Pain in the Neck! An EBM review of emergency department ENT Petr Balcar FRCPC Dec 15, 2011.

Pain in the Neck!Pain in the Neck!

An EBM review of emergency An EBM review of emergency department ENTdepartment ENT

Petr Balcar FRCPCDec 15, 2011

OutlineOutlineReview best evidence in

management of ◦Epistaxis◦Fishbone FB◦Tonsillitis◦Post Tonsillectomy

Epistaxis QuestionsEpistaxis QuestionsDiscuss evidence for:

◦INR◦Cool compress◦Topical antibiotics◦Hemostatic agents◦Oral antibiotics in packing◦Safety of bilateral packing

Epistaxis: PearlsEpistaxis: PearlsSpeculum parallel to floor!Cauterize

◦Only controlled bleed◦Periphery inward◦1cm around bleeder◦Wipe excess AgNO3 off

Rapid Rhino ◦No saline/vaseline◦Impairs mesh thrombosis◦Recheck cuff 10-15min

Epistaxis: AnticoagulationEpistaxis: AnticoagulationNot routineWarfarin with therapeutic INR

◦25% annual rate◦Rare to need reversal

Discussion point:◦Do all need ENT FU?

Epistaxis: Cool CompressEpistaxis: Cool CompressBestBets review

◦3 small studies: 1. Sucking ice = nasal vasoconstriction 2. Neck ice packs = nasal

vasoconstriction 3. Forehead ice = 22/28 bleeds stopped

Summary:◦Scant evidence◦Benign intervention

Discussion point:◦Should we hand out ice at triage?◦Anyone want to do study?

Epistaxis: Topical Epistaxis: Topical AntibioticsAntibioticsMultiple pediatric studies

◦Intranasal antibiotic x 4wks = cautery◦No long term benefit◦Minimal sefx

Staph carriage in adults◦Walker and Baring 2009◦Small RTC n=49◦Nasal swabs ◦No difference in S. aureus carriage

~21%Conclusion

◦Consider in pediatrics

Epistaxis: Hemostasis Epistaxis: Hemostasis AgentsAgentsMultiple thrombogenic products

◦Quixil (fibrin glue spray) ◦Floseal (thromin gel)◦Surgicel◦Gelfoam◦Avitene◦Positive effect in small studies, few

RCTs◦Primarily developed for surgical use

Epistaxis: Fibrin GlueEpistaxis: Fibrin GlueVaiman 2002

◦RCT n 204◦Fibrin glue (Quixil) vs AgNO3 vs

Cautery vs foam packing◦~93% immediate cessation◦Mean 2.5 min◦Fewer mucosal sefx

Epistaxis and Tranexamic Epistaxis and Tranexamic AcidAcidLysine derivative Antifibrinolytic

◦Prevents plasmin to plasminogenHereditary hemorrhagic

telangectasia◦Case studies◦Benefit of intranasal spray

Cochrane study under way

Epistaxis: Antibiotics with Epistaxis: Antibiotics with PackingPackingPostoperative rates 16 : 100,000PO antibiotics do not reduce

nasal staphNo good studies: very rare eventMultiple side-effects of antibioticsMost ENTs do itHigher risk elderly,

immunocompromised, prolonged pack

Discussion Point:◦Do you start antibiotics?

Epistaxis: Bilateral Epistaxis: Bilateral Packing Packing Hollis 2011

◦Anatomical model◦Bilateral pack = decrease in septal

deflectionHady 1983

◦Healthy volunteers packing◦ABG at 24 hrs◦Increased CO2, decreased PO2, pH

equalLoftus 1994

◦19 pts, posterior pack◦Pulse oximetry monitor x 1200hrs◦No desats

Epistaxis: Bilateral Epistaxis: Bilateral PackingPackingHistorical cases with bad outcomes

◦ Posterior packing patients died◦ Hypothesized nasopulmonary reflex

No current evidence of significant morbidity/mortality with bilateral packing

Posterior bleed patients need admit Anterior bleed with bilateral pack

◦ Consider DC in healthy patients, admit in frail/elderly

Discussion point:◦ Who does bilateral packing?◦ Do you admit them?

Fish Bone: QuestionsFish Bone: QuestionsHow useful is plain X-ray?How useful are symptoms?Do all need scope?

Fish Bone: Are Bones Fish Bone: Are Bones Opaque?Opaque?Lue 2000

◦10 fish bones in cadaver head/neck◦Blinded radiologists◦Plain Xray 39% sensitive◦CT 9/10 found◦Cooking did not change opacity◦Variability by species, orientation

Hone1995◦10 fish bones in cadaver neck◦9/10 seen by both rads

Fish Bone: Clinical Xray Fish Bone: Clinical Xray UtilityUtilitySeveral clinical imaging studies

◦Sensitivity ~30%◦Specificity ~88%

Ngan 1990◦Prospective n=358◦Clinical symptoms not reliable for FB◦Clinical symptoms did localize FB if

present◦117 bones found

21 direct removal 82 endoscopic removal

Fish Bone: Clinical Fish Bone: Clinical RelevanceRelevanceImpacted oropharyngeal bone

location Tonsils, base of tongue, vallecula

Impacted bones migrate! Many case reports of significant pathology Abscess, vascular

Should not be ignored!Discussion point:

◦Do you xray all patients?◦Do you get ENT/GI FU for all patients?

