ent emergencies january 29, 2004 aric storck dr. peter gant

ENTENTEmergenciesEmergencies

January 29, 2004January 29, 2004

Aric StorckAric Storck

Dr. Peter GantDr. Peter Gant

ObjectivesObjectives• Ear injuriesEar injuries

• Otitis externaOtitis externa

• Nasal fracturesNasal fractures

• EpistaxisEpistaxis

• PTAPTA

• Airway emergenciesAirway emergencies

• Will not cover: OM, sore throats, Will not cover: OM, sore throats, sinusitis, vertigosinusitis, vertigo

the earthe ear

Ear LacerationsEar Lacerations

• 50 year old man50 year old man

• Playing hockey Playing hockey without helmetwithout helmet

• Laceration to ear Laceration to ear from skatefrom skate

• ?management?management

Roberts: Clinical Procedures in Emergency Medicine, 3rd ed.

QuestionsQuestions

• Do you trim the cartilage?Do you trim the cartilage?

• How do you close the laceration?How do you close the laceration?

• How will you dress it?How will you dress it?

Ear LacerationsEar Lacerations

• AnatomyAnatomy– auricle (pinna) – modified horn shaped structure auricle (pinna) – modified horn shaped structure

composed of elastic cartilage covered by skin – composed of elastic cartilage covered by skin – converges onto the external auditory meatus converges onto the external auditory meatus (canal)(canal)

– Cartilage is avascular and needs blood supply Cartilage is avascular and needs blood supply from overlying skin and perichondriumfrom overlying skin and perichondrium

– earlobeearlobe

• with blunt forces ensure no ruptured TMwith blunt forces ensure no ruptured TM

Ears LacerationsEars Lacerationsmanagementmanagement

• Debride non-viable skin and cartilageDebride non-viable skin and cartilage

• Ensure enough skin to completely cover cartilageEnsure enough skin to completely cover cartilage– can trim up to 5 mm of cartilage while avoiding major can trim up to 5 mm of cartilage while avoiding major

cosmetic defectcosmetic defect

• ““Through and through” lacerations - 3 layer closureThrough and through” lacerations - 3 layer closure1.1. Approximate cartilage edgesApproximate cartilage edges

• 4-0, 5-0 absorbable suture4-0, 5-0 absorbable suture• Include both anterior and posterior perichondrium in suture or Include both anterior and posterior perichondrium in suture or

sutures will pull through cartilage sutures will pull through cartilage• Use the folds of pinna as landmarksUse the folds of pinna as landmarks

2.2. Repair posterior skinRepair posterior skin• 5-0 non-absorbable suture5-0 non-absorbable suture

3.3. Repair anterior surfaceRepair anterior surface• 5-0, 6-0 non-absorbable suture5-0, 6-0 non-absorbable suture• Use landmarksUse landmarks• Ensure edges of free rim are everted to avoid “notching”Ensure edges of free rim are everted to avoid “notching”

• NB: Some ENT’s advocate suturing all three layers togetherNB: Some ENT’s advocate suturing all three layers together

• All repaired ears should be enclosed in a compression dressingAll repaired ears should be enclosed in a compression dressing

• Consider antibiotics for heavily contaminated woundsConsider antibiotics for heavily contaminated wounds

• 16 year old wrestler16 year old wrestler– Head slammed on floor Head slammed on floor

during trainingduring training– Not wearing protective Not wearing protective

headgearheadgear

• Diagnosis?Diagnosis?

• Management?Management?

Source: NEJM 1996: 335(6)

Case 2

Cauliflower EarCauliflower Earsubchondral hematomasubchondral hematoma

• Bridging vessels between perichondrium and cartilage Bridging vessels between perichondrium and cartilage are tornare torn

• Hematoma stimulates cartilage growth in overlying Hematoma stimulates cartilage growth in overlying perichondrium perichondrium “cauliflower” “cauliflower”

• Perfect hemostasis to prevent permanent damagePerfect hemostasis to prevent permanent damage

• Refer all but most simple hematomas to plastics or ENTRefer all but most simple hematomas to plastics or ENT

