ENT EMERGENCY

FOR ADVANCED
DIPLOMA IN
EMERGENCY
NURSING UMMC

Dr Wong Hui Tong

Department of Otorhinolaryngology
University Malaya
 Airway obstruction
 Trauma
 Foreign body
 Head and neck infection
 Epistaxis
 Facial nerve palsy
AIRWAY
 Upper airway
 Lower airway

Important as it provide pathway for

oxygenation
UPPER RESPIRATORY TRACT
-Nostril
- Nasal cavity
- Nasopharynx
- Oropharynx
- Laryngopharynx

Note* : Trachea is
anterior to
esophagus
LOWER RESPIRATORY TRACT
 Larynx
 Trachea
 Bronchus
 Bronchioles
 Alveolus
CAUSES OF OBSTRUCTION
1. Soft tissue obstruction
- Congenital (laryngomalacia, congenital V/C palsy)
- Infection / inflammation (epiglottitis , deep neck space
infection)
- Trauma : maxillofacial / airway injuries
- Neoplasm

2. Foreign body obstruction

- teeth / denture
- secretion
- blood
- foreign debris

3. Bronchospasm/laryngospasm
CLINICAL FEATURES OF AIRWAY
OBSTRUCTION
 Stridor
 Tachypnea
 Use of accessory muscles to help in breathing
 Others : neck or facial swelling, choking sign
STRIDOR
 A type of noisy breathing that occur due to
turbulent flow through partial obstruction of
the airway

 Typically high pitched

TYPES OF STRIDOR
→ Depends on level of
obstruction

Inspiratory stridor :
• Supraglottic

Biphasic stridor :
• Glottic & subglottic
• Extrathoracic trachea

Expiratory stridor :
• Intrathoracic trachea
SIGNS OF RESPIRATORY
DISTRESS
ASESSMENT IN PATIENT WITH
STRIDOR
Clinical
 Airway (open mouth, oral cavity swelling)
 Respiratory rate
 SpO2
 Blood Pressure
 Cyanosis

Endoscopic(ENT)
Fibreoptic endoscope

Radiology imaging : x-ray or CT scan

NORMAL VOCAL CORD
LEFT AE FOLD CYST
SUBGLOTTIC STENOSIS
CT SCAN : EXTERNAL
COMPRESSION
AIM OF MANAGEMENT
 To protect a jeopardized airway

 To establish an airway when none is available

 To maintain patient’s oxygenation

INITIAL MANAGEMENT
 Oxygen supplement ( Nasal prong, face mask)

 Intravenous hydrocortisone 200mg /

intravenous 8 mg
ESTABLISHING
AIRWAY
 Oral airway and face mask
 Laryngeal mask airway

DEFINITIVE AIRWAY
 Endotracheal intubation

SURGICAL AIRWAY
 Cricothyrodotomy - percutaneous needle

- surgical
 Tracheostomy
OROPHARYNGEAL AIRWAY
ENDOTRACHEAL TUBE
CRICOTHYROIDOTOMY
 Between thyroid cartilage and cricoid
cartilage through cricothyroid membrane
IMPORTANT
 Identify signs of respiratory distress
 Identify stridor/wheezing(noisy breathing)
 Supplement oxygenation
 Prepare for further action

(Intubation/surgical airway/medications)
Meds : IV Dexa / hydrocortisone
TRAUMA
 ATLS guidelines of management

 Trauma activation – partial / full

( multidisplinary team approach )
TRAUMA
Primary survey
 A – Airway and Cervical spine protection

( ?stridor, put on cervical collar ,GCS < 8 usually

require intubation

 B – Breathing (chest movement and air entry)

( to look for pneumothorax and haemothorax

 C – Circulation and perfusion

( set iv line, GXM , compression of bleeding
wound)
 D – Disability ( GCS )

 E- Exposure

Adjuncts to primary survey :

