Post on 16-Aug-2019
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Emergencies in ENTEmergencies in ENT
Mr. Guillermo Hurtado Mr. Guillermo Hurtado
B.Med, ORLB.Med, ORL (Hons), FRACS(Hons), FRACS
Ear, Nose andEar, Nose and Throat, Head and NeckThroat, Head and Neck SurgeonSurgeon
Epworth Richmond Private HospitalEpworth Richmond Private Hospital
1818thth March 2015March 2015
Epworth Healthcare
General Practitioner’s Education Session
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Emergencies in ENTEmergencies in ENT
Bleeding EmergenciesBleeding Emergencies
Epistaxis Epistaxis
Post tonsillectomy hemorrhagePost tonsillectomy hemorrhage
Foreign Body emergenciesForeign Body emergencies
EarEar
AirwayAirway
33
EpistaxisEpistaxis
INTRODUCTIONINTRODUCTION
Very common emergencyVery common emergency
1010--12% of the population 12% of the population
•• Only 10% seek medical Only 10% seek medical attentionattention
•• Only 1.6% require admissionOnly 1.6% require admission
SeasonSeason
•• Temperature / humidityTemperature / humidity
Sex Sex
•• Equal distributionEqual distribution
Age Age
•• First 2 decadesFirst 2 decades Anterior and mild episodes Anterior and mild episodes
(90 % of epistaxis)(90 % of epistaxis)
•• > 50 yrs> 50 yrs Posterior and more severe Posterior and more severe
episodesepisodes
44
EpistaxisEpistaxis
INTRODUCTIONINTRODUCTION
Very common emergencyVery common emergency
1010--12% of the population 12% of the population
•• Only 10% seek medical Only 10% seek medical attentionattention
•• Only 1.6% require admissionOnly 1.6% require admission
SeasonSeason
•• Temperature / humidityTemperature / humidity
Sex Sex
•• Equal distributionEqual distribution
Age Age
•• First 2 decadesFirst 2 decades Anterior and mild episodes Anterior and mild episodes
(90 % of epistaxis)(90 % of epistaxis)
•• > 50 yrs> 50 yrs Posterior and more severe Posterior and more severe
episodesepisodes
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EpistaxisEpistaxis
ANATOMYANATOMY
Rich nasal irrigationRich nasal irrigation
Internal Carotid ArtInternal Carotid Art
•• Ethmoidal ArteriesEthmoidal Arteries
External Carotid ArtExternal Carotid Art
•• Facial ArteryFacial Artery
•• Internal Maxillary ArteryInternal Maxillary Artery
PlexusPlexus KiesselbachKiesselbach’’s plexuss plexus
WoodruffWoodruff’’s plexuss plexus
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EpistaxisEpistaxis
ANATOMYANATOMY
Rich nasal irrigationRich nasal irrigation
Internal Carotid ArtInternal Carotid Art
•• Ethmoidal ArteriesEthmoidal Arteries
External Carotid ArtExternal Carotid Art
•• Facial ArteryFacial Artery
•• Internal Maxillary ArteryInternal Maxillary Artery
PlexusPlexus KiesselbachKiesselbach’’s plexuss plexus
WoodruffWoodruff’’s plexuss plexus
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EpistaxisEpistaxis
ANATOMYANATOMY
Rich nasal irrigationRich nasal irrigation
Internal Carotid ArtInternal Carotid Art
•• Ethmoidal ArteriesEthmoidal Arteries
External Carotid ArtExternal Carotid Art
•• Facial ArteryFacial Artery
•• Internal Maxillary ArteryInternal Maxillary Artery
PlexusPlexus KiesselbachKiesselbach’’s plexuss plexus
WoodruffWoodruff’’s plexuss plexus
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EpistaxisEpistaxis
LOCAL CAUSESLOCAL CAUSES
TraumaTrauma
Digital / Fractures / Foreign bodyDigital / Fractures / Foreign body
Chemical irritation / desiccation / Chemical irritation / desiccation / atrophyatrophy
StructuralStructural
Septal perforationSeptal perforation