• Compression dressingCompression dressing

ManagementManagement• Small hematomaSmall hematoma

– Needle drainage (22G) and close Needle drainage (22G) and close observationobservation

• Large hematomaLarge hematoma– I&D (use landmarks to hide incision)I&D (use landmarks to hide incision)– Suction or curettage to remove hematomaSuction or curettage to remove hematoma– Compression dressing x 4-7 daysCompression dressing x 4-7 days

– Close ENT follow-upClose ENT follow-up

Cauliflower EarCauliflower Ear

CASE 3CASE 3

• 26 year old male26 year old male– Just returned from diving holiday in the CaribbeanJust returned from diving holiday in the Caribbean– Right ear itchy x 1 weekRight ear itchy x 1 week– Now c/o right ear pain and moderate dischargeNow c/o right ear pain and moderate discharge– Normal hearingNormal hearing

• O/EO/E– VSSAVSSA– Ear canal erythematous and edematous with some Ear canal erythematous and edematous with some

cloudy discharge.cloudy discharge.– TM moderately red, but not bulgingTM moderately red, but not bulging– Patient very tender when you press on his tragusPatient very tender when you press on his tragus

Acute Otitis ExternaAcute Otitis Externa• What are the most common pathogens?What are the most common pathogens?

– PseudomonasPseudomonas– S. aureusS. aureus

• TreatmentTreatment– CleansingCleansing

• Tap water, vinegarTap water, vinegar

– Topical antibioticsTopical antibiotics• Generally aminoglycoside/steroid, Generally aminoglycoside/steroid,

fluoroquinolone/steroid combinationfluoroquinolone/steroid combination

– Systemic antibioticsSystemic antibiotics• May be necessary in severe cases, particularly if also May be necessary in severe cases, particularly if also

cellulitiscellulitis

• Severe casesSevere cases– Wicking (cotton, gauze)Wicking (cotton, gauze)– Allows medication to penetrate into the Allows medication to penetrate into the

auditory canalauditory canal– Should be left in 2-3 daysShould be left in 2-3 days

• Suppose your patient is an elderly Suppose your patient is an elderly diabetic. What complication are you diabetic. What complication are you concerned about?concerned about?

• Malignant otitis externaMalignant otitis externa– Osteomyelitis of the skull baseOsteomyelitis of the skull base– pseudomonaspseudomonas

the nosethe nose

Case 4Case 4

• 24 year old male24 year old male– DrunkDrunk– Was minding his own business when Was minding his own business when

somebody punched him in the facesomebody punched him in the face– Now moderate epistaxis and crooked Now moderate epistaxis and crooked

nosenose

Nasal FractureNasal Fracturediagnosisdiagnosis• HistoryHistory

– ““Have you broken your nose before?”Have you broken your nose before?”– ““does your nose look normal to you?”does your nose look normal to you?”– Breathing difficultyBreathing difficulty

• Physical examinationPhysical examination– Crepitus, hypermotility, edema, tenderness, Crepitus, hypermotility, edema, tenderness,

deformitydeformity– Depressed, laterally angulated, comminutedDepressed, laterally angulated, comminuted– if mechanism severe look for other injuriesif mechanism severe look for other injuries– epistaxisepistaxis– septal hematomaseptal hematoma

Nasal anatomyNasal 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 Pathophysiology of nasal trauma. A, Lateral nasal trauma with isolated nasal bone fracture. B, Bilateral nasal bone fractures isolated nasal bone fracture. B, Bilateral nasal bone fractures with septal dislocation. C, Frontal trauma with dorsal widening. with septal dislocation. C, Frontal trauma with dorsal widening. D, Comminuted nasal fracture. D, Comminuted nasal fracture.

From Head and Neck Surgery–Otolaryngology. Copyright 1993, Lippincott Williams & Wilkins.

To x-ray or not to x-ray ….To x-ray or not to x-ray ….

• Clayton M, et al. The role of radiography Clayton M, et al. The role of radiography in the management of nasal fractures. J. in the management of nasal fractures. J. Laryngol Otol. 1986: 100:797-801. Laryngol Otol. 1986: 100:797-801.

