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Topics:
Nasal Fracture
Haemorrhage - Epistaxis, Post-op Bleed
Ear Emergencies
Head & Neck Infections
Ingested Foreign...
Nasal Fracture
Exclude intra-cranial, orbital and other facial

injuries
If epistaxis present, apply first-aid measures
...
Nasal Fracture
Investigation

Request for ‘Nasal Bone Xray’
Nasal XR - medicolegal reason
In more serious injury - skul...
Nasal Fracture
Management

Refer to ENT urgently if:
Uncontrolled epistaxis
Presence of septal haematoma
Nasal Fracture
Management

Need for M&R within 14 days of injury
Refer to ENT outpatient to await reduction of

oedema t...
A. Epistaxis
Local causes
Idiopathic (90%)
Traumatic ( fracture, foreign body, nose picking )
Infection
Inflammatory (...
Epistaxis
General causes
Coagulopathy (Dengue, anticoagulant)
Hypertension
Hereditary Haemorrhagic telangiectasia
Rais...
Epistaxis

Majority are self limiting, esp. in children
90% bleed from Kiesselbach’s plexus (Little’s area)
Epistaxis
Kiesselbach plexus
Located on exposed anterior part of septum
Upper portion
ICA ( anterior and posterior ethm...
Epistaxis - First Aid
Sit up with head forward

Pinch the nose firmly with thumb and fingers for >

5min (Cartilaginous ...
Epistaxis - Management
Assess blood loss

Resuscitation, i.v. access
Base line blood investigation
GXM
Medication - s...
Epistaxis - Management
Treat underlying cause
Reverse coagulopathy
Control hypertension
Allergic rhinitis
Sinusitis
...
Epistaxis - Haemostasis
1) Cautery
Silver Nitrate
Electrocautery

2) Anterior Nasal Pack
No clear bleeding point or Failed...
Epistaxis – Admission Criteria
Uncontrolled bleeding
Nasal packing done
Post-operative cases
Haemodynamically unstable...
B. Post-Tonsillectomy bleed
Resuscitation! & i.v. access

Assess for symptoms/signs of shock
Baseline blood including c...
Post-Tonsillectomy bleed
Management

First aid measures, e.g. ice gargle
Pressure (adrenaline gauze)
Silver nitrate
El...
Post-Tonsillectomy bleed
Management& small clot evident
If no active bleed
observe

If large clot, need to remove clot ...
Admission Criteria

All post-operative haemorrhage should be admitted
If bleeding stopped, offer admission for observati...
Ear Emergencies
Admission Criteria
Most ear cases can be reviewed in the next ENT

outpatient clinic
Following needs urg...
Ear Cases Seen at A&E
1.

2.
3.
4.
5.
6.
7.

Impacted ear wax
Traumatic TM Perforation
Otitis Externa
Otitis Media
Sudden ...
Impacted Ear Wax

Prescribe wax softeners (e.g. olive oil ear drops)
Obtain outpatient referral for review
Traumatic TM Perforation
If no other serious head injuries, can be followed up

as outpatient
1 week TCU
Keep ears dry
...
Otitis Externa
Treatment :
Aural toilet
Topical antibiotic ± steroid ear drops
Oral antibiotic for severe cases
Obtai...
Acute Otitis Media
Common in children
Fever, ear- pain
TM - red & bulging
Otitis media can only be diagnosed if the TM...
Acute Otitis Media
Treatment
Topical nasal decongestant
Analgesia
Oral anti-histamine
Antibiotics if patient toxic
Ob...
Chronic Otitis Media (effusion)
Oral antibiotics to prevent infection

If nasal symptoms present, treat with nasal

deco...
Chronic Otitis Media (effusion)
Need to exclude NPC

If persist for more than 2 months, may need

myringotomy and ventil...
Chronic Suppurative Otitis Media
(CSOM)
Aural toilet
Topical ± oral antiobiotics
Keep ears dry
Elective Myringoplasty ...
Sudden Sensorineural Hearing Loss
Loss of hearing of > 30 dB over 3 days, over at

least 3 frequencies
Sudden onset of h...
Sudden Sensorineural Hearing Loss
Refer to next ENT outpatient clinic
Cover with oral prednisolone 1mg/kg if no

contrai...
Sudden Sensorineural Hearing Loss Causes
 Idiopathic – 85%
 Meniere’s disease
 Acoustic Neuroma
 Cerebellar-pointine a...
FB - Ear
Crocodile forceps-

cotton,paper,foam ,
sponge
Blunt hook – round
objects
Suction – fluid
FB - Ear
Syringing – C/I organic material
Insects
Killed by alcohol/lignocaine/olive oil
Removed

