20 - Common ENT Emergencies - Fowler

3/20/2014
ENTEmergencies
JasonC.Fowler,MPAS,PAC
MeadvilleENT Meadville,PA
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
NoDisclosures
LearningObjectives
Recognizeassessmentfindingsconsistentwiththe
followingcommonENTemergencies:complicatedotitis
(mastoiditis,intracranialabscess,facialnerveparalysis),
auricularhematoma,nasalfracture,complicationsof
sinusitis,mucormycosis.
Identifyassessmentfindingsconsistentwithperitonsillar
abscess,retropharyngealabscess,Ludwig'sangina,
periorbital cellulitis,angioedema,adultepiglottitis.
Orderappropriateworkupandperformappropriate
interventionandreferralwhenindicatedforthe
emergenciesdiscussedinthislecture.
3/20/2014
AuricularHematoma
Resultfrombluntforce
trauma,usuallyfrom
sports
Bloodaccumulatesinthe
subperichondrial space
andcanresultin
decreasedbloodflow,
cartilaginousnecrosisand
infection.
PromptI&Dessentialto
management
Cauliflowerearisthe
resultingdeformitydueto
adelayinevacuatingand
treatinganauricular
hematoma
Greywoode JDetal.ManagementofAuricular
HematomaandtheCauliflowerEar.FacialPlast
Surg. 2010Dec;26(6):4515
AuricularHematoma
Historyoftraumaticblow
Tender,fluctuantmass
Dif Dx includedperichondritis,
abscess,relapsing
polychondritis
Promptevacuationwithin710
days*
Varioustechniquesfor
compressiondressingto
preventreaccumulation
*Riviello RJ,BrownNA.Otolaryngologic procedures.In:Clinical
ProceduresinEmergencyMedicine,5thedition,RobertsJR,
HedgesJR.(Eds),SaundersElsevier,Philadelphia,PA2010.
p.1178
LargeLauricularhematoma
fillingtheconchaandoccluding
theexternalacousticmeatus
AuricularHematoma Treatment
Local/regionalanesthesia
12%lidocainew/
epinephrine
Auricularblockworkswell
I&DvsNeedleAspirationvs
penrose
Compressiondressingto
preventreaccumulation
Dentalrolls
Castingagent(Aquaplast)
Mattresssutures
Biedenbach P,Steehler KW,AnonJB,ManagementofAuricular
HematomausingAquaplast PressureDressing.OperativeTechin
OtolaryngologyHNS,vol 8,No2,1997:114115.
Mudry A,Pirsig W.Auricularhematomaandcauliflowerdeformationof
theear:fromarttomedicine.Otol Neurotol.Jan2009;30(1):11620
GilesWC,IversonKC,KingJD,HillFC,WoodyEA,Bouknight AL.Incision
anddrainagefollowedbymattresssuturerepairofauricular
hematoma.Laryngoscope.Dec2007;117(12):20979
Ballenger's
Otorhinolaryngology:Head
andNeckSurgery
3/20/2014
Subtleleftauricularhematomaalongsuperior
aspectoftheantihelix
Auricularhematoma Treatment
Antibioticcoverage
Cephalexin
Antipseudomonal Rx
Levofloxacin
Ciprofloxacin
Amoxicillin/
Clavulanic acid
children
Patientsshouldbe
followedcloselyto
assessforre
accumulationand
infection
Cauliflowerear
Epistaxis
Anteriorand
PosteriorEpistaxis
presentationand
managementare
coveredinthe
CommonNasal
Sinuslectureby
MarieGilbert,PAC
3/20/2014
ComplicationsofAcuteOtitis
Media(AOM)
Drasticdecreasewith
antibioticuse
Highmorbidity/mortality
3routesofspread
Directextension
Thrombophlebitis
Hematogenous spread
ThorneMC,Chewaproug L,Elden LM.
Suppurativecomplicationsofacuteotitismedia:
changesinfrequencyovertime.Arch
Otolaryngol HeadNeckSurg.Jul
2009;135(7):63841
Penido NO,Borin A,Iha LC.Intracranial
complicationsofotitismedia:15yearsof
experiencein33patients.Otolaryngol Head
NeckSurg.2005;132:3742
Complications
Chronicsuppurativeotitis
media
Mastoiditis
Facialnerveparalysis/
paresis
Postauricularabscess
Intracranialabscess
Meningitis
Sigmoidsinusthrombosis
Labrynthitis /labrynthine
fistula
SymptomsofcomplicatedAOM
History:
PhysicalExamination
Severeotalgia (worsee/
immunocompromised)
Vertigo
Fever/malaise
Nausea/vomiting
Headache
Mentalstatuschanges
Profuseotorrhea (often
foulsmelling)
Fever/lethargy
Focalneurologicdeficits
Ataxia,meningealsigns,
ocularpalsy
Mastoidtenderness/
abscess
Facialnerveparesis
Papilledema
Otorrhea /granulation
tissue/auralpolyp
ChronicSuppurativeOtitisMedia
Chronicmiddleeardrainage
withtympanicmembrane
perforation
Chronicinflammation>
edema>infection
(pseudomonas,staph)
Canleadtobonydestruction
0.3 0.9/100,000patients
Workup
Audiogram
HighresolutionCTscanr/o
cholesteatoma
Tx:
Otic drops(quinolone1st line)
Frequentauraltoilet
*Vikram BK,etal..Clinicoepidemiologicalstudyof
complicatedanduncomplicatedchronicsuppurative
otitismedia.JLaryngol Otol.May2008;122(5):4426
Source:BenjaminEarAtlas
*ConsensusPanel,Hannley MT,Dennenny IIIJC.Useof
Ototopical AntibioticsinTreating3CommonEarDiseases.
Otol HeadNeckSurg.2000;93440
3/20/2014
Mastoiditis
Acutemastoiditisseenin
conjunctionwithAOM
Spneumo,mcatarrhalis,h
influenza,s.aureus,GrA.step
IncreaseinMDRs.pneumo*
Usually<2yrs old+/ h/oCOM