– 54 patients54 patients

– Prospective clinical & radiological Prospective clinical & radiological assessment & examination under assessment & examination under anaesthesiaanaesthesia

– X-rays did not change managementX-rays did not change management

• Delacey et al (1977)Delacey et al (1977)

– 100 ED patients with nasal fractures100 ED patients with nasal fractures– Compared normal x-rays to those of Compared normal x-rays to those of

patients with clinical fracturespatients with clinical fractures– No diagnostic utility of x-rays because of No diagnostic utility of x-rays because of

high incidence of “bony abnormalities”high incidence of “bony abnormalities”

• Mayell et al (1973)Mayell et al (1973)

– 107 patients with nasal fractures107 patients with nasal fractures– Negative or positive x-rays did not Negative or positive x-rays did not

change management or reduction change management or reduction decisionsdecisions

The bottom lineThe bottom line

If the nose looks goodIf the nose looks good

……and breaths goodand breaths good

You don’t need x-raysYou don’t need x-rays

Remember, you have a week to fix itRemember, you have a week to fix it

So what are you going to do about it?So what are you going to do about it?

TreatmentTreatment• Primary goalsPrimary goals

– Restore functionRestore function– CosmeticCosmetic

• Consider early reduction ifConsider early reduction if– patient presents before onset of soft tissue edemapatient presents before onset of soft tissue edema– or … severe fracture causing airway problemsor … severe fracture causing airway problems

• After edema, best to wait 3-4 days for re-After edema, best to wait 3-4 days for re-evaluationevaluation

• Closed reduction under local anaesthesia Closed reduction under local anaesthesia possible up to 10 days (less in kids)possible up to 10 days (less in kids)

• F/U within a weekF/U within a week– ENT or plasticsENT or plastics– To ensure acceptable cosmetic result To ensure acceptable cosmetic result

once edema subsidedonce edema subsided

Closed reductionClosed reduction

• AnaesthesiaAnaesthesia– 4% cocaine for intranasal anaesthesia4% cocaine for intranasal anaesthesia– Regional blocks with 1% lidocaine with Regional blocks with 1% lidocaine with

epiepi•Supratrochlear nerveSupratrochlear nerve

• Infraorbital nerveInfraorbital nerve

•Nasal dorsumNasal dorsum

Good job with the fracture …Good job with the fracture …now you look in the nose and now you look in the nose and see…see…

Septal hematomaSeptal hematoma

Septal hematomaSeptal hematoma

• Bulge of nasal mucosaBulge of nasal mucosa• Same colour as mucosaSame colour as mucosa• Prone to infectionProne to infection

– Results in abscess and Results in abscess and cartilage necrosiscartilage necrosis

• I&D with L-shaped incisionI&D with L-shaped incision• Pack nose to prevent Pack nose to prevent

reaccumulationreaccumulation• Close ENT follow-upClose ENT follow-up

Source: Simon, Emergency Procedures and Techniques

Case 5Case 5

• 78 year old male78 year old male– On coumadin and ASA for cardiac diseaseOn coumadin and ASA for cardiac disease– Brisk nosebleed x 2 hoursBrisk nosebleed x 2 hours– Blood mostly from right nareBlood mostly from right nare– Some blood down back of throatSome blood down back of throat

• ?Diagnosis?Diagnosis

• ?Management?Management

Epistaxis: EpidemiologyEpistaxis: Epidemiology

• Annual incidence 15% men, 9% Annual incidence 15% men, 9% womenwomen

• More frequent from November to More frequent from November to MarchMarch

• 15:10,000 seek medical care each 15:10,000 seek medical care each yearyear

• 1.6:10,000 hospitalized each year1.6:10,000 hospitalized each year

Slide courtesy of Dr. Anita Hui

Etiology: Local FactorsEtiology: Local Factors• TraumaTrauma

– Epistaxis digitorumEpistaxis digitorum

• Inflammatory reactions ( allergies, infections, Inflammatory reactions ( allergies, infections, foreign bodies)foreign bodies)