Can be managed in E...
Perichondritis
Perichondritis
Admission for i.v. antibiotics
Risk of cauliflower ear deformity
Pseudocyst of the Pinna
Pseudocyst of the Pinna
TCU next ENT outpatient clinic
Elective excision of pseudocyst
Do not aspirate
Do not perform ...
Giddiness

≠

ENT Referral

Always exclude central causes first
Peripheral causes not life-threatening
Head & Neck Infections
Acute Tonsillitis

Peritonsillar Abscess (Quinsy)
Sinusitis
Epiglottitis
Deep Neck Infection
Acute Tonsillitis

Sorethroat, Fever, Odynophagia
Bilateral tonsils - enlarged, injected, swollen,

purulent exudates

...
Acute Tonsillitis

Treatment : antibiotic, gargles, lozenges, analgesia,

anti-pyretic
Antibiotics of choice:
Penicilli...
Acute Tonsillitis – Admission Criteria
Inadequate oral intake of fluids/food
Signs of peritonsillar abscess (quinsy)
Peritonsillar Abscess
Quinsy
Trismus
Unilateral
Swollen soft palate, uvula displaced
Treatment :
Aspiration
Incision...
Sinusitis

Symptoms :
Purulent nasal discharge
nasal congestion
Facial pain
Headache
Sinusitis - Diagnosis
Clinical
History
Sinus X-ray - not reliable, not necessary
Mucopus seen on nasal endoscopy
Sinusitis - Treatment

Goal : Relieve obstruction of the sinus ostia
Nasal decongestant (oxymetazoline nose drop)
Syste...
Sinusitis - Treatment
Nasal douche

Hypertonic saline
Sodium bicarbonate

Functional Endoscopic Sinus Surgery (FESS)
...
Sinusitis – Admission Criteria
Complicated sinusitis

Orbital cellulitis/abscess
Intracranial abscess
Epiglottitis

Adult and Children
Organism - S. pneumoniae, H.Influenze, Beta-

Haemolytic strep
Epiglottitis

Severe sore throat, odynophagia, high fever
Muffled voice, Difficulty in breathing
Sit erect and bend for...
Epiglottitis

Indirect Laryngoscopy
Flexible Fiberoptic nasopharyngoscope
Lateral neck X-ray - thumb sign
Normal
epiglottis
Swollen
epiglottis
Epiglottitis - Treatment
Airway management
Monitor Closely
Intubation, Cricothyroidectomy, Tracheostomy
Oxygen
Antibi...
Deep Neck Infection
Neck swelling

Sore throat, odynophagia, trismus
Immunocompromised
Fever, unwell
Lateral neck XR
...
Deep Neck
Infection
•Normal retropharyngeal
space on lateral neck XR is
up to 1 vertebral body
width from C5 and below.

W...
FB - Throat
History
Localised
Below post-cricoid region - midline
Mouth/ oropharynx – localised to side

Time of inges...
FB - Throat
History
High risk
Sensory deprivation eg dentures (adults )

Otalgia, neck tenderness, fever, chest or back...
FB - Throat
Examination
Distress
Unable to swallow saliva
Tracheal rock positive
Swallow test positive
Common Sites of impaction of FB
Tonsils
Base of tongue
Vallecula
Pyriform fossa
Cricopharynx
Oesophagus
Common Sites of impaction of FB
Tonsils
Base of tongue
Vallecula
Pyriform fossa
Cricopharynx
Oesophagus
Common Sites of impaction of FB
Tonsils

Base of tongue
Vallecula
Pyriform fossa
Cricopharynx
Oesophagus
Equipment

Head mirror/ head light
Tongue depressor
Laryngeal mirror
Forceps
Direct laryngoscopy*
Flexible Nasophary...
Tongue depressors
to allow
examination of
tonsils
Dental mirrors to
allow examination
of base of tongue
and hypopharynx
For removal of FB in
pharynx
Nagashima forceps:
For removal of FB from base of
tongue, vallecula and hypopharynx
FB Throat - Investigations
Lateral neck XR
CXR
Barium swallow
CT scan – without contrast
Rigid oesophagoscopy
FB
FB
Hyoid bone