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EpistaxisEpistaxis
LOCAL CAUSESLOCAL CAUSES
Inflammatory diseaseInflammatory disease
Viral / bacterial infections Viral / bacterial infections
Granulomatous diseaseGranulomatous disease
Tumours / Vascular Tumours / Vascular malformationmalformation
Benign tumoursBenign tumours
•• Juvenile NasoJuvenile Naso--angiofibromaangiofibroma
•• Inverted papillomaInverted papilloma
Malignant tumoursMalignant tumours
•• SCC / AdenocarcinomaSCC / Adenocarcinoma
1010
EpistaxisEpistaxis
SYSTEMIC CAUSESSYSTEMIC CAUSES
CoagulopathyCoagulopathy
CongenitalCongenital
AcquiredAcquired
Anticoagulant drugsAnticoagulant drugs
Vascular diseaseVascular disease
ArteriosclerosisArteriosclerosis
CardiovascularCardiovascular
HTNHTN
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EpistaxisEpistaxis
DiagnosisDiagnosis Initial evaluationInitial evaluation
Hemodynamic stability Hemodynamic stability
Airway compromise Airway compromise
Airway/Breathing/CirculationAirway/Breathing/Circulation
ManagementManagement Control bleedingControl bleeding
•• Apply pressure Apply pressure
•• Definitive haemostasisDefinitive haemostasis
Intravenous resuscitationIntravenous resuscitation
Correct reversible / contributing Correct reversible / contributing factorsfactors
If possible, If possible, a complete history a complete history should be obtainedshould be obtained Side, amount, ant/post Sx?Side, amount, ant/post Sx?
Precipitants, previous tx, coPrecipitants, previous tx, co--morbidities, medicationsmorbidities, medications
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EpistaxisEpistaxis
Australasian Society of Thrombosis and Haemostasis
Warfarin reversal: consensus guidelines. 2004
DiagnosisDiagnosis Initial evaluationInitial evaluation
Hemodynamic stability Hemodynamic stability
Airway compromise Airway compromise
Airway/Breathing/CirculationAirway/Breathing/Circulation
ManagementManagement Control bleedingControl bleeding
•• Apply pressure Apply pressure
•• Definitive haemostasisDefinitive haemostasis
Intravenous resuscitationIntravenous resuscitation
Correct reversible / contributing Correct reversible / contributing factorsfactors
If possible take If possible take complete complete history history Side, amount, ant/post Sx?Side, amount, ant/post Sx?
Precipitants, previous tx, coPrecipitants, previous tx, co--morbidities, medicationsmorbidities, medications
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EpistaxisEpistaxis
Assessment Assessment EquipmentEquipment
Personal protectionPersonal protection
IlluminationIllumination
InstrumentsInstruments •• SpeculumSpeculum
•• ForcepsForceps
•• Rigid suction probesRigid suction probes
•• Cotton / PledgesCotton / Pledges
•• Vasoconstrictor / anaesthetic sprayVasoconstrictor / anaesthetic spray
•• Tongue depressorsTongue depressors
CauteryCautery •• Chemical / ElectricalChemical / Electrical
Packing materials Packing materials •• MerocelMerocel
•• Rapid RhinoRapid Rhino
•• Vaseline strip gauzeVaseline strip gauze
•• SurgicelSurgicel
EndoscopesEndoscopes
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EpistaxisEpistaxis
Assessment Assessment EquipmentEquipment
Personal protectionPersonal protection
IlluminationIllumination
InstrumentsInstruments •• SpeculumSpeculum
•• ForcepsForceps
•• Rigid suction probesRigid suction probes
•• Cotton / PledgesCotton / Pledges
•• Vasoconstrictor / Vasoconstrictor / anaestheticanaesthetic sprayspray
•• Tongue depressorsTongue depressors
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EpistaxisEpistaxis
Assessment Assessment EquipmentEquipment
Personal protectionPersonal protection
IlluminationIllumination
InstrumentsInstruments •• SpeculumSpeculum
•• ForcepsForceps
•• Rigid suction probesRigid suction probes
•• Cotton / PledgesCotton / Pledges
•• Vasoconstrictor / Vasoconstrictor / anaestheticanaesthetic sprayspray
•• Tongue depressorsTongue depressors
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EpistaxisEpistaxis
Assessment Assessment EquipmentEquipment
Personal protectionPersonal protection
IlluminationIllumination
InstrumentsInstruments •• SpeculumSpeculum
•• ForcepsForceps
•• Rigid suction probesRigid suction probes
•• Cotton / PledgesCotton / Pledges
•• Vasoconstrictor / Vasoconstrictor / anaestheticanaesthetic sprayspray
•• Tongue depressorsTongue depressors
1717
EpistaxisEpistaxis
Assessment Assessment EquipmentEquipment
CauteryCautery •• Chemical / ElectricalChemical / Electrical
Packing materials Packing materials •• MerocelMerocel
•• Rapid RhinoRapid Rhino
•• Vaseline strip gauzeVaseline strip gauze
•• SurgicelSurgicel
EndoscopesEndoscopes
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EpistaxisEpistaxis
Assessment Assessment EquipmentEquipment
CauteryCautery •• Chemical / ElectricalChemical / Electrical
Packing materials Packing materials •• MerocelMerocel
•• Rapid RhinoRapid Rhino
•• Vaseline strip gauzeVaseline strip gauze
•• SurgicelSurgicel
EndoscopesEndoscopes
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EpistaxisEpistaxis
Physical examinationPhysical examination
Nasal examinationNasal examination
•• Evacuate, anesthetise, Evacuate, anesthetise,
decongest and inspect decongest and inspect
anterior nasal cavityanterior nasal cavity
•• If bleeding: control bleeding If bleeding: control bleeding
with nasal packingwith nasal packing
•• If not bleeding and no site is If not bleeding and no site is
identified: refer for posterior identified: refer for posterior
nasal inspectionnasal inspection
LaboratoryLaboratory
FBE, coag screen, Group RHFBE, coag screen, Group RH
ImagingImaging
Clinically guidedClinically guided
2020
EpistaxisEpistaxis
TREATMENTTREATMENT
Medical management Medical management
Humidification, lubricationHumidification, lubrication
Cautery Cautery Silver nitrateSilver nitrate
•• Proper vasoconstrictionProper vasoconstriction
•• Target paused applicationsTarget paused applications
•• Unilateral Unilateral
•• Apply ointment immediately afterApply ointment immediately after
Endoscopic electrocautery Endoscopic electrocautery
•• Bi/MonopolarBi/Monopolar
Laser cauteryLaser cautery
•• KTP laserKTP laser
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EpistaxisEpistaxis
TREATMENTTREATMENT
Nasal packing Nasal packing
Anterior packAnterior pack
•• Vaseline gauzeVaseline gauze
•• Expandable packs Expandable packs
RapidRhino: hydrocolloid RapidRhino: hydrocolloid
(carboxymethylcellulose)(carboxymethylcellulose)
•• Platelet aggregator, lubricant, Platelet aggregator, lubricant,
clot preserved on removalclot preserved on removal
Merocel: (polyvinyl alcohol)Merocel: (polyvinyl alcohol)
Posterior packPosterior pack
•• Will require anterior packing Will require anterior packing
Nasal balloon Nasal balloon
•• Brighton balloon, simpson plug, Brighton balloon, simpson plug, epistat nasal catheterepistat nasal catheter
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EpistaxisEpistaxis
TREATMENTTREATMENT
Nasal packing Nasal packing
Anterior packAnterior pack
•• Vaseline gauzeVaseline gauze
•• Expandable packs Expandable packs