4cases/100k/yr
Approx 7%developintracranial
complications**
Surgicaldisease mastoidectomy
*Ongkasuwan J etal..Pneumococcalmastoiditisinchildren
andtheemergenceofmultidrugresistantserotype19A
isolates.Pediatrics.Jul2008;122(1):349.
**Luntz M,BrodskyA,Nusem S,Kronenberg J,Keren G,
Migirov L,etal.Acutemastoiditistheantibioticera:a
multicenterstudy.Int JPediatr Otorhinolaryngol.Jan
2001;57(1):19
Mercado2013
Mastoiditiscont.
Workup
Presentation
Large%w/ohistoryof
recentAOM
Persistentotorhhea
+/ High,unbreakable
fevers
Mastoidtenderness
Hearingloss
Childrenwithhigh
WBCmorelikelyto
havecomplications
CBC
*highWBCinkidsassoc withinc.
complications
Bloodcultures
Earcultures/tympanocentesis
Audiometry
HighresolutionCTscanattention
toorbits/temporalbone
TX:
Surgery
IVantibitotics /otic drops
*OestreicherKedem Y,etal.Complicationsofmastoiditisinchildren
attheonsetofanewmillennium.AnnOtol Rhinol Laryngol.Feb
2005;114(2):14752
MastoiditisAntiobiotics
Linezolid(zyvvox)
Cefepime (Maxipem)
Vancomycin
Clindamycin(Cleocin)
Meropenem (Merrem)
Piperacillin /
tazobactom (Zosyn)
Oxacillin
Ceftriaxone(Rocephin)
*
Otic drops(adjuvant
therapy)
Ciprofloxacinwithor
withoutsteroid(Cipro
HC,Ciprodex)
Cortisporin otic 1
.
Tobradex
Upto30%resistancein
postpneumococcal
vaccineera
*RoddyMG,GlazierSS,AgrawalD.Pediatric
mastoiditisinthepneumococcalconjugatevaccine
era:symptomdurationguidesempiricantimicrobial
Subperiostal
therapy.Pediatr Emerg Care.Nov2007;23(11):779
Fourth Annual ENT for the PA-C | April 24-27, 2014 abscess
| Pittsburgh, PA
84
(arrowheads)
3/20/2014
Acutemastoiditiswithsofttissue
abscessandintracranialabscess
Yellowarrowheads=softtissueabscess
Redarrowhead=intracranialabscess
Sagital CTshowingmastoiddehiscenceand
intracranialabscessformation
FACIALNERVEPARALYSIS
CausesofFacialNerveParalysis
BellsPalsy
RamseyHuntSyndrome
Bacterialinfection(AOM,mastoiditis)
LymeDisease upto10%Lymepatientwith25%beingbilateral*
Trauma
Atbirth(forceps)penetratingeartrauma
Temporalbonefracturebarotrauma
Noninfectiouscauses:
Tumor cholesteatoma,FNtumor,parotidtumor)
Iatrogenic eg parotid,necksurgery
*ClarkJR,CarlsonRD,SasakiCT,etal.FacialparalysisinLymedisease.Laryngoscope.Nov
1985;95(11):13415
3/20/2014
BellsPalsy
BellsPalsydefinedasacute,unilateralfacial
nerveparesis(weakness)orparalysis(complete
lossofmovement)withonsetinlessthan72
hoursandwithoutanidentifiablecause
Selflimited
Diagnosisofexclusion
PleaserefertolectureonBellsPalsyGuidelines
DebraMunsell
RamseyHuntSyndrome
Acuteperipheralfacial
neuropathyaffectingthe
auricle,externalauditory
canalorthemucous
membranesofthe
oropharynx*
+/ skinvesicles/ulcerations
VaricellaZostervirus
(Shingles)affectsthe
geniculateganglion
Maybecauseofupto20%of
bellspalsycases**
Facialparalysis,hearingloss,
vertigo,tinnitus,ataxiamay
bepresentingsxs
1
.
*Bhupal HK.RamsayHuntsyndromepresentinginprimary
care.Practitioner.Mar2010;254(1727):335
**GilchristJM.Seventhcranialneuropathy.Semin Neurol.
Feb2009;29(1):513
Ramsey Hunt
Syndrome
63wf consultforearpain
3/20/2014
RamseyHuntPresentation/
workup
Presentation:
Paroxysmalpaindeepin
earcanal
Vesicularearormouth
ulcers/precededwith
painprecedingrashby
hourstodays
Facialparesis/paralysis
Atmaxseverityby1week
postonset
Unilateralearpain/
tinnitus(upto50%)
Hearingloss(unilateral)
Headache
Diagnosisoftenobvious
WBC,ESRtor/oinfection/
inflammation
IfCNSinvolvement(ie
meningitis)suspected,CSF
maybeneeded
Imaging CT/MRItor/o
structal lesions
Viralstudies
Tzank smear
Cultures(lowspecificity)
Direct
immunofluorescence
assay(DFA)hashigh
sens/spec*
*CoffinSE,Hodinka RL.Utilityofdirectimmunofluorescenceand
virusculturefordetectionofvaricellazostervirusinskinlesions.J
Clin Microbiol.Oct1995;33(10):27925
Ramsey HuntTreatment
5060%chanceofrecoveryof
facialnerve
Corticosteroidsandantivirals
arethemainstayoftreatment
Antiviralscontroversial*
Paincontrol
Eyecareextremelyimportant!!
Vestibularsuppressantsmaybe
necessaryforvertiginoussxs
Carbamazepineandother
neurologicagentsmayalsobe
used
Noroleforsurgical
decompressionofthenerve
*Uscategui Tetal.AntiviraltherapyforRamsayHuntsyndrome
(herpeszosteroticus withfacialpalsy)inadults.Cochrane
DatabaseSyst Rev.Oct82008
Samepatientfromprevious
slide.Notinabilitytoclose
Righteye
EyeCare
1
.
1
.
Cornealulceration
Moisture
chamber
3/20/2014
FacialNerveparesis/paralysis
complicationofotitismedia
Uncommoncomplicationbut
needforrecognition
Needtor/oothercauses(VZV)
AOMresultsininflammation
ofthefacialnerve
Mostpatientswillrecover
within1styear
Treatmentincludespo /IV
antibiotics
Myringotomy withtube
followedbyotic drops
Popovtzer Aetal.Facialpalsyassociatedwithacuteotitis
media.Otolaryng HeadNeckSurg.2005Feb;132(2)32729.
Makeham TPetal.Infectivecausesoffacialnerveparalysis.
Otol Neurotol 2007Jan;28(1):1003.
2yo presentedtoERwith3daysof
facialasymmetryfollowingepisodeof
AOM.
58yo wm presentswith24hrs offacial