Thyroid cartilage
Cricoid cartilage
FB
Osteophyte
FB
FB
FB
FB
FB
FB Throat

>50% of ingested FB cannot be found!
Discharge with symptomatic treatment
Cover with antibiotics if diabetic...
FB Throat
Can be seen in next ENT clinic if:
No FB found on detailed examination
No chest pain
Symptoms mild
Emergencies in ENT
Emergencies in ENT
Emergencies in ENT
Emergencies in ENT
Emergencies in ENT
Emergencies in ENT
Emergencies in ENT
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Emergencies in ENT
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Emergencies in ENT

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Emergencies in ENT

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Emergencies in ENT

  1. 1. Topics: Nasal Fracture Haemorrhage - Epistaxis, Post-op Bleed Ear Emergencies Head & Neck Infections Ingested Foreign Body
  2. 2. Nasal Fracture Exclude intra-cranial, orbital and other facial injuries If epistaxis present, apply first-aid measures Need to exclude septal haematoma (requires urgent drainage) Isolated nasal fractures can be managed as outpatient
  3. 3. Nasal Fracture Investigation Request for ‘Nasal Bone Xray’ Nasal XR - medicolegal reason In more serious injury - skull and facial XR CT scan - useful for maxillofacial fractures and to exclude other injuries
  4. 4. Nasal Fracture Management Refer to ENT urgently if: Uncontrolled epistaxis Presence of septal haematoma
  5. 5. Nasal Fracture Management Need for M&R within 14 days of injury Refer to ENT outpatient to await reduction of oedema to enable assessment of nasal bone alignment If epistaxis stops and no other significant injuries, provide outpatient ENT follow-up within 1 week of nasal injury
  6. 6. A. Epistaxis Local causes Idiopathic (90%) Traumatic ( fracture, foreign body, nose picking ) Infection Inflammatory ( rhinitits, sinusitis ) Tumour ( rare ) Iatrogenic (Nasal Surgery)
  7. 7. Epistaxis General causes Coagulopathy (Dengue, anticoagulant) Hypertension Hereditary Haemorrhagic telangiectasia Raised venous pressure (whooping cough, pneumonia)
  8. 8. Epistaxis Majority are self limiting, esp. in children 90% bleed from Kiesselbach’s plexus (Little’s area)
  9. 9. Epistaxis Kiesselbach plexus Located on exposed anterior part of septum Upper portion ICA ( anterior and posterior ethmoidal arteries ) Lower portion ECA ( Greater palatine, sphenopalatine, superior labial arteries )
  10. 10. Epistaxis - First Aid Sit up with head forward Pinch the nose firmly with thumb and fingers for > 5min (Cartilaginous part) Breathe through mouth Ice pack on forehead Ice cubes to suck
  11. 11. Epistaxis - Management Assess blood loss Resuscitation, i.v. access Base line blood investigation GXM Medication - sedative or anti-hypertensive
  12. 12. Epistaxis - Management Treat underlying cause Reverse coagulopathy Control hypertension Allergic rhinitis Sinusitis Nasal hygiene Haemostasis
  13. 13. Epistaxis - Haemostasis 1) Cautery Silver Nitrate Electrocautery 2) Anterior Nasal Pack No clear bleeding point or Failed cautery BIPP or Merocel Antibiotic cover
  14. 14. Epistaxis – Admission Criteria Uncontrolled bleeding Nasal packing done Post-operative cases Haemodynamically unstable Poor premorbid conditions Severe bleeds
  15. 15. B. Post-Tonsillectomy bleed Resuscitation! & i.v. access Assess for symptoms/signs of shock Baseline blood including coagulation profile GXM NBM
  16. 16. Post-Tonsillectomy bleed Management First aid measures, e.g. ice gargle Pressure (adrenaline gauze) Silver nitrate Electrocautery Ligation of local bleeder
  17. 17. Post-Tonsillectomy bleed Management& small clot evident If no active bleed observe If large clot, need to remove clot to access if bleeding If active bleeding: Attempt haemostasis at A&E/Clinic Haemostasis under G.A.
