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

• Onset of vertigo is sudden and severe.
• May be paroxysmal and brought on by change in position of head in BPV.
• Associated with nausea and vomiting.
• Tinnitus and deafness especially in Ménière’s disease.
• Exclude central causes with a complete neurological examination.
• Examine the ears for infection/inflammation.

Management

1. Symptomatic with diazepam and/or prochlorperazine.
2. IV fluids if vomiting/dehydrated.
3. If not settling and due to a peripheral cause, refer to ENT service for admission until symptoms settle.

NOSE EMERGENCIES

Acute sinusitis

Most are viral—approximately 90% of patients with upper respiratory tract infection (URTI) have involvement of the paranasal sinuses. However only 0.5–2% of these proceed to have bacterial infection.1

Clinical features

• Symptoms of viral URTI not resolved after 10 days
• Purulent nasal discharge
• Facial or maxillary dental pain
• Fever
• Post-nasal drip
• Tenderness over sinuses
• CT of sinuses confirms sinusitis

Organisms

• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis

Management

1. Analgesia.
2. Antibiotics—amoxicillin/clavulanate is the drug of choice, but is likely to have more side effects, especially diarrhoea. Recent Cochrane review found minimal effect in patients with uncomplicated acute sinusitis of more than 7 days duration.2
3. Intranasal corticosteroids—there is limited evidence to support use as monotherapy or adjunct with antibiotics.3
4. Intranasal saline douches/spray—there is evidence it is helpful in chronic sinusitis,4 sometimes recommended in acute sinusitis as well.
5. Oral steroids are rarely used.

Complications

• Periorbital and orbital cellulitis
• Meningitis
• Brain abscess

Epistaxis

One of the commonest ENT emergencies. Approximately 90% are anterior bleeds from Little’s area of the septum. Posterior bleeds are harder to visualise, more difficult to treat and occur in older patients with coexisting cardiovascular disease.

Clinical features

• Bleeding from nostril
• Blood in the oropharynx
• Airway usually intact
• May be haemodynamically compromised

Management

1. Protect yourself with gloves, gown and goggles.
2. Assess and manage A, B, C initially.
3. Large bore IV cannula and take blood for FBC, coagulation studies and group-and-hold.

Anterior bleeds

1. Ask patient to compress anterior nares between thumb and forefinger, applying constant pressure for 10–15 minutes.
2. Sit the patient up, leaning forwards, and ask the patient to hold a kidney dish below the mouth and spit into this.
3. Now inspect the nose to identify bleeding point.
4. Apply cotton wool pledgets soaked in cophenylcaine to visible bleeding spot or vessel.
5. If bleeding controlled and bleeding point identified, use silver nitrate stick to cauterise the area.
6. Be careful not to apply to large area and do not apply on both sides of septum as this could lead to necrosis of the cartilage.
7. Observe patient for a few hours and, if no further bleeding, may be discharged with outpatient ENT follow-up.
8. If bleeding is too heavy use a nasal (Merocel) tampon (see Box 37.2) or a Rapid Rhino device (inflatable balloon covered with hydrocolloid fabric, see Box 37.3).
9. If above not available, pack with gauze (see Figure 37.3).
10. Depending on hospital policy, patient may require admission if packing left in situ.
11. Prophylactic antibiotics if packing left in situ.

Box 37.2 To insert Merocel nasal tampon

1. Trim to fit through the nostril.
2. Lubricate tip with KY gel.
3. Advance as far as possible along floor of nasal cavity.
4. When soaked with blood, will expand to fill nasal cavity.
5. Tape attached thread to side of face.

Box 37.3 To insert Rapid Rhino device

1. Soak in sterile water for 30 seconds.
2. Get patient to blow nose to expel clots/blood.
3. Insert device along floor of nasal cavity.
4. Use 20-mL syringe to inflate with air until pilot cuff firm. Device will expand to fit nasal cavity.
5. Tape pilot cuff to side of face.

image

Figure 37.3 Correct placement of Vaseline gauze packing, with antibiotics commenced (possible bacteraemia in presence of nasal packing)

Posterior bleeds

Bleeding site usually is not visible.

