RCSI Royal College of Surgeons in Ireland Coliste Roga na Minle in irinn

ENT Emergency
James Paul ONeill
Professor of Otolaryngology, Head and Neck Surgery
Importance of History & Exam

History- presentation of historical findings in the correct

order with absolute confidence !

Exam- from inspection to physical exam.

Become the Doctor you always wanted to be.

THE THROAT
Normal tonsils
Acute Tonsillitis
Tonsillitis

Rx : Penicillin V/ Metronidazole
Analgesia
FBC, Paul Bunnel, LFT

Refer if: Complete dysphagia

Quinsy
Quinsy

What is wrong with

this clinical cartoon ?
Foreign Body
Foreign body - throat
Epiglottis- Swallowing
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
Epiglottitis Croup

Cause Bacterial Viral

Age Any 1-5yrs
Obstruction Supraglottic Subglottic
Fever High Low grade
Dysphagia Marked None
Drooling Present Minimal
Posture Sitting Recumbent
Toxaemia Mild to severe Mild
Cough None Barking, brassy
Voice Muffled Hoarse
RR Rapid Rapid
Laryngeal palpation Tender Not tender
Clinical course Rapid resolution Longer resolution
Stridor

Rx : Oxygen
Adrenaline Nebulisers
Heliox
Steroids
Antibiotics

URGENT ENT Ref.

URGENT Anaesthetic Ref.
URGENT Paed. Ref.
Cricothyroidotomy
THE NOSE
Nasal Fracture Rx : Exclude other max-fax
fractures
Exclude CSF rhinorrhoea
Analgesia

Refer if: Obvious deformity

(5-7 days)
Septal Haematoma
(URGENT)
Nasal Septum
Septal Haematoma
 Littles Area // Kiesselbachs Plexus

Anterior ethmoidal artery

..from the ophthalmic artery

Sphenopalatine artery
..terminal branch of the maxillary artery

Greater palatine artery

..from the maxillary artery

Septal branch of the superior labial artery

..from the facial artery
Epistaxis
Epistaxis

Children: Recurrent self limiting bleeds

Risk factors URTIs, digital trauma
Adults:
Traumatic
Anterior bleed
Littles 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 Chandlers 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
Chandlers grade 3
Orbital Cellulitis

Rx : Systemic antibiotics
Decongestants
Analgesia

URGENT ENT referral

URGENT EYE referral
URGENT CT sinuses
THE EAR
 Otitis Externa - Features
Discharge, pain, hearing loss,
itching
Commonest organisms:
S Aureus
Ps Aeruginosa
Proteus
Predisposing factors:
Water
Cotton buds
Eczema
Treatment:
Topical antibiotics
Aural toilet
Analgesia
Otitis Externa - Variants

Malignant OE
Fungal - 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 > 6/52
Otitis Externa when to refer

Refer if: Non responsive

Canal oedematous
Needs aural toilet
Suspicion of malignant OE
Acute Otitis Media

Symptoms:

Pain Discharge
Hearing loss Pain subsides

Rx : 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

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 Forehead sparing = UMN
or LMN

Try and find a cause Thorough examination

Facial nerve palsy - causes

UMN (forehead sparing): CVA, MS, Ca

LMN (complete):

Intracranial Intratemporal Extracranial

Acoustic neuroma Trauma Trauma
G-Barre Acute otitis media Malignant parotid tumour
TB Malignant otitis externa
Neurosarcoid Ramsey-Hunt syndrome
Glomus tumour SCC
Lyme disease Cholesteatoma

Idiopathic = Bells Palsy

Facial Nerve Palsy (Bells)

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