18: ENT

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Section 18 ENT

Edited by Peter Cameron

18.1 Ears, nose and throat 579

18.1 Ears, nose and throat

Sashi Kumar

Essentials

1 Removal of foreign bodies from the ear requires good lighting, a cooperative or fully restrained patient and a patient/gentle approach by the clinician.
2 Haematoma of the auricle requires urgent release by aseptic incision and immediate application of a firm mastoid bandage.
3 It is important to exclude septal haematoma in patients with a fractured nose. In general X-rays are not warranted.
4 Patients presenting with odynophagia but no dysphagia following ingestion of a fish bone, and negative physical examination and radiology, can be safely discharged for review within 48 h.
5 Sudden sensory neural hearing loss constitutes an ENT emergency, which requires urgent ENT consultation and audiometry.

THE EAR

Introduction

Emergency presentations for ear, nose and throat (ENT) problems are common and all emergency physicians need to be familiar with the basic skills required for assessment and management of these problems.

Foreign body

Foreign bodies in the ear are most common in children under the age of 5 and in mentally handicapped adults. Animate objects such as insects in the ear can affect all ages, especially adults who enjoy the outdoors, particularly at dusk.

Accidental foreign bodies, such as the end of a cotton bud or a matchstick, occur in people obsessed with cleaning their ears with such objects.

Management

Two simple rules in managing foreign bodies in the ear are:

• Do not attempt to remove a foreign body that is not there! (Identify the foreign body prior to attempts at removal.)
• Unless the object is alive, there is no emergency to remove it if it can be done safely at a later time under better conditions.

Removal of a live foreign body

This is a true ENT emergency. The insect should be killed as a matter of urgency, as considerable damage is being done to the sensitive skin of the bony meatus and the tympanic membrane by the flapping wings and appendages of the desperate insect trying to escape.

The movement of the insect also causes intense pain and tinnitus, thereby creating further anxiety and distress.

Any liquid used to kill the insect should be carefully chosen so as to avoid damage to the sensitive skin and tympanic membrane: strong corrosive agents, knockdown spray or alcohol should be avoided. The common agents of choice are lignocaine 2%, olive oil, water for injection or normal saline.

One of the preferred methods is to instil some water for injection from a 10 mL plastic ampoule and leave an examination light on the pinna. The insect swims up to surface towards the light and can be helped to safety by holding the tip of the ampoule.1

Removal of a foreign body in a child or a mentally handicapped adult may be done in one of two ways. The patient is either cooperative and unrestrained or fully restrained. It is vital not to attempt any procedure with partial restraint, as any movement of the patient during the attempt could cause trauma to the ear canal and the tympanic membrane.

There are two techniques used to remove a foreign body. The dry method is by using a Jobson Horne probe for solid objects such as beads or alligator forceps for an insect or a cotton bud. The wet method is by syringing the ear canal with tepid water. The water should be close to body temperature to avoid a caloric effect, which produces nystagmus and vertigo.

The key to success is good lighting, preferably through a head lamp, a cooperative or fully restrained patient, and a patient, gentle approach by the clinician, who knows when to stop if unsuccessful.

Trauma

Trauma to the ear canal requires the ear to be kept dry for about a week with antibiotic ear drops for 4–5 days in severe cases to avoid progressing into otitis externa.

Penetrating trauma can cause perforation of the eardrum and occasionally disruption of the ossicular chain. Dislocation of the footplate of the stapes following such an injury can cause permanent sensorineural hearing loss. Referral to an ENT specialist is essential in all cases of traumatic perforation with suspected ossicular chain disruption.

Blunt trauma

Boxing and other contact sports can lead to blunt trauma to the pinna. Accumulation of blood under the perichondrium, if not treated properly, may progress to cartilage necrosis and the end result is a ‘cauliflower ear’.

A slap on the ear can also produce a ruptured tympanic membrane with or without ossicular chain disruption.

Assessment

Assessment of the injury includes a clinical assessment of the hearing loss. A ruptured eardrum without ossicular chain disruption does not usually cause a significant hearing loss. Any evidence of nystagmus or tinnitus suggests damage to the inner ear.

