Ear, nose and throat

emerg-ENT-cies

with Laura Wilkins

 Contents

Ear emergencies Nose emergencies Throat emergencies

Be sure to add the appropriate symbol to each slide!

 Question 1: How confident do you feel
in management of ENT emergencies?
• I am actually an ENT consultant!
• I feel very confident
• I feel reasonably confident
• I have some idea of some emergencies
• I don’t feel confident at all

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A quick note on history/exams
• In an emergency setting, the key thing is to follow your ABCDE approach, and take a
focused history and examination that will keep the patient safe.

• Otherwise, follow the standard history-taking methods: presenting complaint, medical

history, medications, allergies, systems review etc etc.
• This presentation focuses on the add-ons or extra-important parts you need to not
forget – but the standard history structure is still important.

• In terms of examination, if you’re admitting someone acutely unwell, it’s still important
to do a clerking exam – consider any cardiac/respiratory/gastrointestinal/neurological
signs and symptoms.
• This presentation focuses on the focused aspects of the examination.
Ear emergencies
 Ear
emergencies

Case 1
A 65 year old man presents to his GP with left-
sided hearing loss that occurred overnight. His
GP sent him to A&E.
He is also suffering from vertigo, and is taking
cyclazine for symptomatic relief.
 Ear
emergencies

Sudden sensorineural hearing loss

Presentation:
Unilateral hearing loss over hours
Vertigo

Causes:
Infection
Trauma
Autoimmune disease (eg. MS)
Medications
Blood supply
Inner ear disorders (eg. Meniere’s disease)
 Question 2: Which bedside test is
important to determine the type of
hearing loss?
• The “hum” test
• Weber’s test
• Rinne’s test
• An audiogram

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 Ear

Sudden sensorineural hearing loss

emergencies

Investigations:
We need to exclude concerning differentials so we can treat
them! SSHL is a diagnosis of exclusion.

History – trauma, infection, pain

Examination – cranial nerves, infection, ear canal obstruction
Rinne and Weber tests
Audiography
 Ear
emergencies

Sudden sensorineural hearing loss

Management:
Steroids, 1 week – ENT may perform tympanic steroid injection
Audiogram the next working day
(consider antivirals)
Ear inflammation
Most
Condition common Findings Management Complications
causes
Otitis externa Infection - Otalgia (ear pain) Aural toilet – microsuction Necrotising/
Pseudomonas Itching Antibiotic + topical steroids malignant OE
aeruginosa History of swimming Keep ear dry – pope wick
Staph aureus Deafness
Candida sp Plaques or discharge on examination
Aspergillus Narrowed ear canal
Necrotising/ Diabetes or Ear pain out of proportion (at night) MDT management – ENT, ID, micro, Local infection and
malignant immune Non-resolving OE diabetes, SALT, physio, opthalmology inflammation -
otitis externa suppression – Trismus (lockjaw)/jaw pain Swab and culture discharge, meningitis,
skull base Cranial nerve findings (VII, IX, X, XI) inflammatory markers encephalitis,
osteomyelitis Granulation tissue where cartilage Order ESR if low likelihood NOE – cerebral abscess,
and bone meet in ear canal can rule it out cavernous venous
High ESR CT bone scan – temporal bone thrombosis,
calcium loss/osteitis aspiration due to
Oral ciprofloxacin 6-8 weeks palsy, can be fatal
Admit if unwell, consider surgery
Ear inflammation
Most
Condition common Findings Management Complications
causes
Acute otitis Infection Children (common) Analgesia – most resolve! Local – facial
media Allergies Otalgia Antibiotics if <2yo, bilateral, local weakness,
Pyrexia complications, severe, recurrent, >3 dizziness, visual
Otorrhoea (discharge) days change, neck
Tugging ear, poor feeding, swelling
restlessness Mastoiditis
Chronic – glue ear
Mastoiditis Complication Swelling over mastoid process – Admit Hearing loss
of AOE cardinal signs of inflammation IV antibiotics Cranial nerve
Pyrexia CT scan involvement
?Surgery Local infection
 Ear
emergencies

Case 2
A 3 year old girl is presented to A&E by her father. She
is restless, crying unconsolably, and keeps tugging at
her ear. When her father has tried to have a look at her
ear, the girl won’t let him, and gets more upset.
 Question 3: What should we do?

