Clinical evidence and management: Acute otitis externa is essentially a localized or diffuse infection of the lining of the external auditory meatus commonly associated with organisms such as Pseudomonas aeruginosa, Staphylococcus aureus and occasionally fungi like Candida and Aspergillus (Sander 2001). Acute otitis externa frequently occurs following bathing or swimming because excessive moisture removes the protective cerumen from the ear canal allowing keratin debris to absorb water to create a nourishing environment for bacteria. For this reason it is often referred to as ‘swimmer’s ear’. Infection may be diffuse within the external auditory meatus or it may be focal in the form of a local swelling known as a furuncle, which may be extremely painful. Taking swabs for microbiological studies may not be well tolerated by the patient. It is essential that careful preparation of the patient takes place before any attempt is made to take a swab, especially if the individual is a child. Attempts to take a swab from an uncooperative child should be avoided as there is a risk that the tympanic membrane may be perforated by the swab if the child moves her/his head.

As the external auditory meatus contains no mucus-secreting cells, discharge from the ear is minimal; however, any discharge that does occur is usually thick and foul-smelling infected wax. The canal may also contain cell debris, which is unlikely to cause hearing loss, but may contribute to the intense irritation the individual may experience.

Treatment is based upon cleaning and drying the external auditory meatus. This should only be done after examination of the ear canal to determine the integrity of the tympanic membrane. Following cleansing of the external auditory meatus, topical medication containing steroids and antibiotics is necessary (Abelardo et al. 2007). Acute otitis externa largely results from identifiable causes and therefore lends itself to prevention strategies. The focus of much of the nursing care may revolve around educating the patient on keeping ears dry and on how to instill their prescribed medication.

Clinical evidence and management: Acute otitis media is often associated with systemic illness and fever, which may be attributed to the otitis media alone or occur in conjunction with coincidental upper respiratory tract infection (Ludman 2007). Acute otitis media is characterized by rapid onset of ear pain, headache, tinnitus, hearing loss, and nausea or vomiting. Infants and young children may present with irritability, crying, rubbing or pulling the ear, restless sleep and lethargy (Olson 2003). Children are often prone to acute otitis, with up to 30 % of those presenting with otitis media being children under three years of age, as the infection frequently results from upper respiratory tract infection of bacterial or viral origin.

Antibiotics are not often necessary in the treatment of uncomplicated otitis media with the mainstay of treatment being analgesia with antipyretic properties. Antibiotics in otitis media provide a modest benefit that must be balanced against the risk of adverse effects (Coker et al. 2010). In most cases involving children, antibiotics only provide symptomatic benefits after the first 24 hours, at which time symptoms are generally resolving. Serious complications, such as meningitis, mastoiditis, intracranial abscess, permanent hearing loss and neck abscess can develop as a result of otitis media (Olson 2003).

If the tympanic membrane has perforated, it is often the painful result of otitis media, trauma or foreign body insertion and is associated with loss of hearing. The individual should be advised to keep the ear dry and prevent water entering the ear. However, the ear should not be packed, and the patient should be advised not to do this at home, as it may prevent the discharge draining from the ear. More than 90% of tympanic membrane perforations heal spontaneously and management includes antibiotics, analgesia and antipyretics (Olson 2003). In some cases, where the tympanic membrane is intact, the infective material may cause the membrane to bulge, which also causes pain and loss of hearing. In such cases, admission to hospital is required in order that the tympanic membrane may be surgically perforated under general anaesthetic and grommets inserted to allow the discharge to drain out freely.

Clinical evidence and management: Cerumen may build up in the external auditory meatus, causing mechanical obstruction, which may be exacerbated by cleaning the ear with cotton-tipped buds. Such activities often cause cerumen to be pushed deep into the canal, causing impaction against the tympanic membrane. Obstruction in either case may cause a reduction in hearing, but rarely causes complete deafness. Impacted cerumen is often hard and resistant to removal by syringing alone; thus, in the ED the most appropriate management is to initiate a regimen to soften the cerumen using commercially available eardrops.

Patient education involves self-administration with advice to contact their GP in 2–3 weeks to arrange for ear syringing. Ear syringing is rarely indicated in the ED. Poor technique and failure to take adequate precautions may cause the patient serious harm; it is therefore imperative that ear syringing is carried out by a nurse who is suitably trained in the technique.