Management

A simple traumatic perforation of the eardrum is managed by simple analgesics and keeping the ear dry. On no account should any drops or water be allowed into the ear, as this may precipitate otitis media.

If ossicular chain disruption or inner ear trauma is suspected, an urgent ENT opinion is required to assess the need for urgent tympanotomy and repair.

Haematoma of the pinna requires urgent release of the accumulated blood by aseptic incision and drainage and the immediate application of a firm mastoid bandage to prevent reaccumulation and this should be left in place for up to a week. The patient should be placed on broad-spectrum antibiotics to prevent infection.

Infection

Otitis externa

Infection of the external ear is common and affects between 3 and 10% of the patient population.2 It can be localized (furuncle) or diffuse. The symptoms are pain, itching and tenderness to palpation, followed by aural fullness, hearing loss and discharge. The common pathogens responsible are Pseudomonas aeruginosa, Proteus spp. and Staphylococcus aureus.3

The diagnosis is usually self-evident, but the diagnostic signs of otitis externa are tragal tenderness or pain on pulling the pinna. This is a disease of the cartilaginous ear canal, with swelling and discharge causing occlusion of the meatus. It may be extremely painful to pass the ear speculum and often the tympanic membrane is not able to be visualized.

Management

The most important step in the treatment is thorough and atraumatic cleansing of the ear canal.4 Tolerance and cooperation between the patient and the clinician is vital. Pope Otowick (Xomed)® is very useful in the management of this condition. This is a semirigid foam wick that, when inserted into the ear canal, swells, absorbing moisture to increase the size of the ear canal. Topical otic drops, such as Sofradex® (Roussel), are used three to four times a day and the patient is reviewed on a daily basis to change the wick and continue the ear toilet. Occasionally oral antibiotics such as ciprofloxacin or flucloxacillin may be required,5 particularly if there is evidence of cellulitis. The patient is advised to keep the ear clear of any water. Strong analgesics are usually required.

Fungal otitis externa (otomycosis) tends to be not that painful and is treated with ear toilet as described and topical antifungal ear drops such as Loco corten vioform.

Otitis media

Acute otitis media is a common infection and is due to blocking of the eustachian tube (eustachian catarrh), and negative pressure in the middle ear cavity. Although viral in origin, secondary bacterial infection often supervenes. The most frequently isolated pathogens are Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis.6 The symptoms are earache, fullness, hearing loss and fever, with ear discharge if the drum has perforated. The development of discharge usually marks an improvement in the pain and fever.

The clinical findings vary from a retracted dull eardrum to a congested bulging drum or a white eardrum with pus behind, and a perforated tympanic membrane with discharge in the ear canal. A perforated eardrum without much pain is usually a sign of chronic otitis media.

Management

Treatment is almost always empiric and amoxicillin is a good first-line therapy. Cephalosporins and trimethoprim/sulpha are also used with considerable success. The newer macrolides, such as azithromycin and clarithromycin, are rational alternatives.6

In otitis media with a perforated eardrum, the mainstay of treatment should be toilet by dry mopping followed by antibiotic drops such as Sofradex®. The ear should be kept dry and regular follow-up arranged until the perforation has healed.

Labyrinthitis

Acute labyrinthitis usually has cochlear symptoms such as hearing loss and tinnitus, which should be referred for audiometry and urgent ENT evaluation. If the symptoms are limited to vertigo and nystagmus, it is more likely to be due to acute vestibular neuronitis.

Management

The management of labyrinthitis includes bed rest, antiemetics, e.g. prochlorperazine, benzodiazepine, e.g. diazepam, and admission if severely debilitating. In the presence of hearing loss a course of oral steroids or intra-tympanic dexamethasone may be started after discussions with the ENT surgeon.

Otitis media with effusion (glue ear)

This is most common in children in developed countries. The symptoms are fullness and hearing loss, and occasionally pain. Management includes the diagnosis based on history and examination, which reveals a dull, retracted drum or fluid behind the drum without redness. The most reliable sign of a glue ear is an immobile eardrum on valsalva manoeuvre or pneumatic otoscopy. Repeated attacks of glue ear are an indication for the insertion of tympanostomy tubes.

