ENT EmergenciesENT Emergencies
Paul ChatrathPaul Chatrath
Consultant ENT SurgeonConsultant ENT SurgeonBarking Havering & Redbridge Hospitals NHS Barking Havering & Redbridge Hospitals NHS
TrustTrust
2121stst January 2009 January 2009
THE EARTHE EAR
Otitis Externa - FeaturesOtitis Externa - Features Discharge, pain, hearing loss, Discharge, pain, hearing loss,
itchingitching Commonest organisms:Commonest organisms:
S AureusS Aureus Ps AeruginosaPs Aeruginosa ProteusProteus
Predisposing factors:Predisposing factors: WaterWater Cotton budsCotton buds EczemaEczema
Treatment:Treatment: Topical antibioticsTopical antibiotics Aural toiletAural toilet AnalgesiaAnalgesia
Otitis Externa - VariantsOtitis Externa - Variants
Fungal Malignant OE- Diabetes- VII palsy
Malignant Otitis ExternaMalignant Otitis Externa
Risk factor – DiabetesRisk factor – Diabetes Granulomatous polypoid otitis externaGranulomatous polypoid otitis externa Disproportionately severe painDisproportionately severe pain Associated features:Associated features:
Cranial nerve involvement – VII, IX, X, XI, XIICranial nerve involvement – VII, IX, X, XI, XII Treatment:Treatment:
Topical antibiotics and aural toiletTopical antibiotics and aural toilet i.v. antibiotics > 6/52i.v. antibiotics > 6/52 Hyperbaric oxygenHyperbaric oxygen
Otitis Externa – when to Otitis Externa – when to referrefer
Refer if: Non responsive
Canal oedematous
Needs aural toilet
Suspicion of malignant OE
Acute Otitis MediaAcute Otitis Media
Rx : Systemic antibiotics
Analgesia
Decongestants
Symptoms:
Pain DischargeHearing loss Pain subsides
Acute Otitis MediaAcute Otitis Media
When to refer?:
• Failure of resolution
• Persistent discharge
• Complications• VII palsy• Mastoiditis
Acute MastoiditisAcute Mastoiditis
Rx : Systemic antibiotics
Analgesia
URGENT REFERRAL
Features
Recent URTIEar dischargeBlunting of postaural sulcusFluctuant tender swellingFever
Perichondrial HaematomaPerichondrial Haematoma
Rx : Systemic antibiotics
Analgesia
URGENT REFERRAL for incision & drainage
Perichondrial CellulitisPerichondrial Cellulitis
Rx : Systemic antibiotics
Analgesia
REFERRAL to ENT if no response after 24hr
Cauliflower EarCauliflower Ear
Bead in earBead in ear
Rx : one attempt at removal only.
Try syringing with warm water
Do not use forceps for round objects
Non urgent ENT referral
Insect in EarInsect in Ear
Rx : Kill insect with olive oil
Then try syringing with warm water
Urgent ENT referral
Bloody OtorrhoeaBloody Otorrhoea
CausesCauses Otitis externa/mediaOtitis externa/media Trauma (local)Trauma (local) Trauma (head injury)Trauma (head injury) PostoperativePostoperative
Skull Base FractureSkull Base Fracture
Rx : Do not examine ears with an auriscope.
Admit under the head injury team
Non urgent ENT referral
Unless VII Palsy – ENT EMERGENCY
Case: Facial PalsyCase: Facial Palsy
65yr old female65yr old female 3/52 history right facial 3/52 history right facial
weaknessweakness What are the key points What are the key points
that must be established that must be established in your clinical approach?in your clinical approach?