• Take a thorough history

• Do an initial examination of the ear before acquiring equipment
• Acquire a headlamp or good light
• Acquire suction
• Acquire an otoscope and immediately look in the ear

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 Ear
emergencies

A foreign body in the ear

History:
What could the foreign body be? How worried should we be?
Triage – refer batteries/magnets (risk of tissue necrosis). Treat
<24 hours if penetrating/impacting/swelling

Examination:
They may have pain, inflammation or discharge
Get your equipment ready before examining, as we don’t want
to upset the child
Prepare the parent to hold their child, but we don’t want to
make anything worse!
Make sure you have a light (headlamp best)
 Ear
emergencies

A foreign body in the ear

Management:
Prepare equipment based on
what it could be:
• Hook/forceps
• Saline for irrigation
• Olive oil to kill insects
• Tissue adhesive+cotton swab
 Nose
emergencies

A foreign body in the nose

History & examination: as with ear
May have discharge, odour, epistaxis.
Nasal speculum required

Management:
Attempt positive pressure – parent’s kiss, puff from
bagvalve over mouth with opposite nare occluded
1:1 oxymetazoline:lidocaine to reduce swelling
 Throat
emergencies

A foreign body in the throat

History: as with ear

Examination:
Assess for airway compromise – ABCDE!
Examine oral cavity, tonsils. ?flexible
nasoendoscopy
Can use x-ray

Management:
If soft, conservative management (unless
obstructing airway/persistent)
If sharp/battery, refer urgently to ENT, general
surgeons, anaesthetists
Basic summary of ear emergencies
SSHL Inflammation Foreign body

Good history/exam Locate

to exclude infection, Gather information
trauma etc Good history and first – history!
exam
Assess if Get a good view
sensorineural or Assess if complicated
conductive – diabetes/immune If it can’t be treated
suppression, cranial by you, refer
Steroids nerves, mastoiditis
Halfway point!
LET'S TAKE A MINUTE TO RECHARGE...
Nose emergencies
 Nose
emergencies

Case 3
A 54 year-old inpatient on the haematology ward has had a nose bleed for the last hour. The
ward have attempted to manage this with applying pressure to the anterior portion of the
nose, but it has not resolved.
You are called to the ward to treat him in the treatment room there.
He is not on any anticoagulant medication. His FBC is 98, platelets 54.
 Question 4: From which area of the
nose does most epistaxis occur?
• Anterior third
• Middle third
• Posterior third

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 Nose
emergencies

Epistaxis
Presentation: bleeding from the nose. Common!

Causes:
Most epistaxis occurs in Little’s area (Kiesselbach’s
plexus – an anastomosis of 5 arteries)
Clotting disorders/low platelets
Trauma
Increased pressure in the nose

History:
Where is the bleed? What is its extent?
Epistaxis/trauma/surgery/medical Hx
Medications, social Hx
 Question 5: Which of the following will
you NOT require for treatment?
• Nasal speculum
• Eye protection
• Suction
• Antibiotics
• Headlamp

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 Nose
emergencies

Epistaxis: initial management

Prepare mask, goggles, headlamp, apron, gloves,
suction, speculum

ABCDE
A/B - Suction any clots in mouth. Take observations
(?O2 required)
C - Estimate blood loss

Manage initially with anterior compression

Ice on forehead, base of neck, on palate – can reduce
blood flow up to 25%!
Oxygen, OIV access, FBC, clotting, G&S
Epistaxis
Further management:

Visualise bleed
Apply cotton soaked in adrenaline/ lidocaine
to stem bleeding
Silver nitrate cauterization – 15 secs on dry
edges of bleeding site. Moisturise after
Pack if bleeding continues – remain up to 3
days if anti-coagulated. Consider antibiotics if
longer than this only!
 Nose
emergencies

Posterior epistaxis
In older patients: can be severe,
arterial, posterior!

Consider posterior bleed if you can’t

visualize the bleed focus, or if
bilateral packing doesn’t stop it.
Consider IV fluids, admission

Foley balloon catheter packing!

Surgery for haemostasis if packing
fails L
 Nose
emergencies

Another emergency: nasal fracture

Cause: trauma

Investigation: assess if simple fracture (otherwise need x-ray)

Reassess for deviation after 7 days, when swelling subsides

Management:
Manipulate within 2 weeks – if cosmetic deformity/nasal obstruction
Closed or open reduction
Assess for septal haematoma (obstruction)
Basic summary of nose emergencies
Epistaxis Nasal fracture Foreign body
Assess site and Assess if complex
extent of bleeding
Gather information
Manipulate within 14 first – history!
Attempt simple days
management if
Get a good view
stable Assess for septal
haematoma If it can’t be treated
Cautery/packing if
by you, refer
complex/severe
bleeding
Throat emergencies
 Throat
emergencies

Case 4
A 3 year-old boy is brought in to paediatric A&E by his
mother, who is concerned about his breathing. He has a
several day history of sore throat and fever, which has not
resolved, but instead rapidly worsened over the last few
hours. He did not present before now as his mother
thought she was a simple infection.
On observation, his breathing sounds strained (potentially
stridor), and he looks very uncomfortable and upset.
 Question 6: Which is the most
important initial management?
• Take a very thorough history before acting
• Examine his throat
• Give antibiotics
• Do not examine his throat
• Get IV access

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 Throat
emergencies

Epiglottitis
This is considered a surgical emergency until the
airway is examined and secured.

Do NOT upset the child by:

- Examining the mouth or throat
- Putting in a cannula
- Venepuncture
- Separating from the parent

It is a clinical diagnosis, and is managed by the

ABCDE approach.
 Throat
emergencies

Epiglottitis
Cause: traditionally caused by Haemophilus influenza infection
Presentation: drooling, pyrexia, very unwell appearance, respiratory distress (stridor, tripoding
etc.)

