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ENT Emergencies: Stanford University Division of Emergency Medicine
ENT Emergencies: Stanford University Division of Emergency Medicine
Overview
Otologic Disorders Nasal Disorders Facial, Oral and Pharyngeal Infections Airway Obstruction
Lacerations - single
layer closure, pick up perichondrium, bulky ear dressing Use posterior auricular block for anesthesia
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
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)
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)
Inner Ear
peripheral vertigo (vestibulopathy) BPV, labyrhinthitis - acute onset, no central signs, usually young, horizontal nystagmus Menieres - vertigo, sensorineural hearing loss, tinnitus Treatment - valium, fluids, rest, manipulation for BPV
The Nose
Vascular Supply - Anterior - branches of internal carotid - Posterior - distal branches of external carotid
Epistaxis
Anterior
90% (Littles Area) Kisselbachs plexus usually children, young adults
Etiologies
Trauma, epistaxis digitorum Winter Syndrome, Allergies Irritants - cocaine, sprays Pregnancy
Epistaxis
Posterior
10% of all epistaxis - usually in the elderly Etiologies Coagulopathy Atherosclerosis Neoplasm Hypertension (debatable)
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
Epistaxis Management
Anterior Sites
- Pressure +/- cautery and/or tamponade - all packs require antibiotic prophylaxis
Epistaxis Complications
severe bleeding hypoxia, hypercarbia sinusitis, otitis media necrosis of the columella or nasal ala
Causative Organisms
- gram positives and H. flu (acute) - anaerobes, gram neg (chronic)
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)
Facial Cellulitis
Most common strept and staph, Rarely H.Flu Can progress rapidly
Parotiditis
Usually viral -paramyxovirus Bacterial - elderly, immunosuppressed - associated with dehydration - cover - Staph, anaerobes
Pharyngitis
Irritants -reflux, trauma, gases Viruses - EBV, adenovirus Bacterial -GABHS, mycoplasma, gonorrhea, diptheria
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
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
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
Epiglottitis
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
Infection of the lower molars invade masticator space Swelling, pain fever, TRISMUS Treatment IV antibiotics (PCN or Clindamycin) ENT admission
ANUG
Acute Necrotizing Ulcerative Gingivitis
Bacterial infection causing an acute necrotizing, destructive disease of periodontium Treatment - oral rinses - antibiotics (PCN, clindamycin, tetracycline)
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
Angioedema
Ocassionally life threatening Heriditary and related to ACE inhibitors Antihistamines, steroids and doxepin
Airway Obstruction
Aphonia - complete upper airway Stridor - incomplete upper airway Wheezing - incomplete lower airway Loss of breath sounds- complete lower airway