Management of Management of ENT ENT

EmergenciesEmergenciesSimon LloydSimon Lloyd

Consultant ENT SurgeonConsultant ENT SurgeonCentral Manchester NHS Central Manchester NHS

Foundation TrustFoundation Trust

Facial palsyFacial palsy

AnatomyAnatomy• SensorySensory

– TasteTaste– Posterior ear canalPosterior ear canal

• AutonomicAutonomic– Parasympathetic to:Parasympathetic to:

• Lacrimal glandLacrimal gland• Submandibular glandSubmandibular gland• Sublingual glandSublingual gland

• MotorMotor– Facial expressionFacial expression– StapediusStapedius– Posterior belly of Posterior belly of

digastricdigastric

AetiologyAetiology• Huge differentialHuge differential• CongenitalCongenital

– Neurological eg. Moebius syndromeNeurological eg. Moebius syndrome– Traumatic eg. ForcepsTraumatic eg. Forceps

• AcquiredAcquired– Idiopathic eg. Bell’s palsyIdiopathic eg. Bell’s palsy– Traumatic eg. Temporal bone fractureTraumatic eg. Temporal bone fracture– Iatrogenic eg. SurgeryIatrogenic eg. Surgery– Infection eg. Acute otitis media, malignant Infection eg. Acute otitis media, malignant

otitis media, Ramsey Hunt syndromeotitis media, Ramsey Hunt syndrome– Neoplastic eg. Parotid malignancy Neoplastic eg. Parotid malignancy

ExaminationExamination Facial nerve grading (House Facial nerve grading (House

Brackmann)Brackmann)

Other cranial nervesOther cranial nerves

Tympanic membrane/pinna for vesiclesTympanic membrane/pinna for vesicles

Parotid/mouthParotid/mouth

AssessmentAssessment• House Brackmann Grading (I House Brackmann Grading (I

to VI)to VI)II = Normal = NormalII = Normal at rest, mild weakness II = Normal at rest, mild weakness

on active movementon active movementIII= Good eye closureIII= Good eye closureVV = Some tone = Some toneVI= No movementVI= No movement

Eyes open Eyes closed

Facial PalsyFacial Palsy

52 year old lady52 year old lady Rapid onset left facial Rapid onset left facial

weaknessweakness Left facial numbnessLeft facial numbness No ear symptomsNo ear symptoms Otherwise fit and wellOtherwise fit and well Grade III weaknessGrade III weakness No other No other

abnormalitiesabnormalities

Bell’s PalsyBell’s Palsy• Idiopathic (probably viral – Herpes simplex)Idiopathic (probably viral – Herpes simplex)• Acute unilateral facial palsy (peripheral)Acute unilateral facial palsy (peripheral)• Occasionally other cranial nerve palsies eg. Occasionally other cranial nerve palsies eg.

TrigeminalTrigeminal• Resolves within 3 months in 80% of casesResolves within 3 months in 80% of cases• 10% recur (including contralateral)10% recur (including contralateral)• Higher incidence in diabetesHigher incidence in diabetes• TreatmentTreatment

• Eye Care (lubrication)Eye Care (lubrication)• Oral steroidsOral steroids• No evidence for benefit from antiviralsNo evidence for benefit from antivirals

– Sullivan et al. New England Journal of Medicine 2007Sullivan et al. New England Journal of Medicine 2007

Who to referWho to refer Additional findings (Cr. Nerves, Additional findings (Cr. Nerves,

lumps)lumps)

No improvement at 3 weeksNo improvement at 3 weeks

Incomplete recoveryIncomplete recovery

ConcernsConcerns

Sudden Hearing LossSudden Hearing Loss Normal TM with sudden hearing lossNormal TM with sudden hearing loss Aetiology unknownAetiology unknown

ViralViral VascularVascular

Rarely acoustic neuroma, perilymph leakRarely acoustic neuroma, perilymph leak May be unsteady or vertiginousMay be unsteady or vertiginous

Sudden Hearing LossSudden Hearing LossManagementManagement

Refer urgentlyRefer urgently Treatment optionsTreatment options

Oral steroidOral steroid AntiviralAntiviral

No evidence for efficacyNo evidence for efficacy CarbogenCarbogen

No evidence for efficacyNo evidence for efficacy Intratympanic steroidIntratympanic steroid

Weak evidence for efficacyWeak evidence for efficacy

Allergic response to BIPPAllergic response to BIPP

Acute Otalgia with Acute Otalgia with normal TMnormal TM

Complications ofComplications ofOtitis MediaOtitis Media

MastoiditisMastoiditis Facial palsyFacial palsy LabyrinthitisLabyrinthitis MeningitisMeningitis Intracranial abscessIntracranial abscess Lateral sinus thrombosisLateral sinus thrombosis