• Tumors (juvenile nasopharyngeal Tumors (juvenile nasopharyngeal angiofibroma)angiofibroma)

• Substance abuseSubstance abuse– Cocaine, solventsCocaine, solvents

Slide courtesy of Dr. Anita Hui

Epistaxis: Systemic FactorsEpistaxis: Systemic Factors

• Osler-Weber-Rendu (HHT)Osler-Weber-Rendu (HHT)

• Von Willebrand’s diseaseVon Willebrand’s disease– Bleeding time, quantitative Bleeding time, quantitative

immunoelectrophoresis or ELISAimmunoelectrophoresis or ELISA

• HemophiliaHemophilia

• Leukemia, thrombocytopeniaLeukemia, thrombocytopenia

Slide courtesy of Dr. Anita Hui

Epistaxis: Systemic Factors Epistaxis: Systemic Factors

• MMMM

• HemodialysisHemodialysis

• Nutritional deficiencesNutritional deficiences

• Medications: ASA, NSAIDs, warfarin, Medications: ASA, NSAIDs, warfarin, chloramphenicol, carbenicillin, chloramphenicol, carbenicillin, dipyridamoledipyridamole

Slide courtesy of Dr. Anita Hui

Slide courtesy of Dr. Anita Hui

• Septal wallSeptal wall

• Kiesselbach’s areaKiesselbach’s area– External carotidExternal carotid

• Sphenopalatine arterySphenopalatine artery

– Internal carotidInternal carotid• Anterior ethmoidal Anterior ethmoidal

arteryartery

Anterior Epistaxis – 90-95%Anterior Epistaxis – 90-95%

Slide courtesy of Dr. Anita Hui

Posterior Epistaxis – 5-10%Posterior Epistaxis – 5-10%

• Lateral wallLateral wall

• Both internal & Both internal & external carotidexternal carotid

• ““Woodruff’s plexus”Woodruff’s plexus”– Arterial and venous Arterial and venous

plexusplexus– Most common site of Most common site of

posterior epistaxisposterior epistaxis

Epistaxis: ManagementEpistaxis: Management

• ABC’sABC’s– AirwayAirway– Resp distressResp distress– hypotensionhypotension

• Correct underlying problemCorrect underlying problem– CBC, coagsCBC, coags

• PressurePressure

• IceIce

• Morphine, other medicationsMorphine, other medications

• Cauterization: chemical (Ag Cauterization: chemical (Ag Nitrate), electricalNitrate), electrical

Slide courtesy of Dr. Anita Hui

• Large clots in right nare with ++ oozingLarge clots in right nare with ++ oozing

• You ask patient to blow their noseYou ask patient to blow their nose

• Oozing site visualizedOozing site visualized

• Now what?Now what?

Nasal anaesthesiaNasal anaesthesia

• Cocaine 4%Cocaine 4%

• 2% lidocaine with epinephrine2% lidocaine with epinephrine

• 1:1 mixture of 4% lidocaine and 1:1 mixture of 4% lidocaine and 1:1000 epinephrine1:1000 epinephrine

• CauteryCautery– Silver nitrateSilver nitrate– Bilateral cautery contraindicated – Bilateral cautery contraindicated –

septal perforationseptal perforation

• Anterior nasal packingAnterior nasal packing– Absorbable packing materialsAbsorbable packing materials

•Polysporin/vaseline ointmentPolysporin/vaseline ointment•Gelfoam, SurgicelGelfoam, Surgicel•Addition of hemostatic agents such as Addition of hemostatic agents such as

Avitene, Thrombostat, AmicarAvitene, Thrombostat, Amicar

Slide courtesy of Dr. Anita Hui

• Do you pack both sides?Do you pack both sides?– No good evidenceNo good evidence– Some ENT’s say to pack both sides if using Some ENT’s say to pack both sides if using

vaseline-gauze pack because it relies on vaseline-gauze pack because it relies on pressure and is likely to deviate septumpressure and is likely to deviate septum

– Both sides not necessary with Merocel as it Both sides not necessary with Merocel as it functions mostly by providing matrix for functions mostly by providing matrix for clot formationclot formation

• How long do you leave anterior pack How long do you leave anterior pack in?in?– 48-72 hours48-72 hours

Now supposeNow suppose• Blood coming from both naresBlood coming from both nares

• Lots going down back of throatLots going down back of throat

• No anterior source of blood seenNo anterior source of blood seen

• Diagnosis?Diagnosis?