weaknessafterpreviousdxw/acutesinusitis
CToftheheadinERwasnegativefor
Stroke
PatientgivenadiagnosisofBellsPalsy
andtoldtostayonantibiotics
3weekslaterfollowsupinENToffice
Persistentfacialnerve
dysfunction(HouseBrackman
56/6)withevidenceofAOMon
earexam
3/20/2014
FacialNerveParalysiscont.
Noevidenceofhearinglossor
vertigo
Ventilationtubeplacedandear
aspiratecultured
GrewmethacillinresistantS.
aureus
PlacedonCiprodex gtts and

Augmentininitially,changedto
BactrimDS
Patientfollowedover5year
period.Noimprovementafter18
months..slowimprovement
startingat2years
Currentlyonlyfaintmarginal
mandibularweakness
Misc causesoffacialnerve
paralysis
1
.
Leftparotidmass
Cholesteatoma
Facialnerveweaknessandsevereunilateral
hearingloss3weeksafterafall
Battlessign
indicativeof
temporalbone
fracture
10
3/20/2014
NasalFracture
VeryCommon
1
.
Mostcommonfacialfracture
3rd mostfracturedbone
Highindexofsuspicionforfracture
Mechanism,Changeinappearance
Epistaxis,Nasalobstruction
Examineandpalpatenosecarefully
Instability,Mobility,Crepitation
Lacerations,Septalhematoma
NasalXrays variablereliability
EarlyENTreferral(<5days)
Closed/Openreduction early
Septorhinoplasty late
Krause C. Nasal fractures: Evaluation and repair. In: Mathog