RapidRhino: hydrocolloid RapidRhino: hydrocolloid
(carboxymethylcellulose)(carboxymethylcellulose)
•• Platelet aggregator, lubricant, Platelet aggregator, lubricant,
clot preserved on removalclot preserved on removal
Merocel: (polyvinyl alcohol)Merocel: (polyvinyl alcohol)
Posterior packPosterior pack
•• Will require anterior packing Will require anterior packing
Nasal balloon Nasal balloon
•• Brighton balloon, simpson plug, Brighton balloon, simpson plug, epistat nasal catheterepistat nasal catheter
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COMPLICATIONSCOMPLICATIONS
ImmediateImmediate
•• Nasovagal reflex Nasovagal reflex –– hypotension and hypotension and bradycardiabradycardia
EarlyEarly
•• Persistent / recurrent bleedingPersistent / recurrent bleeding
•• Obstruction Obstruction
•• Nasolacrimal duct: epiphoraNasolacrimal duct: epiphora
•• OMC: sinusitisOMC: sinusitis
•• Nasal airway: hypoxia, OSANasal airway: hypoxia, OSA
•• Airway obstruction Airway obstruction
•• Toxic shock syndromeToxic shock syndrome
•• Staph aureus coverStaph aureus cover
LateLate
•• Nasal alae necrosis Nasal alae necrosis
EpistaxisEpistaxis
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EpistaxisEpistaxis
TREATMENTTREATMENT
Indications for surgical interventionIndications for surgical intervention
Uncontrollable bleedingUncontrollable bleeding
•• Failure of 1 Failure of 1 ––2 properly placed packs2 properly placed packs
Early intervention to reduce Early intervention to reduce
hospital stayhospital stay
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EpistaxisEpistaxis
TREATMENTTREATMENT
DiathermyDiathermy
Ligation Ligation
Endoscopic ligation of Endoscopic ligation of Sphenopalatine art Sphenopalatine art
Transantral ligation of the IMA Transantral ligation of the IMA
External ligation of the ethm arts.External ligation of the ethm arts.
External carotid artery ligationExternal carotid artery ligation
Other nasal surgeryOther nasal surgery
Septoplasty Septoplasty
Septal dermoplastySeptal dermoplasty
Intervention radiologyIntervention radiology
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DiathermyDiathermy
EndoscopicEndoscopic
TargetedTargeted
Bipolar preferable or low Bipolar preferable or low wattage monopolarwattage monopolar
Septal surgerySeptal surgery
AccessAccess
Correct spur or deviationCorrect spur or deviation
Septal dermoplasty for Septal dermoplasty for hereditary hemorrhagic hereditary hemorrhagic telangiectasiatelangiectasia
EpistaxisEpistaxis
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Sphenopalatine artery ligationSphenopalatine artery ligation Endoscopic dissection of Endoscopic dissection of
posterior portion of lateral nasal posterior portion of lateral nasal wallwall
SPA clipped or coagulatedSPA clipped or coagulated
Complications Complications PostPost--operativeoperative
•• EarlyEarly Palatal Palatal numbness 13% numbness 13%
•• LateLate Crusting Crusting 43%43%
Sinusitis 3%Sinusitis 3%
Septal Septal perforation 3%perforation 3%
OutcomesOutcomes Successful haemostasis in 80Successful haemostasis in 80--90% 90%
(small no. studies)(small no. studies)
EpistaxisEpistaxis
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Anterior/posterior ethmoidal Anterior/posterior ethmoidal artery ligationartery ligation
External ethmoidectomy External ethmoidectomy approach (Lynch incision)approach (Lynch incision)
Improve outcomes when Improve outcomes when combined with IMA ligation, combined with IMA ligation, SPA ligationSPA ligation
EpistaxisEpistaxis