Clinical evidence: Older children and adults may present with a history of having a foreign body in the ear. Young children have a tendency to put foreign bodies in their ears, but as they often do not disclose this information, the nurse should be suspicious of children who present with earache, hearing loss and discharge from the ear. Small insects may also crawl into the ear canal and become trapped, causing a great deal of discomfort if still alive and buzzing.

Management: Foreign bodies may be removed using a variety of techniques including irrigation, suction and instrumentation, by individuals with the appropriate skills (Davies & Benger 2000). Care should be taken to ensure that this process does not impact the foreign body further in the ear, causing trauma to the external auditory meatus and the tympanic membrane.

If the tympanic membrane is intact then syringing the external auditory meatus with warm water may flush the foreign body out. However, this should only be carried out under direct visualization by those skilled in the technique.

Severe pain and distress are caused to patients when live insects enter the ear and they need to be killed in situ by the instillation of oil or lignocaine prior to removal (Davies & Benger 2000). Analgesic and/or antibiotic treatments should be prescribed as necessary.

Safe removal of a foreign body from the external auditory meatus requires a skilled operator and a cooperative patient, which is not always possible to achieve in the ED. If in any doubt, the patient should be referred to the ENT department. If the object is not retrieved at the first attempt, the patient should be referred to the ENT department.

Clinical evidence and management: Usually the child will have told the parents that she/he has put something up her/his nose, or the parents will have noticed that the child has a purulent discharge from one nostril. Unilateral discharge is highly suggestive of a foreign body in the nose; however, children are not averse to placing foreign bodies in each nostril, resulting in a bilateral discharge.

The removal of a foreign body in the nose follows the same rules as the removal of a foreign body in the ear. The child should be seated in a dental chair or on a parent’s lap in a semi-recumbent position. Initial assessment and history should ascertain the type of foreign body present, how long it has been in the nostril and whether there has been any bleeding or discharge. Careful explanation and instruction regarding the procedure for removal are required and psychological support for both parents and child is essential both for humanitarian reasons and to gain their cooperation during the procedure. Removal can be attempted using some topical anaesthetic spray, a ring curette or alligator forceps (Olson 2003). Care should be taken to prevent damage to the highly vascular nasal septum and mucosa during removal of a nasal foreign body. If the child is too distressed, the foreign body is too far into the nostril or there is any evidence of trauma to the nostril already, then the child should be referred to the ENT surgeon (Reynolds 2004).

Clinical evidence and management: The patient will present with active bleeding from the nose, or a recent history of bleeding that may have stopped. The main aim of treatment is to stop the epistaxis. If the bleeding is from the anterior end of the septum (Littles’ area), bleeding can usually be alleviated by seating the patient upright and advising her to hold the front soft part of the nose very firmly (Reynolds 2004). The patient’s head should be tilted forward over a bowl.

This compression must be applied for at least 30–40 minutes without interruption. The use of ice can be helpful for its vasconstricting action; however, children and the elderly may find it difficult to tolerate. The patient should be encouraged to expectorate blood rather than swallow it, as this can lead to vomiting, which makes measurement of blood loss difficult. Haematemesis is also very anxiety-provoking for the patient.

If the bleeding is from the posterior part of the nose, as indicated by continued bleeding after compression or as seen on examination, the patient may need to have the nose packed. The procedure may be performed in the ED following the application of local anaesthetic spray to the area. Ribbon gauze, haemostatic absorbent nasal tampons or catheters may be used as directed by the clinician. If unsuccessful, the patient may need to be referred to the ENT surgeon.

Once active haemorrhage is controlled, any precipitating medical factors should be identified and corrected if clinically safe to do so. The anticoagulated patient can pose a challenging problem, because they tend to have more severe epistaxis and bleed from several sites. Because of the risk for serious medical complications, reversal or discontinuation of the anticoagulation medication should not be performed unless it is deemed safe by the initiating medical specialty. During warfarin-related epistaxis, 80 % of patients were outside their disease-specific international normalized ratio (INR) range; therefore, in addition to a complete blood count, all patients should have an INR evaluated at the time of presentation (Smith et al. 2011, Rudmik & Smith 2012). If the patient is hypertensive on presentation an antihypertensive agent, such as nifedipine, may need to be administered.

