CRITICAL ENT!!
Roger Boles, M.D., Endowed Chair in Otolaryngology EducationDepartment of Otolaryngology-Head and Neck Surgery
University of California-San FranciscoSchool of Medicine
Andrew H. Murr, M.D. FACSProfessor of Clinical Otolaryngology
Chief of ServiceSan Francisco General Hospital
SINUSITIS
• 30 MILLION PATIENT VISITS PER YEAR• THE MOST COMMON CHRONIC
COMPLAINT FOR WHICH A PATIENT SEEKS ADVICE FROM A PHYSICIAN IN THE USA
• MULTI-BILLION $$$$$ PHARMACEUTICAL INDUSTRY
History
• Frequency, duration, past intervention, effectiveness of intervention
• Symptoms– Nasal congestion, facial pressure, PND, cough– Facial Pain~ relatively UNCOMMON!!!!– PMH: childhood sinusitis, immunocompromise,
triggering events (time of year)– PSH: sinus or nasal surgery, dental surgery– Medications: Beta blockers, BCP
HISTORY
COMMON• URI• “FLU”• SEASONAL ALLERGIC
RHINITIS• PERENNIAL ALLERGIC
RHINITIS• VASOMOTOR RHINITIS• BACTERIAL
RHINOSINUSITIS• PREGNANCY• SIDE EFFECT OF
MEDICATION• MIGRAINE• TOOTH ABSCESS
LESS COMMON• SARCOID• WEGENERS• T CELL LYMPHOMA• AML, ETC.• SAMTER’S• NASAL POLYPOSIS• FOREIGN BODY• IMMUNOCOMPROMISE• CYSTIC FIBROSIS• ALLERGIC FUNGAL
SINUSISTIS• CILIARY DYSKINESIA• ILLICIT SUBSTANCE USE
Document the Disease Process
• Acute Sinusitis– Less than 6 - 8 weeks of symptomatic infection
• OR– Less than 4 episodes/year 10 days duration
• AND– Complete resolution of mucosal abnormality
• Chronic Sinusitis– 8 weeks of symptomatic infection
• OR– 4 episodes per year 10 days duration
• AND– Mucosal disease on CT scan 4 weeks after Rx
Physical Examination
• Let there be light…• Nasal speculum
examination• Flexible
nasopharyngoscopy• Rigid 30 degree Hopkins
rod telescope
Approach to the patient
Acuteyes no
Rx abi Rx symptoms
improved not improved improved
stop CT scan appropriate management
Pt. presents with acute sinusitis and swollen eye. You should ….
A. S
ign out im
mediat
ely
B. P
rescri
be oral
antib
...
C. P
rescri
be IV
antib
i...
D. O
btain a
CT w
ith c.
..
E. Plai
n films a
re bes
t
1% 4% 1%
81%
13%
1. A. Sign out immediately2. B. Prescribe oral antibiotics3. C. Prescribe IV antibiotics4. D. Obtain a CT with contrast5. E. Plain films are best
DON’T FORGET YOUR ABC’S
• AIRWAY • BREATHING • CIRCULATION
– IV– H/H– Type and Cross– Platelet Count– History!!!
• Aspirin• Coumadin• Bruising• Family history
• We can not treat these patients differently just because they are bleeding from their nose!!
Pt. presents with a nosebleed, you should…
2%
97%
0%1%0%
1. A. Call an immediate ENT consult2. B. Begin an IV, T+C, H+H and ask Pt to blow their
nose3. C. Order a CT with contrast4. D. Call a GI consult5. E. Perform a tracheotomy
SURGICAL AIRWAY CONTROL
• PENETRATING TRAUMA• ANGIOEDEMA• OBSTRUCTING TUMOR
– LARYNGEAL SQUAMOUS CELL CARCINOMA• INFECTION
– LUDWIG’S ANGINA– EPIGLOTTITIS– DEEP NECK INFECTION
• SEPTIC SHOCK
SURGICAL CHOICES
• CRICOTHYROIDOTOMY– EASIER– MORE SUPERFICIAL – RELATIVELY
AVASCULAR– NO THYROID ISTHMUS
TO DEAL WITH
PROBLEMS WITH CRICOTHYROIDOTOMY
• ALL OF THE CONTRARY SEQUELAE OF INTUBATION!
– GRANULOMA– PARESIS– STENOSIS– CARTILAGE NECROSIS
• ACCEPTABLE FOR SHORT PERIODS
• ANY AIRWAY IS ACCEPTABLE
TRACHEOTOMY
• NO CONTRA-INDICATIONS
• ACCEPTABLE LONG TERM
• TUBE IS PRIMARILY DESIGNED FOR THIS PURPOSE
• SAME LEVEL OF DIFFICULTY
• THYROID ISTHMUS!
A surgical airway is required, you should….