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Maxillary artery ligationMaxillary artery ligation Rarely performedRarely performed
Modified CaldwellModified Caldwell--Luc Luc approach, through posterior approach, through posterior wall of maxillary sinus into wall of maxillary sinus into pterygopalatine fossapterygopalatine fossa
Vessel clipped or coagulatedVessel clipped or coagulated
87% effective87% effective
ComplicationsComplications
Infraorbital nerve injury, Infraorbital nerve injury, blindness, post operative blindness, post operative bleeding (15%), devitalised bleeding (15%), devitalised gums and teeth, sinusitis, gums and teeth, sinusitis, epiphoraepiphora
EpistaxisEpistaxis
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External carotid artery External carotid artery
ligationligation
Last resort in profound Last resort in profound
uncontrollable uncontrollable
haemorrhagehaemorrhage
LongLong--term failure rate 45%term failure rate 45%
•• Watershed areas supplied Watershed areas supplied
by contralateral external by contralateral external
carotidcarotid
EpistaxisEpistaxis
3131
Intervention radiologyIntervention radiology Embolisation with coils or Embolisation with coils or
gelfoamgelfoam •• AngiographyAngiography
•• Cannulation of external Cannulation of external carotidcarotid
•• Up to 87% effectiveUp to 87% effective
ComplicationsComplications •• BlindnessBlindness
•• Neurological deficit Neurological deficit
•• CVA CVA
•• False aneurysmFalse aneurysm
EpistaxisEpistaxis
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PostPost--tonsillectomy tonsillectomy
haemorrhagehaemorrhage CLASSIFICATIONCLASSIFICATION
PrimaryPrimary •• At time of surgeryAt time of surgery
•• ReactiveReactive First 6 hrs post opFirst 6 hrs post op
SecondarySecondary •• During recovery periodDuring recovery period
Very serious conditionVery serious condition Death riskDeath risk
ChildrenChildren •• Occult blood loss Occult blood loss
(swallowed)(swallowed)
•• Excellent autoregulationExcellent autoregulation Normal vital signs until Normal vital signs until
potentially fatal blood losspotentially fatal blood loss
3333
PostPost--tonsillectomy tonsillectomy
haemorrhagehaemorrhage TONSILS IRRIGATIONTONSILS IRRIGATION
Facial art.Facial art. Tonsillar branchTonsillar branch
Ascending palatine art.Ascending palatine art.
•• Tonsillar branchTonsillar branch
Lingual art. Lingual art. Dorsal lingualDorsal lingual
•• Tonsillar branchTonsillar branch
Ascending pharyngeal art. Ascending pharyngeal art. Tonsillar branchTonsillar branch
Intern Max art.Intern Max art. Lesser descending palatineLesser descending palatine
•• Tonsillar branchTonsillar branch
3434
PostPost--tonsillectomy tonsillectomy
haemorrhagehaemorrhage Ascending Pharyngeal a.
Lesser palantine a.
Tonsillar branch of
lesser palantine
Tonsillar branch of ascending
Pharyngeal a.
Tonsillar branch of facial a.
Tonsillar branch of
ascending palatine a.
Tonsillar branch of
dorsal lingual a.
TONSILS IRRIGATIONTONSILS IRRIGATION
Facial art.Facial art. Tonsillar branchTonsillar branch
Ascending palatine art.Ascending palatine art.
•• Tonsillar branchTonsillar branch
Lingual art. Lingual art. Dorsal lingualDorsal lingual
•• Tonsillar branchTonsillar branch
Ascending pharyngeal art. Ascending pharyngeal art. Tonsillar branchTonsillar branch
Intern Max art.Intern Max art. Lesser descending palatineLesser descending palatine
•• Tonsillar branchTonsillar branch
3535
SURGICAL TECHSURGICAL TECH
Cold steel vs diathermy Cold steel vs diathermy (O(O’’Leary & Vorrath 2005)Leary & Vorrath 2005)