Mastoiditis

Acute mastoiditis is a complication of acute or chronic otitis media. It is a rare condition in the developed world, although still quite prevalent in the developing world and the aboriginal population of Australia. Otitis externa with a painful and tender postauricular lymph node is usually mistaken for acute mastoiditis due to the postauricular tenderness. Extension of infection can cause meningitis or cerebral abscess, with life-threatening complications if untreated.

Examination reveals infection in the middle ear cavity by way of an injected drum or a perforated drum with discharge. The cardinal sign of acute mastoiditis is tenderness at the base of the mastoid on digital pressure. The diagnosis is confirmed by CT scan.

Management

Admission, intravenous antibiotics and surgical intervention to drain the abscess.

THE NOSE

Foreign body

A foreign body in the nose is common in preschool children and adults with mental retardation. The most common types of foreign body are beads, buttons and pieces of paper.

The diagnostic sign of a neglected nasal foreign body is a unilateral foul-smelling nasal discharge. The patient or the parent usually provides the history as to the type of foreign body and for how long present.

Management

The removal of the foreign body follows the same rules as for a foreign body in the ear. An additional method is to blow forcefully through the patient’s mouth while occluding the unaffected nostril. This could be done by the parent with instruction.

The suggested method of removal is to pass the ring end of a Jobson–Horne probe above and behind the foreign body and to roll it along the floor of the nose. This patient should be cooperative and unrestrained, or fully restrained. At the first sign of trauma or bleeding removal should be organized under general anaesthesia as soon as practically possible.

Trauma

Fractured nose

This is a common presentation in the emergency department. The history is often quite clear and the findings include pain and tenderness over the nasal bones with or without crepitus, and swelling at the bridge of the nose with or without epistaxis.

Careful examination will usually rule out CSF rhinorrhoea due to cribriform plate fracture and any external deformity. Active bleeding from the nostril should be controlled by direct pressure by pinching the nostril; if it does not settle it may require nasal packing.

Radiographs are not indicated for nasal bone fracture as this is a clinical diagnosis. It is often difficult to visualize the fracture line on the X-rays and radiographs do not help in the management. If associated facial fractures are suspected, X-ray facial views or CT scan should be taken.

Management

Acute intervention is required in the following circumstances:

• Continuing epistaxis should be managed along the lines described later.
• Obvious external deformity of the nose needs cosmetic correction, either by immediate reduction under local anaesthetic or by referral to an ENT surgeon for review and reduction in 7–10 days time. A formal rhinoplasty may be required in severe cases. The acute management of a fractured nose is reassurance, analgesia and ice packs, followed by a review by the general practitioner or an ENT surgeon in 7–10 days. The patient is advised to avoid any form of contact sport for a week.
• CSF rhinorrhoea requires a CT scan and neurosurgical referral.
• A septal haematoma, which is clinically apparent as a widened and bulging septum, can become infected, causing a septal abscess that could result in the collapse of the external nose. The diagnosis is made by visualizing the boggy swelling on one or both sides of the septum, and management requires admission, drainage under local or general anaesthesia, followed by nasal packing.

Sinusitis

Approximately 90% of upper respiratory infections have associated sinus cavity disease.7 Viral rhinosinusitis is the most common cause and is associated with the common cold. Approximately 0.5–2% of these cases progress to bacterial sinusitis.

Clinical features

Symptoms of viral sinusitis are rhinorrhoea, nasal obstruction and sneezing, and facial pressure with or without headache. With bacterial superinfection a purulent or coloured nasal discharge and fever of 38 °C or higher develop. Significant facial pain and maxillary toothache with no obvious dental cause also occurs. The common organisms involved are Streptococcus pneumoniae and H. influenzae. Patients with allergic sinusitis typically have sneezing and itching, with watery eyes, as a leading symptom.