81%
3%10%
0%6%
1. Perform a cricothyoidotomy and use a #5 ET tube2. Cut across the anterior jugular veins, then call a surgery consult3. Perform a tracheotomy4. Perform a cricothyroidotomy and use a #8 ET tube5. Try one more time to orally intubate the Pt.
The Nose
• Prominent facial feature– Direct line of sight
• Can give an impression of one’s personality– Tough guy– Self image– Confidence in appearance
• Ethnic characteristic• Airway!
Epidemiology of Nasal Fracture
• Male 2X female– Sports injury– Assault – Etoh
• 2nd and 3rd decade of life-peak
Anatomy
• Septum– Vomer
• Palatine bones• Maxilla
– Perpendicular plate of the ethmoid
– Quadrangular cartilage
Anatomy
• Nerve supply– V1
• Supratrochlear• Infratrochlear
– V2• Infraorbital
• Blood supply– Anterior ethmoid– IMA– Angular artery– Valveless veins
History
• Time, date, associated factors– MVA
• Restraints, airbags– Assault
• Subpoena- photos• Domestic violence
– 30 – 60% of women with facial trauma
– Substance abuse• Withdrawal issues
History
• Epistaxis– Blood loss- H/H, T&C
• Airway obstruction• Anosmia• Clear rhinorrhea• Numbness
– Incisors• Occlusion• Vision• Past nasal surgical history
Physical Examination
• ABC’s of trauma• NEC, ZMC, Le Fort,
Dentoalveolar, Mandible, Skull base!
• Dorsum– Assymmetry/Mobility
• Nasaolabial angle 90-110 degrees
– Periorbital ecchymosis, edema
• Middle and lower third
Septal Examination
• Equipment– Suction, speculum,
headlight, vasoconstrictor, anesthetic
– r/o Septal Hematoma
• Internal exam– 30 degree Hopkins rod– Flexible
nasopharyngoscope
• Brown-Gruss analysis– Upper, middle, and lower
thirds
Management
Trauma ABC’sAcute Management• Bleeding/Clots
– Vasoconstrictors• Afrin• Cocaine (4%)
– Packing- telfa, merocel, vaseline gauze with antibiotic ointment and oral antibiotic coverage
– Hemostatic agents• Avitene, gelfoam, topical
thrombin, floseal
Management
• Immediate v. Delayed reduction– Accurate reduction– Patient expectations and
psychology
• Timing of Delayed reduction– 7- 10 Days
Algorithm
Nasal TraumaStabilize
No deformity Deformity NOE
CRNF ORIF
F/UHigh Satisfaction Persisting Issues
NSR v. Open Septorhinoplasty
Sequelae
• Persisting or noticeable nasal deformity
• Nasal obstruction• Synechiae• Septal perforation• Sinusitis• Epiphora
CRNF
• Office v. O.R.• Tools of the Trade• Technical tips
– Gelfoam roll– Asch forceps– External splint– Telfa
NSR
Severe septal deviationDorsal deviation• Septoplasty• IC incisions• Deglove• UL separation• +/- osteotomies
Septorhinoplasty
• Extremely severe septaldeformity
• Septal perforation• Severe dorsal
deformity/grafting• Tip work• Open- grafting, tip work
Satisfaction
• 80% of patients will be satisfied with CRNF
• 10% of patients will request revision after Rhinoplasty
• Taking care of nasal trauma skillfully can be the best entre into a cosmetic practice
• Otologic conditions the ER staff will torture you with for no apparent reason
• Calls that you can blow off at 3am
Alternate Titles:
Case 1
• 10 yo Boy
• Slapped on Ear by Older Brother
• Intense ear pain, bleeding from canal, hearing loss
Dr. M. Green
Traumatic TM Perforation
• Conservative Management
• Antibiotic Ear Drops (eg Cipro)
• Dry Ear Precautions
• F/U with Audiogram
Case 3 • “Standing on a street corner, minding my own business”
• “I swear to God, doc, I didn’t do Nuthin’ to that @#!$$%^& SOB!”