Bleed rate 1.85% vs 2.35% Bleed rate 1.85% vs 2.35% (p<0.05)(p<0.05)
More reactive bleeds in More reactive bleeds in cold steel groupcold steel group
More secondary bleeds in More secondary bleeds in dissection group dissection group
•• Day 4Day 4--77
Bleeds > 500mL more Bleeds > 500mL more common in diathermy common in diathermy groupgroup
PostPost--tonsillectomy tonsillectomy
haemorrhagehaemorrhage
3636
DIAGNOSISDIAGNOSIS
Initial evaluationInitial evaluation
Hemodynamic stability and Hemodynamic stability and potential airway compromise potential airway compromise
Airway/Breathing/CirculationAirway/Breathing/Circulation
If possible, If possible, a complete a complete
history should be obtainedhistory should be obtained
Time of onset, how many days Time of onset, how many days post surgery, type of procedure, post surgery, type of procedure, type of bleeding (+/type of bleeding (+/-- epistaxis)epistaxis)
Amount of blood lossAmount of blood loss
MedicationsMedications
•• NSAIDNSAID’’s s
•• AnticoagulantsAnticoagulants
PostPost--tonsillectomy tonsillectomy
haemorrhagehaemorrhage
3737
ACTIVE BLEEDING ACTIVE BLEEDING MANAGEMENTMANAGEMENT
Intravenous resuscitationIntravenous resuscitation
•• Blood tests (FBE, coag), group and holdBlood tests (FBE, coag), group and hold
CALL ENTCALL ENT Control bleedingControl bleeding
•• Do not remove the clotsDo not remove the clots
•• May attempt with May attempt with
Ccophenylcaine soaked swab or H202 Ccophenylcaine soaked swab or H202
Correct reversible / contributing Correct reversible / contributing factorsfactors
Bleeding continues Bleeding continues OTOT
PostPost--tonsillectomy tonsillectomy
haemorrhagehaemorrhage
3838
INACTIVE MANAGEMENTINACTIVE MANAGEMENT
Do not remove the clotDo not remove the clot
REFER TO ENTREFER TO ENT
Bleeding stops Bleeding stops bed rest bed rest (admission), IV antibiotics, NBM(admission), IV antibiotics, NBM
Patient to be admitted for Patient to be admitted for observationobservation
PostPost--tonsillectomy tonsillectomy
haemorrhagehaemorrhage
3939
INACTIVE MANAGEMENTINACTIVE MANAGEMENT
Do not remove the clotDo not remove the clot
REFER TO ENTREFER TO ENT
Bleeding stops Bleeding stops bed rest bed rest (admission), IV antibiotics, NBM(admission), IV antibiotics, NBM
Patient to be admitted for Patient to be admitted for observationobservation
PostPost--tonsillectomy tonsillectomy
haemorrhagehaemorrhage
4040
Foreign Body in ENTForeign Body in ENT
EAREAR
SymptomsSymptoms
•• Hypoacusia, otalgia, Hypoacusia, otalgia, dischargedischarge
ClassificationClassification
•• Animated Animated vsvs InertInert
•• AnimatedAnimated EmergencyEmergency
•• Kill insect with Oil Kill insect with Oil
4141
Foreign Body in ENTForeign Body in ENT
EAREAR
SymptomsSymptoms
•• Hypoacusia, otalgia, Hypoacusia, otalgia, dischargedischarge
ClassificationClassification
•• InertInert UrgencyUrgency
•• Irrigation (NOT for Irrigation (NOT for seeds)seeds)
Removal under visionRemoval under vision
•• ONLY with proper ONLY with proper equipment, conditions equipment, conditions and trainingand training
DO not remove if there is DO not remove if there is already blood in EACalready blood in EAC
•• EUA under microscopeEUA under microscope
REFER TO ENTREFER TO ENT
4242
Foreign Body in ENTForeign Body in ENT
NOSENOSE •• Unilateral offensive Unilateral offensive
rinorrhearinorrhea/epistaxis/epistaxis
ManagementManagement •• Ask patient to blow noseAsk patient to blow nose
Can be further aspirated!Can be further aspirated!
