Transcript Management? - Calgary Emergency Medicine

ENT
Emergencies
January 29, 2004
Aric Storck
Dr. Peter Gant
Objectives
• Ear injuries
• Otitis externa
• Nasal fractures
• Epistaxis
• PTA
• Airway emergencies
• Will not cover: OM, sore throats, sinusitis,
vertigo
the ear
Ear Lacerations
• 50 year old man
• Playing hockey
•
•
without helmet
Laceration to ear from
skate
?management
Roberts: Clinical Procedures in Emergency
Medicine, 3rd ed.
Questions
• Do you trim the cartilage?
• How do you close the laceration?
• How will you dress it?
Ear Lacerations
• Anatomy
– auricle (pinna) – modified horn shaped structure
composed of elastic cartilage covered by skin –
converges onto the external auditory meatus (canal)
– Cartilage is avascular and needs blood supply from
overlying skin and perichondrium
– earlobe
• with blunt forces ensure no ruptured TM
Ears Lacerations
management
•
Debride non-viable skin and cartilage
•
Ensure enough skin to completely cover cartilage
–
•
can trim up to 5 mm of cartilage while avoiding major
cosmetic defect
“Through and through” lacerations - 3 layer closure
1.
Approximate cartilage edges
•
•
•
4-0, 5-0 absorbable suture
Include both anterior and posterior perichondrium in suture or
sutures will pull through cartilage
Use the folds of pinna as landmarks
2. Repair posterior skin
•
5-0 non-absorbable suture
3. Repair anterior surface
•
•
•
5-0, 6-0 non-absorbable suture
Use landmarks
Ensure edges of free rim are everted to avoid “notching”
•
NB: Some ENT’s advocate suturing all three layers
together
•
All repaired ears should be enclosed in a compression
dressing
•
Consider antibiotics for heavily contaminated wounds
Case 2
• 16 year old wrestler
– Head slammed on floor
during training
– Not wearing protective
headgear
• Diagnosis?
• Management?
Source: NEJM 1996: 335(6)
Cauliflower Ear
subchondral hematoma
• Bridging vessels between perichondrium and cartilage are
torn
• Hematoma stimulates cartilage growth in overlying
perichondrium  “cauliflower”
• Perfect hemostasis to prevent permanent damage
• Refer all but most simple hematomas to plastics or ENT
• Compression dressing
Management
• Small hematoma
– Needle drainage (22G) and close observation
• Large hematoma
– I&D (use landmarks to hide incision)
– Suction or curettage to remove hematoma
– Compression dressing x 4-7 days
– Close ENT follow-up
Cauliflower Ear
CASE 3
• 26 year old male
–
–
–
–
Just returned from diving holiday in the Caribbean
Right ear itchy x 1 week
Now c/o right ear pain and moderate discharge
Normal hearing
• O/E
– VSSA
– Ear canal erythematous and edematous with some cloudy
discharge.
– TM moderately red, but not bulging
– Patient very tender when you press on his tragus
Acute Otitis Externa
• What are the most common pathogens?
– Pseudomonas
– S. aureus
• Treatment
– Cleansing
• Tap water, vinegar
– Topical antibiotics
• Generally aminoglycoside/steroid, fluoroquinolone/steroid
combination
– Systemic antibiotics
• May be necessary in severe cases, particularly if also cellulitis
• Severe cases
– Wicking (cotton, gauze)
– Allows medication to penetrate into the
auditory canal
– Should be left in 2-3 days
• Suppose your patient is an elderly
diabetic. What complication are you
concerned about?
• Malignant otitis externa
– Osteomyelitis of the skull base
– pseudomonas
the nose
Case 4
• 24 year old male
– Drunk
– Was minding his own business when
somebody punched him in the face
– Now moderate epistaxis and crooked nose
Nasal Fracture
diagnosis
• History
– “Have you broken your nose before?”
– “does your nose look normal to you?”
– Breathing difficulty
• Physical examination
–
–
–
–
–
Crepitus, hypermotility, edema, tenderness, deformity
Depressed, laterally angulated, comminuted
if mechanism severe look for other injuries
epistaxis
septal hematoma
Nasal anatomy
Figure 1. Nasal anatomy. The relationship
between the nasal bones, cartilages, and
septum. From Otolaryngology–Head and Neck
Surgery. 3rd ed. Copyright 1998, Mosby
Figure 2. Anatomy of the nasal septum. 1, Frontal
bone; 2, nasal bones; 3, perpendicular plate of the
ethmoid; 4, vomer; 5, palatine bone; 6, nasal crest
of maxilla; and 7, quadrangular cartilage. From
Otolaryngology–Head and Neck Surgery. 3rd ed.