Radiographs of the sinus are not very helpful unless they demonstrate a distinct air-fluid level, as this increases with the likelihood of bacterial sinusitis. CT can indicate the presence of sinus abnormalities and evidence of infection. A raised white cell count is neither sensitive nor specific in the diagnosis of bacterial sinusitis.

Management of viral rhinosinusitis is symptomatic and it is generally self-limiting. Bacterial sinusitis must be treated with antibiotics: amoxicillin, augmentin or keflex could be used as first-line drugs. Although of unproven value, an oral decongestant or antihistamine is commonly used. Complications of sinus disease include meningitis, orbital extension and brain abscess. Diagnosis is by CT scan and treatment is intravenous antibiotics with surgical intervention by an otolaryngologist.

Epistaxis

Nose bleeding is the most common ENT emergency: a Scottish study reported an incidence of 30/100 000 people8 in which the cause could only be found in 15%.9 The common identified causes are trauma, blood dyscrasias, anticoagulation therapy and occasionally hereditary haemorrhagic telangiectasia.10 Although hypertension has been traditionally labelled as a cause of epistaxis, studies have shown that blood pressure in these patients is no higher than in the control population.11,12

The history is vital and all patients should be asked where the blood appeared first – anteriorly in the nose or in the back of the throat. Anterior epistaxis can usually be controlled in the emergency department and the patient safely discharged home without a nasal pack after cautery.

Management

The control of epistaxis due to a general cause such as uncontrolled warfarin therapy or a bleeding disorder is to reverse the cause. Local measures can still be used to stem the flow.

Idiopathic epistaxis, or that due to a local cause such as trauma, can be dealt with using local measures. The most common cause of anterior epistaxis is bleeding from Kiesselbach’s plexus of the septum13 (Fig. 18.1.1), which can easily be controlled by simple measures in the emergency department. Careful examination of a seated patient applying direct pressure to the bleeding vessel by pinching the anterior nares with the thumb and forefinger for up to 10 min will usually slow or cease the bleeding. At this point it is essential to remove all the blood clots from the nasal cavity and the postnasal space using a suction.

image

Fig. 18.1.1 Arterial supply to the nasal septum.

(From an original drawing by Ian Miller RN.)

Following this, the application of cotton pledgets soaked in 5% cocaine or lignocaine with adrenaline or cophenylcaine (phenylephrine and lignocaine) will provide analgesia and vasoconstriction to the septum and the anterior part of the lateral wall.

Examination may reveal the bleeding vessel on the septum, which can be cauterized under direct vision using silver nitrate sticks. Following this the patient is observed for a short time and can be discharged from the emergency department. The patient is advised not to pick, rub or blow the nose for 10 days and is advised to keep the cauterized area moist by applying chloromycetin eye ointment or Vaseline twice a day.

If the bleeding cannot be controlled by the above measures, or the bleeding point is posteriorly placed, the nasal cavity should be packed. There are several ways to pack the nose, the most traditional being to use ribbon gauze to fill the entire nasal cavity in layers (Fig.18.1.2). A Foley urinary catheter can be used to control the posterior bleed, but it can be better controlled with a specifically designed epistaxis catheter such as a Brighton’s epistaxis catheter, which has a double balloon for anterior and posterior tamponade, or a Merocel® nasal pack (Xomed) or Rapid Rhino, which can be used as a nasal tampon, both of which are quite useful. Almost all patients with nasal packing need admission and observation. When the above measures are unsuccessful, further invasive procedures such as postnasal packing, examination under anaesthesia and septal surgery or arterial ligation may be required under general anaesthesia.

image

Fig. 18.1.2 Insertion of anterior nasal pack (begin at A and finish at B).

(From an original drawing by Ian Miller RN.)

Summary

Patients with anterior nasal bleeds can usually be managed by chemical cautery with silver nitrate and then be discharged. Posterior bleeding or failure to control by simple measures may require nasal packing and admission for further invasive procedures.

THE THROAT

Foreign body

Coins are a common oesophageal foreign body in children. In adults the foreign body is usually a fish, chicken or meat bone, and occasionally objects such as partial dentures, safety pins, etc.