1) ECG , pulse oxymeter, BP
2) Blood ix esp FBC
3) ABG
SECONDARY SURVEY
 Head to toe examination including per rectal
examination and log-roll for back
examination
X-RAY
 Cervical spine x-ray

 Chest x ray
( haemothorax,pneumothorax,widened
mediastinum)

a measured width greater than 6 cm on an

upright PA chest X-ray or 8 cm on supine AP
chest film

 Pelvic x ray
HAEMOTHORAX
PNEUMOTHORAX
WIDENED MEDIASTINUM
ENT TRAUMA
 Nasal trauma
 Ear trauma
 Temporal bone fracture
 Neck trauma
 Laryngeal trauma
 Inhalational injury
NASAL TRAUMA
NASAL TRAUMA
 Nasal bone fracture
 Usually TCA the patient in 5 days while
awaiting swelling to subside.
 Nasal bone # with deviation can undergo
nasal bone reduction

 Septal haematoma
 Need to be drained immediately
 If untreated, can become abscess or cause
septal necrosis
 HAEMATOMA OF EAR
Need to aspirate/drain
and apply bandage
compression/splint
compression
TEMPORAL BONE FRACTURE
Why temporal bone fracture in ENT ?
 Ossicles and inner ear in temporal bone
 Facial nerve course through temporal bone

Sx :
Asymptomatic
Hearing loss
Facial nerve palsy
Vertigo
 Hearing test
( PTA / Tympanometry )

 ENoG / EMG if facial nerve palsy

 Management to specific injuries

NECK TRAUMA
 Aetiology

1) Penetrating wound ( stab / Gunshot wound)

2) Blunt trauma

3) Blast injury (explosion)

PENETRATING INJURY TO NECK
 Do Not remove
ROON AND CHRISTENSEN

Base of skull

Sternal notch
SYMPTOM
 Hoarseness
 Voice change
 Stridor
 Surgical emphysema
 Hemoptysis
 Dysphagia
 Odynophagia
 haematemesis
SELECTIVE SURGICAL
EXPLORATION ALGORITHM
MANAGEMENT
 Observation for small pharyngeal and
esophageal injuries

 Antibiotics

 Nil by mouth

 Surgical management ( endoscopic / surgical

exploration with primary repair )
LARYNGEAL TRAUMA
Pathologic consequences :
1 ) Hyoid bone fracture
2 ) Cartilage injuy – thyroid cartilage ,
arytenoid cartilage
3) Soft tissue :haematoma ,edema , abrasion
EXTERNAL LARYNGEAL
FRAMEWORK
ENDOLARYNX
SCHAEFER CLASSIFICATION
1) Minor endolaryngeal haematomas or
lacerations without detectable fracture

2) More severe edema and haematoma, minor

mucosal disruption without exposed
cartilage , non-displaced fracture

3) Massive edema, large mucosal lacerations,

exposed cartilage, displaced fracture,vocal
cord immobility
4 ) same as 3 +
more severe with disruption of larynx
anterior larynx, unstable fracture, two or more
fracture lines or severe mucosal injuries

5) Complete laryngotracheal separation

INHALATIONAL INJURY
 Hot air/Smoke/Steam

 Fire in confined space

 Anticipate edema and airway obstruction in

inhalational injury
SIGNS OF INHALATIONAL
INJURY
 Soot / Carbonaceous sputum

 Singed nasal hair

 Burned nasal hair

ANTICIPATE EDEMA AND AIRWAY
OBSTRUCTION IN INHALATIONAL INJURY
FOREIGN BODY
 Usually not life threatening except large
object obstructing airway
 Still can lead to marked morbidity (eg
battery)
 Common in children
TYPES OF FOREIGN BODIES
Organic Inorganic
• sponge • bead
• eraser Non-living
• metal
• paper • stones
• wood • plasti c toys
• beans • butt on batt ery
• nuts Living
• worms
• maggots
FOREIGN BODY
Ear
FOREIGN BODY : EAR
 Almost invariably confined to children
→ accidentally/self/friends
 Emergency when associated with vertigo,
profound hearing loss and/or facial palsy
 Do not irrigate organic material (beans) or
with a TM perforation/grommet
 Diagnosis : Otoscopy
: EUM
FOREIGN BODY : EAR
 MANAGEMENT:
 Removal usually in clinic
 Under GA if:
→ Severely impacted
→ Associated with severe OE Insects:
→ Kill first
→ Olive oil, chloroform water,
lignocaine spray
FOREIGN BODY EAR
 Syringing

