COMMON ENT- HNS

EMERGENCIES
(Kegawatdaruratan di Bidang THTKL)

By :
T. Husni T.R,dr.,M.Kes.,SpTHTKL (K).,FICS

ENT - HNS Department / Unsyiah

Zainoel Abidin Hospital
2018
 Emergensi di Bidang THTKL :

 Ear
 Nose
 Throat
 Miscellanous
 Common ENT emergencies
 Foreign bodies
 Trauma
 Complications of ENT infections
 Foreign bodies
 Insects
 Cotton, paper, organic
material
 Small batteries
 Discomfort & agitation
 Secondary complications:
infection & mucosal
erosion
 Foreign bodies

 Kill any live insects

 Remove foreign body
with micro alligator
forceps
 Irrigation ( do not use if
organic FB )
 Auricular Hematoma
 Usually from trauma
 Fluctuant bluish swelling
of auricle
 Drainage
- Needle aspiration
-I&D
 Apply compression
dressing
Traumatic Tympanic Membrane
Perforation
 Compression,
instrumentation &
blast injuries
 Hearing test
 Close observation if
perforation is small
 Paper patch
 Surgery
 Temporal bone fracture
 Blunt head injury
 Longitudinal Fx →
facial n. paralysis,
CHL (ossicular chain
disruption)
 Transverse Fx → SNHL,
dysequilibrium,
CN VII palsy
 Temporal bone fracture
 Battle’s sign (bluish
discoloration of
postauricular region),
raccoon eyes,
hemotympanum, hearing
loss, dizziness, CSF
otorrhea, CN VII palsy
 CT temporal bone
 Acoustic trauma
 Sudden exposure (impact or blast) to noise
 SHNL, tinnitus
 Avoidance/ ear protection
 Corticosteroids, carbogen, vasodilators,
diuretics, anticoagulants, plasma expanders
 Otitic Barotrauma
 Inability to ventilate
middle ear → abnormal
dysfunction of ET
(Eustician Tube)
 Occur in rising ambient
pressure (descent in
flight / scuba diving)
 Can produce
hemotympanum
 Barotrauma

 Repeated Valsalva
maneuver
 Topical nasal
decongestants
 Myringotomy & PE tube
insertion may be needed
 Sudden Hearing Loss
 SNHL ≥ 30 dB over 3
contiguous frequencies
within 3 days or less
 Etiology : Viral &
Infectious, Vascular,
Trauma, Autoimmune,
Neurologic
Complications of Middle Ear infections

 Extracranial
 Acute Mastoiditis

 preceded by AOM
 young children
 severe pain, fever, edema
over mastoid area
 intravenous ATB
 Myringotomy ± PE tube
 Subperiosteal Abscess

 pinna pushed
down & outward
 intravenous ATB
 I&D
 mastoidectomy
 Complications of ME infections
 Intracranial
 Foreign bodies: Symptoms

 Purulent unilateral nasal

discharge
 Usually lodge on the
floor of anterior or
middle third
 Foreign bodies: Management
 Good visualization:
headlamp & nasal speculum
 Alligator forceps should be
used to remove cloth, cotton,
or paper
 Other hard FB are more
easily grasped using bayonet
forceps or Kelly clamps, or
they may be rolled out by
getting behind it using an ear
curette, single skin hook, or
right angle ear hook
 Nasal Fracture

 Hx of fall or force
directed to midface
 Deformity of nose
 Swelling, ecchymosis,
epistaxis
 Close or open reduction
 Septal hematoma/abscess
 Trauma, surgery
 Soft, fluctuant swelling
of septum
 Needle aspiration
or I&D
 Bilateral nasal packing
for several days
 Prophylactic antibiotics
Septal hematoma/abscess
 Epistaxis
 Local  Systemic
Trauma /Nose picking or Blood diseases
blowing / surgery Hereditary hemorrhagic
Dry air / Irritants telangiectasia
Topical medications Drugs (anticoagulants)
(steroids) Hypertension
Foreign body
Tumor / polyp
Epistaxis
 Epistaxis
 Initial first-aid  Most common →
 Assessment of blood loss Kiesselbach’s Plexus
 Evaluation of cause  Squeeze nose 5-20 mins
 Procedure to stop  Insert cotton pledget
bleeding (with decongestant)
 Cautery with silver
nitrate
 Figure 1 Epistaxis management protocol.

Pope, L E R et al. Postgrad Med J 2005;81:309-314

Epistaxis
 Anterior nasal packing
 Local anesthetic &
decongestant
 Nasal packing
- Vasaline guaze
- Absorbable gelfoam
- Oxidized cellulose
(Surgicel)
- Nasal tampon
Anterior nasal packing
 Anterior nasal packing
 Nasal packing
- Vasaline guaze
- Absorbable gelfoam
- Oxidized cellulose
(Surgicel)
- Nasal tampon
 Anterior nasal packing
 Nasal packing
- Vasaline guaze
- Absorbable gelfoam
- Oxidized cellulose
(Surgicel)
- Nasal tampon
 Anterior nasal packing
 Nasal packing
- Vasaline guaze
- Absorbable gelfoam
- Oxidized cellulose
(Surgicel)
- Nasal tampon
 Figure 2 Correct insertion of a nasal tampon (note that the direction is along the floor of the
nasal cavity).

Pope, L E R et al. Postgrad Med J 2005;81:309-314

Copyright ©2005 BMJ Publishing Group Ltd.

