Ear, nose and throat emergencies

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Chapter 37 Ear, nose and throat emergencies

Shalini Arunanthy

The care of these patients requires an organised approach and some basic equipment (see Box 37.1).

Box 37.1 ENT equipment

Head light
Nasal speculum
Ear speculum
Jobson Horne curette
Packing forceps
Alligator forceps
Magill’s forceps
Suction catheters—including fine metal sucker
Cophenylcaine spray

EAR EMERGENCIES

Otitis externa

Clinical features

• Ear pain
• History of water exposure or trauma—commonly cotton tips
• Oedema of canal, with debris

Organisms

• Pseudomonas
• Staphylococcus
• Rarely fungal

Management

1. Analgesia.
2. Remove debris gently—suction catheter or cotton wool swab.
3. Insert Merocel tampon (ear).
4. Instil antibiotic/steroid drops (Otodex, Sofradex).
5. ENT consult for admission and IV antibiotics if spread outside ear canal. Otherwise outpatient ENT follow-up.

Otitis media

Clinical features

• Common in children
• Ear ache ± fever
• Pulling at pinna
• Injection of tympanic membrane with bulging of membrane
• Effusion behind membrane
• Purulent discharge if tympanic membrane ruptured (leads to relief of pain)

Organisms

• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis

Management

1. Analgesia.
2. Antibiotics if less than 6 months old or if systemic features (fever, vomiting).
3. Otherwise wait for 48 hours.
4. Review and start antibiotics if not improving.
5. Antibiotic of choice is amoxicillin.
Note: Antibiotics are no longer routinely recommended for all patients with acute otitis media.

Complications

• Ruptured tympanic membrane usually heals spontaneously without complications within 2–3 weeks. Advise to keep dry and avoid instilling any drops.
• Recurrent infections/otitis media with effusion—refer to ENT as outpatient.
• Mastoiditis—see ‘Mastoiditis’ section below.
• Intracranial complications such as epidural abscess, meningitis are rare.

Mastoiditis

Mastoiditis is a rare but significant complication of otitis media.

Clinical features

• Symptoms of otitis media
• Pain over mastoid region
• Fever
• Erythematous, bulging ear drum
• Tenderness ± swelling over mastoid
• Elevated white cell count (WCC), C-reactive protein (CRP)
• CT scan showing changes of mastoiditis (mainly fluid in mastoid air cells)

Organisms

Similar to acute otitis media.

Management

1. IV antibiotics—usually ceftriaxone plus flucloxacillin.
2. Analgesia.
3. ENT referral for admission ± surgery.

Perichondritis

Becoming more common due to infected ear piercings involving cartilage (high piercings).

Clinical features

• Painful auricle
• Erythema and swelling of auricle
• Fever

Organisms

• Pseudomonas aeruginosa
• Staphylococcus aureus
• Streptococcus pyogenes

Management

1. Analgesia.
2. Antibiotics—flucloxacillin and gentamicin.
3. ENT referral for admission ± drainage.
4. Explain to patient the possibility of necrosis of cartilage with associated deformity.

Ruptured tympanic membrane

Caused by otitis media, blows to the ear or direct trauma, usually due to objects used to clean ear canal.

Clinical features

• Hearing loss—conductive
• If associated with infection acute pain, relieved once membrane ruptured
• Discharge from ear also if associated with infection
• Visible tear of membrane on otoscopy

Management

Most perforations do not require specific treatment and will heal spontaneously, especially if central perforation.

1. Keep ear dry—most important instruction for patient.
2. Antibiotics if associated with infection.
3. Hearing test.
4. Refer to ENT outpatient for follow-up.
5. Refer to ENT immediately if associated tinnitus, vertigo as this signifies inner ear injury.

Auricular haematoma

Clinical features

Patient presents with a swollen, painful pinna following blunt trauma.

Management

ENT referral for drainage and pressure dressing to prevent further bleeding.

Complication

If not treated adequately, the cartilage undergoes necrosis and a ‘cauliflower ear’ will result.

Auricular lacerations

Simple lacerations may be repaired in the emergency department. Complex wounds should be referred to the ENT or plastic surgeon for repair.

Refer the following wounds:

• loss of skin
• multiple lacerations
• exposed cartilage
• involvement of external auditory canal
• avulsion or near avulsion of ear.

Management of simple lacerations

1. Irrigate with saline (place gauze in canal to reduce amount of saline going into external ear).
2. Anaesthetise with a block rather than local infiltration into pinna (see Figure 37.1).
3. Insert needle just above the attachment of the ear to the head. Direct the needle first anteriorly towards tragus and inject local anaesthetic then withdraw to point of insertion and inject posteriorly behind ear. Do the same at inferior attachment of ear. DO NOT inject into pinna.
4. Repair cartilage with 5/0 absorbable suture.
5. Repair skin with 5/0 or 6/0 non-absorbable suture.
6. Pressure dressing.
7. Remove sutures in 5 days.
image

Figure 37.1 Anaesthetic block of the ear

Temporal bone fractures

Temporal bone fractures are reported to be included in 15–20% of all skull fractures. This injury has a low priority in the multitrauma patient, but should not be forgotten.

Clinical features

• CSF or blood in ear canal
• Battle sign—post auricular haematoma
• Facial nerve palsy
• Vertigo
• Deafness
• CT scan with fine cuts through the temporal bone required for evaluation

Management

1. Most important is to look for the injury in the secondary survey.
2. ENT referral.
3. Most are managed conservatively.

Foreign bodies—ear

• Common in children. Usually beads, bits of toys, seeds, paper.
• In adults may be insects or cotton off the tip of a cotton bud.

Clinical features

• Pain
• Discharge if left unattended and gets infected
• Visible foreign body on otoscopy

Management

1. Most important is a cooperative patient. The child may require sedation, e.g. with nitrous oxide. Explain procedure to parents and get them to calm the child.
2. If insect, drown in lignocaine and then remove with alligator forceps.
3. If non-organic and tympanic membrane intact, trial of irrigation.
4. Try suction with small catheter if irrigation fails or as first choice.
5. If unsuccessful use an angled hook or curette to get behind the object and then move the object out along the canal (see Figure 37.2).
6. If unable to remove object refer to ENT.
Note: DO NOT try to grab a hard round object with forceps as this is likely to push it further into the auditory canal.
image

Figure 37.2 Incorrect and correct ways to remove a foreign body from the ear

Vertigo

Vertigo is the sensation of spinning of self or surroundings. Causes may be central or peripheral.

Peripheral causes are labyrinthitis, vestibular neuronitis, Ménière’s disease and benign positional vertigo (BPV). This section will deal only with the peripheral causes.

Clinical features

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