- Long term• Tympanosclerosis• Tympanic membrane perforation• Ossicular damage

Acute MastoiditisAcute Mastoiditis

History of acute otitis History of acute otitis mediamedia

Infection spreads to Infection spreads to mastoidmastoid

Post-auricular abscessPost-auricular abscess

TreatmentTreatment GrommetGrommet Cortical mastoidectomyCortical mastoidectomy

Complications acute otitis Complications acute otitis mediamedia

mastoiditismastoiditis

Intracerebral AbscessIntracerebral Abscess DiagnosisDiagnosis

High index of High index of suspicionsuspicion

HeadacheHeadache Reduced conscious Reduced conscious

levellevel FeverFever SeizuresSeizures

Requires drainageRequires drainageRing enhancement with contract enhanced CT

Lateral Sinus Lateral Sinus ThrombosisThrombosis

DiagnosisDiagnosis High index of suspicionHigh index of suspicion HeadacheHeadache Decreased conscious Decreased conscious

levellevel AtaxiaAtaxia SeizuresSeizures

TreatmentTreatment AnticoagulationAnticoagulation ?thrombectomy?thrombectomy Filling

defect on MRA

EpistaxisEpistaxis

AnatomyAnatomy

AetiologyAetiology Usually idiopathicUsually idiopathic

? atherosclerotic vessels? atherosclerotic vessels Predisposing factorsPredisposing factors

AnticoagulantsAnticoagulants HypertensionHypertension

Trauma eg. Digital, fractured noseTrauma eg. Digital, fractured nose Nasal vestibulitis eg. StaphlococcalNasal vestibulitis eg. Staphlococcal Topical treatment eg. Nasal steroidsTopical treatment eg. Nasal steroids RareRare

HHTHHT NeoplasiaNeoplasia Septal perforationSeptal perforation

Epistaxis First AidEpistaxis First Aid

Conservative ManagementConservative Management Pinch soft part of nosePinch soft part of nose Lean forward and breathe Lean forward and breathe

through mouththrough mouth Ten minutesTen minutes

Protect yourselfProtect yourself GownGown GlovesGloves MaskMask

TreatmentTreatment Identifiable VesselIdentifiable Vessel

Nasal cauteryNasal cautery Examine noseExamine nose Identify vesselIdentify vessel Apply 1 in 10,000 Apply 1 in 10,000

adrenaline and adrenaline and 1%lignocaine on 1%lignocaine on cotton wool cotton wool pledgetpledget

Silver nitrate Silver nitrate cautery of vesselcautery of vessel

Silver nitrate cauterySilver nitrate cautery

TreatmentTreatment No Identifiable VesselNo Identifiable Vessel

Nasal packingNasal packing MerocelMerocel RapidrhinoRapidrhino BIPP packingBIPP packing

Rapid RhinoRapid Rhino

BIPP PackingBIPP Packing

TreatmentTreatment Ongoing bleedingOngoing bleeding

Re-check vital signsRe-check vital signs IV access +/- fluidsIV access +/- fluids Check clottingCheck clotting Posterior packingPosterior packing

Brighton baloonBrighton baloon Foley catheter and Foley catheter and

BIPP packBIPP pack

Surgical InterventionSurgical Intervention SeptoplastySeptoplasty Sphenopalatine artery ligationSphenopalatine artery ligation Anterior ethmoid artery ligationAnterior ethmoid artery ligation Maxillary artery ligationMaxillary artery ligation External carotid artery ligationExternal carotid artery ligation

Management AlgorithmManagement Algorithm

Nasal VestibulitisNasal Vestibulitis PaediatricPaediatric Digital traumaDigital trauma Cautery vs NaseptinCautery vs Naseptin

Equal efficacyEqual efficacy

Bactroban tastes horrible ? Prevents Bactroban tastes horrible ? Prevents digital traumadigital trauma

Fractured noseFractured nose

Fractured noseFractured nose

Ask aboutAsk about EpistaxisEpistaxis CSFCSF Diplopia on upward gazeDiplopia on upward gaze Infraorbital parasthesiaInfraorbital parasthesia Shape changeShape change Nasal obstructionNasal obstruction

FracturedFractured nosenose

ExaminationExamination Nasal bones crepitus, Nasal bones crepitus,

shapeshape Infraorbital parasthesiaInfraorbital parasthesia Orbital rimsOrbital rims Septum for haematomaSeptum for haematoma No need for X ray No need for X ray

unless medicolegalunless medicolegal

Fractured noseFractured nose ManagementManagement If no complicating factors and nose straight If no complicating factors and nose straight

leave alone.leave alone. If orbital fracture or septal haematoma refer If orbital fracture or septal haematoma refer

immediatelyimmediately If shape change with no complicating factors If shape change with no complicating factors

refer to ENT about five days post injuryrefer to ENT about five days post injury

Nose should be reduced within 2 Nose should be reduced within 2 weeks for best chance of good resultweeks for best chance of good result

Complications of Complications of SinusitisSinusitis

Intracranial complicationsIntracranial complications Brain AbscessBrain Abscess MeningitisMeningitis

Orbital complicationsOrbital complications Periorbital cellulitisPeriorbital cellulitis Periorbital abscessPeriorbital abscess Orbital abscessOrbital abscess Pott’s puffy tumourPott’s puffy tumour

Periorbital Cellulitis and Periorbital Cellulitis and AbscessAbscess

UnwellUnwell PyrexiaPyrexia Eye closesEye closes ErythemaErythema ChemosisChemosis Colour vision goes Colour vision goes

off firstoff first Refer urgentlyRefer urgently

Periorbital CellulitisPeriorbital CellulitisTreatmentTreatment

NoseNose Topical decongestantsTopical decongestants

EphidrineEphidrine OtravineOtravine

SystemicSystemic IV antibioticsIV antibiotics

CT imaging to CT imaging to exclude periorbital exclude periorbital abscessabscess

Foreign BodiesForeign Bodies MaterialMaterial

Paper, beads, watch Paper, beads, watch batteries etc.batteries etc.

