This document provides an overview of common acute ENT conditions that may be encountered in a casualty setting. It discusses tonsillitis, epistaxis, rhinitis, sinusitis, laryngeal cancer risk factors, angioedema, and foreign body obstruction of the esophagus and airway. Management strategies are outlined for each condition. It emphasizes the importance of early discussion with ENT specialists for any cases involving airway obstruction or stridor. Surgical cricothyroidotomy and tracheotomy are described as emergency procedures to secure the airway if needed.

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