2.ent Emergencies

ENT Emergencies
Airway obstruction
• Stridor
- an indication airway calibre significantly
reduce
- noisy breath
- symptom not a disease
• Stertor
- low-pitched ,snoring type sound
generated at the level of the nasopharynx &
oropharynx
Characteristic of stridor
• Inspiratory
- Obstruction at or above vocal cords
• Expiratory
- Lower respiratory tract
• Biphasic
- Severe obstruction
-Obstruction at trachea or main bronchi
Grading of severity of airway obstruction
• Grade - 1 -
inspiratory stridor only
• Grade – 2 -
biphasic stridor
• Grade -3 -
biphasic with ↑ respiratory effort
• Grade – 4 -
cyanosis,↓ LOC
Stridor
• Allergy – Angioedema
• Inflammatory – epiglottitis, laryngitis
• Neoplasia – benign/ malignant
• Trauma – thermal, chemical, blunt, sharp,
iatrogenic, foreign body
Managment
• Immediately asses the severity of the
obstruction
• Establish emergency airway if require
• Supplement oxygen
• Further management depend on the cause of
the condition
Angioedema
 Presentation
 acute painless mucosal edema (face
tongue,lips and larynx)
 airway obstruction 20%
 Aetiology
 ACE inhibitor sensitivity most common
Treatment : aggressive
 Secure airway (obs, ET or intubation )
 D/C ACE inhibitor
 Steroid , antihistamine
Foreign bodies
Pharyngooesophagus
FOREIGN-BODY (FB) ASPIRATION
• Peak incidence age 1 to 3 years
– 90% of cases under age 4
• Most commonly foods or toys
– Foods- peanuts, grapes, and hot dogs
– Vegetable matter can cause intense pneumonitis
and subsequent pneumonia
– Toys/objects- typically small, smooth, and round
• In the pharynx , the commonest sites of
impaction
- tonsil & base of tongue account 50%
- valleculla and
priform fossa 5 %
• In the oesophagus
- most lodge at cricopharyngeus ( C5- C6)
- Aortic arch and left mainstem bronchus
• Signs & Symptoms
– Majority with abrupt onset of stridor or
respiratory distress or failure
– Classically, but not always, laryngotracheal FB
cause stridor and bronchial FB cause wheeze
– Some may be asymptomatic and normal P.E.
– FB should be suspected in unilateral wheeze
FOREIGN BODY
• What next if you cannot see it?
• Option 1 – refer
• Option 2 – X-ray. May/may not show the bone
• Option 3 – You are convinced the bone is still
impacted (feeling has not got better / has got
worse) - EUA
FOREIGN BODY
Patient has swallowed a fish bone which has stuck in
the throat
 What is the first step in management?
Get the patient to try and localise by pointing to where
they feel the bone. Try and see it
 What next if you can see it?
Spray throat with topical LA. Use an anaesthetic laryngoscope to
depress the tongue and a suitable forceps to try and grasp it and
remove it
What do you do if you cannot remove it?
Option 1 – refer
Option 2 - EUA and look for it and remove it
Foreign Body
This time the patient has swallowed a more substantial FB
(eg. Piece of bone/lump of half chewed meat) and it has stuck
in the throat
 Where would such a FB usually impact?
Cricopharyngeal sphincter. The next site for impaction is
the mid-third of the oesophagus behind the heart and after
that at the gastro-oesophageal junction
 What is a complication of oesophageal impaction of a FB?
Compression of the trachea from behind to cause

airway obstruction
 What is the slang name given to this when it happens?
A “Mac Attack” from gulping a Big-Mac hamburger
 What is the first Aids management when this occurs ?
Heimlich manoeuvre
Otological Emergencies
Facial nerve
Tympanic membrane Vestibule Cochlea
Pinna
Inner Ear
External auditory meatus Middle Ear

Acute Mastoiditis
• Definition: bacterial infection of the
mastoid air cells.
• It is always a complication of the untreated
or under-treated acute otitis media.
Acute Mastoiditis
ACUTE MASTOIDITIS
 What is the clinical featutre of mastoiditis

- History
. Recent URTI
. Ear pain & discharge
. History of treated AOM
- Physical Examination
. Post auricular swelling
. Mastoid tenderness
. Ear discharge & TM signs of infection
Acute OE/Mastoiditis
Acute OE/Furuncle Mastoiditis
No history of Acute OM History of Acute OM
Deafness: sometimes Deafness