RH, ed. Maxillofacial trauma. Baltimore: Williams & Wilkins,
1984:257
NasalFracture
Management
1
.
NasalXRay
ClosedReduction
NasalBoneFracture
Treatment:
Observation
Earlyreferral!<5days
Closedreduction Early
intervention(<10d)
inofficevsoutpatient
Septo/rhinoplasty late
Complications
Septalhematoma
Nasalobstruction
11
3/20/2014
SeptalHematoma
RarecomplicationofNBfx
Usuallypresentwithnasal
obstructionandblue
erythematousbulgefrom
nasalseptum(unilateralor
bilateral)
PromptI&Dandpackingare
crucialtoprevent
cartilaginousnecrosisof
septum/saddledeformity*
*CantyPA,BerkowitzRG.Hematomaandabscessof
thenasalseptuminchildren.ArchOtolaryngol Head
NeckSurg 1996;122:13736.
2yr oldwhopresented3weeksafterbeing
kickedbyahorsehadpresentedtoER5days
afterinitialvisitwithc/oinabilitytobreath
throughnose
NasalFracture
Complications
1
.
1
.
SeptalHematomawith
overlyingedemaand
occlusionofnare
SeptalHematoma
SeptalHematoma
www.aafp.org
Septalperforationfollowingamissedhematoma
12
3/20/2014
OrbitalBlowOutFracture
2nd mostcommonmidfacial
fracture(nasalbone1st)
Inferiorwall(maxillarysinus)
andMedialwall(ethmoid
sinus)
WatersviewXRaymayshow
fluidinmaxillarysinus
CTdiagnostic
+/ subcutaneousemphysema
Entrapmentofinferiorrectus
musclecanrestricteye
movementcausingdiplopia
Immediatereferralforsurgical
repair,otherwise310days
OrbitalBlowoutFracture
Treatment:
Surgicalrepairoforbitalfloor
Observation
AntibioticsinED
Cephalexin500QIDx10d
Referraltoophthalmology
1/3ofallorbitalblowout
fractureswithnormalinitial
eyeexamwillhaveunderlying
oculartrauma
Conjunctival
hemorrhagein
apatientw/
orbitalfloorfx
(CTbelow)
Abrasion,traumaticiritis,
hyphema,retinaltear/
detachment*
*MitchellJD.OcularEmergencies.InEmergencyMedicine6th
ed.JTintinalli ed.2004.McGrawHill.P.1458.
*Kumaretal.OrbitalTrauma:KeepanEyeoutfortheDetails.J
Fourth Annual ENT
Contemp DentPract.2012Mar1;13(2):2325
for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Orbitalblowoutfracture
MinimallydisplacedfractureRorbital
floor
BloodinLmaxillarysinus(arrow)
Orbitalcontentsdroppinginto
maxillarysinus(arrowheads)
13
3/20/2014
OrbitalFloorFracture
Evaluation
1
.
1
.
NeutralGaze
1
.
LeftOrbitalFloorFracture
UpwardGaze
SuddenSensorineural HearingLoss
(SSNHL)
Rapidonsetofsubjective
hearingloss(within72hrs)in1
orbothears
Mayonlycomplainofblocked
orpluggedear!
90%havetinnitus
Vertigo+/ assoc w/worse
prognosis*
Audiogramshowingsevere
asymmetricalhearingloss(SNHL)
Maybeonlysignofserious
problem
Atleast30dBlossin3
consecutivefrequencies
520/100kpeople4000cases
/yr
Causeonlyidentifiable1015%
ofthetimeatpresentation**
*BenDavidJetal.Vertigoasaprognosticsigninidiopathic
sensorineural hearingloss.IntlTinnitusJ.2001;7(1):62.
**Stachler,RJetal.ClinicalPracticeGuideline:Sudden
HearingLoss.Otolaryngol HeadNeckSurg.March
2012;146:S1 S35
Etiologies:
Infectious
Viral*,meningitis,lyme disease,
syphilis
Medication
aminoglycosides,
chemotherapeutics,antimalarials,
loopdiuretics
Trauma