Do not irrigate/syringe:

→ organic material (vegetables)
→ TM perforation
→ grommet
→ active infection
FOREIGN BODY : EAR
 Suction
 Cold instrumentations
 → Forceps (crocodile)
 → Right angle hook
 → Jobson’s
FOREIGN BODY : EAR
 Role of surgery ???
 → Hard object beyond the isthmus
 → Post-auricular incision
FOREIGN BODY EAR
 • ALWAYS check on the other ear !

 • most complications are due to attempt of

FB removal !!!

 • treat Otitis externa if any!

FOREIGN BODY IN NOSE
Battery
FOREIGN BODY IN NOSE
 Unilateral nasal discharge
 Initially mucoid → mucopurulent with foul smelling
 Epistaxis

Diagnosis:
→ High index of suspicion
→ Unilateral nasal discharge
•Foul smelly/purulent/blood-
stained
→ Unilateral nasal obstruction
Unilateral nasal discharge : FB until proven otherwise !!!
 1st effort is the best !
 Child – upright sitting position with head hold
in position
MANAGEMENT
Removal under LA:
→ Most cases removed in clinic
→ Anteriorly placed
→ Coorperative

Removal under GA with endotracheal intubation :

→ Impacted
→ Uncoorperative
→ Bleeding
→ Posteriorly placed
→ Rhinolith
IMPORTANT POINTS
 Unilateral nasal discharge – assume FB unless
proven otherwise
 Do not push FB backwards → risk of
aspiration
 Always inspect the other nostril or ears
 Antibiotic coverage if infection present
 If FB displaced backwards or suspected
aspiration :

 OBSERVE PATIENT
 CXR
 BRONCHOSCOPY
FOREIGN BODY OF UPPER
DIGESTIVE TRACT
 Fish bone/chicken bone
 Pieces of meat
 Coins
 Toys
 Dentures
FOREIGN BODY : UPPER
DIGESTIVE TRACT
Etiology
 Age: Children and adults/elderly
 Accidental
 Altered sensorium (Reduced protective
reflexes)
 Dentures, drugs, alcohol
 Carelessness: Poor mastication
 Psychiatric
 Esophageal strictures
FOREIGN BODY THROAT
 Tonsil
 Base of tongue
 Pyriform fossa
 Area of constrictions

Common at the constrictions

 15 cm : cricopharynx
 25 cm : arch of aorta
 27 cm : Left bronchus
 40 cm : Right crus of diaphragm
FISH BONE AT LEFT TONSIL
FOREIGN BODY OF THROAT
Fish Bone
FOREIGN BODY IN ESOPHAGUS
SWALLOWED COINS
DENTURES
SYMPTOMS
 H/O FB ingestion in adults → able to localize
 Children and insane H/O FB ingestion +/-
Discomfort / FB sensation
 Throat / retrosternal pain

 Dysphagia / odynophagia
 Drooling of saliva, excessive salivation
 Dyspnoea
 Hoarseness/ stridor → in case of laryngeal
odema / large FB
FOREIGN BODY OBSTRUCTION
 Hemlich Maneuver
MANAGEMENT
 History
 Clinical examination
 X-ray

Acute management eg Heimlich manuver

Foreign body removal
 Easily removed for foreign body at tonsil or
base of tongue
 Other sites foreign body might be difficult to
see and require Direct laryngoscopy and Rigid
esophagoscopy under GA to visualized and to
remove
TRACHEAL AND BRONCHUS
FOREIGN BODY
Suspect in patient with recurrent
pneumonia/wheezing

