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

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

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Textbook of Adult Emergency Medicine