ENT EMERGENCIES

SUAREZ, MARIA CARINA ROSE R.

 ENT EMERGENCIES

Trauma
Aerodigestive Tract Infections
Foreign Body
Others: Epistaxis, Ear Pain, TMJ
Dislocation
 ENT EMERGENCIES

Trauma
Aerodigestive Tract Infections
Foreign Body
Others: Epistaxis, Ear Pain, TMJ
Dislocation
 ENT EMERGENCIES

Trauma
Aerodigestive Tract Infections
Foreign Body
Others: Epistaxis, Ear Pain, TMJ
Dislocation
 ENT EMERGENCIES

Trauma
Aerodigestive Tract Infections
Foreign Body
Others: Epistaxis, Ear Pain, TMJ
Dislocation
 ENT EMERGENCIES

Trauma
Aerodigestive Tract Infections
Foreign Body
Others: Epistaxis, Ear Pain, TMJ
Dislocation
 ENT EMERGENCIES

Trauma
Aerodigestive Tract Infections
Foreign Body
Others: Epistaxis, Ear Pain, TMJ
Dislocation
TRAUMA

Management of trauma:
involves multidisciplinary approach since multiple organs and
regions maybe affected
Management is directed at stabilizing a patients medical
condition and providing safe reconstruction to maximize both
functional and aesthetic rehabilitation.
Cause can be variable:
industrial, motor vehicle accidents, interpersonal altercations
(fistfight or gunshot), sports activities, work-related occurrences
TRAUMA

Basic Tenets of Initial Trauma Stabilization:

Airway
Breathing
Circulation
Disability
Exposure and Environmental control
TRAUMA: Soft Tissue Injuries

Defined as damage to any of the tissues in the body except for

bone
Include: muscles, tendons, ligaments, fascia, nerves, fibrous
tissue, fat, blood vessels, synovial membranes
Classified into 2 main groups: open and closed wounds
OPEN SOFT TISSUE CLOSED SOFT TISSUE
INJURIES INJURIES
- abrasions - contusions
- lacerations - strains
- avulsions - Sprains
- punctured wounds
TRAUMA: Soft Tissue Injuries
TRAUMA: Soft Tissue Injuries

TREATMENT:
Adequate rest, immediate application of ice, proper compression
and elevation within 48-72 hours following the injury
No HARM protocol: no heat, no alcohol, no running or activity,
no massage to be rendered to the soft tissue injury
Full recovery is expected from most soft tissue injuries in one
to six weeks
TRAUMA: Nasal Bone Fracture

Nasal bone: most frequently traumatized bone in

the body due to its exposed location
Signs and symptoms: nasal deformity, edema,
hematoma, bony crepitation on palpation, epistaxis
Classified as open or closed on the basis of
concomitant soft tissue injury
Radiograhic examination: Waters view;
soft tissue lateral is usually made to
compliment Waters view
TRAUMA: Nasal Bone Fracture

Surgical treatment is generally indicated due to the potential for

permanent nasal deformity.
Closed reduction can be performed under local anesthesia in
majority of patients.
Open fracture requires immediate surgical care accompanied by
tetanus prophylaxis and/or tetanus booster.
TRAUMA: Nasal Bone Fracture

The displaced or depressed bone

fragments can be reduced
manually or with the aid of a
special instrument elevator.
Common instruments: Asch
forceps, Walsham forceps, Boies
forceps
After reduction, nasal cavities
should be packed to provide
internal splinting
Plaster may be applied externally
for additional support
TRAUMA: Mandibular Fracture

Area of the mandible that fractures generally

depends on the nature of the external force
and the anatomic predisposition of the
mandible to fracture at specific sites.
Mandible fractures may be displaced and
distracted depending on the pull of the
muscles of mastication.
Bone fracture is classified according to line of fracture into:
- Favorable: line of fracture prevents displacement
- Unfavorable: line of fracture allows displacement
TRAUMA: Mandibular Fracture

Signs & Symptoms

- Malocclusion
- Pain
- Tenderness
- Swelling
- Motion of bony fragments
- Intra-oral lacerations
- Step Defect
Best radiographic examination: panoramic x-ray
Main goal is to restore pre-injury occlusion
TRAUMA: Maxillary Fracture