History: ask about sore throat, swallowing/oral intake, voice changing, breathing, irritability,
immunizations, any immunocompromisation.

Management:
ENT/paediatrics/anaesthetics involvement
Laryngoscopy, secure airway
X-ray may show >6.3 mm epiglottis width (but diagnosis is clinical)
IV antibiotics
 Question 7: Which of the following may
cause acute airway obstruction?
• Croup
• Foreign body
• Neoplasia
• Trauma
• Asthma

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 Question 8: What are the principles of
management for acute airway
obstruction?
• ABD
• BCD
• ABC
• AB—F?

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 Throat
emergencies

Acute airway obstruction

Causes: many, many causes – all have specific treatments
Presentation: stridor/wheeze, use of accessory muscles, cyanosis, A Airway
hyper/hypoventilation, hypoxia B Breathing
The key thing is ABCDE management. C Circulation
Airway before anything else! D Disability
à If their airway is obstructed, it needs assessing. Get senior help – ENT,
anaesthetics, paediatrics
E Exposure
à Jaw thrust, head extension, attempt simple airways, give oxygen
à ?IV steroids ?Salbutamol ?Adrenaline (depending on cause of obstruction)
à Intubation
à Surgical airway - tracheostomy
Throat inflammation
Most
Condition common Findings Management
cause
Pharyngitis / Usually viral Sore throat Analgesia
laryngitis (URTI) – eg. Croaky/hoarse voice Rehydration
influenza, Coryzal symptoms Salt water gargle
coxsackie (runny nose, sneezing,
Or allergies anosmia etc.) Admit if can’t swallow, airway obstruction, abscess
Antibiotics only recommended if high Centor score (fever, exudates, no
cough, lymphadenopathy). Oral penicillin usual choice. Add NSAIDs,
throat lozenges for symptomatic relief. ?steroids.
Tonsillitis Viral or 4-5 days malaise & Rehydration
bacterial headache Analgesia
Sore throat, Salt water gargle
Infectious swallowing difficulties,
mononucleosis cough, pyrexia, fatigue Admit if can’t eat & drink, see pus spots on tonsils or >4 days
(EBV – young White spots on tonsils IV fluids, antibiotics (NOT co-amoxiclav)
adults mainly) (EBV – cervical Consider steroids
lymphadenopathy, Swab, FBC, inflammatory markers, monospot (EBV antibodies)
hepatosplenomegaly, Infectious mononucleosis – avoid contact sports/exercise 2-3 months
rash, lymphocytosis)
Throat inflammation
Most
Condition common Findings Management
cause
Peritonsillar Streptococcus 2-3 days sore throat, As with bacterial tonsillitis – fluids, analgesia, swab, FBC, CRP etc.
abscess pyogenes then pyrexia and Point of care USS – can be as useful as CT
(Quinsy) marked odynophagia
“Hot potato voice” For drainage, use guard to reduce penetration. Require light, suction
Trismus (lockjaw) (avoid airway obstruction), lidocaine/adrenaline anesthesia, blunt
Assymetric tonsils + dissection to locate
uvula deviation
Tender jugulodigastric
lymphadenopathy
Angioedema Hereditary Local/diffuse soft tissue Take a good allergy, medication, family history. Examine airway carefully
Acquired from swelling ABCDE – secure airway
ACE inhibitors Signs of airway ENT/anaesthesia involvement early, ready surgical intubation
compromise (stridor, Fiberoptic nasopharyngoscopy potentially for extent of swelling
swelling, hoarseness
etc.) IM adrenaline (or nebulised)
Severe abdo pain (free CI esterase inhibitors or 2-4U FFP for hereditary
fluid on imaging) NO steroids/anti-histamines
Observe once symptoms improve, send home with epipen, follow-up
and safety netting
 Nose
emergencies

Another emergency: bleeding post-tonsillectomy

Cause: tonsillectomy

Admit if any bleeding – Herald bleed! Or if pyrexia/poor oral intake

Management:
ENT, paediatrics, anaesthetists involvement
Examine for bleeding point, clots
ABCDE – sit up, suction, observations, IV access, FBC, G&S, clotting
Ice in mouth, hydrogen peroxide gargle, adrenaline gauze
If bleeding continues – theatre for haemostasis
Basic summary of throat emergencies
Post-tonsillectomy Throat infection/
Airway obstruction bleed inflammation
ABCDE
Gather information
first – history and
First secure the exam!
Any bleed may be a
airway – oxygen,
Herald
specific treatment Admit if they are
(eg. adrenaline)
ABCDE approach acutely unwell
Step up if airway not Assess & treat
secure – intubate, specific cause
tracheostomy
 Additional Resources

Good reference:
Other good websites:
Oxford Handbook of ENT
Youtube channel on www.entsho.com
and Head and Neck
management of basic https://teachmesurgery.c
Surgery:
ENT conditions: om/
Rogan Corbridge,
Nicholas Steventon Short Sharp Scratch