Unilateral rhinorrhoea Unilateral rhinorrhoea is a foreign body until is a foreign body until proved otherwiseproved otherwise

TreatmentTreatment Wrap up childWrap up child Assistant hold headAssistant hold head RemoveRemove

Complications of TonsillitisComplications of TonsillitisPeritonsillar abscessPeritonsillar abscess

SymptomsSymptoms Pain becomes more unilateralPain becomes more unilateral Often referred otalgiaOften referred otalgia Trismus (therefore difficult to get a good Trismus (therefore difficult to get a good

look)look) DroolingDrooling Systemically unwell with pyrexiaSystemically unwell with pyrexia Normally big tender upper deep cervical nodeNormally big tender upper deep cervical nodeReferRefer

Complications of tonsillitisComplications of tonsillitisPeritonsillar abscess Peritonsillar abscess

(quinsy)(quinsy)

Peritonsillar abscessPeritonsillar abscessTreatmentTreatment Incision and drainage (needle/blade)Incision and drainage (needle/blade) Intravenous penicillin and Intravenous penicillin and

metronidazolemetronidazole First quinsy and previous history of First quinsy and previous history of

tonsillitis… recommend tonsillitis… recommend tonsillectomytonsillectomy

First quinsy with no prior tonsillitis First quinsy with no prior tonsillitis history…verbal warninghistory…verbal warning

StridorStridor

Harsh, high-pitched sound indicative of airway Harsh, high-pitched sound indicative of airway obstruction.obstruction.

InspiratoryInspiratory SupraglotticSupraglottic or Glottic or Glottic

BiphasicBiphasic Subglottic or Extrathoracic Trachea Subglottic or Extrathoracic Trachea ExpiratoryExpiratory Intrathoracic TracheaIntrathoracic Trachea

NB. Stertor – High upper airway obstructionNB. Stertor – High upper airway obstruction

Stridor - AssessmentStridor - Assessment What level ??What level ?? History – What sort of History – What sort of

stridorstridor How severe ??How severe ?? Accessory muscles Accessory muscles Tracheal Tracheal

tug / Recession in childrentug / Recession in children PulsePulsepCOpCO22 Retention Retention

Does the airway need securing ??Does the airway need securing ?? Severe OR patient getting tired.Severe OR patient getting tired.

CausesCauses ChildrenChildren

InfectionInfection Bacterial eg. Bacterial eg.

EpiglottitisEpiglottitis Viral eg. CroupViral eg. Croup

Foreign bodyForeign body

AdultsAdults InfectionInfection

SupraglottitisSupraglottitis NeoplasiaNeoplasia

Squamous cell Squamous cell carcinoma carcinoma

Stridor -managementStridor -management SIT PATIENT UPSIT PATIENT UP OXYGENOXYGEN RE-HYDRATION (i.v.)RE-HYDRATION (i.v.) STEROIDS (Nebulised, i.v. or STEROIDS (Nebulised, i.v. or

oral)oral) ADRENALINE NEBULISERADRENALINE NEBULISER HELIOX – Helium / oxygen HELIOX – Helium / oxygen

mixturemixture ANTI-BIOTICSANTI-BIOTICS AIRWAY INTERVENTIONAIRWAY INTERVENTION

IntubationIntubation BronchoscopyBronchoscopyTracheostomyTracheostomy

““Croup” vs EpiglottitisCroup” vs EpiglottitisCroupCroup EpiglottitisEpiglottitis

AgeAge 1-3years1-3years 3-6 years3-6 years DurationDuration URTI (days)URTI (days)

Short(hours)Short(hours) ClinicalClinical “Viral”“Viral” UnwellUnwell** StridorStridor LoudLoudQuietQuiet

* * Decreased concious level, circumoral palor, rapid Decreased concious level, circumoral palor, rapid deterioration.deterioration.

Airway Foreign BodiesAirway Foreign Bodies

RIGHT main bronchus (more vertical)RIGHT main bronchus (more vertical)

May get air trapping, distal to FB.May get air trapping, distal to FB.

Monophonic wheeze (asthma Monophonic wheeze (asthma POLYphonic)POLYphonic)

High index of suspicion - High index of suspicion - REFERREFER

Rigid bronchoscope

Bronchoscope and camera being used to assess the airway in a child with a tracheostomy