1. Stanford University Division of Emergency Medicine
ENT Emergencies
Stanford University
Division of Emergency Medicine

2. Overview Otologic Disorders Nasal Disorders
Facial, Oral and Pharyngeal Infections
Airway Obstruction

3. Otologic Disorders Anatomy
Auricle
Ear canal
Tympanic membrane
Middle ear and mastoid disorders
Inner Ear

4. Traumatic Disorders of the Auricle
Hematoma
- cartilaginous necrosis
- drain, antibiotics, bulky ear dressing close follow up
Lacerations - single layer closure, pick up perichondrium, bulky ear dressing
Use posterior auricular block for anesthesia

5. Aspiration of Auricular Hematoma

6. Auricle Chondritis - Cellulitis ?
- infectious, difficult to treat because poor blood supply, cover S. Aureus and pseudomonas
- extra care in diabetics
- inflammatory causes related to seronegative arthritis at times indistinguishable from infection usually the ear lobe is spared

7. Otitis Externa
Infection and inflammation caused by bacteria (pseudomonas, staph), and fungi
- treat with antibiotic-steroid drops
- use wick for tight canals
- diabetics can get malignant otitis externa (defined by the presence of granulation tissue)

8. Foreign Bodies in Ear Canal
Usually put in by patient, some bugs fly in
kill bugs with mineral oil, or lidocaine
remove with forceps, suction or tissue adhesive

9. Tympanic Membrane Perforation
Hard to see – Hx of drainage
Usually from middle ear pressure secondary to fluid or barotrauma
Sometimes from external trauma
most heal uneventfully but all need otology follow-up
perfs with vertigo and facial nerve involvement need immediate referral
treat with antibiotics
drops controversial but indicated for purulent discharge (avoid gentamycin drops)

10. Middle Ear
Serous Otitis Media - Eustachian tube dysfunction - treat with decongestants, decompressive maneuvers
Otitis Media - infection of middle ear effusion - viral and bacteria
Mastoiditis - Venous connection with brain, need aggressive treatment (can lead to brain abcess or meningitis)

11. Inner Ear peripheral vertigo (vestibulopathy) BPV, labyrhinthitis
- acute onset, no central signs, usually young, horizontal nystagmus
Meniere’s - vertigo, sensorineural hearing loss, tinnitus
Treatment
- valium, fluids, rest, manipulation for BPV

12. The Nose Vascular Supply - Anterior - branches of internal carotid
- Posterior - distal branches of external carotid

13. Epistaxis Anterior Etiologies
90% (Little’s Area) Kisselbach’s plexus - usually children, young adults
Etiologies
Trauma, epistaxis digitorum
Winter Syndrome, Allergies
Irritants - cocaine, sprays
Pregnancy

14. Epistaxis Posterior 10% of all epistaxis - usually in the elderly
Etiologies
Coagulopathy
Atherosclerosis
Neoplasm
Hypertension (debatable)

15. Epistaxis Management Pain meds, lower BP, calm patient
Prepare ! (gown, mask, suction, speculum, meds and packing ready)
Evacuate clots
Topical vasoconstrictor and anesthetic
Identify source

16. Epistaxis Management Anterior Sites
- Pressure +/- cautery and/or tamponade
- all packs require antibiotic prophylaxis

17. Epistaxis Posterior Packing
Need analgesia and sedation
require admission and 02 saturation monitoring

18. Epistaxis Complications
severe bleeding
hypoxia, hypercarbia
sinusitis, otitis media
necrosis of the columella or nasal ala

19. 7th Nerve Palsy Most cases are idiopathic - link to HSV
- no proof steroids or antivirals are effective, but many advocate
Consider Lyme’s Disease in edemic areas
Surgical decompression indicated in the rare patient not improving by 2 weeks and ENOG out > 90%

20. Facial Infections Sinusitis
Signs and symptoms
- H/A, facial pain in sinus distribution
- purulent yellow-green rhinorrhea
- fever
- CT more sensitive than plain films
Causative Organisms
- gram positives and H. flu (acute)
- anaerobes, gram neg (chronic)

21. Facial Infections Sinusitis
Treatment
acute - amoxil, septra
chronic - amoxil-clavulinic acid, clindamycin, quinolones
decongestants, analgesia, heat
Complications
ethmoid sinusitis - orbital cellulits and abcess
frontal sinusitis - may erode bone (Potts Puffy Tumor, Brain Abcess)

22. Facial Cellulitis Most common strept and staph, Rarely H.Flu
Can progress rapidly

23. Parotiditis Usually viral -paramyxovirus Bacterial
- elderly, immunosuppressed
- associated with dehydration
- cover - Staph, anaerobes

24. Pharyngitis Irritants -reflux, trauma, gases Viruses - EBV, adenovirus
Bacterial
-GABHS, mycoplasma, gonorrhea, diptheria

25. Peritonsillar Abcess Complication of suppurative tonsillitis
Inferior - medial displacement of tonsil and uvula
dysphagia, ear pain, muffled voice, fever, trismus
Treatment
- Antibiotics, I&D, +/-steroids

26. Epiglottitis Clinical Picture
Older children and adults
decrease incidence in children secondary to HIB vaccine
Onset rapid, patients look toxic
prefer to sit, muffled voice, dysphagia, drooling, restlessness

27. Epiglottitis Avoid agitation Direct visualization if patient allows
soft tissue of neck
- thumb print, valecula sign
Prepare for emergent airway, best achieved in a controlled setting
Unasyn, +/- steroids

28. Epiglottitis

29. Retropharyngeal Abcess
Anterior to prevertebral space and posterior to pharynx
Usually in children under 4 (lymphoid tissue in space)
pain, dysphagia, dyspnea, fever
swelling of retropharyngeal space on lateral x-ray
Complications - mediastinitis

30. Masticator - Parapharyngeal Space Infection
Infection of the lower molars invade masticator space
Swelling, pain fever, TRISMUS
Treatment
IV antibiotics (PCN or Clindamycin)
ENT admission

31. ANUG Acute Necrotizing Ulcerative Gingivitis
Bacterial infection causing an acute necrotizing, destructive disease of periodontium
Treatment
- oral rinses
- antibiotics (PCN, clindamycin, tetracycline)

32. Ludwigs Angina
Rapidly progressive cellulitis of the floor of the mouth
usually in elderly debilitated patients and precipitated by dental procedures
massive swelling with impending airway obstruction
Treatment
ICU, antibiotics, airway management

33. Angioedema Ocassionally life threatening
Heriditary and related to ACE inhibitors
Antihistamines, steroids and doxepin

34. Airway Obstruction Aphonia - complete upper airway
Stridor - incomplete upper airway
Wheezing - incomplete lower airway
Loss of breath sounds- complete lower airway

35. Questions and Answers