Case: Facial PalsyCase: Facial Palsy
Key pointsKey points Establish whether Establish whether
UMNUMN or or LMNLMN
Try and find a Try and find a causecause
Forehead sparing = UMN
Thorough examination
Facial nerve palsy - causesFacial nerve palsy - causes
UMN (forehead sparing): CVA, MS, CaUMN (forehead sparing): CVA, MS, Ca LMN (complete):LMN (complete):
IntracranialAcoustic neuromaG-BarreTBNeurosarcoidGlomus tumourLyme disease
IntratemporalTraumaAcute otitis mediaMalignant otitis externaRamsey-Hunt syndromeSCCCholesteatoma
ExtracranialTraumaMalignant parotid tumour
Idiopathic = Bell’s Palsy
Facial Nerve Palsy (Bell’s)Facial Nerve Palsy (Bell’s)
Rx : Prednisolone 30mg
Acyclovir 200mg 5x/day
Hypermellose eye drops
Lacrilube ointment
Red bulging ear drum = URGENT ENT review
If not, Non urgent ENT review
If poor eye closure = Ophthalmology review
THE NOSETHE NOSE
Nasal FractureNasal Fracture
Rx : Exclude other max-fax fractures
Exclude CSF rhinorrhoea
Analgesia
Refer if: Obvious deformity (5-7 days)
Septal Haematoma
(URGENT)
Septal HaematomaSeptal Haematoma
Normal Inferior TurbinateNormal Inferior Turbinate
SeptumIT
EpistaxisEpistaxis
Little’s AreaLittle’s Area
EpistaxisEpistaxis Children: Recurrent self limiting bleedsChildren: Recurrent self limiting bleeds
Risk factors – URTIs, digital traumaRisk factors – URTIs, digital trauma Adults:Adults:
TraumaticTraumatic Anterior bleedAnterior bleed
Little’s areaLittle’s area Recurrent, self-limitingRecurrent, self-limiting
Posterior bleedPosterior bleed ElderlyElderly Medical comorbidities (hypertension, aspirin, Medical comorbidities (hypertension, aspirin,
warfarin)warfarin) More severeMore severe AdmissionAdmission
EpistaxisEpistaxis
Rx : RESUSCITATE
FBC, G&S, Clotting
Local pressure
(Cautery)
Nasal Packing
Nasal PackingNasal Packing
BIPP
MerocelTM
Rapid RhinoTM
How NOT to pack a nose!!!How NOT to pack a nose!!!
Foreign Body in NoseForeign Body in Nose
Rx : one attempt at removal only.
Do not use forceps for round objects
Urgent ENT referral
Orbital cellulitis – Chandler’s Orbital cellulitis – Chandler’s classificationclassification
Grade 1 Periorbital cellulitis (preseptal)
Grade 2 Orbital cellulitis (postseptal)
Grade 3 Subperiosteal abscess
Grade 4 Intraorbital abscess
Grade 5 Cavernous sinus thrombosis
Subperiosteal abscess – Subperiosteal abscess – Chandler’s grade 3Chandler’s grade 3
Orbital CellulitisOrbital Cellulitis
Rx : Systemic antibiotics
Decongestants
Analgesia
URGENT ENT referral
URGENT EYE referral
URGENT CT sinuses
THE THROATTHE THROAT
Normal tonsilsNormal tonsils
Acute tonsillitisAcute tonsillitis
TonsillitisTonsillitis
Rx : Penicillin V/ Metronidazole
Analgesia
FBC, Paul Bunnel, LFT
Refer if: Complete dysphagia
Quinsy
QuinsyQuinsy
Foreign body - throatForeign body - throat
Fish Bone in TonsilFish Bone in Tonsil
Fish Bones & XrayFish Bones & Xray
Very Opaque:
Cod, Haddock, Cole fish, Lemon sole, Gurnard
Moderate Opaque:
Grey Mullet, Plaice, Monkfish, Red Snapper
Not Opaque:
Herring (Kipper), Salmon, Mackerel, Trout, Pike
EpiglottitisEpiglottitis
EpiglottitisEpiglottitis
Children – life threateningChildren – life threatening Adults – supraglottitisAdults – supraglottitis SymptomsSymptoms
FeverFever Recent URTIRecent URTI Sitting forwards, droolingSitting forwards, drooling Sore throatSore throat Plummy voicePlummy voice DysphagiaDysphagia
Causative organism:Causative organism: Children: H Influenzae type BChildren: H Influenzae type B Adults: Broad range of Adults: Broad range of
respiratory pathogensrespiratory pathogens
Epiglottitis v CroupEpiglottitis v Croup
Epiglottitis Croup
Cause Bacterial ViralAge Any 1-5yrsObstruction Supraglottic SubglotticFever High Low gradeDysphagia Marked NoneDrooling Present MinimalPosture Sitting RecumbentToxaemia Mild to severe MildCough None Barking, brassyVoice Muffled HoarseRR Rapid RapidLaryngeal palpation Tender Not tenderClinical course Rapid resolution Longer resolution
StridorStridor
Rx : Oxygen
Adrenaline Nebulisers
Heliox
Steroids
Antibiotics
URGENT ENT Ref.
URGENT Anaesthetic Ref.
URGENT Paed. Ref.
Emergency Trachy??Emergency Trachy??
CricothyroidotomyCricothyroidotomy
ENT EmergenciesENT Emergencies
Paul ChatrathPaul ChatrathConsultant ENT SurgeonConsultant ENT SurgeonQueen’s/King George’s Queen’s/King George’s HospitalsHospitals
Any Questions?
Email:Email:[email protected]@bhrhospitals.nhs.uk
[email protected]@chatrath.com
