This document provides information on various ear, nose, throat and head and neck conditions commonly seen in emergency departments. It discusses the presentation, investigations, management and criteria for admission of nasal fractures, epistaxis, post-tonsillectomy bleeding, ear emergencies, head and neck infections, and ingested foreign bodies. Procedures for examining and removing foreign bodies from the throat are also outlined. The document serves as a guide for evaluating and treating ENT emergencies.

2. Topics:
Nasal Fracture
Haemorrhage - Epistaxis, Post-op Bleed
Ear Emergencies
Head & Neck Infections
Ingested Foreign Body

4. 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

5. 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

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

7. 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

9. A. Epistaxis
Local causes
Idiopathic (90%)
Traumatic ( fracture, foreign body, nose picking )
Infection
Inflammatory ( rhinitits, sinusitis )
Tumour ( rare )
Iatrogenic (Nasal Surgery)

10. Epistaxis
General causes
Coagulopathy (Dengue, anticoagulant)
Hypertension
Hereditary Haemorrhagic telangiectasia
Raised venous pressure (whooping cough,
pneumonia)

11. Epistaxis
Majority are self limiting, esp. in children
90% bleed from Kiesselbach’s plexus (Little’s area)

12. 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 )

13. 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

14. Epistaxis - Management
Assess blood loss
Resuscitation, i.v. access
Base line blood investigation
GXM
Medication - sedative or anti-hypertensive

15. Epistaxis - Management
Treat underlying cause
Reverse coagulopathy
Control hypertension
Allergic rhinitis
Sinusitis
Nasal hygiene
Haemostasis

16. Epistaxis - Haemostasis
1) Cautery
Silver Nitrate
Electrocautery
2) Anterior Nasal Pack
No clear bleeding point or Failed
cautery
BIPP or Merocel
Antibiotic cover

17. Epistaxis – Admission Criteria
Uncontrolled bleeding
Nasal packing done
Post-operative cases
Haemodynamically unstable
Poor premorbid conditions
Severe bleeds

18. B. Post-Tonsillectomy bleed
Resuscitation! & i.v. access
Assess for symptoms/signs of shock
Baseline blood including coagulation profile
GXM
NBM

19. Post-Tonsillectomy bleed
Management
First aid measures, e.g. ice gargle
Pressure (adrenaline gauze)
Silver nitrate
Electrocautery
Ligation of local bleeder

20. 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.

21. Admission Criteria
All post-operative haemorrhage should be admitted
If bleeding stopped, offer admission for observation

23. 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

24. 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

25. Impacted Ear Wax
Prescribe wax softeners (e.g. olive oil ear drops)
Obtain outpatient referral for review

26. 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

27. Otitis Externa
Treatment :
Aural toilet
Topical antibiotic ± steroid ear drops
Oral antibiotic for severe cases
Obtain outpatient referral for review

28. Acute Otitis Media
Common in children
Fever, ear- pain
TM - red & bulging
Otitis media can only be diagnosed if the TM is
visualised!

29. Acute Otitis Media
Treatment
Topical nasal decongestant
Analgesia
Oral anti-histamine
Antibiotics if patient toxic
Obtain outpatient referral for review

30. Chronic Otitis Media (effusion)
Oral antibiotics to prevent infection
If nasal symptoms present, treat with nasal
decongestants
Valsalva manouvre

31. 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

32. 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

33. 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

34. 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

35. 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

36. FB - Ear
Crocodile forceps-
cotton,paper,foam ,
sponge
Blunt hook – round
objects
Suction – fluid

37. FB - Ear
Syringing – C/I organic material
Insects
Killed by alcohol/lignocaine/olive oil
Removed
Can be managed in ENT outpatient clinic

38. Perichondritis

39. Perichondritis
Admission for i.v. antibiotics
Risk of cauliflower ear deformity

40. Pseudocyst of the Pinna

41. Pseudocyst of the Pinna
TCU next ENT outpatient clinic
Elective excision of pseudocyst
Do not aspirate
Do not perform I & D

