in voice
- pain
- dyspnea
- dysphagia
- odynophagia
- hemoptysis
- inability to tolerate the supine position
PE for dx laryngeal injury?
- RR
- stridor
- neck skin: contusions, abrasions, or line pattern
- subq emphysema
- tracheal deviation
- open wound: air bubbles (tracheal disruption), exposed tracheal cartilage
- don’t probe open wounds: may dislodge a hematoma
Dx laryngeal injury - studies?
- unstable: tracheotomy and neck exploration
- stable pts: flexible fiberoptic laryngoscopy in ER
CT scan, direct laryngoscopy, bronchoscopy, and esophagoscopy
Medical management for laryngeal injury?
- min of 24 hr close observation
- head of bed elevation
- voice rest
- anti-reflux meds
- serial flexible fiberoptic exams
- abxs for laryngeal mucosa disruption
When a pt that has suspected laryngeal trauma is exhibiting respiratory distress what should be performed?
- tracheotomy
- anticipate and calle ENT or surgeon
Sxs, dx, and tx of nasal fb?
- sxs: unilateral rhinitis, foul odor, epistaxis, pain
- dx: direct visualization (nasal speculum or rhinos copy) or Xray
- tx: remove with forceps or suction
Most common sites for epistaxis?
- most common site of bleeding is in the anterior portion: kiesselbach’s plexus
- posterior bleeds tend to be more severe and harder to tx: sphenopalatine artery
Underlying causes of epistaxis?
- local: trauma, epistaxis digitorum, fbs, meds, vascular malformation, chronic sinusitis, neoplasm, polyps, irritants
- systemic: hemophilia, htn, leukemia, liver disease, **anticoagulants, blood dyscrasias
Initial management of epistaxis?
- have pts blow nose to clear clots
- spray with topical vasoconstrictor like Afrin (oxymetazoline)
- lean forward and pinch the nares together for at least 20 min continuously
- examine nose with nasal speculum to locate site of bleeding
Anterior vs posterior bleeding?
- big deal b/c txs diff
- difficult to tell but most bleeds are anterior (visual inspection of nares is mandatory)
- may need to pack anterior then examine pt to look for continued brisk bleeding then it is most likely posterior
Next steps of tx anterior nasal bleed if pinching nares didn’t work
- cautery - silver nitrate sticks
- if this doesn’t work - place packing or nasal tampon
- leave in place for 48 hrs
- f/u reqd in 24-48 hrs
- necrosis may occur if packing too tight
Posterior packing?
- need to call ENT
- most of these pts are admitted to hospital
Complications of epistaxis?
- severe bleeding- shock could be from warfarin
- sinusitis, otitis media
- pressure necrosis from packing
- TSS
Auricular cellulitis? Etiologies?
who is at risk?
- most common etiology is S. aureus and pseudomonas
- painful
- diabetics at high risk
- difficult to tx due to poor blood supply
- inflammatory causes related to seronegative arthritis at times indistinguishable from infection usually ear lobe is spared
Etiology and tx of barotrauma?
- etiology: flying, diving, blast injuries - tx: supportive, keep ear dry, recheck in 4 weeks to determine if TM is healed audiometry eval
TM rupture - most common cause, tx?
- if assoc with vertigo or facial nerve deficit, immediate referral is indicated
- infection MC cause
tx:
-keep ear dry until TM is healed
-most heal spontaneously (recheck in 4 weeks) - abx drops: ofloxicin for 3-4 days, oral abx may be indicated as well
- gentamicin, neomycin sulfate, tobramycin CI b/c of ototoxicity
Etiology, and presentation of epiglottitis?
- H flu type B, strep pneumo, strep agalactiae, staph aureus, strep pyogenes, M cat
- presentation:
drooling, fever, hoarseness, difficulty swallowing, stridor
Eval and tx of epiglottitis?
- dx can be clinical, lateral neck xray may help support suspicion (thumb sign), think ahead call ENT or surgeon
- tx: emergent ENT referral (IV abx and possible intubation)
What is peritonsiallar abscess (Quincy)? What can be a complication?
- complication of tonsillitis
- can extend into deep neck structures and occlude the airway
- airway occlusion may be more pronounced in children due to smaller airway
Presentation of peritonsillar abscess?