• Management?Management?

• Disposition?Disposition?

Management of refractory Management of refractory epistaxisepistaxis

• Greater palatine foramen blockGreater palatine foramen block

• Laser photocoagulation (Arg, Laser photocoagulation (Arg, Nd:YAG)Nd:YAG)

• Angiographic embolizationAngiographic embolization

• Surgical ligationSurgical ligation

Slide courtesy of Dr. Anita Hui

the throatthe throat

Case 6Case 6

• 22 year old male22 year old male

• 1 week history of worsening sore 1 week history of worsening sore throatthroat

• Now talking funny – “hot potato voice”Now talking funny – “hot potato voice”

• Unable to open mouth as wide as Unable to open mouth as wide as beforebefore

• Rigors, general malaiseRigors, general malaise

Slide courtesy of Dr. P. Park

You look in his mouth …

Peritonsillar AbscessPeritonsillar AbscessPresentationPresentation

• Sore throatSore throat

• OdynophagiaOdynophagia

• Trismus (pterygoid muscle inflammation)Trismus (pterygoid muscle inflammation)

• Hot potato voiceHot potato voice

• FeverFever

• OtalgiaOtalgia

• Unilateral swelling of the soft palate and Unilateral swelling of the soft palate and anterior pillar with deviation of the uvulaanterior pillar with deviation of the uvula

EtiologyEtiology

• inadequately treated tonsillitisinadequately treated tonsillitis• recurrent or chronic tonsillitisrecurrent or chronic tonsillitis• mixed bugsmixed bugs

– Aerobic - GABHSAerobic - GABHS– Anaerobic - FusobacteriumAnaerobic - Fusobacterium

• pus is in between the tonsillar pus is in between the tonsillar capsule and the bedcapsule and the bed

AnatomyAnatomy

Source: Roberts. Clinical Procedures in Emergency Medicine

DDxDDx

• acute acute – unilateral tonsillitisunilateral tonsillitis– peritonsillar cellulitisperitonsillar cellulitis– carotid artery aneurysmcarotid artery aneurysm– MononucleosisMononucleosis– Odontogenic infectionOdontogenic infection

• chronicchronic– LeukemiaLeukemia– CarcinomaCarcinoma– Parapharyngeal space tumorParapharyngeal space tumor

Peritonsillar AbscessPeritonsillar Abscessvsvs

CellulitisCellulitis• Trismus uncommon with cellulitisTrismus uncommon with cellulitis• ““hot potato voice” more common with abscesshot potato voice” more common with abscess

• Positive aspiration diagnosticPositive aspiration diagnostic– negative aspiration does not rule out abscessnegative aspiration does not rule out abscess

• Intraoral sonographyIntraoral sonography– Sensitivity 91%Sensitivity 91%– Specificity 80%Specificity 80%

• CTCT

How are you going to treat How are you going to treat it?it?

Needle AspirationNeedle Aspirationvsvs

Incision & DrainageIncision & Drainage1.1. 3 RCTs3 RCTs

2.2. Spires, et al. Treatment of peritonsillar abscess. A prospective Spires, et al. Treatment of peritonsillar abscess. A prospective study of aspiration vs incision and drainage. Arch Otolaryngol study of aspiration vs incision and drainage. Arch Otolaryngol Head Neck Surg 1987;113:984-6Head Neck Surg 1987;113:984-6

– Endpoint = return to normal dietEndpoint = return to normal diet– Initial successInitial success

• 95% - Needle95% - Needle

• 100% - I&D100% - I&D

Stringer, et al. A randomized trial for Stringer, et al. A randomized trial for outpatient management of peritonsillar outpatient management of peritonsillar abscess. Arch Otolaryngol Head Neck Surg abscess. Arch Otolaryngol Head Neck Surg 1988; 114:2961988; 114:296

• N=52N=52

• 93% success needle aspiration93% success needle aspiration

• 92% success I&D92% success I&D

• NB: No statistical analysis of P-values NB: No statistical analysis of P-values reportedreported– Numbers analyzed showed insignificant Numbers analyzed showed insignificant

resultresult

Maharaj et al. Management of Maharaj et al. Management of peritonsillar abscess. J Laryngol Otol peritonsillar abscess. J Laryngol Otol 1991;105:743-5.1991;105:743-5.

