COMMON ENT

EMERGENCIES
DR:AYMAN YAKOUT
GMU AJMAN UAE

Common ENT
emergencies

Foreign bodies
Trauma
Complications of ENT infections

Foreign bodies

Insects
Cotton, paper,
organic material
Small batteries
Discomfort &
agitation
Secondary
complications:
infection & mucosal
erosion

Foreign bodies

Kill any live insects

Remove foreign
body with micro
alligator forceps
Irrigation ( do not
use if organic FB )

Auricular Hematoma

Usually from
trauma
Fluctuant bluish
swelling of auricle
Drainage
- Needle aspiration
-I&D
Apply compression
dressing

Traumatic TM
Perforation

Compression,
instrumentation &
blast injuries
Hearing test
Close observation
if perforation is
small
Paper patch
Surgery

Temporal bone fracture

Blunt head injury

Longitudinal Fx
facial n. paralysis,
CHL (ossicular
chain disruption)
Transverse Fx
SNHL,
dysequilibrium,
CN VII palsy

Temporal bone fracture

Battles sign (bluish

discoloration of
postauricular
region), raccoon
eyes,
hemotympanum,
hearing loss,
dizziness, CSF
otorrhea, CN VII
palsy
CT temporal bone

Acoustic trauma

Sudden exposure (impact or blast) to

noise
SHNL, tinnitus
Avoidance/ ear protection
Corticosteroids, carbogen,
vasodilators, diuretics,
anticoagulants, plasma expanders

Otitic Barotrauma

Inability to
ventilate middle
ear abnormal
dysfunction of ET
Occur in rising
ambient pressure
(descent in flight /
scuba diving)
Can produce
hemotympanum

Barotrauma

Repeated Valsalva
maneuver
Topical nasal
decongestants
Myringotomy & PE
tube insertion may
be needed

Sudden Hearing Loss

SNHL 30 dB
over 3 contiguous
frequencies within
3 days or less
Etiology : Viral &
Infectious,
Vascular, Trauma,
Autoimmune,
Neurologic

Complications of ME
infections

Extracranial

Acute Mastoiditis

preceded by AOM
young children
severe pain, fever,
edema
over mastoid area
intravenous ATB
Myringotomy PE
tube

Subperiosteal Abscess

pinna pushed
down & outward
intravenous ATB
I&D
mastoidectomy

Complications of ME
infections

Intracranial

Foreign bodies:
Symptoms

Purulent unilateral
nasal discharge
Usually lodge on
the floor of
anterior or middle
third

Foreign bodies:
Management

Good visualization:
headlamp & nasal
speculum
Alligator forceps should
be used to remove cloth,
cotton, or paper
Other hard FB are more
easily grasped using
bayonet forceps or Kelly
clamps, or they may be
rolled out by getting
behind it using an ear
curette, single skin hook,
or right angle ear hook

Nasal Fracture

Hx of fall or force
directed to midface
Deformity of nose
Swelling,
ecchymosis,
epistaxis
Close or open
reduction

Septal
hematoma/abscess

Trauma, surgery
Soft, fluctuant
swelling of septum
Needle aspiration
or I&D
Bilateral nasal
packing for several
days
Prophylactic
antibiotics

Septal
hematoma/abscess

Epistaxis

Local

Trauma /Nose
picking or
blowing / surgery
Dry air / Irritants
Topical medications
(steroids)
Foreign body
Tumor / polyp

Systemic

Blood diseases
Hereditary
hemorrhagic
telangiectasia
Drugs
(anticoagulants)
Hypertension

Epistaxis

Epistaxis

Initial first-aid
Assessment of
blood loss
Evaluation of
cause
Procedure to stop
bleeding

Most common
Kiesselbachs
Plexus
Squeeze nose 5-20
mins
Insert cotton
pledget (with
decongestant)
Cautery with silver
nitrate

Figure 1 Epistaxis management protocol.

Pope, L E R et al. Postgrad Med J 2005;81:309-314

Epistaxis

Anterior nasal packing

Local anesthetic &

decongestant
Nasal packing
- Vasaline guaze
- Absorbable
gelfoam
- Oxidized cellulose
(Surgicel)
- Nasal tampon

Anterior nasal packing

Anterior nasal packing

Nasal packing
- Vasaline guaze
- Absorbable
gelfoam
- Oxidized
cellulose
(Surgicel)
- Nasal tampon

Anterior nasal packing

Nasal packing
- Vasaline guaze
- Absorbable
gelfoam
- Oxidized
cellulose
(Surgicel)
- Nasal tampon

Anterior nasal packing

Nasal packing
- Vasaline guaze
- Absorbable
gelfoam
- Oxidized
cellulose
(Surgicel)
- Nasal tampon

Figure 2 Correct insertion of a nasal tampon (note that the direction is along the floor of the
nasal cavity).

Pope, L E R et al. Postgrad Med J 2005;81:309-314

Copyright 2005 BMJ Publishing Group Ltd.

