management of emergency ENT conditions for primary care doctors or junior ENT trainees

1. Mr Derrick Siau
Consultant ENT Surgeon
ECT &UHSM

2. Mr Derrick Siau

3. Introduction
 Limited ENT exposure during medical training
 ENT conditions are ubiquitous, up to 30% of primary
care presentations ENT related
 Brief overview of common acute ENT conditions you
are likely to encounter in casualty
 Best way to learn – come and sit in in clinic

5. Tonsillitis
Mostly Viral as part of URTI
5-30% caused by bacteria
 Grp A β haemolytic strep (most common)
 H.influenzae
 Staph aureus
 Strep Pneumoniae
Management
 IV antibiotics – benzyl-pen +/- metronidazole
 IV fluids
 Adequate analgesia

13. Epistaxis

14. Epistaxis
 Most common acute ENT admission
 Most settle conservatively – Ice pack + pinching
 ABC – resuscitation
 Topical anaesthetic/decongestant spray– silver nitrate
cautery
 Anterior – younger, nasal tampons, balloon. BIPP pack
 Posterior – Elderly requires Foley’s, posterior packs
 FLOSEAL – Human Thrombin

16. Anterior Packing

17. Posterior Packing

21. Rhinitis causes
 Infection : Viruses – common cold, self-limiting. Last for
a week
Rhinovirus, corona virus, RSV etc
 Allergies – very common, half of all rhinitis in clinic
 Occupational – air-borne irritants e.g. Cooks,
swimming-pools, chemical workers
 Drug induced – decongestant abuse !!! Damage lining of
nose, very difficult to treat
 Others drugs : anti-inflammatory drugs, ACE-
inhibitors, B-Blockers , anti-depressants
 Smoking !!

22. Rhinitis in elderly (senile rhinitis/Old man’s drip)
 Dry nose
 Watery discharge- cold air, eating, exercise etc
 Due to hyperactive autonomic nerves – stimulating
watery secretions
 RINATEC - Ipratropium bromide can be helpful
Idiopathic rhinitis
 No causes found

23. Nasal allergies
 Most common
 Due to hypersensitivity towards air-borne allergens
 Affects one in four people - 25%
 Seasonal e.g. - sneezing, itching, watery eyes, watery
discharge
 Perennial – more blocked nose, and catarrh
 Associated with asthma, can make asthma worse

24. Common triggers

27. Tests
 Bloods test – expensive, 2 weeks for results
 Skin prick test – quick, instant result

28. Treatment
 AVOIDANCE
 Anti-histamines e.g. Piriton, cetirizine, loratidine
 Anti-leukotrines – Monteleukast esp asthma
 Nasal steroid spray –Nasonex, Flixonase, Avamys
 Drops – Flixonase nasules, betnesol
If severe –one week course of steroid tablets
New agents - DYMISTA spay – combination anti-histamine
and steroid spray in one
Nasal decongestants – no more than 1 week at a time

29. Sinusitis
 Inflammation of lining of nose and sinuses
ACUTE –
 usually follows viral cold. Bacterial super-infection
 Last for a few weeks to months (cold not improving)
 Temperature, unwell, green thick nasal discharge,
facial pain
 Treatment : steam, salt water douching , nasal
decongestants. Antibiotics if severe ( co-amoxyclav)

31. Urgent Ophthalmology/ENT opinion
IV ABX – co-amocyclav or clindamycin + ciprofloxacin. Nasal steroid, saline
deuching
CT Scan – WITH CONTRAST ?

34. Oesophagus- foreign bodies
? Airway FB – always AP and Lateral views

35. Oesophagus - foreign bodies
Treatment –
 If caustic i.e. battery remove ASAP
 Otherwise can observe for 24hrs (most will pass in a
24hr period) IV Buscopan
 Endoscopy with direct visualisation
 BONY FB = SURGICAL EMERGENCY (risk of
perforation)

36. Stridor
 Stridor = audible wheeze, vibratory sound produced by
turbulent airflow across a partially obstructed airway.
 ENT EMERGENCY!
 Poiseuille's Equation
 At least 75% narrowing of airway
 Case should be discussed with SpR +/- Anaesthetist
EARLY
 History and Examination including Fibreoptic
Nasoendoscopy to try to visualise cause of stridor.

37. Strategy
 Acute obstruction :
High flow O2
Adrenaline neubliser 5mls 1:1000
Corticosteroids IV – if oedema present
Iv Abx – in infective cases
Surgical airway considered as Plan B
Heliox 21% O2 79% He
Imaging useful in establishing cause but not in
unstable pt
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42. Laryngeal Ca – risk factors

43. Laryngeal Ca- risk factors
 Prolonged use of tobacco and excessive ETOH use
primary risk factors
 The two substances together have a synergistic effect
on laryngeal tissues
 90% of patients with laryngeal cancer have a history of
both
 HPV 16+ 18 – young patients with oropharyngeal CA
 Gardasil – vaccine HPV 6/11/16/18

46. Angioedema
 Causes:
 ACE inhibitors - 0.68% of patients treated with the
ACE inhibitor enalapril developed angioedema ( due
to C1 esterase inhibitor deficiency)
 Shell fish
 Peanut allergy
 Tx – IV steroids, nebulised adrenaline if airway
compromise, antihistamines. HDU observation
 Icatibant - peptide which blocks bradykinin-receptors.

51. What if things don’t go to plan?
 Always have back-up plan
 Surgical airway!

52. Surgical Cricothyroidotomy
 3cm linear incision
 Horizontal stab inferior
part of membrane
 Incision dilated
 Custom tube or size 6
ET tube
 Must be converted
tracheostomy–
subglottic stenosis,
dysphonia
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53. Tracheotomy
 Emergency surgical- If in extremis, cricothyrodotomy
cannot be established(not officially in guidelines)
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54.  Percutaneous Tracheostomy can be considered if
ventilation not critical
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55. Summary
 Ask for help if unsure, pop in to discuss anything
 Needless to say – PRIORITIZE emergencies ABC ,
AIRWAY comes first
 ENT is good fun – once you know what to do!
 Come observe in our clinic, theatre. More than
welcome