Ent gp emergencies (edited)


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Management of ENT Emergencies

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  • Stem cells are “non-specialized” cells that have the potential to form into other types of specific cells, such as blood, muscles or nerves. They are unlike 'differentiated' cells which have already become whatever organ or structure they are in the body. Stem cells are present throughout our body, but more abundant in a fetus.
    Medical researchers and scientists believe that stem cell therapy will, in the near future, advance medicine dramatically and change the course of disease treatment. This is because stem cells have the ability to grow into any kind of cell and, if transplanted into the body, will relocate to the damaged tissue, replacing it. For example, neural cells in the spinal cord, brain, optic nerves, or other parts of the central nervous system that have been injured can be replaced by injected stem cells. Various stem cell therapies are already practiced, a popular one being bone marrow transplants that are used to treat leukemia. In theory and in fact, lifeless cells anywhere in the body, no matter what the cause of the disease or injury, can be replaced with vigorous new cells because of the remarkable plasticity of stem cells. Biomed companies predict that with all of the research activity in stem cell therapy currently being directed toward the technology, a wider range of disease types including cancer, diabetes, spinal cord injury, and even multiple sclerosis will be effectively treated in the future. Recently announced trials are now underway to study both safety and efficacy of autologous stem cell transplantation in MS patients because of promising early results from previous trials.
    Research into stem cells grew out of the findings of two Canadian researchers, Dr’s James Till and Ernest McCulloch at the University of Toronto in 1961. They were the first to publish their experimental results into the existence of stem cells in a scientific journal. Till and McCulloch documented the way in which embryonic stem cells differentiate themselves to become mature cell tissue. Their discovery opened the door for others to develop the first medical use of stem cells in bone marrow transplantation for leukemia. Over the next 50 years their early work has led to our current state of medical practice where modern science believes that new treatments for chronic diseases including MS, diabetes, spinal cord injuries and many more disease conditions are just around the corner. For more information please visit http://www.neurosurgeonindia.org/
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Ent gp emergencies (edited)

  1. 1. Management of ENT Emergencies Simon Lloyd Consultant ENT Surgeon Central Manchester NHS Foundation Trust
  2. 2. Facial palsy
  3. 3. Anatomy <ul><li>Sensory </li></ul><ul><ul><li>Taste </li></ul></ul><ul><ul><li>Posterior ear canal </li></ul></ul><ul><li>Autonomic </li></ul><ul><ul><li>Parasympathetic to: </li></ul></ul><ul><ul><ul><li>Lacrimal gland </li></ul></ul></ul><ul><ul><ul><li>Submandibular gland </li></ul></ul></ul><ul><ul><ul><li>Sublingual gland </li></ul></ul></ul><ul><li>Motor </li></ul><ul><ul><li>Facial expression </li></ul></ul><ul><ul><li>Stapedius </li></ul></ul><ul><ul><li>Posterior belly of digastric </li></ul></ul>
  4. 4. Aetiology <ul><li>Huge differential </li></ul><ul><li>Congenital </li></ul><ul><ul><li>Neurological eg. Moebius syndrome </li></ul></ul><ul><ul><li>Traumatic eg. Forceps </li></ul></ul><ul><li>Acquired </li></ul><ul><ul><li>Idiopathic eg. Bell’s palsy </li></ul></ul><ul><ul><li>Traumatic eg. Temporal bone fracture </li></ul></ul><ul><ul><li>Iatrogenic eg. Surgery </li></ul></ul><ul><ul><li>Infection eg. Acute otitis media, malignant otitis media, Ramsey Hunt syndrome </li></ul></ul><ul><ul><li>Neoplastic eg. Parotid malignancy </li></ul></ul>