- severe unilateral throat pain, fever, difficulty swallowing, hot potato voice, halitosis, neck pain, ear pain on affected side, HA and trismus
Management of peritonsillar abscess?
workup?
- supportive therapy: airway, fever, pain and hydration - work up: dx is mainly clinical \+/- lateral neck xray to rule out other causes, +/- CT scan with contrast - immediate ENT referral for IND - IV abxs (clindamycin)
What is a retropharyngeal abscess?
- deep tissue neck infection (usually strep of staph - rapid spread)
- serious and can be life threatening: asphyxia, spread of infection
Etiology of retropharyngeal abscess in children and adults?
- children: usually from lymph node that drains the head and neck
- adults: penetrating trauma (chicken bone), from an infection in mouth/teeth, lymph nodes that drain the head and neck
Signs and sxs of retropharyngeal abscess?
- fever
- dysphagia
- neck pain
- limitation of cervical motion
- cervical lymphadenopathy
- sore throat
- poor oral intake
- muffled voice
- respiratory distress
- stridor more likely in children
- inflammatory torticollis
Work up of retropharyngeal abscess?
- lateral soft tissue xray of neck during inspiration
- ct scan of neck is gold std!
Tx of retropharyngeal abscess?
- immediate ENT consult
-tx is surgical incision and drainage - IV hydration and IV abx to be started in ER: clindamycin adult dose 600-900 mg IV q 8 hrs
or
ampicillin sulbactam (unasyn) adult dose 1500-3000 mg q 6 hrs
Complications of retropharyngeal abscess?
- extension of infection into mediastinum: pleural or pericardial effusion
- upper airway asphyxia
- sudden rupture: aspiration pneumonia, widespread infection - sepsis
What is Ludwig’s angina? complications?
- infection of submandibular space (floor of mouth under tongue)
- rapidly progressive gangrenous cellulitis of soft tissues of neck and floor of mouth
- swelling of soft tissues and elevation of posterior development of tongue causes airway obstruction
- etiology: odontogenic 90% of cases (staph, strep, and bacteriodes)
Signs and sxs of ludwigs angina?
- dental pain, recent hx of dental procedures, neck swelling, neck pain, change in voice, difficulty swallowing, tongue swelling, dyspnea, tachypnea, stridor
- life threatening emergency
- PE:
bilateral submandibular swelling, protruding tongue (not good!)
Dx and tx of ludwigs angina?
- clinical dx: CT to determine degree of abscess
- tx: intubation, IND, broad spectrum abxs: combo of PCN, clindamycin, and metronidazole
FB aspiration? Tx?
- most common in less than 5 yos
- smaller objects aspirated
- larger objects swallowed
- laryngeal objects: airway emergency
- remove in controlled fashion
- laryngeal: ASAP
- bronchial same day as dx
- esophageal: variable
What is Pott’s puffy tumor?
workup?
- complication of frontal sinusitis or trauma
- most commonly in kids and teens
- osteomyelitis of frontal bone
- can lead to intracranial abscess or venous sinus thrombosis
- work up: CT
- immediate referral for surgical drainage, debridement, and IV abx
&th nerve palsy? (bells palsy)
hallmark?
etiologies?
tx?
- most cases idiopathic
- hallmark: sudden onset
- consider lyme disease in endemic areas
- HSV or herpes zoster may be cause
- 80% recover to normal or near normal fxn
- steroids +/- acyclovir
- rule out tumor
Facila cellulitis?
- involves deeper dermis and subq fat
- most common: strep and staph
- can progress rapidly
- tx with abx: bactrim, keflex
- f/u
- admit if RFs
Erysipelis?
- involves upper dermis and superficial lymphatics
- these lesions are raised above level of surrounding skin
- usually assoc with systemic sxs
- IV abxs for strep and staph
Complications of infections involving medial third of face?
- can be complicated by septic cavernous thrombosis, since veins in region are valveless
Denta; emergencies?
- pts present with acute dental pain from caries or fractures
- put avulsed teeth back in socket if possible
- little if any ED tx available other than analgesia
- abx if you suspect dental abscess
- apical dental blocks
- find local dentist and know referral procedures
