ENT Emergencies

C. Rebus R3-EMDrRebus.com

http://www.boxingscene.com/forums/showthread.php?t=329320

Conflicts

None Errors - Mine. Thanks to:

Dr. Marc Francis Dr. Colleen Carey

Goals

Common and Nightmare ENT presentations, management and follow up.

http://meded.ucsd.edu/clinicalimg/head_pharyngitis.htm

http://meded.ucsd.edu/clinicalimg/head_pharyngitis.htm

DDx?

Acute Pharyngitis (cont)

Life-threatening Epiglottitis, diphtheria, Ludwig’s angina, peritonsillar

abscess, retropharyngeal abscess, gonococcal pharyngitis, infectious mononucleosis (occlusion), and GABHS (...ARF).

Garden Variety Infectious viral pharyngitis, non-GABHS bacterial pharyngitis,

and candidiasis. Non-infectious

Laryngeal/pharyngeal trauma, GERD, persistent cough or post-nasal drainage, thyroiditis, and malignancies.

Acute Pharyngitis

What!? I'm an EMERG DOC! In the top 10 presentations Females: #5 Males: #10

National Health Statistics Reports, Number 7, August 6, 2008 (US data).

http://4.bp.blogspot.com/_uekyjQXowno/SwreRGgnJ6I/AAAAAAAADwU/8VqTb-gSWl4/s1600/dung-beetle1.jpg

Acute Pharyngitis (cont)

Acute Pharyngitis (cont)

Who is worse then MD at DDx Bact vs Viral? No one.

Epid Group A Streptococcal pharyngitis is disease of

youth. 50% of pts 5 – 15 yo. Peak incidence first few years of school. GAS uncommon <3 yo

Acute Pharyngitis (cont)

Dx? Classic Symptoms of GABHS Pharyngeal or tonsillar exudate Swollen anterior cervical LN Hx fever >38*C Absence of cough

If all 4 symptoms: 44% chance they will NOT have GABHS.

Coin 50%.

http://www.afreeman.org/wp-content/uploads/2009/02/nickel.jpg

Acute Pharyngitis (cont)

Rapid Strep test? Not recommended in AB Lacks sensitivity and evidence of improved clinical

outcome. ASOT? Lets use some science please...

Not in Dx or mgmt of acute pharyngitis. Post treatment swab?

Not routinely.

Acute Pharyngitis (cont)

How to diagnose this simple beast? Throat Swab. In pts with >2 classic symptoms. Sensitivity 90 - 95%.

Acute Pharyngitis (cont)

MCC? Viral ~90% Bacterial: MCC: GABHS

GCBHS, GGBHS, N. Gonorrhoeae, arcanobacterium haemolyticum

http://textbookofbacteriology.net/themicrobialworld/pathogenesis.html

Acute Pharyngitis (cont)

Infectious? 2-5 d prior to symptoms During acute illness ~7 d after if untreated

Back to School? 24 hrs after start ABx Unless symptoms don't improve -?Tx failure.

Acute Pharyngitis (cont)

Mgmt Swab and wait.

Rheumatic fever? “I got the stuff they want”

Penicillin (no documented resistance). Allergy? Clindamycin or Erythromycin. Not getting better 48 – 72 hrs? FUGP.

http://www.naze.net/2005/images/2005%200122%20jack%20blood%20in%20sink.jpg

Post-Tonsillectomy

Time Honoured Tradition of Hemostasis Tonsils are supplied by 5 arteries in an area unable

to collapse on itself.

Post-Tonsillectomy (Cont)

Janfaza et al. 2001. Surgical anatomy of the head and neck

http://www.instantanatomy.net/headneck/areas/phoropharynx.html

Post-Tonsillectomy (Cont)

This is bad. Move them somewhere besides PLC eyeroom. Trauma bay or get an airway cart. IV x2, CBC,

INR/aPTT, crossmatch. Ask for tonselectomy bleed pack. Let ENT know early.

Post-Tonsillectomy (Cont)

0.5 – 10% depending on Sx. Bleeding

Intraoperative Primary (<24hrs) Secondary (1-10 days)

5 – 7 POD most common

Post-Tonsillectomy (Cont)

Post-op day 5 – 7

Post-Tonsillectomy (Cont)

Minor Bleeding Seated position in surgical area Suction Look Call ENT – likely reluctant

Post-Tonsillectomy (Cont)

Major Bleeding Back to basics – Pressure. Kelly clamp + epi 2% soaked gauze. ENT. They need OR. Presume stomach is full of blood from ooze. It is a bad airway.