  5. 5. Examination <ul><li>Facial nerve grading (House Brackmann) </li></ul><ul><li>Other cranial nerves </li></ul><ul><li>Tympanic membrane/pinna for vesicles </li></ul><ul><li>Parotid/mouth </li></ul>
  6. 6. Assessment <ul><li>House Brackmann Grading (I to VI) </li></ul><ul><ul><ul><li>I = Normal </li></ul></ul></ul><ul><ul><ul><li>II = Normal at rest, mild weakness on active movement </li></ul></ul></ul><ul><ul><ul><li>III= Good eye closure </li></ul></ul></ul><ul><ul><ul><li>V = Some tone </li></ul></ul></ul><ul><ul><ul><li>VI= No movement </li></ul></ul></ul>Eyes open Eyes closed
  7. 7. Facial Palsy <ul><li>52 year old lady </li></ul><ul><li>Rapid onset left facial weakness </li></ul><ul><li>Left facial numbness </li></ul><ul><li>No ear symptoms </li></ul><ul><li>Otherwise fit and well </li></ul><ul><li>Grade III weakness </li></ul><ul><li>No other abnormalities </li></ul>
  8. 8. Bell’s Palsy <ul><li>Idiopathic (probably viral – Herpes simplex) </li></ul><ul><li>Acute unilateral facial palsy (peripheral) </li></ul><ul><li>Occasionally other cranial nerve palsies eg. Trigeminal </li></ul><ul><li>Resolves within 3 months in 80% of cases </li></ul><ul><li>10% recur (including contralateral) </li></ul><ul><li>Higher incidence in diabetes </li></ul><ul><li>Treatment </li></ul><ul><ul><ul><li>Eye Care (lubrication) </li></ul></ul></ul><ul><ul><ul><li>Oral steroids </li></ul></ul></ul><ul><ul><ul><li>No evidence for benefit from antivirals </li></ul></ul></ul><ul><ul><ul><ul><li>Sullivan et al. New England Journal of Medicine 2007 </li></ul></ul></ul></ul>
  9. 9. Who to refer <ul><li>Additional findings (Cr. Nerves, lumps) </li></ul><ul><li>No improvement at 3 weeks </li></ul><ul><li>Incomplete recovery </li></ul><ul><li>Concerns </li></ul>
  10. 10. Sudden Hearing Loss <ul><li>Normal TM with sudden hearing loss </li></ul><ul><li>Aetiology unknown </li></ul><ul><ul><li>Viral </li></ul></ul><ul><ul><li>Vascular </li></ul></ul><ul><li>Rarely acoustic neuroma, perilymph leak </li></ul><ul><li>May be unsteady or vertiginous </li></ul>
  11. 11. Sudden Hearing Loss Management <ul><li>Refer urgently </li></ul><ul><li>Treatment options </li></ul><ul><ul><li>Oral steroid </li></ul></ul><ul><ul><li>Antiviral </li></ul></ul><ul><ul><ul><li>No evidence for efficacy </li></ul></ul></ul><ul><ul><li>Carbogen </li></ul></ul><ul><ul><ul><li>No evidence for efficacy </li></ul></ul></ul><ul><ul><li>Intratympanic steroid </li></ul></ul><ul><ul><ul><li>Weak evidence for efficacy </li></ul></ul></ul>
  12. 12. Allergic response to BIPP
  13. 13. Acute Otalgia with normal TM
  14. 14. Complications of Otitis Media <ul><li>Mastoiditis </li></ul><ul><li>Facial palsy </li></ul><ul><li>Labyrinthitis </li></ul><ul><li>Meningitis </li></ul><ul><li>Intracranial abscess </li></ul><ul><li>Lateral sinus thrombosis </li></ul><ul><ul><li>Long term </li></ul></ul><ul><ul><ul><li>Tympanosclerosis </li></ul></ul></ul><ul><ul><ul><li>Tympanic membrane perforation </li></ul></ul></ul><ul><ul><ul><li>Ossicular damage </li></ul></ul></ul>
  15. 15. Acute Mastoiditis <ul><li>History of acute otitis media </li></ul><ul><li>Infection spreads to mastoid </li></ul><ul><li>Post-auricular abscess </li></ul><ul><li>Treatment </li></ul><ul><ul><li>Grommet </li></ul></ul><ul><ul><li>Cortical mastoidectomy </li></ul></ul>
  16. 16. Complications acute otitis media mastoiditis
  17. 17. Intracerebral Abscess <ul><li>Diagnosis </li></ul><ul><ul><li>High index of suspicion </li></ul></ul><ul><ul><li>Headache </li></ul></ul><ul><ul><li>Reduced conscious level </li></ul></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Seizures </li></ul></ul><ul><li>Requires drainage </li></ul>Ring enhancement with contract enhanced CT
  18. 18. Lateral Sinus Thrombosis <ul><li>Diagnosis </li></ul><ul><ul><li>High index of suspicion </li></ul></ul><ul><ul><li>Headache </li></ul></ul><ul><ul><li>Decreased conscious level </li></ul></ul><ul><ul><li>Ataxia </li></ul></ul><ul><ul><li>Seizures </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>Anticoagulation </li></ul></ul><ul><ul><li>?thrombectomy </li></ul></ul>Filling defect on MRA
