Head and Neck Emergencies: Nosebleeds, Facial Palsy, Sinusitis, Cellulitis, Epiglottitis, Pharyngitis, Peritonsillar Abscess, Ludwig's Angina, Angiodema, Airway Obstruction

Question 1

Anterior vs posterior nosebleeds

• causes
• management
• prognosis

Answer 1

MOST COMMON = Anterior
ICA
-children, young adults
-trauma
-winter, allergies, irritants (cocaine, spray)

Less common = posterior
ECA
-older adults
-coagulopathy, atherosclerosis, neoplasm, HTN
Harder to control

Community - ABC
-sits, pinch nose, head forward, breathe through mouth, spit out blood, ice pack behind neck

Secondary care

• Analgesia, lower BP
• Evacuate clot
• Topical VC, anaesthetic
• cauterise with AgNO3 if you can see source
• pack with Rapid Rhino for 24hrs and admit

Hemorrhage
Resp failure
Sinusitis, OM

Question 2

Facial nerve palsy

• supply
• causes (LMN, UMN)
• management

Answer 2

Face - muscles of facial expression
Ear - nerve to stapedius
Taste - ant 2/3d
Tear - PNS to lacrimal, salivary

MOST COMMON - idiopathic
LMN - non forehead sparing
-Bells
-Ramsey Hunt
-acoustic neuroma
-parotid tumour

UMN
-stroke - forehead sparing

Treat underlying cause

Question 3

Sinusitis

• risk factors
• presentation
• management

Answer 3

Nasal obstruction
Recent local infection
Swimming/diving
Smoking

S pneumonia, Hibs, rhinovirus

Facial pain - frontal pressure worse bending forward
Nasal discharge, obstruction

Conservative - simple analgesia

• IN CS if symptoms persist
• PO ABx for severe presentations

Question 4

Cellulitis, ersipelas

• difference
• presentation
• management for facial/periorbital cellulitis

Answer 4

Cellulitis - skin + SC inflammation 
-S pyogenes, S aureus
Most commonly found on shins
Skin redness, swelling
Systemic upset if severe

Clinical diagnosis
Admit + IV ABx for facial/periorbital cellulitis
-mild/moderate - fluclox
-severe - coamox

Erysipelas - skin inflammation
-S pyogenes => fluclox

Question 5

Epiglottitis

• causative organism
• presentation
• diagnosis
• management

Answer 5

Hibs

• acute fever
• stridor, drooling, tripod

Diagnosis - direct visualisation
Xray - steeple, thumb sign

Immediate senior involvement

• intubation may be needed to protect airway
• O2, IV ABx, SC, adrenaline

Question 6

Peritonsillar abscess

• presentation, cause
• management

Answer 6

Complication of tonsilitis (S pyogenes)

• severe lateralising throat pain
• uvula deviation
• trismus, reduced neck mv

ENT review

Needle aspiration + IV ABx
-tonsillectomy to prevent recurrence if needed

Question 7

Ludwig’s Angina

• risk factors
• presentation
• investigations
• management

Answer 7

Dental infection/poor hygiene/elderly (S viridans, S epidermis, S aureus)

Infection of soft tissue under tongue => breathing, swallowing difficulties

• neck pain
• systemic upset
• drooping
• raised tongue

Clinical diagnosis
-blood culture to confirm organism

Secure airway => ICU
Abscess drainage + IV Abx

Question 8

Angioedema

• pathophysiology
• presentation
• management

Answer 8

Swelling under skin => life threatening if breathing affected

• hands, feet
• eyes, lips, tongue
• hives, abdo pain

Allergic reaction to
-food, ACEi
MOST ARE IDIOPATHIC

Self limiting within days
Allergic, idiopathic 
-avoid triggers
-antihistamines => CS => adrenaline
Drug induced
-stop causative medication
Hereditary
-prophylactic danazol/oxandrolone

Question 9

Airway obstruction

• presentation of partial and complete obstruction
• management

Answer 9

Partial
-stridor, wheeze, additional sounds

Complete
-unconscious, cardiac arrest

CORRECT OBSTRUCTION FIRST
Solids - cough, back blows, abdo thrusts
Liquids - suction
Lost muscle tone - head tilt, chin lift, jaw trust

Once airway is open but cannot ventilate => emergency tracheostomy

Question 10

Pharyngitis

• presentation
• management

Answer 10

Sore throat, runny nose, cough, headache
Swollen LN, hoarse voice

3-5days, often viral and sekf limiting
-use CENTOR

Question 11

Tonsilitis

• presentation
• management

Answer 11

Sore throat, difficulty swallowing, fever
Swollen tonsils, can be purulent

GAS - most common

IV paracetamol/dexmeth, fluid, ABx

Question 12

Centor score

• what is it
• interpretation

Answer 12

Criteria used to identify likelihood of GAS

C- cough absent
E- exudate
N-nodes
T-fever
OR-old or young modifier (U15 +1, 44+ -1)

0-2 - viral => analgesia, fluids
3-4 - ABx

Question 13

Retropharyngeal abscess

• presentation
• investigations
• management

Answer 13

U4 children
-pain, dysphagia, SOB, neck stiff, fever

Lateral neck Xray - swelling of ant neck

IV ABx
Drain if
-difficulty breathing
-large 
-symptoms don't improve on ABx

Complications - mediastinitis