ENT Quiz on Epistaxis and Mastoiditis

ENT Emergencies Overview

• ENT emergencies encompass various disorders affecting the ears, nose, and throat.
• Specific categories include otologic disorders, nasal disorders, facial, oral, and pharyngeal infections, and airway obstruction.

Otologic Disorders Anatomy

• Auricle (outer ear)
• Ear canal
• Tympanic membrane
• Middle ear and mastoid disorders
• Inner ear

Traumatic Disorders of the Auricle

• Hematoma: Cartilaginous necrosis, requiring drainage, antibiotics, and a bulky dressing. Close follow-up is necessary.
• Lacerations: Single layer closure, perichondrium pick up, and bulky ear dressing. Posterior auricular block for anesthesia.

Aspiration of Auricular Hematoma

• Procedure involves aspiration of the hematoma.
• Perichondrium and cartilage are visualized.

Auricle - Chondritis/Cellulitis

• Infections, difficult to treat due to poor blood supply.
• Includes S. Aureus and Pseudomonas.
• Requires extra care in diabetics.
• Inflammatory causes, sometimes indistinguishable from infection, often sparing the ear lobe.

Otitis Externa

• Infection and inflammation caused by bacteria (Pseudomonas, staph) and fungi.
• Treatment involves antibiotic-steroid drops.
• Tight canals may require a wick.
• Diabetics are at risk for malignant otitis externa, characterized by granulation tissue.

Foreign Bodies in Ear Canal

• Often self-inserted or windblown debris.
• Treatment involves mineral oil, lidocaine, forceps, suction, or tissue adhesive removal.

Foreign Body in the Nose

• Common presentations include purulent discharge (unilaterally), nasal bleeding, and one-sided obstruction.
• Treatment involves moving the foreign object using appropriate tools.

Foreign Bodies in Ear Canal (Children)

• Children, individuals with mental retardation, and adults using cotton swabs may introduce foreign bodies into the ear canal.
• Microscopic examination and specialized tools are often required.
• Ear lavage may be necessary.
• Perforated eardrums contraindicate lavage.
• Edema should be relieved.
• A liquid solution of lidocaine or boric acid can be used to remove certain foreign bodies.
• Surgery is rarely needed.

Pharyngeal Foreign Bodies

• Common in children.
• Foreign body may be seen in the mouth.
• Patients may refuse to eat.
• Children with difficulty swallowing may have difficulty tolerating saliva.
• Fishbone, tonsils, soft palate, are common sources.
• Palpation is contraindicated.
• Flexible nasopharyngolaryngoscopy is useful (FNFL).

Laryngotracheobronchial Foreign Bodies

• Life-threatening due to airway obstruction potential.
• Use Heimlich maneuver if necessary.
• Bronchoscopy in the operating room is frequently required.

Tympanic Membrane Perforation

• Difficult to detect, frequently preceded by middle ear pressure due to fluid or barotrauma.
• External trauma can sometimes cause perforations.
• Most heal on their own, but otology follow-up is required.
• Perforations associated with vertigo and facial nerve involvement require immediate medical care.
• Treatment typically involves antibiotics.
• Ear drops are sometimes required, but avoid gentamicin.

Middle Ear

• Serous Otitis Media: Eustachian tube dysfunction. Treatment includes decongestants and maneuvers.
• Otitis Media: Middle ear infection, often viral or bacterial.
• Mastoiditis: Venous connection to the brain, a serious condition. aggressive treatment is required. Brain abscess or meningitis may result.

Inner Ear

• Peripheral Vertigo: Vestibulopathy, including BPPV and labyrinthitis. Characterized by sudden onset without central signs, often with horizontal nystagmus in younger patients.
• Ménière's Disease: Vertigo, sensorineural hearing loss, and tinnitus.
• Treatment: Valium, fluids, rest, and manipulation for BPPV are common interventions.

The Nose - Vascular Supply

• Supply from branches of the internal carotid artery and external carotid artery.
• Key areas include the anterior and posterior regions.

Epistaxis (Anterior)

• Most common in children and young adults.
• Usually due to Kisselbach's plexus (Little's area).
• Etiologies include trauma, winter syndrome, allergies, irritants, and pregnancy.

Epistaxis (Posterior)

• Less common, occurring mostly in the elderly.
• Etiologies include coagulopathy, atherosclerosis, neoplasm, and hypertension (debatable).

Epistaxis Management

• Pain medication and blood pressure control.
• Patient preparation (gown, mask, suction, speculum, medications, and packing).
• Clot evacuation.
• Topical vasoconstrictors and anesthetics.
• Identifying the source of bleeding.