The common lodgement sites include the cricopharynx, the oesophagus at the level of the aortic arch, and the gastro-oesophageal junction. Fish bones can lodge in the tonsil, the posterior third of the tongue or the vallecula prior to entering the oesophagus.

Management

Careful examination of the oropharynx initially, especially if the patient localizes the foreign body above the level of the hyoid and to one side. If the foreign body is found it should be removed under direct vision.

A foreign body at or below the cricopharynx requires general anaesthesia and endoscopy.

Lateral X-ray of the neck is useful in identifying and localizing radio-opaque foreign bodies, such as coins and bones, including large fish bones.

Patients presenting with odynophagia but no dysphagia following the ingestion of a fish bone, and a negative physical examination, can be discharged safely for review in 48 h. Symptoms of increasing odynophagia, fever, haematemesis or dysphagia warrant admission for endoscopy. Patients with a confirmed foreign body should be admitted for endoscopy and removal.

A food bolus not containing bone causing obstruction should have a trial of i.v. glucagon 1 mg, i.v. buscopan 20–40 mg and sips of a fizzy drink before arranging for an endoscopy, as one of these may dislodge the obstruction, thereby avoiding an urgent endoscopy. Recurrent food bolus obstructions require an endoscopy to rule out stricture or malignancy.

Button batteries

Button battery lodged in the oesophagus can cause liquefaction necrosis and perforation so urgent endoscopy and removal is recommended.14

If the battery is lodged past the oesophagus in the stomach most, if not all, will pass in the next 48–72 h and the patient can be safely discharged following reassurance.15

Infection

Tonsillitis

Patients with acute tonsillitis present to the general practitioner and occasionally to the emergency department. The emergency department patients usually have severe symptoms or are not responding to oral antibiotics. They are often dehydrated, toxic, with a high temperature and unable to take adequate oral fluids. Treatment includes intravenous penicillin in high doses (e.g. 2 g 4 hourly), intravenous fluids and adequate analgesia.

Infectious mononucleosis (Glandular fever)

The symptoms are similar to severe tonsillitis with odynophagia, fever and a hot potato voice. The tonsils are quite swollen but have a smooth diffuse swelling with not much exudate on the fossa. The cervical lymph nodes are enlarged and tender and there may also be axillary and inguinal lymphadenopathy with or without hepatosplenomegaly.

The diagnosis is made by abnormal lymphocytes in the blood film and monospot test.

Treatment is symptomatic. Amoxicillin should not be used as it produces a rash.

Quinsy

Peritonsillar abscess or quinsy is a condition in which the infection in the tonsil has breached the capsule and caused cellulitis in the adjacent soft palate (peritonsillitis), and eventually a collection of pus (quinsy).

Examination reveals a congested tonsil being pushed medially and downwards by a diffuse swelling of the soft palate. The opposite tonsil may look injected. There are often unilateral or bilateral enlarged and tender jugulodigastric lymph nodes in the neck. The patient is usually febrile, toxic and dehydrated. There is marked trismus due to masseteric spasm and referred otalgia.

Management includes admission to hospital for intravenous fluids, penicillin or cephalosporin, and adequate analgesia. Aspiration of the pus using a large-bore needle or incision and drainage of the quinsy can be done in the emergency department under local anaesthesia in a conscious patient sitting up. Sometimes this needs general anaesthesia. Intubation of such patients should be performed by a skilled anaesthetist preferably by awake fibre optic technique and every effort must be made to avoid rupturing the abscess to avoid aspiration of pus.

Retropharyngeal abscess

This is predominantly a disease of young children, as the retropharyngeal lymph nodes atrophy after the age of 5. In older patients it could be secondary to trauma or lodgement of a foreign body, such as a fish bone. Diagnosis is made on symptoms of fever, swelling of the neck due to cervical lymphadenopathy and, especially in young children, stridor. Clinical suspicion leads to imaging procedures such as CT, which is diagnostic.

Management includes admission to hospital, intravenous antibiotics and urgent ENT consultation. Treatment is incision and drainage of the abscess under general anaesthesia.