Copyright 1998
Pathophysiology of nasal trauma. A, Lateral nasal trauma with isolated
nasal bone fracture. B, Bilateral nasal bone fractures with septal
dislocation. C, Frontal trauma with dorsal widening. D, Comminuted
nasal fracture.
From Head and Neck Surgery–Otolaryngology.
Copyright 1993, Lippincott Williams & Wilkins.
To x-ray or not to x-ray ….
• Clayton M, et al. The role of radiography
in the management of nasal fractures. J.
Laryngol Otol. 1986: 100:797-801.
– 54 patients
– Prospective clinical & radiological assessment
& examination under anaesthesia
– X-rays did not change management
• Delacey et al (1977)
– 100 ED patients with nasal fractures
– Compared normal x-rays to those of patients
with clinical fractures
– No diagnostic utility of x-rays because of high
incidence of “bony abnormalities”
• Mayell et al (1973)
– 107 patients with nasal fractures
– Negative or positive x-rays did not change
management or reduction decisions
The bottom line
If the nose looks good
…and breaths good
You don’t need x-rays
Remember, you have a week to fix it
So what are you going to do about it?
Treatment
• Primary goals
– Restore function
– Cosmetic
• Consider early reduction if
– patient presents before onset of soft tissue edema
– or … severe fracture causing airway problems
• After edema, best to wait 3-4 days for reevaluation
• Closed reduction under local anaesthesia
possible up to 10 days (less in kids)
• F/U within a week
– ENT or plastics
– To ensure acceptable cosmetic result once
edema subsided
Closed reduction
• Anaesthesia
– 4% cocaine for intranasal anaesthesia
– Regional blocks with 1% lidocaine with epi
• Supratrochlear nerve
• Infraorbital nerve
• Nasal dorsum
Good job with the fracture …now
you look in the nose and see…
Septal hematoma
Septal hematoma
• Bulge of nasal mucosa
• Same colour as mucosa
• Prone to infection
– Results in abscess and cartilage
necrosis
• I&D with L-shaped incision
• Pack nose to prevent
•
reaccumulation
Close ENT follow-up
Source: Simon, Emergency Procedures and Techniques
Case 5
• 78 year old male
–
–
–
–
On coumadin and ASA for cardiac disease
Brisk nosebleed x 2 hours
Blood mostly from right nare
Some blood down back of throat
• ?Diagnosis
• ?Management
Epistaxis: Epidemiology
• Annual incidence 15% men, 9% women
• More frequent from November to March
• 15:10,000 seek medical care each year
• 1.6:10,000 hospitalized each year
Slide courtesy of Dr. Anita Hui
Etiology: Local Factors
• Trauma
– Epistaxis digitorum
• Inflammatory reactions ( allergies, infections,
foreign bodies)
• Tumors (juvenile nasopharyngeal angiofibroma)
• Substance abuse
– Cocaine, solvents
Slide courtesy of Dr. Anita Hui
Epistaxis: Systemic Factors
• Osler-Weber-Rendu (HHT)
• Von Willebrand’s disease
– Bleeding time, quantitative
immunoelectrophoresis or ELISA
• Hemophilia
• Leukemia, thrombocytopenia
Slide courtesy of Dr. Anita Hui
Epistaxis: Systemic Factors
• MM
• Hemodialysis
• Nutritional deficiences
• Medications: ASA, NSAIDs, warfarin,
chloramphenicol, carbenicillin,
dipyridamole
Slide courtesy of Dr. Anita Hui
Anterior Epistaxis – 90-95%
• Septal wall
• Kiesselbach’s area
– External carotid
• Sphenopalatine artery
– Internal carotid
• Anterior ethmoidal artery
Slide courtesy of Dr. Anita Hui
Posterior Epistaxis – 5-10%
• Lateral wall
• Both internal & external
carotid
• “Woodruff’s plexus”
– Arterial and venous plexus
– Most common site of
posterior epistaxis
Slide courtesy of Dr. Anita Hui
Epistaxis: Management
• ABC’s
– Airway
– Resp distress
– hypotension
• Correct underlying problem
– CBC, coags
•
•
•
•
Pressure
Ice
Morphine, other medications
Cauterization: chemical (Ag
Nitrate), electrical
Slide courtesy of Dr. Anita Hui
• Large clots in right nare with ++ oozing
• You ask patient to blow their nose
• Oozing site visualized
• Now what?
Nasal anaesthesia
• Cocaine 4%
• 2% lidocaine with epinephrine
• 1:1 mixture of 4% lidocaine and 1:1000
epinephrine
• Cautery
– Silver nitrate
– Bilateral cautery contraindicated – septal
perforation
• Anterior nasal packing
– Absorbable packing materials
• Polysporin/vaseline ointment
• Gelfoam, Surgicel
• Addition of hemostatic agents such as Avitene,
Thrombostat, Amicar
Slide courtesy of Dr. Anita Hui
• Do you pack both sides?
