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
Welcome to the Dept of ENT
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
Emergencies

Obstruction
Infection
Trauma
Throat
Obstruction

Flies: ear should be filled with water or oil or lidocaine to

kill the insect and remove it by forceps
Foreign bodies: should be removed immediately
Foreign Body
Foreign body - throat
Normal
tonsils
Acute Tonsillitis
Acute Tonsillitis
Viral Bacterial
Causativ Adenovirus S. Pneumonia
e Parainfluenza virus H. Influenza
organism M. Catarrhalis
s
Mild sore throat, low Severe sore throat lasting >
Symptom
grade fever, mild 48 hours
s
adenopathy
FBC
Paul Bunnell test (test for detection of heterophil
Dx
antibodies in infectious mononucleosis)
LFT: may cause liver toxicity
Broad spectrum Abx
(amoxicillin +/- Clavulanic
acid)
Analgesia
Rx Bed rest
Antipyretics
Rehydration
Acute Tonsillitis - Quinsy
Definition:
Peritonsillar abscess
Pus collection between tonsillar capsule
and the superior constrictor muscle
Presentation:
Severe sore throat, dysphagia,
odynophagia
Trismus (jaw locking)
Hot potato voice
Referred pain
Causative organisms: S. aureus, S.
pneumonia, Bacteroides
Rx: Admit + IV Abx + drainage of the
abscess
Acute Tonsillitis tonsillectomy
Indications:
Tonsillitis: SIGN guidelines:
Recurrent sore throats due to acute tonsillitis
The episodes of sore throat are disabling
7 episodes in the last 1 year
5 episodes in each of last 2 year
3 episodes in each of last 3 year
Obstructive sleep apnoea
Malignancy

Complications:
General: bleeding, anesthesia
Specific: palatal dysfunction
Epiglottitis
Swallowing
Epiglottitis
Epiglottitis
Children (1-6 yrs): emergency / life threatening!!! Due
to risk of airway obstruction
Adults: supraglottitis

Symptoms
High Fever
Sore throat > unable to swallow saliva > saliva
goes down to chin > unable to speak or swallow
(plummy voice + dysphagia)
Swelling of epiglottis
Cant cough
Dyspnoea
NO COUGH!!
Recent URTI
Immobile, Sitting forwards, open mouth (drooling)

Causative organism:
Children: H Influenza type B (rare due to vaccine)
Adults: Broad range of respiratory pathogens
Epiglottitis
Rx:
Urgent ENT, peads and anaesthesia referral
Admission
Take to OR > intubation
Then take to ICU > wait for 48 hours
Then take back to OR and see if swelling in
epiglottis subsided or not
Oxygen
Heliox (mix oxygen and helium)
Adrenaline Nebulisers
Steroids
Antibiotics: 3rd generation cephalosporin
(cefuroxime) for 2-3 days
DO NOT: lye child down, examine throat or
take a lateral x-ray
Rifampicin: prophylaxis given to contacts
Epiglottitis vs. 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 (lying
down)
Toxaemia Mild to severe Mild
Cough None Barking, brassy
Voice Muffled Hoarse
Respiratory Rate Rapid Rapid
Laryngeal palpation Tender Not tender
Clinical course Rapid resolution Longer
resolution
Cricothyroidotomy
Nose
THE NOSE
Obstruction

One attempts to remove only

Do not use forceps if round object
Urgent referral to ENT
Nasal fracture

Rx:
Analgesia
Exclude other Max fax fractures and
CSF rhinorrhea
Refer if: obvious deformity or septal
hematoma (urgent)
Risk of cartilage necrosis
Risk of abscess formation
Rx:
Bone manipulation: best time to
manipulate it is within 5-7 days
Rhinoplasty
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
90% from Littles area/ Kiesselbachs plexus
Risk factors: URTIs, digital trauma, nose picking, allergic rhinitis
Investigation if: weight loss, easy bruising, unilateral
Adults:
Traumatic
Anterior bleed:
Littles area (anastomosis of 4 arteries in anterior part of septum)
Recurrent, self-limiting
Posterior bleed:
Elderly / Medical comorbidities (hypertension, aspirin, warfarin)
More severe, need admission
Most commonly from sphenopalatine artery
Rx:
Resuscitate
FBC, Group and &X match, Platelets
BP
IV Line
Control bleeding with:
Cautery: Silver nitrate cautery
Nasal Packing (for minimum 48 hours): BIPP: Bismuth Iodoform Paraffin Paste, Merocel, Rapid Rhino
Embolization (angiography)
How NOT to pack a nose!!!
Ear
THE EAR
Emergencies include:

Otitis externa and malignant otitis externa

Acute otitis media
Acute mastoditis
Perichondrial Haematoma
Mastoiditis
Perichondrial Haematoma

Rx :
Systemic antibiotics
Analgesia
URGENT REFERRAL for incision &
drainage to prevent development
of cauliflower ear
Perichondrial Haematoma Cauliflower ear

Loss of blood
supply to cartilage
> loss of cartilage
> loss of normal
structure of ear
Ear thickened or
deformed
Cause: repeated
blows (boxing or
rugby)
Bloody otorrhea

Causes:
Otitis externa/media
Trauma (local or
head injury)
Post-op
Precautions

Primary
surveillance

Secondary
surveillance

Radiology

Head injury team

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
Forehead sparing = UMN
UMN or LMN

Try and find a cause Thorough examination

Facial Nerve Palsy (Bells)

Red bulging ear drum =

URGENT ENT review
If not, Non urgent ENT
review
If poor eye closure =
Ophthalmology review