  18. 18. Admission Criteria All post-operative haemorrhage should be admitted If bleeding stopped, offer admission for observation
  19. 19. Ear Emergencies Admission Criteria Most ear cases can be reviewed in the next ENT outpatient clinic Following needs urgent admission: Acute Mastoiditis Acute perichondritis of the pinna Any ear infection/trauma with facial nerve palsy
  20. 20. Ear Cases Seen at A&E 1. 2. 3. 4. 5. 6. 7. Impacted ear wax Traumatic TM Perforation Otitis Externa Otitis Media Sudden Sensorineural Hearing Loss Foreign Body Ear Miscellaneous
  21. 21. Impacted Ear Wax Prescribe wax softeners (e.g. olive oil ear drops) Obtain outpatient referral for review
  22. 22. Traumatic TM Perforation If no other serious head injuries, can be followed up as outpatient 1 week TCU Keep ears dry Antibiotics not required Obtain outpatient referral for review
  23. 23. Otitis Externa Treatment : Aural toilet Topical antibiotic ± steroid ear drops Oral antibiotic for severe cases Obtain outpatient referral for review
  24. 24. Acute Otitis Media Common in children Fever, ear- pain TM - red & bulging Otitis media can only be diagnosed if the TM is visualised!
  25. 25. Acute Otitis Media Treatment Topical nasal decongestant Analgesia Oral anti-histamine Antibiotics if patient toxic Obtain outpatient referral for review
  26. 26. Chronic Otitis Media (effusion) Oral antibiotics to prevent infection If nasal symptoms present, treat with nasal decongestants Valsalva manouvre
  27. 27. Chronic Otitis Media (effusion) Need to exclude NPC If persist for more than 2 months, may need myringotomy and ventilation tube insertion Can be managed in ENT outpatient clinic
  28. 28. Chronic Suppurative Otitis Media (CSOM) Aural toilet Topical ± oral antiobiotics Keep ears dry Elective Myringoplasty if perforation does not heal Can be managed in ENT outpatient clinic
  29. 29. Sudden Sensorineural Hearing Loss Loss of hearing of > 30 dB over 3 days, over at least 3 frequencies Sudden onset of hearing loss Normal ear examination Diagnose SNHL with tuning fork tests or puretone audiogram
  30. 30. Sudden Sensorineural Hearing Loss Refer to next ENT outpatient clinic Cover with oral prednisolone 1mg/kg if no contraindication Acyclovir 800mg 5x/day for 5 days, if onset within 1 week
  31. 31. Sudden Sensorineural Hearing Loss Causes  Idiopathic – 85%  Meniere’s disease  Acoustic Neuroma  Cerebellar-pointine angle tumours  Ototoxicity  Noise-induced  Trauma  Viral infection  Vascular - impairment of cochlear blood supply  Syphillis  Immunological disorders
  32. 32. FB - Ear Crocodile forceps- cotton,paper,foam , sponge Blunt hook – round objects Suction – fluid
  33. 33. FB - Ear Syringing – C/I organic material Insects Killed by alcohol/lignocaine/olive oil Removed Can be managed in ENT outpatient clinic
  34. 34. Perichondritis
  35. 35. Perichondritis Admission for i.v. antibiotics Risk of cauliflower ear deformity
  36. 36. Pseudocyst of the Pinna
  37. 37. Pseudocyst of the Pinna TCU next ENT outpatient clinic Elective excision of pseudocyst Do not aspirate Do not perform I & D
  38. 38. Giddiness ≠ ENT Referral Always exclude central causes first Peripheral causes not life-threatening
  39. 39. Head & Neck Infections Acute Tonsillitis Peritonsillar Abscess (Quinsy) Sinusitis Epiglottitis Deep Neck Infection
  40. 40. Acute Tonsillitis Sorethroat, Fever, Odynophagia Bilateral tonsils - enlarged, injected, swollen, purulent exudates Diptheria, Infectious Mononucleosis
  41. 41. Acute Tonsillitis Treatment : antibiotic, gargles, lozenges, analgesia, anti-pyretic Antibiotics of choice: Penicillin Augmentin Clindamycin Erythromycin