Temporalbonefx,barotrauma
Neoplasm
Acousticneuroma(210%ofSSNHL)
Autoimmune
Vascular(CVA,cochlearinfarct)
Idiopathic
Viral,autoimmune,vascular
CoronalMRIslice
demonstratingleftsided
acousticneuroma
14
3/20/2014
PhysicalExam
Tuningforks(Weber,
Rinne)
Pneumaticotoscopy
Workup
r/otreatableetiology
Audiogram
Bloodtestsnotroutine
Lymeexceptionifsuspicion
MRIwithgadolinium
contrastattentiontothe
IACs(orbits)
ABR notassensitiveas
MRI
DistinguishSSNHLand
acuteCVAbasedon
neurologicalfindings
Ataxia
Facialweakness
UnilateralHorners
syndrome
Diplopia
*CTscanningnot
recommendedforroutine
workupofSSNHLunless
neurologicalfindingssuggest
otherwise
*Stachler,RJetal.ClinicalPracticeGuideline:Sudden
HearingLoss.Otolaryngol HeadNeckSurg.March
2012;146:S1 S35
SSNHL Treatment
Oralglucocorticoids highdose
Ideallywithin14daysofonsetof
SSNHL,butbenefitsshownupto6
weeks
Prednisone1mg/kg(60mgtaper)
or
Dexamethasone10mg/d
Prognosis:
WorseifHLprofound
Ifnoimprovementat3mos,
usuallywillnotimprove
Approx 2/3ofallSSNHLpatients
experiencesomedegreeof
recovery
Oftenwithin10days
or
Methylprednisolone48mg/d
Followupaudiogramat6months
Transtympanicmembrane
glucocorticoidinjection
Dexamethasone24,16or10mg/ml
Roughly0.5ml
Repeatq37daysfor34weeks
Monitorwithserialaudiograms
Patienteducationandcounseling
areintegralpartsoftreatment
Peritonsillar Abscess
Complicationofacute
suppurativetonsillitis
Accumulationofpurulentdebris
inthepotentialspacebetween
tonsilcapsuleandpharyngeal
musculature
Oftenahistoryofrecurrent
tonsillitisbutnotnecessarily
30casesper100kinUS
Noraceorsexpredilection
Usually3rd4th decadesand
childrenover10
Strepandanaerobesmost
common
Subtleeffacement
anderythemaofL
palatoglossal fold
andtonsilbed
15
3/20/2014
Symptoms
PhysicalExam
Malaise
Fever
Severpain razorblades
Drooling
Trismus
hotpotatoevoice
Referredearpain
Dehydration
+/ Fever
Appearuncomfortable
Trismus
Asymmetryoftonsillar
poleoftenwithbulging
anddisplacementofthe
uvulatothemidlineor
contralateralside
+/ palpablefluctuance in
tonsillar bed
Halitosis
Cervicaladenopathy
Workup:
RapidStrep/culture
Monospot
CBC
Computed
tomographyis
frequentlyusedinthe
emergencysetting,
howeverthiscanoften
beavoidedbyENT
consultationwhen
available.*
TransoralUSalsoof
utilityintrainedhands
*Blotteretal.Otolaryngologyconsultationfor
peritonsillar abscessinthepediatric
population.Laryngoscope. 2000Oct;110(10Pt
1):1698701.
Fowler2014
Treatment
Broadspectrumantibiotics
withgoodanaerobiccoverage
SignificantprotrusionofR
tonsilwithdisplacement
towardsthemidline
AugmentinorClindamycinpo
Ceftriazone orClindamycinIV
Corticosteroidsforsevere
swelling/edema
Decreasedpain*
Needleaspirationwithlarge
boreneedle
OpenI&D
Quinsytonsillectomy
IVfluidforrehydration
*Chauetal.Corticosteroidsinperitonsillar abscess
treatment:ablindedplacebocontrolledstudy.
Laryngoscope2014Jan;124(1):97103
Fowler2014
16
3/20/2014
RetropharyngealAbscess
Deepneckinfection
secondarytosuppurative
pharyngitis
Children>adults
Highmorbidityand