•• Spray topic Spray topic anaesthanaesth//vasoconstricvasoconstric
•• Removal under visionRemoval under vision ONLY with proper equipment, ONLY with proper equipment,
conditions and trainingconditions and training
DO not remove if there is DO not remove if there is already blood in nostril or already blood in nostril or it is too deepit is too deep
•• Batteries need to come out Batteries need to come out fastfast
REFER TO ENTREFER TO ENT
4343
Foreign Body in ENTForeign Body in ENT
Upper airwayUpper airway PHARYNXPHARYNX •• HistoryHistory
Recent choking/gagging episode Recent choking/gagging episode while feedingwhile feeding
•• SymptomsSymptoms Odinophagia, globus a/dysphagia, Odinophagia, globus a/dysphagia,
sialorrheasialorrhea Localized pain, haemoptisisLocalized pain, haemoptisis
•• Airway compromiseAirway compromise Dyspnea, WOB, stridorDyspnea, WOB, stridor
•• IF complicatedIF complicated Fever, otalgia, torticolis, trismusFever, otalgia, torticolis, trismus Chest pain, tachypnea, tachycardia, Chest pain, tachypnea, tachycardia,
hypotensionhypotension
4444
Foreign Body in ENTForeign Body in ENT
Upper airwayUpper airway PHARYNXPHARYNX •• HistoryHistory
Recent choking/gagging episode Recent choking/gagging episode while feedingwhile feeding
•• SymptomsSymptoms Odinophagia, globus a/dysphagia, Odinophagia, globus a/dysphagia,
sialorrheasialorrhea Localized pain, haemoptisisLocalized pain, haemoptisis
•• Airway compromiseAirway compromise Dyspnea, WOB, stridorDyspnea, WOB, stridor
•• IF complicatedIF complicated Fever, otalgia, torticolis, trismusFever, otalgia, torticolis, trismus Chest pain, tachypnea, tachycardia, Chest pain, tachypnea, tachycardia,
hypotensionhypotension
4545
Foreign Body in ENTForeign Body in ENT
Upper airwayUpper airway
PHARYNXPHARYNX
ManagementManagement
•• Adequate inspectionAdequate inspection
•• Imaging may be necessaryImaging may be necessary
•• DO NOTDO NOT Rely on local anaesthetic effect. Rely on local anaesthetic effect.
Attempt blind removal from the Attempt blind removal from the
throat with a finger or instrumentthroat with a finger or instrument
•• Removal under visionRemoval under vision
ONLY with proper ONLY with proper
equipment, conditions and equipment, conditions and
trainingtraining
POTENTIAL AIRWAY POTENTIAL AIRWAY COMPROMISECOMPROMISE
REFER TO ENTREFER TO ENT
•• Keep NBM Keep NBM
x
4646
Foreign Body in ENTForeign Body in ENT
AirwayAirway Larynx / Trachea / BronchusLarynx / Trachea / Bronchus Challenging diagnosis and treatment Challenging diagnosis and treatment
A high index of suspicionA high index of suspicion
3000 deaths / year from foreign body 3000 deaths / year from foreign body
aspirationaspiration •• Most deaths occurring before hospitalMost deaths occurring before hospital
Treatment Treatment
Open approach Open approach Bronchotomy (1800Bronchotomy (1800’’s)s)
Endoscopic removal Endoscopic removal •• From 1897. From 1897. •• Chevalier Jackson developed rodChevalier Jackson developed rod--
lens telescope lens telescope •• Improvements in anesthetic Improvements in anesthetic
techniques made a safer techniques made a safer procedure.procedure.
4747
Foreign Body in ENTForeign Body in ENT
AirwayAirway Larynx / Trachea / BronchusLarynx / Trachea / Bronchus
FrequencyFrequency
Most of aspirations occur in children Most of aspirations occur in children 11--3 yrs. 3 yrs.
•• Predisposing factorsPredisposing factors
•• Lack of molars for grinding Lack of molars for grinding •• Lack coordination of swallowing and Lack coordination of swallowing and
glottic closureglottic closure •• They tend to be running or playing and They tend to be running or playing and
put objects in their mouth more put objects in their mouth more frequently.frequently.
Vegetable matter the most commonVegetable matter the most common SeedsSeeds
4848
Foreign Body in ENTForeign Body in ENT
AirwayAirway Larynx / Trachea / BronchusLarynx / Trachea / Bronchus
PathophysiologyPathophysiology
•• 8080--90% become lodged in the bronchi.90% become lodged in the bronchi.
•• In adults: Right main bronchus (lesser angle In adults: Right main bronchus (lesser angle
of convergence carina location left of the of convergence carina location left of the midline.midline.
•• Equal frequency of right and left bronchial Equal frequency of right and left bronchial foreign bodies in children.foreign bodies in children.
•• Larger objects tend to become lodged in the Larger objects tend to become lodged in the
larynx or trachealarynx or trachea..
4949
Foreign Body in ENTForeign Body in ENT
ImagingImaging
HighHigh--kilovolt AP and Lateral chest films kilovolt AP and Lateral chest films
Greater definition of the airway while reducing the Greater definition of the airway while reducing the effect of the surrounding bony structures.effect of the surrounding bony structures.