  19. 19. Epistaxis
  20. 20. Anatomy
  21. 21. Aetiology <ul><li>Usually idiopathic </li></ul><ul><ul><li>? atherosclerotic vessels </li></ul></ul><ul><ul><li>Predisposing factors </li></ul></ul><ul><ul><ul><li>Anticoagulants </li></ul></ul></ul><ul><ul><ul><li>Hypertension </li></ul></ul></ul><ul><li>Trauma eg. Digital, fractured nose </li></ul><ul><li>Nasal vestibulitis eg. Staphlococcal </li></ul><ul><li>Topical treatment eg. Nasal steroids </li></ul><ul><li>Rare </li></ul><ul><ul><li>HHT </li></ul></ul><ul><ul><li>Neoplasia </li></ul></ul><ul><ul><li>Septal perforation </li></ul></ul>
  22. 22. Epistaxis First Aid <ul><li>Conservative Management </li></ul><ul><ul><li>Pinch soft part of nose </li></ul></ul><ul><ul><li>Lean forward and breathe through mouth </li></ul></ul><ul><ul><li>Ten minutes </li></ul></ul><ul><li>Protect yourself </li></ul><ul><ul><li>Gown </li></ul></ul><ul><ul><li>Gloves </li></ul></ul><ul><ul><li>Mask </li></ul></ul>
  23. 23. Treatment <ul><li>Identifiable Vessel </li></ul><ul><ul><li>Nasal cautery </li></ul></ul><ul><ul><ul><li>Examine nose </li></ul></ul></ul><ul><ul><ul><li>Identify vessel </li></ul></ul></ul><ul><ul><ul><li>Apply 1 in 10,000 adrenaline and 1%lignocaine on cotton wool pledget </li></ul></ul></ul><ul><ul><ul><li>Silver nitrate cautery of vessel </li></ul></ul></ul>
  24. 24. Silver nitrate cautery
  25. 25. Treatment <ul><li>No Identifiable Vessel </li></ul><ul><ul><li>Nasal packing </li></ul></ul><ul><ul><ul><li>Merocel </li></ul></ul></ul><ul><ul><ul><li>Rapidrhino </li></ul></ul></ul><ul><ul><ul><li>BIPP packing </li></ul></ul></ul>
  26. 26. Rapid Rhino
  27. 27. BIPP Packing
  28. 28. Treatment <ul><li>Ongoing bleeding </li></ul><ul><ul><li>Re-check vital signs </li></ul></ul><ul><ul><li>IV access +/- fluids </li></ul></ul><ul><ul><li>Check clotting </li></ul></ul><ul><ul><li>Posterior packing </li></ul></ul><ul><ul><ul><li>Brighton baloon </li></ul></ul></ul><ul><ul><ul><li>Foley catheter and BIPP pack </li></ul></ul></ul>
  29. 29. Surgical Intervention <ul><li>Septoplasty </li></ul><ul><li>Sphenopalatine artery ligation </li></ul><ul><li>Anterior ethmoid artery ligation </li></ul><ul><li>Maxillary artery ligation </li></ul><ul><li>External carotid artery ligation </li></ul>
  30. 30. Management Algorithm
  31. 31. Nasal Vestibulitis <ul><li>Paediatric </li></ul><ul><li>Digital trauma </li></ul><ul><li>Cautery vs Naseptin </li></ul><ul><ul><li>Equal efficacy </li></ul></ul><ul><ul><li>Bactroban tastes horrible ? Prevents digital trauma </li></ul></ul>
  32. 32. Fractured nose
  33. 33. Fractured nose <ul><li>Ask about </li></ul><ul><li>Epistaxis </li></ul><ul><li>CSF </li></ul><ul><li>Diplopia on upward gaze </li></ul><ul><li>Infraorbital parasthesia </li></ul><ul><li>Shape change </li></ul><ul><li>Nasal obstruction </li></ul>
  34. 34. Fractured nose <ul><li>Examination </li></ul><ul><li>Nasal bones crepitus, shape </li></ul><ul><li>Infraorbital parasthesia </li></ul><ul><li>Orbital rims </li></ul><ul><li>Septum for haematoma </li></ul><ul><li>No need for X ray unless medicolegal </li></ul>
  35. 35. Fractured nose <ul><li>Management </li></ul><ul><li>If no complicating factors and nose straight leave alone. </li></ul><ul><li>If orbital fracture or septal haematoma refer immediately </li></ul><ul><li>If shape change with no complicating factors refer to ENT about five days post injury </li></ul><ul><li>Nose should be reduced within 2 weeks for best chance of good result </li></ul>
  36. 36. Complications of Sinusitis <ul><li>Intracranial complications </li></ul><ul><ul><li>Brain Abscess </li></ul></ul><ul><ul><li>Meningitis </li></ul></ul><ul><li>Orbital complications </li></ul><ul><ul><li>Periorbital cellulitis </li></ul></ul><ul><ul><li>Periorbital abscess </li></ul></ul><ul><ul><li>Orbital abscess </li></ul></ul><ul><ul><li>Pott’s puffy tumour </li></ul></ul>