mortalityifleftuntreated.
GroupBstrep,anaerobes,
andgramnegative
speciesmostcommon.
MRSAontherise
AbdelHaq N,QuezadaM,Asmar BI.
RetropharyngealAbscessinChildren:
TheRisingIncidenceofMethicillin
ResistantStaphylococcusaureus.
Pediatr InfectDisJ.Jul2012;31(7):696
9
Largeinferiorpharyngealabscess
(arrowheads)
Workup/Management
Secureairway/supplemental
O2
1
CBC,bloodcultures
.
CRP>100maybeindicative
ofcomplicationsand
increasedhospitalstay*
Lateralneckfilmmaynotbe
sensitiveenough useclinical
suspicion
APdiameterofprevertebral
softtissueshouldnotexceed
thatofthevertebralbodies
Pre
vertebral
softtissue Vertebr
al
bodies
CTw/IVcontrastisgold
standard
*WangLF,TaiCF,Kuo WR,Chien CY.Predisposing
factorsofcomplicateddeepneckinfections:12
yearexperienceatasingleinstitution.J
Otolaryngol HeadNeckSurg.Aug2010;39(4):335
41
FalsePositiveLateralNeckXRay
CTwithContrast
17
3/20/2014
Treatment
Medications
AggressiveIVantibiotic
therapy
Tracheostomymaybe
requiredforairway
compromise
Majoritywillrequireeither
needleaspirationorsurgical
I&D
Clindamycin+metronidazole
PenG+metronidazole
Cefoxitin
Ticarcillin andclavulonic acid
(Timentin)
Piparacillin andtazobactam
(Zosyn)
Reviewof162patientsatSt.
LouisCHPrevealed126
requiredinitialsurgical
interventionandof36
observed,17subsequently
requiredsurgery.*
*PageNC,BauerEM,LieuJE.Clinical
featuresandtreatmentofretropharyngeal
abscessinchildren.Otolaryngol HeadNeck
Surg.Mar2008;138(3):3006
TheRedHerringTonsil
45malepresentswith1mo
h/oworseningdifficulty
swallowingandenlarged
lefttonsilonexam.
Referredfromurgentcare
withdxofPTA
Nofever,NormalWBC
Minimalthroatpain
Moderatetrismus
Noreferredotalgia
Nonsmoker
Leftnecknodesenlargedbut
nontender
PrimaryLymphomaoftheTonsil
DentalAbscess
Commonentityoften
encounteredintheprimarycare/
ERsetting
Periapical originatesinpulp
secondarytocaries(kids)
Periodontal usuallydueto
impactedFB/foodinthegingiva
Noraceorsexpredilection
Presentwithlocalizedpain/
swelling,occasionalfever
Bacteroides,Fusobacterium,
Actinomyces,
Peptococcus,Peptostreptococcus,
Strepviridans,Prevotela oralis
Fluctuantareainginigivallabial
sulcusunderlying1st Lmaxillary
premolar(#12) notedentalcaries
18
3/20/2014
DentalAbscess Workup/
Treatment
Noworkupnecessaryif
uncomplicated tear
ComplicatedAbscess:
Treatment
CBC
Bloodcultures
Aerobic/anaerobic
PriortoIVantibiotics
NeedleaspirationoropenI&Dwith
cultures(aerobic/anaerobic)
Assessairwayifsevere
presentation
I&Dfacilitatesrapidresolution
Empiricbroadspectrumantibx
coverage
Parentalantibioticsif
complicated(ie facialcellulitis)
Antibiotics:
PCN notsufficientcoverage
30%betalactamase+
organisms*
Canaddmetronidazoleor
azithromycin
Clindamycin
Amox /clav
*BrookI.Microbiologyandmanagementof
endodonticinfectionsinchildren.JClin
Pediatr
Fourth
Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Dent.2003;28(1):137
DentalAbscessI&D
Rightmaxillaryabscess
PostI&Dwithpenrose drainsewnin
Fourth Annual ENT for the PA-C | April 24-27,