CXR

Rigid bronchoscope and foreign body removal

TRACHEAL FOREIGN BODY
ENT , HEAD AND NECK
INFECTIONS
 Usually localized to the organ involved
 Serious complications can occur in view of
close proximity to the skull base and brain
 Infections/abscess also can lead to airway
obstruction
 Can also cause mediastinitis
PERICHONDRITIS OF EAR
 Inflame
 Redness
 Tender
 Fever

Common cause : CMC

Mx : antibiotic ,
steroid cream
OTITIS MEDIA ? EMERGENCY
 Extracranial Complication:
 Mastoiditis
 Petrositis
 Facial paralysis
 Labrinthitis

 Intracranial Complication:
 Extradural abscess
 Subdural abscess
 Meningitis
 Brain abscess
 Lateral Sinus Thrombophlebitis
 Otitic hydrocephalus
MASTOIDITIS / ABSCESS
INFECTIONS OF THE NOSE
 Septal abscess
 Sinusitis
SEPTAL ABSCESS/ HAEMATOMA
 Collection of blood under perichondrium of nasal septum.
 Cause by trauma, septal surgery or bleeding disorder.
 Presents as bilateral nasal obstruction, painful, fever

Examinations :
 smooth swelling of the septum which soft and fluctuant.
 Inflame septum

Management :
 Aspirate, I&D, drain, antibiotic.

Complications:
 Organized cause thicken septum
 Necrosed cartilage cause depress nose
 Septal perforation
SINUSITIS
SINUSITIS
 Purulent nasal discharge.
 Facial pain.
 Nasal block.
 Vague headache.
 Halitosis.
 Anosmia.
 Post- nasal drip with cough.
EXAMINATIONS
 Mucopurulent discharge from middle
turbinate.
 Tender on palpation.
 Anatomical variant - Deviated nasal septum
concha bulosa.
 Nasal polyposis.
 Mucosa oedema from recurrent infection.
? EMERGENCY
Associated with complications eg :

Facial cellulitis
Orbital cellulitis
Orbital abscess
Intracranial abscess
ORBITAL CELLULITIS / ABSCESS
FACIAL CELLULITIS
MANAGEMENT OF SINUSITIS
 Management of complications
 IV antibiotics
 Nasal decongestion
 Sinus : Drainage ( endoscopic / caldwel luc)
LARYNGOLOGY , HEAD AND
NECK INFECTIONS
 Acute and chronic infection to Head and
Neck region
 Acute tonsillitis
 Peritonsillar Abscess (Quinsy)
 Ludwig Angina
 Parapharyngeal Abscess
 Retropharyngeal Abscess
 Acute Epilgotitis
ACUTE TONSILLITIS
 IV drip if poor oral intake
 Antibiotics if bacterial infections
PERITONSILLAR ABSCESS
(QUINSY)
 Collection of pus in the peritonsillar space

Aetiology:
 Crypta magna infected burst through the tonsillar capsule into
peritonsillar space

Clinical Features :
 Adult > Children
 Generalised malaise, fever
 Odynophagia
 Foul breath.
 Muffled voice
 Trismus
 Ear pain.
PERITONSILLAR ABSCESS
On Examination:
 Pillars and soft palate congested and swollen.
 Uvula swollen and push opposite side.

Treatment:
 Antibiotic
 Analgesic
 I&D

Complication:
 Parapharyngeal abscess
 Airway compromise
LUDWIG ANGINA
LUDWIG ANGINA
 Infection of Submandibular space
between mucosa membrane of the
floor of mouth, tongue and extend
between hyoid and mandible

 Diffuse cellulitis of floor of mouth

Aetiology:
 Dental / Sialadenitis.