• RCTRCT

• SuccessSuccess– Needle = 87%Needle = 87%– I&D = 90%I&D = 90%

• No statistical analysis doneNo statistical analysis done– However numbers analyzed show no However numbers analyzed show no

significant differencesignificant difference

• Anesthesia with topical +/- sc Anesthesia with topical +/- sc lidocainelidocaine

• 18 - 22 gauge needle18 - 22 gauge needle– Aspirate area of greatest Aspirate area of greatest

fluctuancefluctuance– Tonsil itself not aspirated (pus Tonsil itself not aspirated (pus

is in peritonsillar space)is in peritonsillar space)– Aim medially (avoid carotid)Aim medially (avoid carotid)– Look for pus in superior, Look for pus in superior,

middle, and inferior polesmiddle, and inferior poles

Needle Aspiration

Incision and DrainageIncision and Drainage

• Consider I&D if Consider I&D if aspiration positiveaspiration positive– Guarded #11 Guarded #11

scalpelscalpel– Aim at area of Aim at area of

greatest fluctuancegreatest fluctuance– Don’t aim laterally!Don’t aim laterally!– Break loculations Break loculations

with blunt with blunt instrumentinstrument

DispositionDisposition

• Admission vs dischargeAdmission vs discharge

• AbxAbx– IV vs oralIV vs oral– PCN, 2PCN, 2ndnd 3 3rdrd generation cephalosporin, clindamycin generation cephalosporin, clindamycin

• Referral for tonsillectomyReferral for tonsillectomy– If other indications for tonsillectomyIf other indications for tonsillectomy– Following 2 PTA’sFollowing 2 PTA’s

Case 7Case 7

• 5 year old girl5 year old girl– Tonsillectomy 7 days ago for recurrent Tonsillectomy 7 days ago for recurrent

tonsillitistonsillitis– Benign post-operative course thus farBenign post-operative course thus far– Now brisk bleeding from mouth x 30 Now brisk bleeding from mouth x 30

minutesminutes– O/E: 120 85/60 pale spitting up bloodO/E: 120 85/60 pale spitting up blood

Posttonsillectomy Posttonsillectomy hemorrhagehemorrhage• 4300 cases/year in US4300 cases/year in US• 1-5% of cases1-5% of cases

• When do they occur?When do they occur?– Primary - <24 hoursPrimary - <24 hours

•Related to surgical technique, hemostasisRelated to surgical technique, hemostasis

– Secondary - >24 hoursSecondary - >24 hours•5-10 days5-10 days•Sloughing of surgical escharSloughing of surgical eschar

• Tonsillar blood supplyTonsillar blood supply– 5 arteries5 arteries

•Ascending pharyngealAscending pharyngeal

•Ascending palatineAscending palatine

•Anterior tonsillar branch of lingual arteryAnterior tonsillar branch of lingual artery

• Inferior tonsillar branch of facial arteryInferior tonsillar branch of facial artery

•Superior tonsillar branch of the descending Superior tonsillar branch of the descending palatine arterypalatine artery

• Tonsilloadenoidectomy (TA)Tonsilloadenoidectomy (TA)– 1975 – 685,0001975 – 685,000– 1980 – 464,0001980 – 464,000– 1991 – 86,0001991 – 86,000

Post-tonsillectomy bleedPost-tonsillectomy bleedmanagementmanagement

• The usual ABC’sThe usual ABC’s

• A & B – head up and forwardA & B – head up and forward

• C – fluid resuscitation, group & C – fluid resuscitation, group & screenscreen

• Post-tonsillectomy bleed trayPost-tonsillectomy bleed tray

• Remove clot with suctionRemove clot with suction– allows vessels to contractallows vessels to contract

