ENT Emergencies
Paul Chatrath
Consultant ENT Surgeon
Barking Havering & Redbridge Hospitals NHS Trust
21st January 2009
THE EAR
Otitis Externa - Features
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Discharge, pain, hearing loss,
itching
Commonest organisms:
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Predisposing factors:
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S Aureus
Ps Aeruginosa
Proteus
Water
Cotton buds
Eczema
Treatment:
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Topical antibiotics
Aural toilet
Analgesia
Otitis Externa - Variants
Fungal
Malignant OE
- Diabetes
- VII palsy
Malignant Otitis Externa
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Risk factor – Diabetes
Granulomatous polypoid otitis externa
Disproportionately severe pain
Associated features:
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Cranial nerve involvement – VII, IX, X, XI, XII
Treatment:
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Topical antibiotics and aural toilet
i.v. antibiotics > 6/52
Hyperbaric oxygen
Otitis Externa – when to refer
Refer if: Non responsive
Canal oedematous
Needs aural toilet
Suspicion of malignant OE
Acute Otitis Media
Symptoms:
Pain
Hearing loss
Rx :
Discharge
Pain subsides
Systemic antibiotics
Analgesia
Decongestants
Acute Otitis Media
When to refer?:
•
Failure of resolution
• Persistent discharge
• Complications
• VII palsy
• Mastoiditis
Acute Mastoiditis
Features
Recent URTI
Ear discharge
Blunting of postaural sulcus
Fluctuant tender swelling
Fever
Rx : Systemic antibiotics
Analgesia
URGENT REFERRAL
Perichondrial Haematoma
Rx :
Systemic antibiotics
Analgesia
URGENT REFERRAL for
incision & drainage
Perichondrial Cellulitis
Rx :
Systemic antibiotics
Analgesia
REFERRAL to ENT if no
response after 24hr
Cauliflower Ear
Bead 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 Ear
Rx :
Kill insect with
olive oil
Then try syringing with
warm water
Urgent ENT referral
Bloody Otorrhoea
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Causes
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Otitis externa/media
Trauma (local)
Trauma (head injury)
Postoperative
Skull 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 Palsy
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65yr old female
3/52 history right
facial weakness
What are the key
points that must be
established in your
clinical approach?
Case: Facial Palsy
Key points
 Establish whether
UMN or LMN
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Try and find a cause
Forehead sparing = UMN
Thorough examination
Facial nerve palsy - causes
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UMN (forehead sparing): CVA, MS, Ca
LMN (complete):
Intracranial
Intratemporal
Extracranial
Acoustic neuroma
G-Barre
TB
Neurosarcoid
Glomus tumour
Lyme disease
Trauma
Acute otitis media
Malignant otitis externa
Ramsey-Hunt syndrome
SCC
Cholesteatoma
Trauma
Malignant parotid tumour
Idiopathic = Bell’s Palsy
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 NOSE
Nasal Fracture
Rx :
Exclude other max-fax
fractures
Exclude CSF rhinorrhoea
Analgesia
Refer if: Obvious deformity
(5-7 days)
Septal Haematoma
(URGENT)
Septal Haematoma
Normal Inferior Turbinate
IT
Septum
Epistaxis
Little’s Area
Epistaxis
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Children: Recurrent self limiting bleeds
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Risk factors – URTIs, digital trauma
Adults:
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Traumatic
Anterior bleed
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Little’s area
Recurrent, self-limiting
Posterior bleed
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Elderly
Medical comorbidities (hypertension, aspirin, warfarin)
More severe
Admission
Epistaxis
Rx :
RESUSCITATE
FBC, G&S, Clotting
Local pressure
(Cautery)
Nasal Packing
Nasal Packing
BIPP
MerocelTM
Rapid RhinoTM
How NOT to pack a nose!!!
Foreign Body in Nose
Rx :
one attempt at removal
only.
Do not use forceps for round
objects
Urgent ENT referral
Orbital cellulitis – Chandler’s
classification
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 –
Chandler’s grade 3
Orbital Cellulitis
Rx :
Systemic antibiotics
Decongestants
Analgesia
URGENT ENT referral
URGENT EYE referral
URGENT CT sinuses
THE THROAT
Normal tonsils
Acute tonsillitis
Tonsillitis
Rx :
Penicillin V/ Metronidazole
Analgesia
FBC, Paul Bunnel, LFT
Refer if: Complete dysphagia
Quinsy
Quinsy
Foreign body - throat
Fish Bone in Tonsil
Fish 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
Epiglottitis
Epiglottitis
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Children – life threatening
Adults – supraglottitis
Symptoms
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Fever
Recent URTI
Sitting forwards, drooling
Sore throat
Plummy voice
Dysphagia
Causative organism:
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Children: H Influenzae type B
Adults: Broad range of respiratory
pathogens
Epiglottitis v Croup
Cause
Age
Obstruction
Fever
Dysphagia
Drooling
Posture
Toxaemia
Cough
Voice
RR
Laryngeal palpation
Clinical course
Epiglottitis
Croup
Bacterial
Any
Supraglottic
High
Marked
Present
Sitting
Mild to severe
None
Muffled
Rapid
Tender
Rapid resolution
Viral
1-5yrs
Subglottic
Low grade
None
Minimal
Recumbent
Mild
Barking, brassy
Hoarse
Rapid
Not tender
Longer resolution
Stridor
Rx :
Oxygen
Adrenaline Nebulisers
Heliox
Steroids
Antibiotics
URGENT ENT Ref.
URGENT Anaesthetic Ref.
URGENT Paed. Ref.
Emergency Trachy??
Cricothyroidotomy
ENT Emergencies
Any Questions?
Paul Chatrath
Consultant ENT Surgeon
Queen’s/King George’s Hospitals
Email:
paul.chatrath@bhrhospitals.nhs.uk
paul@chatrath.com