• Assaulated to head w/ Baseball Bat
• Temporary LOC• Headache, bloody otorrhea,
hearing loss
Dr. Doug Ross
Longitudinal T-Bone Fx
• Common structures involved:– Tympanic Membrane– Roof of Middle Ear– Anterior Petrous Apex– Tympanic portion of FN most common
Case 4 • Next day, also minding own business on same corner, the SOB that hit the first guy is hit himself
• Headache, bloody otorrhea, hearing loss, facial nerve palsy, vertigo
Transverse T-Bone Fx
• Common structures involved:– traverse the otic capsule– May lead to deafness, vertigo, facial nerve palsy
T-Bone Fractures-Evaluation
• ABC’s• CN exam, esp Facial Nerve
– Unconscious pts-painful stimulus elicits grimmace
• Vestibular Eval, Vertigo (nystagmus?)• Hearing-Tuning Fork in ER• EAC Eval (usually bloody)• Otic Capsule “sparing” or “involvement”
T-Bone Fx’s-Evaluaton
• Radiology: CT > MRI• Audiogram• Vestibular Studies• FN Studies:
– Evoked EMG-– Direct Stimulation-MST-(Hilger nerve stim)
Indications for Surgical Intervention:– CSF Leak– Persistent PLF– Ossicular Disruption (late)– Non-healing TM Perf (late)– Secondary Cholesteatoma (late): Skin
implosion or canal stenosis
T-Bone Fx’s-Treatment
T-Bone Fx-Facial Nerve Surgery
Indications for Surgical Inervention:
Absolute
Immed FN Paralysis w/ radiograph evidence
Relative
Evoked EMG >95% degeneraton
No recovery after 4-12 months
Case 5
• 8 yo Boy fell while running around with Q-tip in ear
• Pain, Hearing Loss, bloody otorrhea
Nurse Hathaway
Case 6
• Scuba Diver• Had cold but went diving
anyway…• Intense pressure, pain on
descent• Now he is very dizzy and
cannot hear out one ear, and has an intense ringing.
Dr. Carter
Inner Ear Barotrauma
• “Alternobaric” Trauma– Transient vestib/auditory dysfunction
• “Barotrauma”– Extreme fluctuations in ME pressure, causing
labyrinthine concussion, membrane tears, oval or round window fisutae
• “Decompression Sickness”-the bends
Barotrauma-Treatment
• Bed Rest• Head elevation• Close monitoring of hearing and balance• Steroids?• Surgery for progressive HL or perisitent vertigo >
5 days• Avoid diving at least 3 months, forever if
permanent damage has resulted
Decompression Sickness
• Usually dives > 100 m• Formation of gas bubbles in body• Joint Pains and CNS findings present• Permanent auditory/vestibular injury• Rx-IMMEDIATE Recompression
Case 7
• 40 yo Woman• 3 Days s/p Cholesteatoma surgery
@ outside hosp.• Fevers, Headache, myalgias, ear
pain• Otorrhea
Dr. Benton
CSF Otorrhea
• Non-traumatic: Tumors, Congenital, Osteo• Traumatic: Trauma vs Surgical
• Dx:– “Halo” Sign, Glucose > 30mg/ml, ß-transferrin– CT-Metrizamide Scan, flourescein, MRI
CSF Otorrhea-Management
• Depends on location & etiology of leak• Decrease CSF Pressure
– Bed rest, HOB elevation, laxatives, diuretics, avoidance of noise-blowing, lifting, etc…
– Serial LP’s vs lumbar drain
• Surgery– Closure of dural defect, closure of bony defect
Facial Palsy-DDX
• Polyneuritis-– Bells, HZV, GB, Autoimm, Lyme, HIV, Kawasaki
• Trauma-– TB Fx, Barotrauma, Birth trauma
• Otitis Media- AOM, COM, Chole• Sarcoid• Melkersson-Rosenthal• Neurologic - HIV, CVA• Malignancy - parotid, metastatic• Benign Tumors - schwannoma, glomus
“Bell’s” Palsy
• Dx of Exclusion• Probable viral • Hyperacusis in 30%• MRI-when no recovery in 12 weeks• Rx-Steroids, ?antivirals, • Surgical decompression-controversial• Outcome-if incomplete: 95-100% recover
Case 9• Screaming 4 year
old• Painful Right Ear• Cochroach in canal
How do I get those ENTresidents to
NOTICE me?!?
Coalescent Mastoiditis + SS Thrombosis
• Emergent mastoidectomy• Myringotomy + Tube• IV Antibiotics
• Controversial: anticoagulation
Dr. Kovak
•65 year old man•Insulin Dependent Diabetic•Chronic external OE•Facial Nerve Palsy x 2 weeks
Case 11
From: Singh et al. Skull Base Osteomyelitis: Diagnostic and Therapeutic Challenges in Atypical Presentation. Otolaryngol HNS 2005 Jul;133(1):121-5.
Malignant Otitis Externa / Skull Base Osteomyelitis
• Immunocompromised or Diabetics• Dx = CT, MRI, Bone Scans• Follow resolution with
– Technetium scans = osteoblastic activity– Gallium 67 scans = granulocytic activity
• 6-8 weeks of IV antipseudomonal ABx
• Controversial: surgical debridement
Pt presents with ear trauma and TM perforation. You should…
3%
11%
22%
2%
62%
1. A. insist that the ENT on call come in immediately to operate on the Pt.
2. B. Reassure the Pt, make an appt to see the ENT in 1 week.3. C. Reassure the Pt. make an appt to see the ENT in 1 week with an
audiogram4. D.Place a hot poker in the ear canal5. E. Obtain a CT scan