• Pack bleeding site with epinephrine soaked Pack bleeding site with epinephrine soaked padspads

• Bipolar cautery if bleeding site visualizedBipolar cautery if bleeding site visualized

• Call ENT surgeon – to OR if necessaryCall ENT surgeon – to OR if necessary

Post-tonsillectomy bleedPost-tonsillectomy bleedmanagementmanagement

• December 14, December 14, 17991799– 60’s male60’s male– Sore throatSore throat– Increasing Increasing

hoarseness and hoarseness and stridorstridor

– Did not respond to Did not respond to routine course of 2L routine course of 2L bloodlettingbloodletting

Case 8

EpiglottitisEpiglottitis

• 1980 – children: adults = 2.6:11980 – children: adults = 2.6:1

• 1993 = 0.4:11993 = 0.4:1– Coincides with mass vaccination for HIBCoincides with mass vaccination for HIB

• Mortality rateMortality rate– Children <1%Children <1%– Adults 6-7%Adults 6-7%

Epiglottitis – presentationEpiglottitis – presentation• Khilanani et al. (1984)Khilanani et al. (1984)

– Sore throat – 100%Sore throat – 100%– Dysphagia - 76%Dysphagia - 76%– Fever – 88%Fever – 88%– SOB – 78%SOB – 78%– Pain to palpation of larynxPain to palpation of larynx

DiagnosisDiagnosis

• Soft tissue neck x-Soft tissue neck x-rayray– Sensitivity 38%Sensitivity 38%– Specificity 76%Specificity 76%

• Stankiewica J, Bowes A. Croup and Stankiewica J, Bowes A. Croup and epiglottitis. A radiologic study. epiglottitis. A radiologic study. Laryngoscope 1985;95:1159-1160Laryngoscope 1985;95:1159-1160

DiagnosisDiagnosisVisualizationVisualization

• No respiratory distressNo respiratory distress– Direct laryngoscopyDirect laryngoscopy– Fiberoptic laryngoscopyFiberoptic laryngoscopy

• Drooling, stridor, Drooling, stridor, dysphoniadysphonia– Direct laryngoscopy only Direct laryngoscopy only

when prepared to capture when prepared to capture airwayairway

– Indirect laryngoscopy Indirect laryngoscopy relatively contraindicatedrelatively contraindicated

EpiglottitisEpiglottitismicrobiologymicrobiology

• H. influenzaeH. influenzae

• H. parainfluenzaeH. parainfluenzae

• PneumococcusPneumococcus

• S. aureusS. aureus

• GABHSGABHS

• Viral/fungalViral/fungal

• AbxAbx– IntravenousIntravenous– Good coverage of Good coverage of

gram +, anaerobesgram +, anaerobes• Cefoxetin, clindaCefoxetin, clinda

Intubation Intubation vs vs

Conservative ManagementConservative Management• Dort J, et al. Acute Epiglottitis in Adults: Diagnosis and Dort J, et al. Acute Epiglottitis in Adults: Diagnosis and

Treatment in 43 Patients. J of Otolaryngology 1994;23(4)Treatment in 43 Patients. J of Otolaryngology 1994;23(4)– Retrospective review of 43 patientsRetrospective review of 43 patients– X-rays – 35/40 positive for epiglotitisX-rays – 35/40 positive for epiglotitis– Immediate intubation N=14Immediate intubation N=14– Expectant Management N=29Expectant Management N=29

• 1 developed stridor and required intubation on ward1 developed stridor and required intubation on ward

– Patients intubated more likely tachycardic and stridorousPatients intubated more likely tachycardic and stridorous– 1 death from septic shock1 death from septic shock– No airway related deathsNo airway related deaths

• Wolf m, et al. Conservative management of adult Wolf m, et al. Conservative management of adult epiglottitis. Laryngoscope 1990;100:183-185.epiglottitis. Laryngoscope 1990;100:183-185.– 30 patients treated conservatively regardless of airway 30 patients treated conservatively regardless of airway

symptomssymptoms– No airway interventionsNo airway interventions– No deathsNo deaths– advocate conservative managementadvocate conservative management