Post-Tonsillectomy (Cont)

Dispo ENT to R/V. (Admission)

http://www.beerkada.net/images/nosebleed1.jpg

Epistaxis

So?

http://www.esnr.com/www/case_studies/content/nosebleeds_epistaxis_fig1.htm

Epistaxis (cont)

Anterior 95%

Epistaxis (cont)

Posterior 5%

Epistaxis (cont)

Posterior

Posterior epistaxis from the left sphenopalatine artery.

http://emedicine.medscape.com/article/863220-media

Epistaxis (cont)

http://chestofbooks.com/health/anatomy/Human-Body-Construction/The-Mouth-And-Throat-Part-2.html

Epistaxis (cont)

Roberts: Clinical Procedures in Emergency Medicine, 5th ed.

Epistaxis (cont)

Br J Ophthalmol 2003;87:1051 doi:10.1136/bjo.87.8.1051

Epistaxis (cont)

http://academia.hixie.ch/bath/eye/home.html

Epistaxis (cont)

Fatal Posterior Nasal Packing? (from a fictitious CMPA call) 'You put what, where?'

Epistaxis, medical history, and the nasopulmonary reflex: what is clinically relevant? Otolaryngol Head Neck Surg. 1994 Apr;110(4):363-9

Jacobs et al. Posterior packs and the nasopulmonary reflex. Laryngoscope. 1981 Feb;91(2):279-84.

Epistaxis (cont)

http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79932-80545-113132.jpg

Epistaxis (cont)

Posterior Nasal Packing *to stabilize the anterior

packing = tamponade Nasostat Rubber Chicken Foley

Roberts: Clinical Procedures in Emergency Medicine, 5th ed.

Epistaxis (cont)

Posterior Nasal Packing – 10F Foley

http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79932-80545-113136.jpg

10-15ml N.S.

Epistaxis (cont)

Show of hands: Rx ABx with packing? I'll tell you, it's Zero. Unless you have structural heart disease.

Concern Staph toxic shock syndrome, sinusitis, and

clinically-evident bacteremia Evidence

3 RCT, 163 pts. Lack power. Incomplete evidence. Polymixin B/oxytetracycline reduced flora on

packing.

Epistaxis (cont)

Why so much about a bloody nose? It is distressing. It is common. Public (and health care) knowledge of 1st aid is

poor. The next bloody nose visit can be a public health

moment (teaching=freedom).

Epistaxis (cont)

http://drdavidson.ucsd.edu/Portals/0/Pathway/NoseBled.htm

http://www.aafp.org/afp/2007/0115/p243.html

Sinusitis

The Forgotten Badboy of the URTI

http://www.topalbertadoctors.org/informed_practice/cpgs/acute_sinusitis.html

Sinusitis

Defn Inflammation of one or more of the paranasal sinus

cavities, the cause of which may be allergic, viral, bacterial, or rarely fungal

Exclusions <6wks, immunocomp, severe underlying dz,

complications of acute bacterial sinusitis, hospital acquired sinusitis.

Sinusitis (cont)

Acute Sinusitis <4 wks.

Recurrent 4+ episodes/yr lasting 10+ days, symptom free b/w.

Chronic >12 wks with/without Rx.

Sinusitis (cont)

MCC? Viral 200x that of bacterial!

S. pneumoniae, H.influenzae

Sinusitis (cont)

Persistent symptoms of URTI without improvement after 10 - 14 days or worsening after 5 days with both:

nasal congestion/purulent nasal discharge and facial pain

+/- fever, maxillary toothache, facial swelling. Physical findings of: swelling and/or erythema, tenderness

on palpation/percussion of paranasal sinuses, periorbital swelling, erythema/swelling of nasal mucosa, post nasal drip

Nasal/nasopharyngeal cultures NOT recommended Transillumination of the sinuses is of limited value in adults

TOP Guidelines, 2008 Update

Sinusitis (cont)

Abx? 1st Line Amoxicillin 500mg PO TID 10d Allergy? Doxycycline 200mg PO once, then 100mg PO BID 10 d TMP/SMX 1 DS PO bid 10d

TOP Guidelines, 2008 Update

Sinusitis (cont)

What!? I'm an EMERG DOC! Progress, in this case, is bad.

