Emergency Tht

8/11/2019 Emergency Tht

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BLOK EMERGENCY

THT


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Overview

Otologic Disorders

Nasal Disorders

Facial, Oral and Pharyngeal

Infections

Airway Obstruction


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Otologic Disorders

Anatomy

Auricle

Ear canal

Tympanic

membrane Middle ear and

mastoid disorders

Inner Ear


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Aspiration of Auricular Hematoma


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Auricle

Chondritis - Cellulitis ?- infectious, difficult to treat

because poor blood supply,

cover S. Aureus and

pseudomonas

- extra care in diabetics

- inflammatory causes related

to seronegative arthritis at

times indistinguishable from

infection usually the ear lobeis spared


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Otitis Externa

Infection and inflammationcaused by bacteria

(pseudomonas, staph), and

fungi

- treat with antibiotic-steroiddrops

- use wick for tight canals

- diabetics can get malignant

otitis externa (defined by the

presence of granulation

tissue)


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Foreign Bodies in Ear Canal

Usually put in by patient,

some bugs fly in

kill bugs with mineral oil,

or lidocaine remove with forceps,

suction or tissue adhesive


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Tympanic Membrane Perforation

Hard to seeHx of drainage Usually from middle ear pressure

secondary to fluid or barotrauma

Sometimes from external trauma

most heal uneventfully but all needotology follow-up

perfs with vertigo and facial nerveinvolvement need immediate referral

treat with antibiotics

drops controversial but indicated forpurulent discharge (avoid gentamycindrops)


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Middle Ear Serous Otitis Media - Eustachian

tube dysfunction - treat withdecongestants, decompressive

maneuvers

Otitis Media - infection of middle

ear effusion - viral and bacteria

Mastoiditis - Venous connection

with brain, need aggressive

treatment (can lead to brain

abcess or meningitis)


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Inner Ear

peripheral vertigo (vestibulopathy)

BPV, labyrhinthitis

- acute onset, no central signs, usually

young, horizontal nystagmus

Menieres - vertigo, sensorineural hearing

loss, tinnitus

Treatment- valium, fluids, rest, manipulation for BPV


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The Nose

Vascular Supply

- Anterior - branches of

internal carotid

- Posterior - distalbranches of external

carotid


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EpistaxisAnterior

90% (Littles Area) Kisselbachs plexus -usually children, young adults

Etiologies

Trauma, epistaxis digitorum

Winter Syndrome, Allergies

Irritants - cocaine, sprays

Pregnancy


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EpistaxisPosterior

10% of all epistaxis - usually in the elderly

Etiologies

Coagulopathy Atherosclerosis

Neoplasm

Hypertension (debatable)


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Epistaxis

Management

Pain meds, lower BP, calm patient

Prepare ! (gown, mask, suction, speculum,

meds and packing ready)

Evacuate clots

Topical vasoconstrictor and anesthetic

Identify source


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Epistaxis

Management

Anterior Sites- Pressure +/- cautery

and/or tamponade

- all packs require antibiotic

prophylaxis


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Epistaxis

Posterior Packing

Need analgesia and

sedation

require admission and

02 saturationmonitoring


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Epistaxis

Complications

severe bleeding

hypoxia, hypercarbia

sinusitis, otitis media necrosis of the columella or nasal ala


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7th Nerve Palsy

Most cases are idiopathic- link to HSV

- no proof steroids or antivirals are

effective, but many advocate

Consider Lymes Disease inedemic areas

Surgical decompression

indicated in the rare patient not

improving by 2 weeks andENOG out > 90%

F i l I f ti


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Facial Infections

Sinusitis

Signs and symptoms- H/A, facial pain in sinus

distribution

- purulent yellow-greenrhinorrhea

- fever- CT more sensitive than

plain films

Causative Organisms

- gram positives and H. flu(acute)

- anaerobes, gram neg(chronic)


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Facial Infections

Sinusitis Treatmentacute - amoxil, septra

chronic - amoxil-clavulinic acid,clindamycin, quinolones

decongestants, analgesia, heat Complications

ethmoid sinusitis - orbital cellulitsand abcess

frontal sinusitis - may erode bone(Potts Puffy Tumor, BrainAbcess)


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Facial Cellulitis

Most common strept

and staph,

Rarely H.Flu

Can progress rapidly


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Parotiditis

Usually viral-paramyxovirus

Bacterial

- elderly, immunosuppressed

- associated with dehydration

- cover - Staph, anaerobes


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Pharyngitis

Irritants

-reflux, trauma, gases

Viruses

- EBV, adenovirus

Bacterial

-GABHS, mycoplasma, gonorrhea,

diptheria


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Peritonsillar Abcess

Complication of suppurative tonsillitis

Inferior - medial displacement of tonsil and

uvula

dysphagia, ear pain, muffled voice, fever,

trismus

Treatment

- Antibiotics, I&D, +/-steroids


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EpiglottitisClinical Picture

Older children and adults

Onset rapid, patients look

toxic

prefer to sit, muffled voice,dysphagia, drooling,

restlessness


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Epiglottitis

Avoid agitation

Direct visualization if patient allows

soft tissue of neck

- thumb print, valecula sign

Prepare for emergent airway, best achieved

in a controlled setting

Unasyn, +/- steroids


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Epiglottitis


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Retropharyngeal Abcess

Anterior to prevertebral spaceand posterior to pharynx

Usually in children under 4

(lymphoid tissue in space)

pain, dysphagia, dyspnea, fever

swelling of retropharyngeal

space on lateral x-ray

Complications - mediastinitis


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Masticator - Parapharyngeal

Space Infection Infection of the lower

molars invade masticator

space

Swelling, pain fever,

TRISMUS Treatment

IV antibiotics (PCN or

Clindamycin)

ENT admission


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ANUGAcute Necrotizing Ulcerative Gingivitis

Bacterial infection causing anacute necrotizing, destructive

disease of periodontium

Treatment

- oral rinses

- antibiotics (PCN, clindamycin,

tetracycline)


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Ludwigs Angina

Rapidly progressive cellulitis ofthe floor of the mouth

usually in elderly debilitated

patients and precipitated by

dental procedures massive swelling with impending

airway obstruction

Treatment

ICU, antibiotics, airway

management


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Angioedema

Ocassionally lifethreatening

Heriditary and related

to ACE inhibitors

Antihistamines,steroids and doxepin


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Airway Obstruction

Aphonia - complete upper airway

Stridor - incomplete upper airway

Wheezing - incomplete lower airway

Loss of breath sounds- complete lower

airway


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