1. ENT Emergencies C. Rebus R3-EM DrRebus.com http://www.boxingscene.com/forums/showthread.php?t=329320

2. Conflicts None Errors - Mine. Thanks to: Dr. Marc Francis Dr. Colleen Carey

3. Goals Common and Nightmare ENT presentations, management and follow up.

4. http://meded.ucsd.edu/clinicalimg/head_pharyngitis.htm

5. DDx?

6. Acute Pharyngitis (cont) Life-threatening Epiglottitis, diphtheria, Ludwig’s angina, peritonsillar abscess, retropharyngeal abscess, gonococcal pharyngitis, infectious mononucleosis (occlusion), and GABHS (...ARF). Garden Variety Infectious viral pharyngitis, non-GABHS bacterial pharyngitis, and candidiasis. Non-infectious Laryngeal/pharyngeal trauma, GERD, persistent cough or post-nasal drainage, thyroiditis, and malignancies.

7. Acute Pharyngitis What!? I'm an EMERG DOC! In the top 10 presentations Females: #5 Males: #10 National Health Statistics Reports, Number 7, August 6, 2008 (US data). http://4.bp.blogspot.com/_uekyjQXowno/SwreRGgnJ6I/AAAAAAAADwU/8VqTb-gSWl4/s1600/dung-beetle1.jpg

8. Acute Pharyngitis (cont)

9. Who is worse then MD at DDx Bact vs Viral? No one. Epid Group A Streptococcal pharyngitis is disease of youth. 50% of pts 5 – 15 yo. Peak incidence first few years of school. GAS uncommon <3 yo

10. Acute Pharyngitis (cont) Dx? Classic Symptoms of GABHS Pharyngeal or tonsillar exudate Swollen anterior cervical LN Hx fever >38*C Absence of cough If all 4 symptoms: 44% chance they will NOT have GABHS. Coin 50%. http://www.afreeman.org/wp-content/uploads/2009/02/nickel.jpg

11. Acute Pharyngitis (cont) Rapid Strep test? Not recommended in AB Lacks sensitivity and evidence of improved clinical outcome. ASOT? Lets use some science please... Not in Dx or mgmt of acute pharyngitis. Post treatment swab? Not routinely.

12. Acute Pharyngitis (cont) How to diagnose this simple beast? Throat Swab. In pts with >2 classic symptoms. Sensitivity 90 - 95%.

13. Acute Pharyngitis (cont) MCC? Viral ~90% Bacterial: MCC: GABHS GCBHS, GGBHS, N. Gonorrhoeae, arcanobacterium haemolyticum http://textbookofbacteriology.net/themicrobialworld/pathogenesis.html

14. Acute Pharyngitis (cont) Infectious? 2-5 d prior to symptoms During acute illness ~7 d after if untreated Back to School? 24 hrs after start ABx Unless symptoms don't improve -?Tx failure.

15. Acute Pharyngitis (cont) Mgmt Swab and wait. Rheumatic fever? “I got the stuff they want” Penicillin (no documented resistance). Allergy? Clindamycin or Erythromycin. Not getting better 48 – 72 hrs? FUGP.

16. http://www.naze.net/2005/images/2005%200122%20jack%20blood%20in%20sink.jpg

17. Post-Tonsillectomy Time Honoured Tradition of Hemostasis Tonsils are supplied by 5 arteries in an area unable to collapse on itself.

18. Post-Tonsillectomy (Cont) Janfaza et al. 2001. Surgical anatomy of the head and neck

19. http://www.instantanatomy.net/headneck/areas/phoropharynx.html

20. Post-Tonsillectomy (Cont) This is bad. Move them somewhere besides PLC eyeroom. Trauma bay or get an airway cart. IV x2, CBC, INR/aPTT, crossmatch. Ask for tonselectomy bleed pack. Let ENT know early.

21. Post-Tonsillectomy (Cont) 0.5 – 10% depending on Sx. Bleeding Intraoperative Primary (<24hrs) Secondary (1-10 days) 5 – 7 POD most common

22. Post-Tonsillectomy (Cont) Post-op day 5 – 7

23. Post-Tonsillectomy (Cont) Minor Bleeding Seated position in surgical area Suction Look Call ENT – likely reluctant

24. Post-Tonsillectomy (Cont) Major Bleeding Back to basics – Pressure. Kelly clamp + epi 2% soaked gauze. ENT. They need OR. Presume stomach is full of blood from ooze. It is a bad airway.