– No good evidence
– Some ENT’s say to pack both sides if using
vaseline-gauze pack because it relies on
pressure and is likely to deviate septum
– Both sides not necessary with Merocel as it
functions mostly by providing matrix for clot
formation
• How long do you leave anterior pack in?
– 48-72 hours
Now suppose
• Blood coming from both nares
• Lots going down back of throat
• No anterior source of blood seen
• Diagnosis?
• Management?
• Disposition?
Management of refractory epistaxis
• Greater palatine foramen block
• Laser photocoagulation (Arg, Nd:YAG)
• Angiographic embolization
• Surgical ligation
Slide courtesy of Dr. Anita Hui
the throat
Case 6
• 22 year old male
• 1 week history of worsening sore throat
• Now talking funny – “hot potato voice”
• Unable to open mouth as wide as before
• Rigors, general malaise
You look in his mouth …
Slide courtesy of Dr. P. Park
Peritonsillar Abscess
Presentation
•
•
•
•
•
•
•
Sore throat
Odynophagia
Trismus (pterygoid muscle inflammation)
Hot potato voice
Fever
Otalgia
Unilateral swelling of the soft palate and anterior
pillar with deviation of the uvula
Etiology
• inadequately treated tonsillitis
• recurrent or chronic tonsillitis
• mixed bugs
– Aerobic - GABHS
– Anaerobic - Fusobacterium
• pus is in between the tonsillar capsule and
the bed
Anatomy
Source: Roberts. Clinical Procedures in Emergency Medicine
DDx
• acute
–
–
–
–
–
unilateral tonsillitis
peritonsillar cellulitis
carotid artery aneurysm
Mononucleosis
Odontogenic infection
• chronic
– Leukemia
– Carcinoma
– Parapharyngeal space tumor
Peritonsillar Abscess
vs
Cellulitis
• Trismus uncommon with cellulitis
• “hot potato voice” more common with abscess
• Positive aspiration diagnostic
– negative aspiration does not rule out abscess
• Intraoral sonography
– Sensitivity 91%
– Specificity 80%
• CT
How are you going to treat it?
Needle Aspiration
vs
Incision & Drainage
• 3 RCTs
1.
Spires, et al. Treatment of peritonsillar abscess. A prospective study of
aspiration vs incision and drainage. Arch Otolaryngol Head Neck Surg
1987;113:984-6
– Endpoint = return to normal diet
– Initial success
• 95% - Needle
• 100% - I&D
Stringer, et al. A randomized trial for outpatient
management of peritonsillar abscess. Arch
Otolaryngol Head Neck Surg 1988; 114:296
• N=52
• 93% success needle aspiration
• 92% success I&D
• NB: No statistical analysis of P-values
reported
– Numbers analyzed showed insignificant result
Maharaj et al. Management of peritonsillar
abscess. J Laryngol Otol 1991;105:743-5.
• RCT
• Success
– Needle = 87%
– I&D = 90%
• No statistical analysis done
– However numbers analyzed show no
significant difference
Needle Aspiration
• Anesthesia with topical +/- sc
lidocaine
• 18 - 22 gauge needle
– Aspirate area of greatest
fluctuance
– Tonsil itself not aspirated (pus is
in peritonsillar space)
– Aim medially (avoid carotid)
– Look for pus in superior, middle,
and inferior poles
Incision and Drainage
• Consider I&D if
aspiration positive
– Guarded #11 scalpel
– Aim at area of greatest
fluctuance
– Don’t aim laterally!
– Break loculations with
blunt instrument
Disposition
• Admission vs discharge
• Abx
– IV vs oral
– PCN, 2nd 3rd generation cephalosporin, clindamycin
• Referral for tonsillectomy
– If other indications for tonsillectomy
– Following 2 PTA’s
Case 7
• 5 year old girl
– Tonsillectomy 7 days ago for recurrent
tonsillitis
– Benign post-operative course thus far
– Now brisk bleeding from mouth x 30 minutes
– O/E: 120 85/60 pale spitting up blood
Posttonsillectomy hemorrhage
• 4300 cases/year in US
• 1-5% of cases
• When do they occur?