1. Options are:

• Merocel nasal tampon (see Box 37.2)—may not be effective in posterior bleeds.
• Rapid Rhino Posterior device (see Box 37.3).
• Epistat nasal balloon (see Box 37.4).
• Foley catheter and vaseline gauze pack (see Figure 37.4).

2. May need to pack both sides to stop bleeding.
3. All patients need admission under the care of the ENT team.
4. Prophylactic antibiotics.

Box 37.4 To insert Epistat nasal balloon

1. Lubricate and insert to full length.
2. Inflate posterior balloon with approximately 5 mL of air.
3. Pull forward gently till fits against posterior choana.
4. Fill anterior balloon till tamponade achieved.
5. Tape to side of face.

image

Figure 37.4 Foley’s catheter used as postnasal balloon packing, with gauze anterior pack

Foreign bodies—nose

Usually seen in children. Beads, parts of toys, paper, seeds, pebbles are some of the objects inserted by children. Usually present soon after as child tells parent or parent/sibling witnesses the child putting something in the nose. If presentation delayed, may present with offensive unilateral nasal discharge.

Note: Button batteries should be removed as soon as possible. If left for any length of time, they lead to a corrosive injury.

Management

1. Spray cophenylcaine into nostril.
2. Sedate child if not cooperative.
3. Get a good view using headlight (if available).
4. If hard, round object use angled hook to get behind object and pull out.
5. If soft, irregular and can be grasped by forceps, use this.
6. Other methods described include using a Foley or Fogarty catheter to get behind the object and then blow balloon up and pull object out or use suction catheter to apply suction on object and bring it out.
7. Once removed re-inspect to make sure object removed completely and no other objects present.

Fractured nasal bones

One of the commonest bones fractured in the body.

Note: Diagnosis of nasal fractures is a clinical one and X-rays are rarely if ever indicated.

Clinical features

• History of direct trauma to nose.
• Patient may have noticed an immediate deformity if fracture with displacement.
• Swelling of nose.
• Epistaxis.
• May have a palpable step in the bone.
• X-rays are difficult to interpret.

Management

1. Treat any other life-threatening injuries first.
2. Exclude other facial bone injuries.
3. Manage epistaxis if present with pressure or packing.
4. Inspect for septal haematoma—cherry red swelling arising from septum. If present, the patient should be immediately referred to the ENT service for drainage. If left untreated, may lead to necrosis of cartilage with resultant saddle nose deformity.
5. The fracture is left for a few days until the swelling has gone down.
6. If deformity is present at that time, should be referred to ENT or plastic surgeon for reduction.

THROAT EMERGENCIES

Pharyngitis/tonsillitis

• More common in children.
• It is difficult to differentiate clinically between bacterial and viral. However, it is important to try and differentiate between group B haemolytic streptococcal infection and other causes of sore throat.

Aetiology

• Viral including Epstein Barr virus (EBV)
• Group B haemolytic Streptococcus (GBHS)
• Other bacteria including other Streptococcus, Chlamydiae, Gonococcus

Clinical features

• Sore throat
• Fever
• Odynophagia
• Generalised symptoms of headache, malaise—thought to be more likely bacterial but often viral, especially EBV
• Associated runny nose, cough—more likely with viral
• Inflamed pharynx, enlarged tonsils with or without exudate/pus upon examination
• Cervical lymphadenopathy
• Hepatosplenomegaly usually indicates EBV
• Raised WCC, CRP
• Lymphocytosis with atypical lymphocytes—viral, especially EBV
• Abnormal liver function tests (LFTs)—EBV
• Throat swab for GBHS
• Monospot, EBV serology

Of the above, a combination of fever > 38°C, tender cervical lymphadenopathy, tonsillar exudate and no cough is suggestive of GBHS sore throat.

Management

1. Analgesia.
2. IV fluids as often dehydrated.
3. Steroids are often used to reduce symptoms, but not much evidence to support it. Dexamethasone 4–8 mg as a once off dose is used.5
4. Penicillin for GBHS if high index of clinical suspicion or confirmed on throat swab PCR or culture.
5. If uncomplicated may be discharged after symptomatic treatment.