 Posterior nasal packing

 Topical anesthetic &

decongestant
 Posterior nasal
packing
 Double balloon device
 Foley catheter
 Posterior nasal packing

 Topical anesthetic &

decongestant
 Posterior nasal packing
 Double balloon device
 Foley catheter
Posterior nasal packing

 Topical anesthetic &

decongestant
 Posterior nasal packing
 Double balloon device
 Foley catheter
 Complications of sinusitis
 Orbital complications
 Intracranial complications
Classification of orbital inflammation
Stage Inflammation
I Inflammatory edema
(periorbital cellulitis)
II Orbital cellulitis
III Subperiosteal abscess
IV Orbital abscess
V Cavernous sinus thrombosis
 Complications of sinusitis
 Periorbital cellulitis:
periorbital erythema,
edema, pain & fever
 Purulent nasal discharge
 S.pneumoniae, S.aureus,
coagulase-negative
staphylococci
 Broad-speculum
antibiotics
 Complications of sinusitis
 Orbital complications
(stages II-V)
 Periorbital swelling &
pain, fever
 Proptosis, chemosis,
restriction of ocular
movement & visual
disturbance
 Complications of sinusitis
 CT scan → subperiosteal
& orbital abscess
 Admission & IV broad-
spectrum antibiotics
 Surgery (drainage) if
- failed medication
- develop abscess
- visual drop
 Complications of sinusitis
Intracranial complications
 Cavernous sinus thrombosis, meningitis,
extradural abscess, intracranial abscess &
subdural empyema
 Purulent rhinorrhea, fever, frontal/retro-orbital
headache
 Personality change/lethargy, seizures, N/V,
focal neurological deficits
 Complications of sinusitis
Intracranial complications
 Diagnosis → MRI scan with gadolinium

 Admission, IV broad-spectrum antibiotics &

surgical drainage
 Swallowed foreign body

 Peanuts, coins, batteries,

fish bone, meat & bone
pieces, dentures
 Location of pain
indicates FB location
 Swallowed foreign body

 Fish bones tend to lodge

in oropharynx, produced
ipsilateral symptoms
 Esophagus FB localize in
midline: dramatic acute
dysphagia
 Swallowed Foreign bodies

 Most FB in oropharynx
can be identified
 Esophageal FB: pooling
of saliva in piriform
 X-rays may be helpful in
radio-paque objects
 Swallowed Foreign bodies
 Visualized FB can be
removed with angled
forceps
 Sharp FB should be
removed at the earliest
opportunity due to risk
of perforation
 Swallowed Foreign bodies

 Coins → removed if in
cervical or mid
esophagus → removed
within 12 hrs if in distal
esophagus
 Batteries → removed
emergency
 Swallowed Foreign bodies
 Airway compromise
- Heimlich maneuver
- Emergency
cricothyrotomy/
tracheostomy
 Endoscopy with removal
in OR
 Inhaled Foreign bodies
 Sudden onset of
coughing, wheezing or
stridor in previously
healthy child
 Unilateral wheezing,
poor chest movement &
reduced breath sound
 CXR: hyperinflate,
infection, collapse
 Inhaled Foreign bodies

 Heimlich manuver
 Secure airway
 Endoscopic removal
under general anesthesia
 Airway Obstruction
 Neonatal : Congenital tumors, cysts, webs
: Laryngomalacia
: Subglottic stenosis
 Children : Laryngotracheobronchitis
: Supraglottitis (epiglottitis)
: Foreign body
: Retropharyngeal abscess
: Respiratory papilloma
 Adults : Laryngeal cancer
: Laryngeal trauma
: Epiglottis & deep neck infection
Deep neck infections
 Peritonsillar abscess

 Pus forms between

tonsils capsule &
superior constrictor
 Group A Streptococcus
 Peritonsillar abscess

 Severe, unilateral sore

throat
 fever
 Hot potato voice
 Uvula deviates to
opposite side
 Swollen tonsils
 Peritonsillar abscess

 CBC, throat C/S

 Antibiotics
- Oral
- Parenteral
 needle aspiration or I&D
 Ludwig’s Angina
 Rapid swelling cellulitis
of sublingual &
submaxillary spaces
 Dental infection, floor of
mouth, salivary gland
 Fever, edema &
erythema of neck under
chin & floor of mouth
 Ludwig’s Angina
 Open mouth,
 Tongue → upward &
backward → airway
obstruction
 Streptococci, Bacteroides,
S.aerues
 Tracheostomy
 IV antibiotic
 I&D, tooth extraction
 Epiglottitis
 Age 3-7 yrs old
 H. influenzae type B,
Group A Streptococcus
 severe sore throat &
fever, dysphagia, drooling
 Stridor
 Breathing with raised
chin & open mouth
 Epiglottitis

 CBC: leukocytosis
 Film lateral neck →
thumb shaped epiglottis
 Avoid tongue depressor
 Controlled intubation
 Intravenous ATB
 Retropharyngeal Abscess
 Infants & children
 Secondary to
oropharyngeal infection
 Severe dysphagia &
respiratory distress
 airway observation
 IV antibiotic
 Surgical drainage
( prevent pus aspiration)
 Tracheostomy
Emergency tracheostomy
in the case of upper airways
obstruction
1. Tumor in the larynx
2. Trauma of the larynx
3. Bilateral vocal cord
paralysis
4. F.B. in the larynx after
failure of Heimlich’s
manuver
Teunom Atjeh Jaya District Jan 2005
@ Field Hospital, Just a Volunteer