Posterior nasal packing

Topical anesthetic
& decongestant
Posterior nasal
packing
Double balloon
device
Foley catheter

Posterior nasal packing

Topical anesthetic
& decongestant
Posterior nasal
packing
Double balloon
device
Foley catheter

Posterior nasal packing

Topical anesthetic
& decongestant
Posterior nasal
packing
Double balloon
device
Foley catheter

Complications of
sinusitis

Orbital complications
Intracranial complications

Classification of orbital
inflammation
Stage
I
II
III
IV
V

Inflammation
Inflammatory edema
(periorbital cellulitis)
Orbital cellulitis
Subperiosteal abscess
Orbital abscess
Cavernous sinus
thrombosis

Complications of
sinusitis

Periorbital cellulitis:
periorbital erythema,
edema, pain & fever
Purulent nasal
discharge
S.pneumoniae,
S.aureus, coagulasenegative
staphylococci
Broad-speculum
antibiotics

Complications of
sinusitis

Orbital complications
(stages II-V)
Periorbital swelling
& pain, fever
Proptosis, chemosis,
restriction of ocular
movement & visual
disturbance

Complications of
sinusitis

CT scan
subperiosteal &
orbital abscess
Admission & IV
broad- spectrum
antibiotics
Surgery (drainage) if
- failed medication
- develop abscess
- visual drop

Complications of
sinusitis
Intracranial complications
Cavernous sinus thrombosis,
meningitis, extradural abscess,
intracranial abscess & subdural
empyema
Purulent rhinorrhea, fever,
frontal/retro-orbital headache
Personality change/lethargy, seizures,
N/V, focal neurological deficits

Complications of
sinusitis
Intracranial complications
Diagnosis MRI scan with
gadolinium
Admission, IV broad-spectrum
antibiotics & surgical drainage

Swallowed foreign body

Peanuts, coins,
batteries, fish
bone, meat & bone
pieces, dentures
Location of pain
indicates FB
location

Swallowed foreign body

Fish bones tend to

lodge in
oropharynx,
produced ipsilateral
symptoms
Esophagus FB
localize in midline:
dramatic acute
dysphagia

Swallowed Foreign
bodies

Most FB in
oropharynx can be
identified
Esophageal FB:
pooling of saliva in
piriform
X-rays may be
helpful in radiopaque objects

Swallowed Foreign
bodies

Visualized FB can
be removed with
angled forceps
Sharp FB should
be removed at the
earliest
opportunity due to
risk of perforation

Swallowed Foreign
bodies

Coins removed if
in cervical or mid
esophagus
removed within 12
hrs if in distal
esophagus
Batteries
removed emergency

Swallowed Foreign
bodies

Airway
compromise
- Heimlich
maneuver
- Emergency
cricothyrotomy/
tracheostomy
Endoscopy with
removal in OR

Inhaled Foreign bodies

Sudden onset of
coughing, wheezing
or stridor in
previously healthy
child
Unilateral wheezing,
poor chest movement
& reduced breath
sound
CXR: hyperinflate,
infection, collapse

Inhaled Foreign bodies

Heimlich manuver
Secure airway
Endoscopic
removal under
general anesthesia

Airway Obstruction

Neonatal : Congenital tumors, cysts, webs

: Laryngomalacia
: Subglottic stenosis
Children : Laryngotracheobronchitis
: Supraglottitis (epiglottitis)
: Foreign body
: Retropharyngeal abscess
: Respiratory papilloma
Adults
: Laryngeal cancer
: Laryngeal trauma
: Epiglottis & deep neck infection

Deep neck infections

Peritonsillar abscess

Pus forms between

tonsils capsule &
superior
constrictor
Group A
Streptococcus

Peritonsillar abscess

Severe, unilateral
sore throat
fever
Hot potato voice
Uvula deviates to
opposite side
Swollen tonsils

Peritonsillar abscess

CBC, throat C/S

Antibiotics
- Oral
- Parenteral
needle aspiration
or I&D

Ludwigs Angina

Rapid swelling
cellulitis of
sublingual &
submaxillary spaces
Dental infection,
floor of mouth,
salivary gland
Fever, edema &
erythema of neck
under chin & floor of
mouth

Ludwigs Angina

Open mouth,
Tongue upward &
backward airway
obstruction
Streptococci,
Bacteroides,
S.aerues
Tracheostomy
IV antibiotic
I&D, tooth extraction

Epiglottitis

Age 3-7 yrs old

H. influenzae type B,
Group A
Streptococcus
severe sore throat &
fever, dysphagia,
drooling
Stridor
Breathing with raised
chin & open mouth

Epiglottitis

CBC: leukocytosis
Film lateral neck
thumb shaped
epiglottis
Avoid tongue
depressor
Controlled
intubation
Intravenous ATB

Retropharyngeal Abscess

Infants & children

Secondary to
oropharyngeal
infection
Severe dysphagia &
respiratory distress
airway observation
IV antibiotic
Surgical drainage
( prevent pus
aspiration)

Tracheostomy
Emergency
tracheostomy
in the case of upper
airways obstruction
1. Tumor in the larynx
2. Trauma of the larynx
3. Bilateral vocal cord
paralysis
4. F.B. in the larynx
after failure of
Heimlichs manuver