Complications

• Airway compromise—unusual if not complicated. Requires admission to high dependency unit under the care of the ENT team. Nasendoscopy performed by ENT to assess degree of swelling/obstruction. Rarely requires airway intervention.
• Peritonsillar abscess—see below.

Peritonsillar abscess (Quinsy)

Starts as a pharyngitis or tonsillitis and progresses to form abscess. Common in young adults.

Usually polymicrobial with a mixture of aerobic and anaerobic organisms.

Clinical features

• Starts like a sore throat, but gets progressively worse.
• Difficulty swallowing, opening mouth and talking.
• Fever and systemic symptoms more marked.
• Examination reveals a unilateral swelling displacing the tonsil inferomedially.
• Uvula is displaced to the contralateral side.
• Enlarged cervical lymph nodes.

Management

1. Analgesia.
2. IV fluids.
3. Antibiotics—combination of penicillin and metronidazole.6
4. Clindamycin may be used instead of metronidazole.6
5. Anaesthetise with cophenylcaine spray.
6. Needle aspiration (see Box 37.5) is generally curative, and incision and drainage is rarely indicated.
7. ENT referral for 24 hour admission or follow-up if discharged from emergency department.
8. Use of steroids is controversial.7

Box 37.5 Needle aspiration

1. Have patient sitting up with kidney dish under chin. Have suction ready.
2. Use a large bore needle on a 10-mL syringe and insert at area of maximal pointing while applying continuous negative pressure until you feel a ‘give’ when should have entered abscess cavity.
3. Aspirate pus and send for culture.

Epiglottitis

Inflammation of the supraglottic region, including epiglottis, should be called supraglottitis.

Epiglottitis used to be a disease of childhood. After immunisation against H. influenzae B was started, now usually seen in adults.

Clinical features

• Sore throat—pain is lower than in tonsillitis.
• Muffled voice.
• Difficulty swallowing.
• Fever.
• Acute onset in children, may have prodromal URTI symptoms in adults.
• Examination reveals a toxic-looking patient.
• Drooling of saliva in children.
• Cervical lymphadenopathy may be present.
• Stridor is a late sign.
• Lateral soft tissue X-ray of neck may show classic ‘thumb print’.

Organisms

• H. influenzae, type B
• Streptococcus pneumoniae
• Streptococcus pyogenes
• Staphylococcus aureus and gram negatives are less common

Management

1. If respiratory distress with stridor, consult anaesthetics and ENT and organise urgent transfer to operating theatre for gaseous induction and intubation.
2. If intubation fails, cricothyroidotomy or tracheostomy will need to be performed.
3. In adults who are not in respiratory distress, ENT consult for nasendoscopy.
4. Airway intervention is rarely required in adults.
5. IVC inserted and bloods taken for FBC, electrolytes, urea, creatinine (EUC), blood cultures.
6. Ceftriaxone is antibiotic of choice.
7. Steroids may be used to reduce swelling.
8. Admit to high dependency unit or ICU for close observation and airway intervention if required.
9. If patient has a respiratory arrest, commence bag-valve-mask ventilation and then intubation should be attempted. If this fails, proceed to a cricothyroidotomy.

Foreign bodies—oropharyngeal

Note: Button battery if swallowed is an emergency, and the ENT service should be called immediately.

Usually an adult who has eaten chicken or fish and has a bone stuck in the pharynx.

Clinical features and examination

• History as above.
• Feeling of foreign body stuck in throat.
• Examine neck for surgical emphysema.
• Inspect pharynx with headlight to visualise object if able.
• X-ray lateral soft tissue neck looking for foreign body and retropharyngeal air.

Management

1. If foreign body visible with headlight and tongue depressor, anaesthetise with lignocaine spray and remove with Magill’s forceps.
2. If not visualised but visible on X-ray, refer to ENT for endoscopic removal.
3. If not visualised on inspection and not visible on X-ray, a foreign body may still be present or the patient may feel a scratch on the mucosa as a foreign body. These patients will also require endoscopy if the feeling of foreign body is persistent.