  42. 42. Acute Tonsillitis – Admission Criteria Inadequate oral intake of fluids/food Signs of peritonsillar abscess (quinsy)
  43. 43. Peritonsillar Abscess Quinsy Trismus Unilateral Swollen soft palate, uvula displaced Treatment : Aspiration Incision and drainage
  44. 44. Sinusitis Symptoms : Purulent nasal discharge nasal congestion Facial pain Headache
  45. 45. Sinusitis - Diagnosis Clinical History Sinus X-ray - not reliable, not necessary Mucopus seen on nasal endoscopy
  46. 46. Sinusitis - Treatment Goal : Relieve obstruction of the sinus ostia Nasal decongestant (oxymetazoline nose drop) Systemic decongestant (pseudoephedrine) Antibiotic (at least 10 days)
  47. 47. Sinusitis - Treatment Nasal douche Hypertonic saline Sodium bicarbonate Functional Endoscopic Sinus Surgery (FESS) Failed medical treatment for chronic cases
  48. 48. Sinusitis – Admission Criteria Complicated sinusitis Orbital cellulitis/abscess Intracranial abscess
  49. 49. Epiglottitis Adult and Children Organism - S. pneumoniae, H.Influenze, Beta- Haemolytic strep
  50. 50. Epiglottitis Severe sore throat, odynophagia, high fever Muffled voice, Difficulty in breathing Sit erect and bend forward Salivating
  51. 51. Epiglottitis Indirect Laryngoscopy Flexible Fiberoptic nasopharyngoscope Lateral neck X-ray - thumb sign
  52. 52. Normal epiglottis
  53. 53. Swollen epiglottis
  54. 54. Epiglottitis - Treatment Airway management Monitor Closely Intubation, Cricothyroidectomy, Tracheostomy Oxygen Antibiotic Epinephrine, steroids
  55. 55. Deep Neck Infection Neck swelling Sore throat, odynophagia, trismus Immunocompromised Fever, unwell Lateral neck XR Airway control Admission for CT, KIV I&D
  56. 56. Deep Neck Infection •Normal retropharyngeal space on lateral neck XR is up to 1 vertebral body width from C5 and below. Widened retropharyngeal space on lateral neck XR •Up to half a vertebral body width from C1 to C4 is normal
  57. 57. FB - Throat History Localised Below post-cricoid region - midline Mouth/ oropharynx – localised to side Time of ingestion
  58. 58. FB - Throat History High risk Sensory deprivation eg dentures (adults ) Otalgia, neck tenderness, fever, chest or back pain, haemetamesis
  59. 59. FB - Throat Examination Distress Unable to swallow saliva Tracheal rock positive Swallow test positive
  60. 60. Common Sites of impaction of FB Tonsils Base of tongue Vallecula Pyriform fossa Cricopharynx Oesophagus
  61. 61. Common Sites of impaction of FB Tonsils Base of tongue Vallecula Pyriform fossa Cricopharynx Oesophagus
  62. 62. Common Sites of impaction of FB Tonsils Base of tongue Vallecula Pyriform fossa Cricopharynx Oesophagus
  63. 63. Equipment Head mirror/ head light Tongue depressor Laryngeal mirror Forceps Direct laryngoscopy* Flexible Nasopharyngoscope*
  64. 64. Tongue depressors to allow examination of tonsils
  65. 65. Dental mirrors to allow examination of base of tongue and hypopharynx
  66. 66. For removal of FB in pharynx
  67. 67. Nagashima forceps: For removal of FB from base of tongue, vallecula and hypopharynx
  68. 68. FB Throat - Investigations Lateral neck XR CXR Barium swallow CT scan – without contrast Rigid oesophagoscopy
  69. 69. FB
  70. 70. FB
  71. 71. Hyoid bone Thyroid cartilage Cricoid cartilage FB Osteophyte
  72. 72. FB
  73. 73. FB
  74. 74. FB
  75. 75. FB
  76. 76. FB
  77. 77. FB Throat >50% of ingested FB cannot be found! Discharge with symptomatic treatment Cover with antibiotics if diabetic patient or immunocompromised FB advice Chest pain, fever, increasing symptoms
  78. 78. FB Throat Can be seen in next ENT clinic if: No FB found on detailed examination No chest pain Symptoms mild

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