Radiopaque objects are visible, but Radiopaque objects are visible, but radiolucent objects (eg, plastic) are not.radiolucent objects (eg, plastic) are not.
Chest radiographs may reveal obstructive Chest radiographs may reveal obstructive emphysema or hyperinflation, atelectasis, emphysema or hyperinflation, atelectasis, and consolidation.and consolidation.
Lateral decubitus chest Lateral decubitus chest
•• In childrenIn children
•• Obstructed dependent lung remains Obstructed dependent lung remains inflatedinflated
Chest inspiratory and expiratory Chest inspiratory and expiratory radiographs radiographs
•• Atelectasis on inspiration and Atelectasis on inspiration and hyperinflation on expiration with a foreign hyperinflation on expiration with a foreign body obstructing the bronchus.body obstructing the bronchus.
..
5050
Foreign Body in ENTForeign Body in ENT
AirwayAirway
Laryngeal Foreign Bodies Laryngeal Foreign Bodies
•• Typically dysphonia and Typically dysphonia and stridor. stridor.
Can mimic CROUPCan mimic CROUP
•• Airway emergency that Airway emergency that requires lifesaving first aid requires lifesaving first aid before transport to the before transport to the hospital. hospital.
•• Partial obstruction Partial obstruction
Irregular foreign bodies Irregular foreign bodies
Sagittal orientationSagittal orientation
•• Laryngeal edema can lead to Laryngeal edema can lead to complete obstruction. complete obstruction.
5151
Foreign Body in ENTForeign Body in ENT
AirwayAirway
Tracheal Foreign Bodies Tracheal Foreign Bodies
•• Typically do not have Typically do not have hoarseness. hoarseness.
"asthmatoid wheeze," the "asthmatoid wheeze," the "audible slap"audible slap”” and the and the "palpable thud" over the "palpable thud" over the trachea.trachea.
As with laryngeal foreign As with laryngeal foreign bodies, edema can bodies, edema can progress to complete progress to complete obstruction.obstruction.
•• Stridor featuresStridor features Inspiratory / Expiratory Inspiratory / Expiratory
5252
Foreign Body in ENTForeign Body in ENT
AirwayAirway Bronchial FBBronchial FB
Initial phaseInitial phase •• At the moment of aspirationAt the moment of aspiration •• Choking, gagging, and paroxysms of Choking, gagging, and paroxysms of
coughing or airway obstruction coughing or airway obstruction
Asymptomatic phaseAsymptomatic phase •• FB lodged and reflexes fatigue. FB lodged and reflexes fatigue. •• Hours to weeks. Hours to weeks.
Third phase with complicationsThird phase with complications •• Obstruction, erosion, or infection Obstruction, erosion, or infection
causes hemoptysis, pneumonia, causes hemoptysis, pneumonia, atelectasis, abscess, or fever. atelectasis, abscess, or fever.
Sudden Sudden ““asthmaasthma”” onsetonset Persistent LRIPersistent LRI
5353
Foreign Body in ENTForeign Body in ENT
AirwayAirway Bronchial FBBronchial FB
CAREFUL history and examinationCAREFUL history and examination
Typical triadTypical triad •• Cough, unilateral wheezing, and Cough, unilateral wheezing, and
decreased breath sounds decreased breath sounds •• Only present in 65% of patientsOnly present in 65% of patients
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Foreign Body in ENTForeign Body in ENT
AirwayAirway
Esophageal foreign body Esophageal foreign body impaction impaction
•• Vomiting, odynophagia, Vomiting, odynophagia, dysphagia, and ptyalism.dysphagia, and ptyalism.
If the ingestion is witnessed, If the ingestion is witnessed, gagging or choking may be gagging or choking may be reported. reported.
A large foreign body may A large foreign body may cause symptoms of airway cause symptoms of airway obstruction and cough caused obstruction and cough caused by compression or irritation of by compression or irritation of the upper airway / left the upper airway / left bronchus.bronchus.
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Thanks for your attentionThanks for your attention