– Primary - <24 hours
• Related to surgical technique, hemostasis
– Secondary - >24 hours
• 5-10 days
• Sloughing of surgical eschar
• Tonsillar blood supply
– 5 arteries
• Ascending pharyngeal
• Ascending palatine
• Anterior tonsillar branch of lingual artery
• Inferior tonsillar branch of facial artery
• Superior tonsillar branch of the descending
palatine artery
• Tonsilloadenoidectomy (TA)
– 1975 – 685,000
– 1980 – 464,000
– 1991 – 86,000
Post-tonsillectomy bleed
management
• The usual ABC’s
• A & B – head up and forward
• C – fluid resuscitation, group & screen
Post-tonsillectomy bleed
management
• Post-tonsillectomy bleed tray
• Remove clot with suction
– allows vessels to contract
• Pack bleeding site with epinephrine soaked pads
• Bipolar cautery if bleeding site visualized
• Call ENT surgeon – to OR if necessary
Case 8
• December 14, 1799
– 60’s male
– Sore throat
– Increasing hoarseness
and stridor
– Did not respond to
routine course of 2L
bloodletting
Epiglottitis
• 1980 – children: adults = 2.6:1
• 1993 = 0.4:1
– Coincides with mass vaccination for HIB
• Mortality rate
– Children <1%
– Adults 6-7%
Epiglottitis – presentation
• Khilanani et al. (1984)
– Sore throat – 100%
– Dysphagia - 76%
– Fever – 88%
– SOB – 78%
– Pain to palpation of larynx
Diagnosis
• Soft tissue neck x-ray
– Sensitivity 38%
– Specificity 76%
• Stankiewica J, Bowes A. Croup and
epiglottitis. A radiologic study. Laryngoscope
1985;95:1159-1160
Diagnosis
Visualization
• No respiratory distress
– Direct laryngoscopy
– Fiberoptic laryngoscopy
• Drooling, stridor, dysphonia
– Direct laryngoscopy only
when prepared to capture
airway
– Indirect laryngoscopy
relatively contraindicated
Epiglottitis
microbiology
•
•
•
•
•
•
H. influenzae
H. parainfluenzae
Pneumococcus
S. aureus
GABHS
Viral/fungal
• Abx
– Intravenous
– Good coverage of
gram +, anaerobes
• Cefoxetin, clinda
Intubation
vs
Conservative Management
• Dort J, et al. Acute Epiglottitis in Adults: Diagnosis and Treatment in
43 Patients. J of Otolaryngology 1994;23(4)
–
–
–
–
Retrospective review of 43 patients
X-rays – 35/40 positive for epiglotitis
Immediate intubation N=14
Expectant Management N=29
• 1 developed stridor and required intubation on ward
– Patients intubated more likely tachycardic and stridorous
– 1 death from septic shock
– No airway related deaths
• Wolf m, et al. Conservative management of adult
epiglottitis. Laryngoscope 1990;100:183-185.
– 30 patients treated conservatively regardless of airway
symptoms
– No airway interventions
– No deaths
– advocate conservative management
• Khilanani U, et al. Acute epiglottitis in adults. Am J Med
Sci 1984;287:65-70.
–
–
–
–
162 patients reviewed
17.6% mortality in patients with airway symptoms
Many deaths occurred while “monitoring” or during intubation
Advocate aggressive approach
• Friedman M, et al. A plea for uniformity in the staging
and management of adult epiglottitis. ENTJ
1988;67:873-880.
– Proposed staging system for management
– Not validated
– Stage I
• No respiratory distress, RR<20
• Observation in ICU
– Stage II
• Some respiratory distress, RR 20-30
• Intubation in OR
– Stage III-IV
• RR>30, pCO2 >45, severe respiratory distress
• Immediate airway intervention
Case 8
• 45 year old man
–
–
–
–
Seen in ER yesterday for dental pain
Started on oral antibiotics and T3’s
Hasn’t been able to see dentist yet
Today trouble speaking, swallowing, neck swelling
• OE – 105 25 120/80 38 99
–
–
–
–
Marked submental/submandibular swelling
Tongue elevated in mouth
Drooling
“hot potato voice”
Ludwig’s Angina
From: Roberts: Clinical Procedures in Emergency Medicine
• Cellulitis, inflammation, swelling of
– Submandibular space
– Submental space
– Sublingual space
• Usually odontogenic source of infection
• Staph / Strep most common bugs
Ludwig’s Angina
Presentation
• Rapidly progressive
• Asymptomatic to respiratory compromise in hours
• Sx
–
–
–
–
–
Chills
Fever
Dysphagia
Stiffness of tongue movements
Trismus
• Signs
– Elevated tongue
– Edematous oral pharynx
– Swollen submandibular space
Source: Hartmann R. American Family Physician. 1999
Diagnosis
• Primarily clinical diagnosis
• Adjunct investigations
– Soft tissue neck x-rays
– CT
– U/S
Managment
•
•
•
•
Sitting position
ICU / ENT / Anaesthesia
Broad spectrum antibiotics
Awake intubation
– Fiberoptic guided
• Surgical airway
– Difficult due to neck swelling
– Can spread infection to mediastinal space
• Surgery
– Dental intervention of underlying cause
– I&D reserved for
• Not responding to Abx
• Proven fluid/gas collection
the end