42. Giddiness
≠
ENT Referral
Always exclude central causes first
Peripheral causes not life-threatening

44. Head & Neck Infections
Acute Tonsillitis
Peritonsillar Abscess (Quinsy)
Sinusitis
Epiglottitis
Deep Neck Infection

45. Acute Tonsillitis
Sorethroat, Fever, Odynophagia
Bilateral tonsils - enlarged, injected, swollen,
purulent exudates
Diptheria, Infectious Mononucleosis

46. Acute Tonsillitis
Treatment : antibiotic, gargles, lozenges, analgesia,
anti-pyretic
Antibiotics of choice:
Penicillin
Augmentin
Clindamycin
Erythromycin

47. Acute Tonsillitis – Admission Criteria
Inadequate oral intake of fluids/food
Signs of peritonsillar abscess (quinsy)

48. Peritonsillar Abscess
Quinsy
Trismus
Unilateral
Swollen soft palate, uvula displaced
Treatment :
Aspiration
Incision and drainage

49. Sinusitis
Symptoms :
Purulent nasal discharge
nasal congestion
Facial pain
Headache

50. Sinusitis - Diagnosis
Clinical
History
Sinus X-ray - not reliable, not necessary
Mucopus seen on nasal endoscopy

51. Sinusitis - Treatment
Goal : Relieve obstruction of the sinus ostia
Nasal decongestant (oxymetazoline nose drop)
Systemic decongestant (pseudoephedrine)
Antibiotic (at least 10 days)

52. Sinusitis - Treatment
Nasal douche
Hypertonic saline
Sodium bicarbonate
Functional Endoscopic Sinus Surgery (FESS)
Failed medical treatment for chronic cases

53. Sinusitis – Admission Criteria
Complicated sinusitis
Orbital cellulitis/abscess
Intracranial abscess

54. Epiglottitis
Adult and Children
Organism - S. pneumoniae, H.Influenze, Beta-
Haemolytic strep

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

56. Epiglottitis
Indirect Laryngoscopy
Flexible Fiberoptic nasopharyngoscope
Lateral neck X-ray - thumb sign

57. Normal
epiglottis

58. Swollen
epiglottis

59. Epiglottitis - Treatment
Airway management
Monitor Closely
Intubation, Cricothyroidectomy, Tracheostomy
Oxygen
Antibiotic
Epinephrine, steroids

60. Deep Neck Infection
Neck swelling
Sore throat, odynophagia, trismus
Immunocompromised
Fever, unwell
Lateral neck XR
Airway control
Admission for CT, KIV I&D

61. 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

63. FB - Throat
History
Localised
Below post-cricoid region - midline
Mouth/ oropharynx – localised to side
Time of ingestion

64. FB - Throat
History
High risk
Sensory deprivation eg dentures (adults )
Otalgia, neck tenderness, fever, chest or back pain,
haemetamesis

65. FB - Throat
Examination
Distress
Unable to swallow saliva
Tracheal rock positive
Swallow test positive

66. Common Sites of impaction of FB
Tonsils
Base of tongue
Vallecula
Pyriform fossa
Cricopharynx
Oesophagus

67. Common Sites of impaction of FB
Tonsils
Base of tongue
Vallecula
Pyriform fossa
Cricopharynx
Oesophagus

68. Common Sites of impaction of FB
Tonsils
Base of tongue
Vallecula
Pyriform fossa
Cricopharynx
Oesophagus

69. Equipment
Head mirror/ head light
Tongue depressor
Laryngeal mirror
Forceps
Direct laryngoscopy*
Flexible Nasopharyngoscope*

70. Tongue depressors
to allow
examination of
tonsils

72. Dental mirrors to
allow examination
of base of tongue
and hypopharynx

74. For removal of FB in
pharynx

75. Nagashima forceps:
For removal of FB from base of
tongue, vallecula and hypopharynx

76. FB Throat - Investigations
Lateral neck XR
CXR
Barium swallow
CT scan – without contrast
Rigid oesophagoscopy

77. FB

78. FB

79. Hyoid bone
Thyroid cartilage
Cricoid cartilage
FB
Osteophyte

80. FB

81. FB

82. FB

83. FB

84. FB

85. 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

86. FB Throat
Can be seen in next ENT clinic if:
No FB found on detailed examination
No chest pain
Symptoms mild