Common ENT emergencies include foreign bodies, trauma, and complications of infections in the ear, nose, and throat. Foreign bodies in the ear can cause discomfort and infection if not removed. Epistaxis (nosebleeds) may be caused by trauma, dry air, or medical issues and are typically managed first by applying pressure and then treatments like cauterization if needed. Infections of the sinuses can lead to orbital or intracranial complications requiring intravenous antibiotics or surgery. Deep neck infections like peritonsillar abscesses or Ludwig's angina require needle aspiration, drainage, or tracheostomy. Airway obstruction emergencies are treated by securing the airway through maneuvers like Heimlich

1. COMMON ENT EMERGENCIES Thongchai Luxameechanporn ENT department Ramathibodi hospital

2. Common ENT emergencies Foreign bodies Trauma Complications of ENT infections

3. ear

4. Foreign bodies Insects Cotton, paper, organic material Small batteries Discomfort & agitation Secondary complications: infection & mucosal erosion

5. Foreign bodies Kill any live insects Remove foreign body with micro alligator forceps Irrigation ( do not use if organic FB )

6. Auricular Hematoma Usually from trauma Fluctuant bluish swelling of auricle Drainage - Needle aspiration - I & D Apply compression dressing

7. Traumatic TM Perforation Compression, instrumentation & blast injuries Hearing test Close observation if perforation is small Paper patch Surgery

8. Temporal bone fracture Blunt head injury Longitudinal Fx -> facial n. paralysis, CHL (ossicular chain disruption) Transverse Fx -> SNHL, dysequilibrium, CN VII palsy

9. Temporal bone fracture Battle’s sign (bluish discoloration of postauricular region), raccoon eyes, hemotympanum, hearing loss, dizziness, CSF otorrhea, CN VII palsy CT temporal bone

10. Acoustic trauma Sudden exposure (impact or blast) to noise SHNL, tinnitus Avoidance/ ear protection Corticosteroids, carbogen, vasodilators, diuretics, anticoagulants, plasma expanders

11. Otitic Barotrauma Inability to ventilate middle ear -> abnormal dysfunction of ET Occur in rising ambient pressure (descent in flight / scuba diving) Can produce hemotympanum

12. Barotrauma Repeated Valsalva maneuver Topical nasal decongestants Myringotomy & PE tube insertion may be needed

13. Sudden Hearing Loss SNHL ≥ 30 dB over 3 contiguous frequencies within 3 days or less Etiology : Viral & Infectious, Vascular, Trauma, Autoimmune, Neurologic

14. Complications of ME infections Extracranial

15. Acute Mastoiditis preceded by AOM young children severe pain, fever, edema over mastoid area intravenous ATB Myringotomy ± PE tube

16. Subperiosteal Abscess pinna pushed down & outward intravenous ATB I&D mastoidectomy

17. Complications of ME infections Intracranial

18. nose

19. Foreign bodies: Symptoms Purulent unilateral nasal discharge Usually lodge on the floor of anterior or middle third

20. Foreign bodies: Management Good visualization: headlamp & nasal speculum Alligator forceps should be used to remove cloth, cotton, or paper Other hard FB are more easily grasped using bayonet forceps or Kelly clamps, or they may be rolled out by getting behind it using an ear curette, single skin hook, or right angle ear hook

21. Nasal Fracture Hx of fall or force directed to midface Deformity of nose Swelling, ecchymosis, epistaxis Close or open reduction

22. Septal hematoma/abscess Trauma, surgery Soft, fluctuant swelling of septum Needle a spiration or I&D Bilateral nasal packing for several days Prophylactic antibiotics

23. Septal hematoma/abscess

24. Epistaxis Local Trauma /Nose picking or blowing / surgery Dry air / Irritants Topical medications (steroids) Foreign body Tumor / polyp Systemic Blood diseases Hereditary hemorrhagic telangiectasia Drugs (anticoagulants) Hypertension

25. Epistaxis

26. Epistaxis Initial first-aid Assessment of blood loss Evaluation of cause Procedure to stop bleeding Most common -> Kiesselbach’s Plexus Squeeze nose 5-20 mins Insert cotton pledget (with decongestant) Cautery with silver nitrate

27. Pope, L E R et al. Postgrad Med J 2005;81:309-314 Figure 1 Epistaxis management protocol.

28. Epistaxis

29. Anterior nasal packing Local anesthetic & decongestant Nasal packing - Vasaline guaze - Absorbable gelfoam - Oxidized cellulose (Surgicel) - Nasal tampon

30. Anterior nasal packing

31. Anterior nasal packing Nasal packing - Vasaline guaze - Absorbable gelfoam - Oxidized cellulose (Surgicel) - Nasal tampon

32. Anterior nasal packing Nasal packing - Vasaline guaze - Absorbable gelfoam - Oxidized cellulose (Surgicel) - Nasal tampon

33. Anterior nasal packing Nasal packing - Vasaline guaze - Absorbable gelfoam - Oxidized cellulose (Surgicel) - Nasal tampon

34. Copyright ©2005 BMJ Publishing Group Ltd. Pope, L E R et al. Postgrad Med J 2005;81:309-314 Figure 2 Correct insertion of a nasal tampon (note that the direction is along the floor of the nasal cavity).