  37. 37. Periorbital Cellulitis and Abscess <ul><li>Unwell </li></ul><ul><li>Pyrexia </li></ul><ul><li>Eye closes </li></ul><ul><li>Erythema </li></ul><ul><li>Chemosis </li></ul><ul><li>Colour vision goes off first </li></ul><ul><li>Refer urgently </li></ul>
  38. 38. Periorbital Cellulitis Treatment <ul><li>Nose </li></ul><ul><ul><li>Topical decongestants </li></ul></ul><ul><ul><ul><li>Ephidrine </li></ul></ul></ul><ul><ul><ul><li>Otravine </li></ul></ul></ul><ul><li>Systemic </li></ul><ul><ul><li>IV antibiotics </li></ul></ul><ul><li>CT imaging to exclude periorbital abscess </li></ul>
  39. 39. Foreign Bodies <ul><li>Material </li></ul><ul><ul><li>Paper, beads, watch batteries etc. </li></ul></ul><ul><li>Unilateral rhinorrhoea is a foreign body until proved otherwise </li></ul><ul><li>Treatment </li></ul><ul><ul><li>Wrap up child </li></ul></ul><ul><ul><li>Assistant hold head </li></ul></ul><ul><ul><li>Remove </li></ul></ul>
  40. 40. Complications of Tonsillitis Peritonsillar abscess <ul><li>Symptoms </li></ul><ul><li>Pain becomes more unilateral </li></ul><ul><li>Often referred otalgia </li></ul><ul><li>Trismus (therefore difficult to get a good look) </li></ul><ul><li>Drooling </li></ul><ul><li>Systemically unwell with pyrexia </li></ul><ul><li>Normally big tender upper deep cervical node </li></ul><ul><li>Refer </li></ul>
  41. 41. Complications of tonsillitis Peritonsillar abscess (quinsy)
  42. 42. Peritonsillar abscess <ul><li>Treatment </li></ul><ul><li>Incision and drainage (needle/blade) </li></ul><ul><li>Intravenous penicillin and metronidazole </li></ul><ul><li>First quinsy and previous history of tonsillitis… recommend tonsillectomy </li></ul><ul><li>First quinsy with no prior tonsillitis history…verbal warning </li></ul>
  43. 43. Stridor <ul><li>Harsh, high-pitched sound indicative of airway obstruction. </li></ul><ul><li>Inspiratory Supraglottic or Glottic </li></ul><ul><li>Biphasic Subglottic or Extrathoracic Trachea </li></ul><ul><li>Expiratory Intrathoracic Trachea </li></ul><ul><li>NB. Stertor – High upper airway obstruction </li></ul>
  44. 44. Stridor - Assessment <ul><li>What level ?? History – What sort of stridor </li></ul><ul><li>How severe ?? Accessory muscles Tracheal tug / Recession in children Pulse pCO 2 Retention </li></ul><ul><li>Does the airway need securing ?? </li></ul><ul><li>Severe OR patient getting tired. </li></ul>
  45. 45. Causes <ul><li>Children </li></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><ul><li>Bacterial eg. Epiglottitis </li></ul></ul></ul><ul><ul><ul><li>Viral eg. Croup </li></ul></ul></ul><ul><ul><li>Foreign body </li></ul></ul><ul><li>Adults </li></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><ul><li>Supraglottitis </li></ul></ul></ul><ul><ul><li>Neoplasia </li></ul></ul><ul><ul><ul><li>Squamous cell carcinoma </li></ul></ul></ul>
  46. 46. Stridor -management <ul><li>SIT PATIENT UP </li></ul><ul><li>OXYGEN </li></ul><ul><li>RE-HYDRATION (i.v.) </li></ul><ul><li>STEROIDS (Nebulised, i.v. or oral) </li></ul><ul><li>ADRENALINE NEBULISER </li></ul><ul><li>HELIOX – Helium / oxygen mixture </li></ul><ul><li>ANTI-BIOTICS </li></ul><ul><li>AIRWAY INTERVENTION Intubation Bronchoscopy Tracheostomy </li></ul>
  47. 47. <ul><li>“ Croup” vs Epiglottitis </li></ul><ul><li>Croup Epiglottitis </li></ul><ul><li>Age 1-3years 3-6 years </li></ul><ul><li>Duration URTI (days) Short(hours) </li></ul><ul><li>Clinical “Viral” Unwell * </li></ul><ul><li>Stridor Loud Quiet </li></ul><ul><li>* Decreased concious level, circumoral palor, rapid deterioration. </li></ul>
  48. 48. Airway Foreign Bodies <ul><li>RIGHT main bronchus (more vertical) </li></ul><ul><li>May get air trapping, distal to FB. </li></ul><ul><li>Monophonic wheeze (asthma POLYphonic) </li></ul><ul><li>High index of suspicion - REFER </li></ul>
  49. 51. Rigid bronchoscope
  50. 52. Bronchoscope and camera being used to assess the airway in a child with a tracheostomy