25. Post-Tonsillectomy (Cont) Dispo ENT to R/V. (Admission)

26. http://www.beerkada.net/images/nosebleed1.jpg

27. Epistaxis So? http://www.esnr.com/www/case_studies/content/nosebleeds_epistaxis_fig1.htm

28. Epistaxis (cont) Anterior 95%

29. Epistaxis (cont) Posterior 5%

30. Epistaxis (cont) Posterior

31. Posterior epistaxis from the left sphenopalatine artery. http://emedicine.medscape.com/article/863220-media

32. Epistaxis (cont) http://chestofbooks.com/health/anatomy/Human-Body-Construction/The-Mouth-And-Throat-Part-2.html

33. Epistaxis (cont) Roberts: Clinical Procedures in Emergency Medicine, 5th ed.

34. Epistaxis (cont) Br J Ophthalmol 2003;87:1051 doi:10.1136/bjo.87.8.1051

35. Epistaxis (cont) http://academia.hixie.ch/bath/eye/home.html

36. Epistaxis (cont) Fatal Posterior Nasal Packing? (from a fictitious CMPA call) 'You put what, where?' Epistaxis, medical history, and the nasopulmonary reflex: what is clinically relevant? Otolaryngol Head Neck Surg. 1994 Apr;110(4):363-9 Jacobs et al. Posterior packs and the nasopulmonary reflex. Laryngoscope. 1981 Feb;91(2):279-84.

37. Epistaxis (cont) http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79932-80545-113132.jpg

38. Epistaxis (cont) Posterior Nasal Packing *to stabilize the anterior packing = tamponade Nasostat Rubber Chicken Foley Roberts: Clinical Procedures in Emergency Medicine, 5th ed.

39. Epistaxis (cont) Posterior Nasal Packing – 10F Foley http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79932-80545-113136.jpg 10-15ml N.S.

40. Epistaxis (cont) Show of hands: Rx ABx with packing? I'll tell you, it's Zero. Unless you have structural heart disease. Concern Staph toxic shock syndrome, sinusitis, and clinically-evident bacteremia Evidence 3 RCT, 163 pts. Lack power. Incomplete evidence. Polymixin B/oxytetracycline reduced flora on packing.

41. Epistaxis (cont) Why so much about a bloody nose? It is distressing. It is common. Public (and health care) knowledge of 1 st aid is poor. The next bloody nose visit can be a public health moment (teaching=freedom).

42. Epistaxis (cont) http://drdavidson.ucsd.edu/Portals/0/Pathway/NoseBled.htm

43. http://www.aafp.org/afp/2007/0115/p243.html

44. Sinusitis The Forgotten Badboy of the URTI http://www.topalbertadoctors.org/informed_practice/cpgs/acute_sinusitis.html

45. Sinusitis Defn Inflammation of one or more of the paranasal sinus cavities, the cause of which may be allergic, viral, bacterial, or rarely fungal Exclusions <6wks, immunocomp, severe underlying dz, complications of acute bacterial sinusitis, hospital acquired sinusitis.

46. Sinusitis (cont) Acute Sinusitis <4 wks. Recurrent 4+ episodes/yr lasting 10+ days, symptom free b/w. Chronic >12 wks with/without Rx.

47. Sinusitis (cont) MCC? Viral 200x that of bacterial! S. pneumoniae, H.influenzae

48. Sinusitis (cont) Persistent symptoms of URTI without improvement after 10 - 14 days or worsening after 5 days with both: nasal congestion/purulent nasal discharge and facial pain +/- fever, maxillary toothache, facial swelling. Physical findings of: swelling and/or erythema, tenderness on palpation/percussion of paranasal sinuses, periorbital swelling, erythema/swelling of nasal mucosa, post nasal drip Nasal/nasopharyngeal cultures NOT recommended Transillumination of the sinuses is of limited value in adults TOP Guidelines, 2008 Update

49. Sinusitis (cont) Abx? 1st Line Amoxicillin 500mg PO TID 10d Allergy? Doxycycline 200mg PO once, then 100mg PO BID 10 d TMP/SMX 1 DS PO bid 10d TOP Guidelines, 2008 Update