2014 | Pittsburgh, PA
place
FacialCellulitis complicationof
dentalabscess
Patientfromprevious
images:
c/ofacialpain,HAand
malaise
hadlowgradefever100.1F
WBCof26,000
Mildinfraorbital
erythema/edema
(arrowhead)
Treatment:
I&Dasabove
IVclindamycin900mgTID
Referraltotertiaryoral
surgeryservice
19
3/20/2014
LudwigsAngina
1
.
Submandibular/Sublingual
Infection
Odontogenic Source(70%)
Edema/Induration Floorof
Mouth
Management
SecureAirwayEarly
Rapidprogressioncommon
Respiratorydistress(>25%)
Panorex/CTwithContrast
Determinesourceandextent
ofinfection
IVantibiotics Strep,anaerobes
MRSAontherise*
I&D
+/ Tracheotomy
*Pateletal.IsolationofStaphylococcusaureus andblack
pigmentedbacteroides indicateahighriskforthedevelopment
ofLudwig'sangina.OralSurg OralMedOralPathol OralRadiol
Endod.2009;108(5):667
LudwigsAngina
Radiology
1
.
1
.
PeriapicalAbscess
SubmandibularAbscess
DeepNeckSpaceInfections
SourceofInfection
Pediatric tonsil/sinus/otitis
Adult teeth/salivary
gland/skin
Unidentifiedsource(50%)
SignsandSymptoms
dependsonspace
Fever,Pain,Swelling(>90%)
Dysphagia,Trismus (18%)
Fluctuance
uncommon(27%)
Microbiology
StrepandStaph most
common
Gramnegative
Mixedflora(40%)
Anaerobes
LeftNeckAbscess
20
3/20/2014
DeepNeckSpaceInfections:
Management
Secureairway asneeded
CTscanwithcontrast
Cellulitisvs.Abscess
Identifiesneckspaceinvolved
Cultures bloodandaspirates
IVantibiotics
IncisionandDrainage
Obvious abscess
Failuretoimproveonantibiotics
Impendingcomplication
Complications
Mediastinitis/Sepsis,IJthrombosis
Osteomyelitis(mandible,Cspine),
Cerebrovascularcomplications
CTwithContrast
SevereFacial/DeepNeck
Infection
28yo wf statuspostdentalextraction.Presentedwithincreasingpain,
swellinganderythemaofleftfaceandneck.continueddespitep.o.
clindamycin.
Requiredtracheostomyanddebridementx5over7days
Penrosedrainsplacedinlat canthusofeyeandintraorally
Angioedema
Acutepainlessmucosaledema
Face,Lips,Tongue,Larynx
Airwayobstruction 20%
Etiology
ACEInhibitor mostcommon
HereditaryAngioedema rare
Idiopathic unknowntrigger(allergicreaction?)
AggressiveEarlyTreatment Required
SecureAirwayEarly
Epinephrine(airwaycompromise),
Corticosteroids,Antihistamines
DiscontinueACEinhibitors,NSAIDs
Medicalconsult bloodpressurecontrol
Earlyangioedemaofthe
uvulaattributedtoNSAID
intake
21
3/20/2014
Angioedema
ClinicalPresentation
1
.
1
.
Sinusitis:Complications
Orbital
YoungChildren/
Ethmoiditis
SignsandSymptoms
1
.
Lidedema,Chemosis,
Proptosis
Ophthalmoplegia,Visualloss
CTwithContrast
Subperiosteal Abscess
OrbitalCellulitisvs.
Abscess
Management
IVAntibioticsStrep,Staph
OphthalmologicEvaluation
Surgery
Ethmoidectomy
OrbitalDrainage
22
3/20/2014
Orbital
1
.
1
.
Intracranial
1
.
YoungAdults commonly
FrontalorPansinusitis
Meningitis,Epidural
abscess
SignsandSymptoms
Severeheadache,Fever,
MS
Nuchalrigidity,Seizure,
Coma
CTwithcontrast/MRI
LumbarPuncture
UrgentConsultation
ENT/Neurosurgery
IntracranialandLocal
1
.
1
.
BrainAbscess
FrontalBoneOsteomyelitis
23
3/20/2014
ImmunocompromisedHost
SinusitisCommon
HIV/AIDS75%
Chemotherapy/
Neutropenia
1
.
SignsandSymptoms
Fever,Progressive
symptoms
Poorresponseto
antibiotics
Management
CultureDirectedTherapy
EarlyCT/IVAntibiotics
InfectiousDisease
Consultation
MiddleMeatusPurulence
InvasiveFungalRhinosinusitis (mucormycosis)
ImmunocompromisedPatient
Uncontrolleddiabetic
(ketoacidosis)
Oncologicpatient
(neutropenia)
Fewsymptoms discharge,pain
Intranasalexam blackened
mucosa
CT/MRItoevaluateinvasion
Tx*:
aggressivesurgical
debridement
Antifungalagents
amphotericinB,
posaconazole
Prognosis verypoor
Correctunderlying
immunodeficiency
Controlbloodsugar
1
.
NecroticNasal
Mucosa
*Spellberg B,IbrahimA,Roilides E,etal.Combination

