ENT Emergencies THE EAR Perichondrial Haematoma Rx : Systemic antibiotics Analgesia URGENT REFERRAL for incision & drainage Cauliflower Ear Perichondrial Cellulitis Rx : Systemic antibiotics Analgesia REFERRAL to ENT if no response after 24hr Otitis Externa - Features Discharge, pain, hearing loss, itching Commonest organisms: Predisposing factors: S Aureus Ps Aeruginosa Proteus Water Cotton buds Eczema Treatment: Topical antibiotics Aural toilet Analgesia Otitis Externa - Variants Fungal Malignant OE - Diabetes - VII palsy Malignant Otitis Externa Risk factor – Diabetes Granulomatous polypoid otitis externa Disproportionately severe pain Associated features: Cranial nerve involvement – VII, IX, X, XI, XII Treatment: Topical antibiotics and aural toilet i.v. antibiotics 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 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 Causes 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 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 Try and find a cause Forehead sparing = UMN Thorough examination Facial nerve palsy - causes 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 Children: Recurrent self limiting bleeds Risk factors – URTIs, digital trauma Adults: Traumatic Anterior bleed Little’s area Recurrent, self-limiting Posterior bleed 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 Children – life threatening Adults – supraglottitis Symptoms Fever Recent URTI Sitting forwards, drooling Sore throat Plummy voice Dysphagia Causative organism: 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?