Clinical features:
 Difficult in swallowing
 Submandibular swelling
 Raise floor of mouth
 Tongue push up and back
 Difficult in breathing
 Abscess may be present.
Treatment :
 Systemic Antibiotic
 Surgical: I&D
 Tracheostomy

Complications:
 Spread to
parapharyngeal,
Retropharyngeal,
Mediastinum.
 Airway obstruction
 Septicaemia
 Aspiration pneumonia
DEEP NECK SPACES INFECTIONS
 Ludwig angina
 Parapharyngeal space
 Retropharyngeal space
 Preverterbral space
 Masticator space

Occur because there are different fascia lining

the neck
NECK ABSCESS
PARAPHARYNGEAL ABSCESS
PARAPHARYNGEAL ABSCESS
Clinical Features:
 Neck Swelling
 Odynophagia
 Sorethroat

Complication:
 Air way obstruction
 Thrombophlebitis
 Carotid Aneurysm
 Retropharyngeal abscess
 Mediastinitis
 EPIGLOTTITIS
Common in children age 2-7
Aetiology:
H. influenza/ Staphylococus
Clinical Features:
Abrupt onset
Dyspnoea and stridor
Fever
Tripot signs
Drowling of saliva.
Examination to the larynx try to avoid
Lateral Neck X ray: Thumb sign
Rx:
Addmission
Antibiotic
Steroid
KIV Tracheostomy/ intubation.
AIRWAY COMPROMISE
ENT INFECTIONS
 Can be potentially fatal
 Can cause airway obstruction

Investigations :
Blood : FBC , RP
Radiographic : CT scan

Management :
1) Airway
2) Antibiotics
3) Surgical Drainange
Thank You
QUESTIONS
EPISTAXIS
LOCAL (ENT)

 Spontaneous
 Trauma
 Post-operative
 Tumours ( angiofibroma )
 Telangiectasia
 Rhinitis
ANGIOFIBROMA
GENERAL/SYSTEMIC CAUSES
 Hypertension
 Haemophilia
 Leukaemia
 Anticoagulant therapy
 Thrombocytopenia
BLOOD SUPPLY OF SEPTUM
MANAGEMENT ---COMPRESSION
FURTHER MANAGEMENT
 Nasal Packing

Cauterisation–chemical
 Silver nitrate
Tri-ChloroAcetic acid (TCA)

 Bipolar cauterisation

 Surgical Management (endoscopic SPA ligation ,

ECA ligation , ligate ant and post ethmoidal
artery)
BIPP (BISMUTH IODOFORM
PARAFFIN PASTE)
NASAL PACKING- ANTERIOR
POSTERIOR PACKING
POSTERIOR PACKING WITH
FOLEY CATHETER
INITIAL MANAGEMENT
 Investigate for systemic causes and correct
coagulopathy
 Maintain haemodynamic

( IV line, IV drip , blood product )

 Oxygen
 Tranexamic Acid IV
 Prepare for packing…
PREPARATION
 Gloves
 Mask
 Apron
 Ribbon Gauze
 Head light
 Adrenaline (for packing)
 Umbilical clamp
 Merocel / Foley Catheter / Posterior packing
PERSISTENT EPISTAXIS
Endoscopic assessment in OT :
KIV sphenopalatine artery ligation/ external
carotid artery ligation/ anterior and posterior
ethmoidal artery ligation

Angiogram and embolization

FACIAL NERVE PALSY
ORBITAL! (EARLY)
1)EXPOSURE KERATITIS
2)CORNEA ULCERATION
INVESTIGATIONS
 HRCT temporal

 Topodiagnostic test (Schimer

test,taste,stapedial reflex)

 Nerve conduction study(ENoG) / EMG

COMMON DISORDERS IN ENT

 Bell’s palsy
 Ramsay Hunt syndrome
 Middle/external ear diseases
 Otitismedia
 Cholesteatoma
 Malignant otitisexterna
 Trauma
 Iatrogenic: parotid, temporal bone surgery
 Accidental: temporal bone fracture
 Facial neuroma
MANAGEMENT
 Facial nerve exercise
 Eye pad at night
 Artificial tears ( 2 drops every 2 hours)
 Steroids ( oral / IV )
 Surgical exploration