Epistaxis Management (Anterior Sites)

• Pressure, cautery, and tamponade.
• Antibiotic prophylaxis for packs.

Epistaxis Management (Posterior Packing)

• Analgesia and sedation.
• Hospital admission and oxygen saturation monitoring are often necessary.

Epistaxis Complications

• Severe bleeding, hypoxia, hypercarbia, sinusitis, otitis media, and necrosis of the columella or nasal ala.

7th Nerve Palsy

• Typically idiopathic.
• No proven effectiveness of steroids or antivirals, but many recommend them.
• Consider Lyme's disease in endemic areas.
• Surgical decompression is sometimes required for non-improving cases after two weeks with >90% ENOG (ear-nose-throat) out.

Facial Infections - Sinusitis

• Symptoms includes headache, sinus pain, yellow-green nasal discharge, and fever.
• CT scans are more sensitive than plain X-rays in detecting sinusitis.
• Causative organisms include gram-positive bacteria like Streptococcus and Haemophilus influenzae (acute sinusitis), and anaerobes or gram-negative bacteria for chronic cases.

Facial Infections - Sinusitis - Treatment

• Treatment for acute sinusitis often involves amoxicillin or septra.
• Chronic cases might require amoxicillin-clavulanate, clindamycin, or quinolones.
• Decongestants, analgesics, and heat are frequently included.

Facial Infections - Sinusitis - Complications

• Ethmoid sinusitis can lead to orbital cellulitis and abscess.
• Frontal sinusitis can potentially erode the bone and lead to complications like Potts puffy tumor or brain abscess.

Facial Cellulitis

• Most common causes include Streptococcus and Staphylococcus.
• Haemophilus influenzae is sometimes involved.
• Facial cellulitis can progress rapidly.

Parotiditis

• Typically viral, often caused by paramyxovirus.
• Bacteria can also cause parotiditis, particularly in the elderly and immunocompromised patients, sometimes associated with dehydration.
• Common bacterial culprits include Staphylococcus and anaerobes.

Pharyngitis

• Irritants (reflux, trauma, gases), viruses (EBV, adenovirus), and bacteria (GABHS, mycoplasma, gonorrhoea, diphtheria) can all lead to pharyngitis.

Peritonsillar Abscess

• Complication of suppurative tonsillitis.
• Inferior-medial displacement of the tonsil and uvula.
• Dysphagia, ear pain, muffled voice, fever, and trismus are possible symptoms.
• Treatment usually involves antibiotics, incision and drainage (I&D), and sometimes steroids.

Epiglottitis (Clinical Picture)

• Incidence has decreased in children due to vaccinations.
• Symptoms include rapid onset, toxic appearance, preference for sitting posture, muffled voice, dysphagia, drooling, and restlessness.

Epiglottitis (Management)

• Avoid agitation; direct visualization if possible.
• Assess soft tissues of the neck, including signs like thumb printing and valecula signs.
• Prepare for emergency airway management.
• Steroids may be used.

Retropharyngeal Abcess

• Located anterior to the prevertebral space and posterior to the pharynx.
• Common in young children due to lymphoid tissue.
• Symptoms include pain, dysphagia, dyspnea, fever, and retropharyngeal space swelling on lateral X-rays.
• Potential complication: mediastinitis.

Masticator-Parapharyngeal Space Infection

• Infection of the lower molars extending to the masticator space.
• Symptoms include swelling, pain, fever, and trismus (restricted jaw movement).
• Treatment: IV antibiotics (penicillin or clindamycin). ENT admission.

ANUG (Acute Necrotizing Ulcerative Gingivitis)

• Bacterial infection that causes acute necrosis, destroying the periodontium.
• Treatment includes oral rinses and antibiotics (penicillin, clindamycin, tetracycline).

Ludwig's Angina

• Rapidly progressing cellulitis of the floor of the mouth, usually affecting elderly, debilitated patients.
• Frequently precipitated by dental procedures.
• Massive swelling, sometimes with impending airway obstruction.
• Treatment: ICU admission, antibiotics, and airway management.

Angioedema

• Can be life-threatening.
• May be hereditary or related to ACE inhibitors.
• Treatment involves antihistamines and steroids.

Airway Obstruction

• Aphonia: Complete upper airway obstruction.
• Stridor: Incomplete upper airway obstruction.
• Wheezing: Incomplete lower airway obstruction.
• Loss of breath sounds: Complete lower airway obstruction.