Pain on moving auricle Pain on mastoid pressure
Normal TM TM: Signs of infection

Localised or diffuse canal Sagging of the post meatal
wall swelling wall, The pinna is protruded
forward and downward
CT scan: Normal Changes in middle ear,
mastoid
Treatment of Acute Mastoiditis
• Contact the ENT surgeon
1- Intravenous antibiotics
2- Patient may require Myringotomy
3- Drainage of the subperiosteal abscess
4- Cortical Mastoidectomy, if no improvement
after 24 hours
Acute Mastoiditis
A 18 month girl brought by his mother as she
was concern about left ear, which protruding
and started to displace downward. She also
notice a red swelling behind the ear
what is the differential diagnosis?
- mastoid lymphadenitis ( scalp infection )
- furunculosis of meatus
- acute mastoiditis
 The same child diagnosed acute mastoiditis.
what is three common micro-
organizm in acute mastoiditis?
- Gram –ve bacilli
- Pseudomonas,
- Proteus sp
- E-coli
 What are acute mastoidits complication?
- intracranial complication
- meningitis ,brain abscess , extradural abscess
and lateral sinus thrombosis
- extracranial complication
-facial nerve palsy, labryntitis ,Bezeloid abscess
and hearing loss
Foreign Body in the
Ear
Foreign body in the ear
• Common problem
• children at school age
• Adults: cotton wool
• Types
1- organic: seeds, pieces of papers
2- Non organic: beads, stone
3- Insects
Clinical Features
• Ear pain and discharge
• Deafness
• Otitis Externa if organic
• Asymptomatic inorganic
• OTOSCOPY easy to diagnose
FOREIGN BODY IN THE
EAR
• Dealing with foreign body
- Take a good history
. Nature
. Shape
. Size
- First attempt is likely to be the most
successful -
Remove organic FB within 24hrs -
Inorganic can be removed next day
Management
• Technique
- Syringing
. 90 % case sucussefull
. Avoid in organic substance
- Spirts kill insects
- Under Microscope
. Suction , Ear hook, Jobson probe
.
Childern under GA
when to referal to ENT?
- Attempt of removal felt
- Type of foreign body
. Batteries disc
. Spherical & Sharp edge
. Vegetable matters
- Patient profile
. Age < 4
. Agitated child
- Poorly visualized foreign body
Epistaxis: easy vs. difficult
EPISTAXIS (NOSE BLEEDS)
• IN CHILDREN
– Usually bleed from Little’s area (Ant. Bleed)
– May be associated with
• URTI
• Rhinitis (e.g. Hay fever)
• Nose picking (digital trauma)
• Foreign body (foul discharge)
NOSE BLEEDS IN ADULTS
• Adults:
– Anterior bleed
• Little’s area
• Recurrent,
• self-limiting
– Posterior bleed
• Elderly
• Medical comorbidities (hypertension, aspirin, warfarin)
• More severe than anterior bleed
• consider nasal packing if can’t stop it
• Remember ABC –call for help quickly
Little’s area- anterior bleed from septum
HOW TO STOP A NOSE BLEED
ACUTE MANAGEMENT
• Pinch soft part of nose

• Put head forward NOT back
• Avoid tissues
• Avoid nose blowing
What to do when the bleeding has
stopped?
• Examine Little’s area - ? Bleeding vessel
• Use lignocaine applied with a cotton bud
• Wait 5 mins
• Cauterise with a silver nitrate stick
• NEVER do both sides at one go
• If no bleeding vessel obvious try CHLORHEXIDINE

CREAM for 7 days
• If keeps bleeding ? Clotting abnormal (e.g. warfarin)

– Check bloods
Post packing management
• Analgesia
• Try only pack one nasal cavity
• Consider supplementary oxygen
• Bed rest
• Ref to ENT services
 15 year old boy. Frequent nose bleeds recently. Not
bleeding now. Prominent vessel on the anterior
septum
What type of epistaxis would you suspect?
“Easy” nose bleed
What is the First Aid management?
Pinch the nose

What is the definitive treatment?
Cautery of the offending vessel
How do you do this?

Topical local anaesthetic – apply silver
nitrate stick
 He comes back 2 weeks later. Still getting nose
bleeds. If anything they are worse.
What other symptoms should you ask about?
General - Anything suspicious of a bleeding tendency.
Specific – Because he is an adolescent male, blocked
nose. Why?
Angiofibroma is a tumour occurring at the back of
the nose specific to adolescent males
 What investigation is needed?
CT/MRI scan
 If a tumour is identified what investigation
is done prior to surgery and what will be
done during this investigation?
Angiogram with embolisation of the tumour
Foreign Body in Nose
 What would make you suspect a FB in the nose?
- unilateral nasal discharge
- nasal obstruction
 What options for removal of nasal foreign bodies ?
- Nose blowing
- Oral positive pressure
technique -
Instrumentation
- Balloon catheter
Complication of sinusitis
• Implies the adverse progression of acute

bacterial rhino-sinusitis
• Clinically -
local (orbital ) -
distant (intracranial ,septicaemia )
• The incidence decrease in developed
world ,unfortunately quiet common in South
Africa
• Condition predominant affects young adolescent
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
• Rx :
- Systemic antibiotics
- Decongestants
- Analgesia
• URGENT EYE referral
• URGENT CT sinuses
• URGENT ENT referral

2.ent Emergencies

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2.ent Emergencies

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ENT Emergencies

Compression of the trachea from behind to cause

Tympanic membrane Vestibule Cochlea

External auditory meatus Middle Ear

 What is the clinical featutre of mastoiditis

No history of Acute OM History of Acute OM

Deafness: sometimes Deafness

Normal TM TM: Signs of infection

• Pinch soft part of nose

• If no bleeding vessel obvious try CHLORHEXIDINE

• If keeps bleeding ? Clotting abnormal (e.g. warfarin)

Pinch the nose

Cautery of the offending vessel

How do you do this?

 What options for removal of nasal foreign bodies ?

• Implies the adverse progression of acute

Grade 1 Periorbital cellulitis (preseptal)

Grade 2 Orbital cellulitis (postseptal)

Grade 3 Subperiosteal abscess

Grade 4 Intraorbital abscess

Grade 5 Cavernous sinus thrombosis

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