35. Posterior nasal packing Topical anesthetic & decongestant Posterior nasal packing Double balloon device Foley catheter

36. Posterior nasal packing Topical anesthetic & decongestant Posterior nasal packing Double balloon device Foley catheter

37. Posterior nasal packing Topical anesthetic & decongestant Posterior nasal packing Double balloon device Foley catheter

38. Complications of sinusitis Orbital complications Intracranial complications

39. Classification of orbital inflammation Stage I II III IV V Inflammation Inflammatory edema (periorbital cellulitis) Orbital cellulitis Subperiosteal abscess Orbital abscess Cavernous sinus thrombosis

40. Complications of sinusitis Periorbital cellulitis: periorbital erythema, edema, pain & fever Purulent nasal discharge S.pneumoniae, S.aureus, coagulase-negative staphylococci Broad-speculum antibiotics

41. Complications of sinusitis Orbital complications (stages II-V) Periorbital swelling & pain, fever Proptosis, chemosis, restriction of ocular movement & visual disturbance

42. Complications of sinusitis CT scan -> subperiosteal & orbital abscess Admission & IV broad- spectrum antibiotics Surgery (drainage) if - failed medication - develop abscess - visual drop

43. Complications of sinusitis Intracranial complications Cavernous sinus thrombosis, meningitis, extradural abscess, intracranial abscess & subdural empyema Purulent rhinorrhea, fever, frontal/retro-orbital headache Personality change/lethargy, seizures, N/V, focal neurological deficits

44. Complications of sinusitis Intracranial complications Diagnosis -> MRI scan with gadolinium Admission, IV broad-spectrum antibiotics & surgical drainage

45. throat

46. Swallowed foreign body Peanuts, coins, batteries, fish bone, meat & bone pieces, dentures Location of pain indicates FB location

47. Swallowed foreign body Fish bones tend to lodge in oropharynx, produced ipsilateral symptoms Esophagus FB localize in midline: dramatic acute dysphagia

48. Swallowed Foreign bodies Most FB in oropharynx can be identified Esophageal FB: pooling of saliva in piriform X-rays may be helpful in radio-paque objects

49. Swallowed Foreign bodies Visualized FB can be removed with angled forceps Sharp FB should be removed at the earliest opportunity due to risk of perforation

50. Swallowed Foreign bodies Coins -> removed if in cervical or mid esophagus -> removed within 12 hrs if in distal esophagus Batteries -> removed emergency

51. Swallowed Foreign bodies Airway compromise - Heimlich maneuver - Emergency cricothyrotomy/ tracheostomy Endoscopy with removal in OR

52. Inhaled Foreign bodies Sudden onset of coughing, wheezing or stridor in previously healthy child Unilateral wheezing, poor chest movement & reduced breath sound CXR: hyperinflate, infection, collapse

53. Inhaled Foreign bodies Heimlich manuver Secure airway Endoscopic removal under general anesthesia

54. Airway Obstruction Neonatal : Congenital tumors, cysts, webs : Laryngomalacia : Subglottic stenosis Children : Laryngotracheobronchitis : Supraglottitis (epiglottitis) : Foreign body : Retropharyngeal abscess : Respiratory papilloma Adults : Laryngeal cancer : Laryngeal trauma : Epiglottis & deep neck infection

55. Deep neck infections

56. Peritonsillar abscess Pus forms between tonsils capsule & superior constrictor Group A Streptococcus

57. Peritonsillar abscess Severe, unilateral sore throat fever Hot potato voice Uvula deviates to opposite side Swollen tonsils

58. Peritonsillar abscess CBC, throat C/S Antibiotics - Oral - Parenteral needle aspiration or I&D

59. Ludwig’s Angina Rapid swelling cellulitis of sublingual & submaxillary spaces Dental infection, floor of mouth, salivary gland Fever, edema & erythema of neck under chin & floor of mouth

60. Ludwig’s Angina Open mouth, Tongue -> upward & backward -> airway obstruction Streptococci, Bacteroides, S.aerues Tracheostomy IV antibiotic I&D, tooth extraction

61. Epiglottitis Age 3-7 yrs old H. influenzae type B, Group A Streptococcus severe sore throat & fever, dysphagia, drooling Stridor Breathing with raised chin & open mouth

62. Epiglottitis CBC: leukocytosis Film lateral neck -> thumb shaped epiglottis Avoid tongue depressor Controlled intubation Intravenous ATB

63. Retropharyngeal Abscess Infants & children Secondary to oropharyngeal infection Severe dysphagia & respiratory distress airway observation IV antibiotic Surgical drainage ( prevent pus aspiration)

64. Tracheostomy Emergency tracheostomy in the case of upper airways obstruction 1. Tumor in the larynx 2. Trauma of the larynx 3. Bilateral vocal cord paralysis 4. F.B. in the larynx after failure of Heimlich’s manuver