Complications

If left unattended, may perforate and lead to retropharyngeal infection and mediastinitis.

Foreign bodies—oesophageal

Depending on the hospital policy, these may be dealt with by ENT or gastroenterology. Upper oesophageal objects are commonly dealt with by the ENT service. In adults usually a food bolus and in children a coin are the commonest objects. Beware of button batteries in children as this is an emergency to prevent perforation of the oesophagus.

Clinical features

• Sensation of foreign body
• Inability to swallow—varying degrees depending on degree of obstruction
• Drooling in complete obstruction
• Chest X-ray ± lateral soft tissue neck depending on level of obstruction

Note: Coin in oesophagus appears in coronal plane (front on) on X-ray. Coin in airway appears in sagittal plane (side on) due to incomplete tracheal rings posteriorly.

Management

1. Trial of glucagon 1–2 mg IV ± carbonated beverage if foreign body is food bolus or coin. Do not attempt if sharp object or button battery.
2. If above method unsuccessful or sharp object/button battery, urgent ENT referral for endoscopic removal.
3. Keep patient nil-by-mouth (NBM).
4. Pre-anaesthetic work-up if indicated.

Complications

Oesophageal perforation and mediastinitis

Foreign bodies—airway

Common in children and very elderly. Usually aspirated and lodged in right main or lower lobe bronchus. Complete airway obstruction is a life-threatening emergency and should be treated with back blows.

Clinical features

• History of choking, coughing, gagging.
• If aspirated child may be minimally symptomatic initially and only have a cough or wheeze, especially unilateral wheeze.
• Stridor.
• Respiratory distress if causing upper airway obstruction.
• Chest X-ray may reveal foreign body if radio-opaque or unilateral hypertranslucency, atelectasis or consolidation.

Management

1. Supportive therapy till endoscopic removal—O2, IV access and monitoring.
2. Urgent ENT referral for endoscopy.
3. If patient has complete obstruction and respiratory arrest, intubate and push tube as far as possible thus pushing object into one bronchus. Then withdraw the tube to normal position to ventilate until endoscopic removal is organised.

Post-tonsillectomy bleed

Secondary haemorrhage may occur after 24 hours, but commonly between 5 and 10 days. Can be fatal from airway obstruction or haemorrhagic shock.

Management

1. Keep patient seated upright with kidney dish to spit into.
2. Monitor haemodynamics and oxygen saturation.
3. Keep NBM.
4. Obtain large bore IV access and send blood for FBC, UEC, coagulation studies and group-and-hold.
5. Resuscitate as required including airway protection if necessary. Be prepared to perform surgical airway if unable to intubate.
6. Notify ENT team immediately.
7. Commence IV penicillin and metronidazole.
8. Hydrogen peroxide gargles are prescribed but there is no evidence to support their use.

REFERENCES

1 Gwaltney J.M. Acute community-acquired sinusitis. Clin Infect Dis. 1996;23(6):1209-1223.

2 Ahovuo-Saloranta A, Borisenko OV, Kovanen N et al. Antibiotics for acute maxillary sinusitis. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD000243. DOI: 10.1002/14651858.CD000243.pub2.

3 Zalmanovici A, Yaphe J. Steroids for acute sinusitis. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD005149. DOI: 10.1002/14651858.CD005149.pub2.

4 Harvey R, Hannan SA, Badia L et al. Nasal saline irrigations for the symptoms of chronic rhinosinusitis. Cochrane Database of Systematic Reviews, 2007, Issue 3. Art. No.: CD006394. DOI: 10.1002/14651858.CD006394.pub2.

5 Bulloch B., Kabani A., Tenenbein M. Oral dexamethasone for the treatment of pain in children with acute pharyngitis: a randomized, double-blind, placebo-controlled trial. Ann Emerg Med. 2003;41(5):601-608.

6 Antibiotic guidelines eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited; 2006.

7 Ozbek C., Aygenc E., Tuna E.U., et al. Use of steroids in the treatment of peritonsillar abscess. J Laryngol Otol. 2004;118(6):439-442.

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