• Khilanani U, et al. Acute epiglottitis in adults. Am J Khilanani U, et al. Acute epiglottitis in adults. Am J Med Sci 1984;287:65-70.Med Sci 1984;287:65-70.– 162 patients reviewed162 patients reviewed– 17.6% mortality in patients with airway symptoms17.6% mortality in patients with airway symptoms– Many deaths occurred while “monitoring” or during Many deaths occurred while “monitoring” or during

intubationintubation– Advocate aggressive approachAdvocate aggressive approach

• Friedman M, et al. A plea for uniformity in the Friedman M, et al. A plea for uniformity in the staging and management of adult epiglottitis. staging and management of adult epiglottitis. ENTJ 1988;67:873-880.ENTJ 1988;67:873-880.

– Proposed staging system for managementProposed staging system for management– Not validatedNot validated– Stage IStage I

• No respiratory distress, RR<20No respiratory distress, RR<20• Observation in ICUObservation in ICU

– Stage IIStage II• Some respiratory distress, RR 20-30Some respiratory distress, RR 20-30• Intubation in ORIntubation in OR

– Stage III-IVStage III-IV• RR>30, pCO2 >45, severe respiratory distressRR>30, pCO2 >45, severe respiratory distress• Immediate airway interventionImmediate airway intervention

Case 8Case 8• 45 year old man45 year old man

– Seen in ER yesterday for dental painSeen in ER yesterday for dental pain– Started on oral antibiotics and T3’sStarted on oral antibiotics and T3’s– Hasn’t been able to see dentist yetHasn’t been able to see dentist yet– Today trouble speaking, swallowing, neck Today trouble speaking, swallowing, neck

swellingswelling

• OE – 105 25 120/80 38 99OE – 105 25 120/80 38 99– Marked submental/submandibular swellingMarked submental/submandibular swelling– Tongue elevated in mouthTongue elevated in mouth– DroolingDrooling– ““hot potato voice”hot potato voice”

Ludwig’s AnginaLudwig’s Angina

From: Roberts: Clinical Procedures in Emergency Medicine

• Cellulitis, inflammation, swelling ofCellulitis, inflammation, swelling of– Submandibular spaceSubmandibular space– Submental spaceSubmental space– Sublingual spaceSublingual space

• Usually odontogenic source of Usually odontogenic source of infectioninfection

• Staph / Strep most common bugsStaph / Strep most common bugs

Ludwig’s AnginaLudwig’s AnginaPresentationPresentation

• Rapidly progressiveRapidly progressive• Asymptomatic to respiratory compromise in hoursAsymptomatic to respiratory compromise in hours• SxSx

– ChillsChills– FeverFever– DysphagiaDysphagia– Stiffness of tongue movementsStiffness of tongue movements– TrismusTrismus

• SignsSigns– Elevated tongueElevated tongue– Edematous oral pharynxEdematous oral pharynx– Swollen submandibular spaceSwollen submandibular space

Source: Hartmann R. American Family Physician. 1999

DiagnosisDiagnosis

• Primarily clinical diagnosisPrimarily clinical diagnosis

• Adjunct investigationsAdjunct investigations– Soft tissue neck x-raysSoft tissue neck x-rays– CTCT– U/SU/S

ManagmentManagment• Sitting positionSitting position• ICU / ENT / AnaesthesiaICU / ENT / Anaesthesia• Broad spectrum antibioticsBroad spectrum antibiotics• Awake intubationAwake intubation

– Fiberoptic guidedFiberoptic guided

• Surgical airwaySurgical airway– Difficult due to neck swellingDifficult due to neck swelling– Can spread infection to mediastinal spaceCan spread infection to mediastinal space

• SurgerySurgery– Dental intervention of underlying causeDental intervention of underlying cause– I&D reserved forI&D reserved for

• Not responding to AbxNot responding to Abx• Proven fluid/gas collectionProven fluid/gas collection

the endthe end