Occasionally, the patient with an epistaxis may need resuscitative care due to blood loss. The siting of a large-bore intravenous line and commencement of replacement fluid, monitoring of vital signs, and taking of blood for a full blood count and cross-match are necessary in this case. All patients with epistaxis have the potential to become shocked if bleeding is not stopped. Initial assessment involves an estimate of the amount of bleeding, the length of time active bleeding has been taking place and any previous relevant medical history. Physical assessment of the patient should always include monitoring of vital signs (Melia & McGarry 2011).

Clinical evidence and management: There will be a history of trauma to the nose, swelling deformity and occasionally epistaxis. It is important to examine the nose for any evidence of cerebrospinal fluid (CSF), rhinorrhoea and any indication of fractures to the cribiform plate. Normal CSF is clear and slightly yellow, but CSF nasal drainage is frequently mixed with blood. Gisness (2003) describes septal haematoma as a bulging, tense bluish mass that feels doughy when palpated. Septal haematomas should be urgently drained to prevent airway obstruction and necrosis of the septal cartilage. Septal haematoma may strip the septal cartilage of blood supply and progress to abscess formation or later cartilage necrosis, resulting in significant nasal deformity and septal perforation. An overlooked septal haematoma may critically disfigure the patient and it should always be ruled out (Lynham et al. 2012).

Generally, little can be done for patients following a fracture of the nose until 5–10 days after the initial injury, due to soft tissue swelling. The patient should therefore be referred to the ENT outpatients department. Since the nasal bones will become firmly set within 3 weeks of the injury, reduction of a nasal fracture is indicated in any patient with significant cosmetic deformity or functional compromise (Vats et al. 2007). X-rays are often requested for medico-legal reasons, but are not strictly necessary (see also Chapter 10).

Clinical evidence and management: The patient presents with a runny nose or the sensation of something dripping down the back of the throat. The discharge may be clear or purulent. The causes are:

The patient may need to have a foreign body removed. If an allergy is suspected, antihistamines may be prescribed, and advice should be given on avoidance of common allergens, i.e., grass/tree pollen, dust and cat or dog fur. The patient may also need to be referred to an allergy clinic. Infective rhinosinusitus may need treatment with antibiotics. If a tumour is suspected, urgent referral to ENT will be necessary.

Advice, explanation and health education regarding the taking of antihistamines (whose main side-effect is drowsiness) and antibiotics should be given to the patient. If the rhinitis is viral in origin, antibiotics will have little or no effect, and they should therefore not be seen as a panacea for this, or any other, condition.

Clinical evidence and management: The main symptoms a patient can present to the ED are sneezing, headache and facial pain which are worse when bending forward, and a recent history of upper respiratory tract infection. Maxillary toothache without obvious dental cause may also occur. The patient may be very worried about the severity of their headache. A set of baseline observations of pulse, blood pressure, temperature and respirations will aid diagnosis. This, along with a clinical history, may help to rule out other diagnoses such as hypertension or subarachnoid haemorrhage.

Treatment usually involves prescription of a broad-spectrum antibiotic. Advice can be given to take analgesia and to use a decongestant spray. The patient should be advised to see their GP if symptoms persist, as referral to the ENT department may be necessary. Complications of sinus disease include meningitis, orbital extension and brain abscess (Kumar 2004).

Clinical evidence and management: Abscesses of the teeth may need drainage and/or antibiotic therapy, which is most appropriately carried out by a dental practitioner. Frequently the most appropriate course of action is to refer the patient to their GP, but in the interim the patient may be prescribed antibiotics and analgesia. Patient education may focus upon the safe and efficacious use of prescribed medication and the initiation of oral hygiene measures including saline mouthwashes and tooth brushing.

Aetiology of anaphylactic shock: Anaphylaxis is a severe, life-threatening, generalized or systemic hypersensitivity reaction. It is characterized by rapidly developing life-threatening airway and/or breathing and/or circulation problems usually associated with skin and/or mucosal changes. The incidence of anaphylaxis appears to be increasing, in part given the possibility of omission of a precise diagnosis for a patient (Simons & Sampson 2008, Younker & Soar 2011). It generally follows from exposure to a foreign protein to which the patient has been previously sensitized. The individual becomes sensitized to the allergen by the production of antibodies in response to this exposure. These bind to basophils in the blood and sensitize the cells. Common sensitizing substances are antibiotic medication, especially penicillin and penicillin derivatives, bee stings, foodstuffs such as peanuts and non-steroidal anti-inflammatory medications. When the allergen re-enters the body, this stimulates the release of mediators of anaphylaxis, e.g., histamine, serotonin, slow-release substances of anaphylaxis (SRS-A) and platelet-activating factors (PAF), which result in cellular damage.