Facial bone commonly injured in low-velocity trauma

Signs & Symptoms
- Edema
- Periorbital hematoma
- Depressed cheek prominence
- Enophthalmos
- Trismus
- Cheek numbness
TRAUMA: Zygomatic Fracture

Facial bone commonly injured in low-velocity

trauma
Signs & Symptoms:
- Edema
- Periorbital hematoma
- Depressed cheek prominence
- Enophthalmos
- Trismus
- Cheek numbness
TRAUMA: Zygomatic Fracture

Repair is often accomplished on an elective basis.

Isolated arch fractures: elevated via a classic Gillies approach
Alternative: Keens technique
Main goals: restore facial asymmetry, prevent late orbital
complications
AERODIGESTIVE TRACT INFECTION:
Peritonsillar Cellulitis and Abscess

o Tonsillar infections proceed to a diffuse

cellulitis of the peritonsillar area extending to
soft palate.
o May proceed to abscess formation
o Spread on infection: start from superior
pole of the tonsil with pus formation between
the tonsillar bed and capsule
o Unilateral and the pain is quite severe
o Drooling is caused by odynophagia and
dysphagia
AERODIGESTIVE TRACT INFECTION:
Peritonsillar Cellulitis and Abscess

o Patient speaks in muffled tone or a hot potato voice

o Examination: reveal bulging peritonsillar area pushing uvula
across midline towards opposite side
o Usually polymicrobial origin both aerobic and anaerobic
o Intravenous antibiotics
o Abscess: surgical drainage by need aspiration or incision and
drainage
o Swelling: can cause significant obstruction > airway intervention
AERODIGESTIVE TRACT INFECTION:
Ludwigs Angina

Cellulitis of the superior compartment of the

suprahyoid space
Causes extreme firmness at the floor of the
mouth pushing tongue upward and posteriorly
obstructing the airway
Preparation for tracheostomy be made prior to
surgical incision through the midline
Intubation would be difficult as the tongue can
obstruct the view and cannot be compressed
by laryngoscope
 AERODIGESTIVE TRACT INFECTION:
Epiglottitis

Not seen in modern times with the advent of the

Haemophilus influenzae type B vaccine
Previously common life threatening infection in children
Child is usually seated in tripod position with his neck
sticking out and arms propped on the legs for support
Drooling and dysphagia are common
Dyspnea may progress rapidly due to the obstruction of the
laryngeal inlet secondary to the swollen epiglottitis
Death from asphyxia may occur few hours after onset
AERODIGESTIVE TRACT INFECTION:
Epiglotittis

Never press on the posterior tongue with

a tongue blade
Soft tissue lateral radiograph:
narrowing of subglottic area or an
enlarged epiglottis described as thumb
sign
Intravenous fluids and antibiotic therapy
should be started at once
Patient should carefully observe with
preparations for intubation or
tracheostomy
 FOREIGN BODY: Airway

Can occur in both children and in adults

Child: lacks molars for proper grinding and the proper
coordination of swallowing and glottis closure; tend to
put things frequently into their mouth
More often found in the right main bronchus
Initial symptoms: forceful coughing, with or without
cyanosis, dyspnea, stridor, and pain; if the foreign body
moves with respiration, an audible slap or palpable thug
would be appreciated
Chest radiograph: location of radiopaque objects
Endoscopy: for both diagnostic and therapeutic removal
of foreign material
FOREIGN BODY: Esophagus

o Ingested foreign body would present with gagging, choking, vomiting, or

drooling of saliva
o Complain of odynophagia, dysphagia, and a subjective sense of foreign body
causing retrosternal or sub sternal discomfort
o Cricopharyngeus: most common site of lodgment; other areas are
indentation of arch of aorta and entrance of stomach
o Radiographs: helpful in identifying and localization of radiopaque objects;
postero-anterior and lateral view would be required
o Radiolucent objects: a barium swallow using cotton or
marshmallow with a bit of contrast medium would be
helpful to catch foreign body upon deglutition
FOREIGN BODY: Nasal Cavity

o Child is usually brought to the clinic for

evaluation of unilateral foul smelling
discharge
o Always be presumed to be caused by
foreign body until proven otherwise
o Organic materials like beans or peanut
which would tend to swell and cause
obstruction due to moisture absorption
o Removal in a supine position would be
preferred to prevent aspiration which is
more likely if done upright
FOREIGN BODY: Ear Canal