therapyformucormycosis:why,what,andhow?.Clin
InfectDis.Feb2012;54Suppl 1:S738
*Spellberg B,WalshTJ,Kontoyiannis DP,EdwardsJJr,
IbrahimAS.Recentadvancesinthemanagementof
mucormycosis:frombenchtobedside.Clin InfectDis.
Jun152009;48(12):174351
SelectedReferences
1. AmericanAcademyofOtolaryngologyandHead&NeckSurgery
Foundation.OtolaryngologyEmergencies.ppt Presentation Mark
Wilson,MDFACS,JohnsHopkinsDept ofOtolaryngology.1999
2. http://www.ninds.nih.gov/disorders/bells/detail_bells.htm
3. http://oto.sagepub.com
4. RamseyHuntSyndrome:
http://emedicine.medscape.com/article/1166804overview
5. ComplicationsofOtitisMedia
http://emedicine.medscape.com/article/860323overview
6. *Stachler,RJetal.ClinicalPracticeGuideline:SuddenHearingLoss.
Otolaryngol HeadNeckSurg.March2012;146:S1 S35
24
3/20/2014
Referencescontinued
7. http://www.uptodate.com/contents/subman
dibularspaceinfectionsludwigsangina
8. Angioedema:
http://emedicine.medscape.com/article/1352
08overview
25

20 - Common ENT Emergencies - Fowler

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

20 - Common ENT Emergencies - Fowler

Uploaded by

Copyright:

Available Formats

3/20/2014

Usually<2yrs old+/ h/oCOM

58yo wm presentswith24hrs offacial

PlacedonCiprodex gtts and

Krause C. Nasal fractures: Evaluation and repair. In: Mathog

for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Fourth Annual ENT for the PA-C | April 24-27,

*Spellberg B,IbrahimA,Roilides E,etal.Combination

You might also like