Epiglottitis

Childhood epiglottitis is rare these days due to a highly successive immunization programme against Haemophilus influenza. Adults with epiglottitis are still occasionally seen in emergency departments. The classical symptoms are acutely painful throat, drooling, odynophagia and increased pain to speech with enlarged tender bilateral cervical lymph nodes.

A quick bedside test is to ask the patient to poke his or her tongue out and wiggle it from side to side as this will increase the pain substantially.

Management is mainly intravenous antibiotics and analgesia. If the patient is showing signs of imminent upper airway obstruction, an attempt should be made to intubate by the most skilled emergency doctor available with the surgical airway kit readily available in case of failure.

All other patients should be taken to the operating theatre for a gaseous induction by a skilled anaesthetist with an ENT surgeon standing by for immediate surgical airway if unable to intubate.

Post-tonsillectomy bleed

Haemorrhage from the tonsillar fossa that occurs 24 h after tonsillectomy is termed ‘secondary haemorrhage’. This differs from primary, which happens during surgery, and reactionary haemorrhage, which occurs within 24 h of surgery whilst the patient is still in the hospital. The cause of secondary haemorrhage is usually infection and this occurs classically 10 days postoperatively. This incidence is about 1% and is usually not very severe. The management is intravenous antibiotics, usually penicillin. The patient should be admitted and bloods taken for estimation of haemoglobin and cross-matching. Application of a swab soaked in 1 in 1000 adrenaline (epinephrine) to the tonsillar fossa after removal of the clot may help to stop the bleeding. Rarely the patient may need to have a general anaesthetic to cauterize/ligate the bleeder.16

Controversies

1 Timing of nasal fracture reduction. This may be performed either immediately or after 7–10 days.
2 The method used for control of epistaxis. There is no clear advantage in using one method over another.

References

1 Kumar S. An interesting method of removal of live foreign body from the ear. Emerg. Med. 1998;10:278.

2 Bojrab DI, Bruderly T, Razzak YA. Otitis externa. Otolaryngology Clinics of North America. 1996;29(5):761-782.

3 Briggs RJ. Otitis externa: presentation and management. Australian Family Physician. 1995;24(10):1859-1864.

4 Ali Raza S, Denholm SW, Wong JCH. An audit of the management of acute otitis externa in an ENT casualty clinic. Journal of Laryngology and Otology. 1995;109:130-133.

5 Mirza N. Otitis externa – management in the primary care office. Postgraduate Medicine. 1996;99(5):153-158.

6 Block SL. Causative pathogens, antibiotic resistance and therapeutic considerations in acute otitis media. Paediatric Infectious Diseases Journal. 1997;16(4):449-456.

7 Bukata R. Sinusitis, a ubiquitous, yet enigmatic disease. Emergency Medicine and Acute Care Essays. 1997;21(3):1-4.

8 Kotecha B, Fowler S, Harkness P, et al. Management of epistaxis: a national survey. Annals of the Royal College of Surgeons of England. 1996;78:444-446.

9 Small M, Maran AGD. Epistaxis and arterial ligation. Journal of Laryngology and Otology. 1984;98:281-284.

10 Juselius H. Epistaxis. Journal of Laryngology and Otology. 1974;88:317-327.

11 Shaheen OH. Studies of nasal vasculature and problems of arterial ligation for epistaxis. Annals of the Royal College of Surgeons of England. 1970;47:30-44.

12 Weiss NS. The relation of high blood pressure to headache and epistaxis and selected other symptoms. New England Journal of Medicine. 1972;287:631-633.

13 Darry KW, Barlow F, Deleyiannis WB, Pinczower EF. Effectiveness of surgical management of epistaxis at a tertiary care center. Laryngoscope. 1997;107:21-24.

14 Gordon AC, Gough MH. Oesophageal perforation after button battery ingestion. Ann Coll Surg Engl. 1993;75:362-364.

15 Kumar S. Management of foreign bodies in the ear, nose and throat. Emergency Medicine. 2004;16:17-20.

16 Evans JNG, editor. Scott Brown’s Otolaryngology, 5th edn. Butterworth, London, 1987, 96.

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