http://www.emedmag.com/html/pre/fea/features/061505.asp

Sinusitis (cont)

Preseptal cellulitis Orbital cellulitis * Subperiosteal abscess Orbital abscess.

http://www.emedmag.com/html/pre/fea/features/061505.asp

Sinusitis (cont)

Still not worried? Cavernous sinus thrombosis

Sinusitis – CST (cont)

Watch for: Headache Ophthalmoplegia Exopthalmos Fever Chemosis Altered

Sinusitis – CST (cont)

Vague symptoms, vague findings. Dx? CT or *MRI LP

Opening pressures? 450 – 500 mmH2O ~75% CSF – Normal ~75%

CXR? Dispo

Admit

Sinusitis – CST (cont)

Facial Danger Zone

http://resources0.news.com.au/images/2008/07/22/va1237320544789/Tom-Cruise-in-Top-Gun-6158917.jpg

Sinusitis – CST (cont)

Suspect it. Preferred Ix: MRV Neg CT can't rule it out.

Sinusitis (cont)

Still not worried? Meningitis Intracranial abscess

Summary

Pharyngitis – You can make a difference. Post tonsilectomy bleed – It's bad. Epistaxis – Fulfil you urge to put something in

there. Pack. Pack, Pack. Pack, Pack, Pack. Pack, Pack, Pack, Pack.

Sinusitis – If you see it, treat it.

Things I Wish I knew Before I was Staff

http://www.charlton.hillbillyfunnies.com/emdoc1.jpg

Qs

http://travel.webshots.com/photo/1451171186076146350zjzyCY

ReferencesBr J Ophthalmol 2003;87:1051 doi:10.1136/bjo.87.8.1051

Janfaza et al. 2001. Surgical anatomy of the head and neck.

Kidermann et al. British Journal of General Practice, March 2005. Adjuvant prednisone therapy in pharyngitis: a randomised controlled trial from general practice.

Middleton, Paul M. Epistaxis. Emergency medicine Australasia (2004) 16, 428-440.

Pofh et al. Burden and Economic Cost of Group A Streptococcal Pharyngitis. PEDIATRICS Vol. 121 No. 2 February 2008, pp. 229-234 (doi:10.1542/peds.2007-0484)

National Health Statistics Reports Number 7 August 6, 2008

Roberts: Clinical Procedures in Emergency Medicine, 5th ed.(via cma.ca)

Tintinalli JE, Kelen GD, Stapczynski JS, Ma OJ, Cline DM: Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 6e: http://www.accessmedicine.com/content.aspx?aID=609033.

Waters Thomas A, Peacock IV W. F, "Chapter 241. Nasal Emergencies and Sinusitis" (Chapter). Tintinalli JE, Kelen GD, Stapczynski JS, Ma OJ, Cline DM:

http://www.bestbets.org/bets/bet.php?id=1412http://www.emedmag.com/html/pre/fea/features/040040035.asphttp://emedicine.medscape.com/article/764304-diagnosis

Images, In order:http://www.boxingscene.com/forums/showthread.php?t=329320http://meded.ucsd.edu/clinicalimg/head_pharyngitis.htmhttp://textbookofbacteriology.net/themicrobialworld/pathogenesis.htmlhttp://www.afreeman.org/wp-content/uploads/2009/02/nickel.jpghttp://www.naze.net/2005/images/2005%200122%20jack%20blood%20in%20sink.jpghttp://www.instantanatomy.net/headneck/areas/phoropharynx.htmlhttp://www.esnr.com/www/case_studies/content/nosebleeds_epistaxis_fig1.htmhttp://www.beerkada.net/images/nosebleed1.jpghttp://chestofbooks.com/health/anatomy/Human-Body-Construction/The-Mouth-And-Throat-Part-2.htmlhttp://drdavidson.ucsd.edu/Portals/0/Pathway/NoseBled.htmhttp://emedicine.medscape.com/article/863220-mediahttp://img.medscape.com/pi/emed/ckb clinical_procedures/79926-79932-80545-113132.jpghttp://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79932-80545-113136.jpghttp://academia.hixie.ch/bath/eye/home.htmlhttp://www.topalbertadoctors.org/informed_practice/cpgs/acute_sinusitis.htmlhttp://www.emedmag.com/html/pre/fea/features/061505.asphttp://travel.webshots.com/photo/1451171186076146350zjzyCYhttp://www.bartleby.com/107/illus571.html