Pharyngitis: QuestionsPharyngitis: QuestionsReview pathogensBest evidence:

◦When to treat ◦Which antibiotics and how long◦What to do if treatment fails◦Analgesia

Pharyngitis: Bug PearlsPharyngitis: Bug Pearls Usually viral

◦ Consider EBV

GAS◦ Very common

◦ Serious Complications

◦ GBS/GCS minimal complications

HIV in at risk population◦ Early diagnosis/treatment

Mycoplasma / Chlamydia◦ Peds RCT n=133

◦ >30% carriage, not improved by Azithro

Ghonococcal ◦ 5-15% carriage in MSM

◦ Rare symtomatic, Rc Ceftriaxone

Diptheria◦ Un-immunized, endemic travel

Pharyngitis: Why Treat Pharyngitis: Why Treat GAS?GAS?Prevent complications

◦Suppurative◦Rheumatic Fever

Up to 9 days post ssx◦Scarlet Fever

Reduce symptoms◦If within 48hrs

Reduce transmission◦~35% close contacts◦Within 24hr, 80% swab neg

Pharyngitis: AntibioticsPharyngitis: AntibioticsPenicillin

◦100% susceptibility◦Pen V PO x 10days◦Pen G IM lasts 3-4 weeks!

Amoxicillin◦100% susceptibility◦Tastes better (yum)◦AOM 15%

Clindamycin◦93% susceptibility ◦Better staph/anaerobe

Pharyngitis: AntibioticsPharyngitis: Antibiotics Cephalosporins

◦ 100% susceptibility

◦ Casey et al 2004

Meta analysis: pen vs cephalosporin

<18yrs, n=7135

Clinical and culture cure

Both superior in cephalosporins

Cost more, increased use in community

Macrolides

◦ 93% susceptibility

◦ Meta analysis shows improved compliance

Pharyngitis: Why Pharyngitis: Why Antibiotics FailAntibiotics FailConfirmed GAS

◦ Chronic Carrier (up to 20% peds)

◦ Poor compliance

◦ Re-infection

Pet, toothbrush, dentures

◦ Other beta-lactamase flora

◦ Poor antibiotic penetration of tissue

◦ Resistant strain (No pen resist strain

Identified!)

◦ Treat too early, reduced immune responseNon GASSuppurative complication

Pharyngitis: When Pharyngitis: When Treatment FailsTreatment FailsNo Specific EvidenceScreen for atypical etiologyLook for abscessRepeat culture GAS +

◦Consider other PO Abx +/- IM PenRecurrent episodes

◦Consider testing family and treat all +ve

◦Consider chronic carrier with Viral◦6/year = tonsillectomy

Pharyngitis: Evidence for Pharyngitis: Evidence for SteroidsSteroidsAll ENT’s do it!Cochrane study in progressMultiple small studies

◦Pediatrics 3 studies Oral Dexamethason

◦Adults 7 studies IM or PO steroid

◦Overall ~ 5-6hr quicker pain relief◦No Early difference in Sefx

Pharyngitis: SummaryPharyngitis: SummaryConsider atypical causesHigh risk: tearly + swabAntibiotics

◦Penicillin still 1st choice◦Cephalosporins excellent◦Amoxil peds

Failure re-testAnalgesia

◦Topical lozenges◦Steroids

Peritonsillar Abscess: Peritonsillar Abscess: QuestionsQuestionsUtility of USBest treatment options

Peritonsillar Abscess: US Peritonsillar Abscess: US ImagingImagingRelatively new Several small studiesExcellent for Abscess locations

◦Intraoral = 95% sensitive◦Transcutaneous = 80% sensitive

Peritonsillar Abscess: US Peritonsillar Abscess: US DrainageDrainageCostantino 2010

◦RCT n=23◦ED physician, US vs blind drainage◦Diagnosis 100% vs 63%◦Aspiration 100% vs 42%◦ENT Referal 8% vs 55%

Peritonsillar Abscess: Peritonsillar Abscess: TreatmentTreatmentSeveral poor studiesOverall I&D = Needle

◦ ~90% success rateConsider primary tonsillectomyAntibiotics

◦Usually polymicrobial◦IV Pen/Clinda◦PO Pen/Clinda/Amox-clav

Steroids reduce morbidity

Peritonsillar Abscess: Peritonsillar Abscess: SummarySummaryNeedle okayUS guided probably bestIv steroid dose helpsDiscussion point:

◦Lets buy an oral probe!

Post Tonsillectomy: Post Tonsillectomy: QuestionsQuestionsIndicationsHow much bleeding is

concerning?Analgesic options

Post Tonsillectomy: Post Tonsillectomy: BleedingBleedingSignificant hemorrhage 1-3%1:40,000 fatal95% secondary (>24 hr) Up to 39 daysBlood = ENTConsider admitActive bleed

◦Pressure◦Epi◦+/-Thrombin

Post Tonsillectomy: Post Tonsillectomy: AnalgesiaAnalgesiaExpected pain pattern:

◦Improve over 3-5 days◦Then increases for 1-2 days◦Resolves

Steroids given periopNSAIDS?

Post Tonsillectomy: Post Tonsillectomy: NSAIDSNSAIDSSurgeon will not be pleased!Several RCTs, 2 good reviews

◦Marret 2003 N = 262 Need for OR

NNH 29

◦Moinche 2003 N = 970 Need for OR

NNH 60

Reduction in N/V vs opioid NNT 9

Post Tonsillectomy: Post Tonsillectomy: SummarySummaryDelayed pain presentationAny bleed need ENT FUNo NSAIDs

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