Inanimate objects are usually asymptomatic; only noted

upon direct visualization of the ear canal
Secondary pain and bleeding may occur due to forceful
self-attempts to remove it
Hearing loss can be a possible delayed presentation
Removed using extraction hooks, irrigation, or suctioning
Pain is common during the removal process that children
may be sedated during the procedure
Removal should not be immediately done for live insects;
insects should be immobilized by flooding ear canal with
10% lidocaine solution, isopropyl alcohol or mineral oil
OTHER EMERGENCIES: Epistaxis

Common problem that would seek a

physicians help
USUAL CAUSES: acute rhinitis, allergies,
local manipulation, systemic disease such as
DM, hypertension, and blood disorders
Kiesselbachs area: most common site;
richly vascularized
Elderly: elevated BP is the most common
cause usually a posterior epistaxis
(sphenopalatine artery)
OTHER EMERGENCIES: Epistaxis

Bleeding located anteriorly:

continuous pressure on the nose from the side towards septum; head
maintained in an upright neutral position
chemical cauterization using silver nitrate sticks
If the anterior epistaxis persists, patient is seated in an upright position unless
hypotensive. Patient is asked to blow out clots followed by application of topic
vasoconstrictors such as epinephrine 1:1000 or pseudoephedrine.
Anterior nasal packing using long strips of sterile gauze impregnated with
antibiotic ointment are laid down on the nasal floor moving up in accordion
pattern to fill up the nasal cavity achieving hemostasis.
Alternatively, compressed cellulose can be used.
OTHER EMERGENCIES: Epistaxis

Bleeding located posteriorly:

Foley catheter number 14 is inserted into the nostrils up to the nasopharynx.
Balloon is inflated with 10-15 mL saline and pulled back into place using an
umbilical clamp.
Saline solution is used for inflation which would alert the patient if the balloon
ruptures once he tastes something salty.
Anterior nasal packing is then applied to complete the procedure.
For extreme cases of posterior epistaxis, vascular ligation or embolization of
the sphenopalatine artery can be done.
OTHER EMERGENCIES: Epistaxis

o Antibiotics and analgesics: to prevent infection and for pain control;

should be given to patient with anterior and posterior nasal packing;
patients with a posterior nasal pack should always be admitted
OTHER EMERGENCIES: Ear Pain

Tympanic Membrane Perforation:

Sudden alteration in pressure in the EAC
Compression (slap/hit)
Blast
Instrumentation
Burn
Fractures
Assessment: Toynbee Maneuver (if intact it will retract medially; pneumatic otoscope
Management: baseline audiogram, keep ear dry, antibiotics, 90% heal spontaneously, 10%
require tympanoplasty (harvest fascia of temporalis muscle)
OTHER EMERGENCIES:
Temporomandibular Joint
Dislocation and Reduction

o Painful condition wherein the mandibular

condyle becomes fixed in the anterosuperior
aspect of the articular eminence.
o jaw is out and mouth will not close
o Common causes: trauma to a partially opened
mandible, excessive opening of mouth after
yawning, laughing, large bite of food, dental
extraction
o Dystonic drug reaction
o Careful history and PE would be sufficient for
diagnosis
OTHER EMERGENCIES:
Temporomandibular Joint
Dislocation and Reduction

TECHNIQUE FOR REDUCTION:

Patient is seated in a low foot stool facing forward with
his back against the walk (head braced against
something firm)
Physician should be gloved with pieces of layered gauze
over the thumbs to prevent trauma > place on the
lower molar intra-orally while the fingers are wrapped
around both mandible > steady pressure downward and
posteriorly (bending from the waist)
Physicians arms are bent in a 90 degree position
Mandible should be at or below the level of the forearm
Apply cervical collar or Bartons bandage after
reduction to temporary immobilize the jaw