50. Sinusitis (cont) What!? I'm an EMERG DOC! Progress, in this case, is bad. http://www.emedmag.com/html/pre/fea/features/061505.asp

51. Sinusitis (cont) Preseptal cellulitis Orbital cellulitis * Subperiosteal abscess Orbital abscess. http://www.emedmag.com/html/pre/fea/features/061505.asp

52. Sinusitis (cont) Still not worried? Cavernous sinus thrombosis

53. Sinusitis – CST (cont) Watch for: Headache Ophthalmoplegia Exopthalmos Fever Chemosis Altered

54. Sinusitis – CST (cont) Vague symptoms, vague findings. Dx? CT or *MRI LP Opening pressures? 450 – 500 mmH2O ~75% CSF – Normal ~75% CXR? Dispo Admit

55. Sinusitis – CST (cont) Facial Danger Zone http://resources0.news.com.au/images/2008/07/22/va1237320544789/Tom-Cruise-in-Top-Gun-6158917.jpg

56. Sinusitis – CST (cont) Suspect it. Preferred Ix: MRV Neg CT can't rule it out.

57. Sinusitis (cont) Still not worried? Meningitis Intracranial abscess

58. Summary Pharyngitis – You can make a difference. Post tonsilectomy bleed – It's bad. Epistaxis – Fulfil you urge to put something in there. Pack. Pack, Pack. Pack, Pack, Pack. Pack, Pack, Pack, Pack. Sinusitis – If you see it, treat it.

59. Things I Wish I knew Before I was Staff http://www.charlton.hillbillyfunnies.com/emdoc1.jpg

60. Qs http://travel.webshots.com/photo/1451171186076146350zjzyCY

61. References Br J Ophthalmol 2003;87:1051 doi:10.1136/bjo.87.8.1051 Janfaza et al. 2001. Surgical anatomy of the head and neck. Kidermann et al. British Journal of General Practice, March 2005. Adjuvant prednisone therapy in pharyngitis: a randomised controlled trial from general practice. Middleton, Paul M. Epistaxis. Emergency medicine Australasia (2004) 16, 428-440. Pofh et al. Burden and Economic Cost of Group A Streptococcal Pharyngitis. PEDIATRICS Vol. 121 No. 2 February 2008, pp. 229-234 (doi:10.1542/peds.2007-0484) National Health Statistics Reports Number 7 August 6, 2008 Roberts: Clinical Procedures in Emergency Medicine, 5th ed.(via cma.ca) Tintinalli JE, Kelen GD, Stapczynski JS, Ma OJ, Cline DM: Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 6e: http://www.accessmedicine.com/content.aspx?aID=609033. Waters Thomas A, Peacock IV W. F, "Chapter 241. Nasal Emergencies and Sinusitis" (Chapter). Tintinalli JE, Kelen GD, Stapczynski JS, Ma OJ, Cline DM: http://www.bestbets.org/bets/bet.php?id=1412 http://www.emedmag.com/html/pre/fea/features/040040035.asp http://emedicine.medscape.com/article/764304-diagnosis Images, In order: http://www.boxingscene.com/forums/showthread.php?t=329320 http://meded.ucsd.edu/clinicalimg/head_pharyngitis.htm http://textbookofbacteriology.net/themicrobialworld/pathogenesis.html http://www.afreeman.org/wp-content/uploads/2009/02/nickel.jpg http://www.naze.net/2005/images/2005%200122%20jack%20blood%20in%20sink.jpg http://www.instantanatomy.net/headneck/areas/phoropharynx.html http://www.esnr.com/www/case_studies/content/nosebleeds_epistaxis_fig1.htm http://www.beerkada.net/images/nosebleed1.jpg http://chestofbooks.com/health/anatomy/Human-Body-Construction/The-Mouth-And-Throat-Part-2.html http://drdavidson.ucsd.edu/Portals/0/Pathway/NoseBled.htm http://emedicine.medscape.com/article/863220-media http://img.medscape.com/pi/emed/ckb clinical_procedures/79926-79932-80545-113132.jpg http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79932-80545-113136.jpg http://academia.hixie.ch/bath/eye/home.html http://www.topalbertadoctors.org/informed_practice/cpgs/acute_sinusitis.html http://www.emedmag.com/html/pre/fea/features/061505.asp http://travel.webshots.com/photo/1451171186076146350zjzyCY http://www.bartleby.com/107/illus571.html