Clinical evidence of anaphylactic shock: Anaphylaxis is likely when all of the following three criteria are met:

Physiological changes include:

These changes may result in some or all of the following symptoms:

Symptoms can occur within minutes of ingestion, with the allergen gaining rapid access to the circulatory system through the digestive tract and activating mast cells in the mouth, throat, lungs, skin, abdomen and other tissues and organs (Crusher 2004). Management is based on positioning of the patient in the supine position and the administration of adrenaline (epinephrine) via the intramuscular route. This is supported with high-flow oxygen to combat potential hypoxia. Where adrenaline is administered, the patient should be admitted for a period of observation. If possible, the allergen should be identified to enable the patient to avoid this in the future.

Those patients with mild reactions and who are discharged home require advice on the safe and efficacious use of any prescribed medications, most likely antihistamine tablets. Specifically they should be warned of the sedative effects of this type of medication and thus the implications for driving and operating machinery while taking the medication. Subsequent exposure to an unidentified allergen may cause a more severe reaction which could be potentially fatal. It is crucial that these patients are offered advice on identifying the allergen which caused the reaction. This is perhaps best achieved by referral to their own GP who may arrange appropriate tests and support.

Clinical evidence: External as well as internal trauma may cause oedema in this region. People who have attempted suicide by hanging or strangulation and those involved in accidents involving strictures around the neck account for a proportion of this group of patients. In cases of strangulation and hanging where the patient is unable to self-advocate, for whatever reason, consideration should be given to any medico-legal implications, and where appropriate the police may need to be informed. Victims of road traffic accidents may also suffer trauma to this region of the body which can be easily overlooked in the presence of more obvious injuries, highlighting the importance of thorough primary and secondary surveys. Where neck injuries are apparent, the possibility of trauma to the internal structures should be considered.

Inhalation injury due to hot gases and flames may be present in burn-injured patients. Signs of inhalation injury from hot substances are not always evident, but a useful sign to look for is singed nostril hairs. If the gas was hot enough to damage these hairs then airway damage should be expected. Similarly, the ingestion of corrosive substances may also cause burns and swelling to the pharynx area. Inhalation of small foreign bodies, such as fish bones, rarely causes airway obstruction, but they can be troublesome, causing irritation, increased salivation and coughing because they are lodged in the pharynx. Patients should be advised that fish bones can often scratch the side of the throat on the way down, leaving them with the feeling that the foreign body is still there.

Management: The airway is the number one priority. Careful and accurate assessment of the patient and the extent of injuries must be carried out early. If the patient is conscious, a history of the event and mechanism of injury will give an indication of the stresses involved. Signs of airway obstruction such as noisy breathing should be noted and monitored for deterioration. Admission is essential where there is a degree of swelling which is likely to increase, leading to the airway becoming compromised.

For patients with small foreign bodies in their pharynx, X-ray examination may be helpful and could reveal radio-opaque objects. A plain lateral soft-tissue X-ray of the neck can provide valuable information about tissue swelling.

Clinical evidence: There will be a number of patients attending the ED with simple sore throats. They often only need reassurance and simple advice, possibly with referral to their GP if symptoms persist. There will be some adults among them with a peritonsillar abscess that will require further intervention. Children are less likely to complain of a sore throat but often go off their food and generally feel unwell and are pyrexial. These children may present with dysphagia, a wheeze or stridor and will need careful assessment. The possible cause of these symptoms is epiglottitis, which is a potentially fatal inflammation of the epiglottis and pharynx as a result of infection. McEwan et al. (2003) report an age range of presentation between 6 months and a little over 10 years.

Management: Peritonsillar abscesses in need of drainage will require the attention of the ENT team. The patient should be referred as soon as the diagnosis has been made. As a general anaesthetic may be required, the patient should be kept nil by mouth, and unnecessary examination of the throat should be avoided as this is likely to be very uncomfortable.

Children with epiglottitis will require urgent assessment and admission by the paediatric team. It is essential that the child is kept calm and is not distressed, that examination in the ED is kept to a minimum, and that insertion of instruments, such as thermometers or tongue depressors, should not take place, as this may cause the epiglottis to be pushed onto the larynx, thus occluding the airway completely. Endotracheal intubation should only be carried out by those who are extremely experienced in these techniques. If the airway becomes occluded then patency should be ensured by means of cricothyrotomy.