ENT Urgencies - EmergenciesIn Primary Care.ppt

1、ENT Urgencies / Emergencies In Primary Care,Reginald F. Baugh, M.D. Professor, Department of Surgery Chief, Division of Otolaryngology,Adult with Airway Obstruction History,Precipitating event Aspiration Trauma reaction Systemic illness Time course Previous intubation or neck trauma,Adult with Airwa

2、y Obstruction Etiology,Traumatic Laryngeal or tracheal fracture Oropharyngeal laceration Edema from injury to head and neck Subglottic stenosis or granulation tissue secondary to intubation Infectious Epiglottitis (more supraglottitis in adults) Peritonsillar abscess Signs & Systems: sore throat, fe

3、ver, “hot potato” voice, drooling, bulging tonsil Treatment: aspiration vs. I & D Quinsy tonsillectomy (non-involved side tends to bleed more than usual) Deep neck abscess Paraphayrngeal space Prevertebral space Submental space Ludwigs angina,Adult with Airway Obstruction Etiology,Mechanical Foreign

4、 body Blood Vomitus Neoplastic Tumors occluding airway Tumors eroding into major vessels with massive blood loss into airway Allergic,Pharyngeal Foreign Bodies,Presentation Sensation of something “sticking” in throat, typically following fish mealDiagnosis Must be differentiated from superficial muc

5、osal abrasion, which presents identically. Soft tissue lateral x-ray rarely helpful. Direct oral and mirror pharyngeal exam. Typical site of fish bone is in base of tongue or tonsil. Fish bone may be mistaken for a strand of saliva.,Pharyngeal Foreign Bodies,Treatment Perform oral removal as out pat

6、ient if object visible and easily accessible. Endoscopy if object visible but not accessible or if no foreign body seen and symptoms persist beyond 4-5 days.,Esophageal Foreign Bodies,Presentation Sensation of something “sticking” after swallowing. This may result in severe dysphagia with inability

7、to swallow even saliva. Diagnosis Fiberoptic exam to rule out pharyngeal foreign body Plain films for radio opaque foreign bodies, such as coins Barium swallow Barium “burger”, marshmallow, or barium soaked pledgets.,Esophageal Foreign Bodies,Treatment Many foreign bodies pass spontaneously, and mil

8、d symptoms may be secondary to local trauma, rather than an actual foreign body. Foreign bodies that fail to pass into the stomach are usually trapped in the cervical portion of the esophagus below the cricopharyngeus muscle. If the foreign body reaches the stomach, it will, in most cases, pass comp

9、letely through the remainder of the gastrointestinal tract. For severe or persistent symptoms, or hazardous objects, rigid esophagoscopy. A meat bolus lodged in the esophagus can sometimes be pushed into the stomach or removed endoscopically, but do not use a meat tenderizer After initial resolution

10、, rule out underlying cause of impaction, such as stricture or tumor.,Sore Throat or Difficulty Swallowing,History Sore throat Duration Associated complaints Fever Neck nodes Oral lesions Hoarseness Systemic infection, immunodeficiency History of smoking or chewing tobacco,Sore Throat or Difficulty

11、Swallowing,History (continued) Difficulty Swallowing above questions plus the following: Type Large bolus to liquids intrinsic or extrinsic obstruction Liquids only neurologic involvement Aspiration or nasal regurgitation Odynophagia Referred otalgia Vomiting History of foreign body or caustic inges

12、tion Weight loss Reflux History of neck or chest surgery,Sore Throat or Difficulty Swallowing,Treatment Correct dehydration, especially important in children Caustic ingestion Do not induce vomiting Do not perform a gastric lavage Do not order a barium swallow Early aggressive endoscopy and assessme

13、nt of devitalized tissue,Epistaxis,Usually located on anterior septum Try 5-10 minutes of pressure. Get hypertension under control Topical epinephrine / Neo-synephrine on pledgets as vasoconstrictor Pull pledgets out and look fast for the bleeding site Suction away blood and cauterize with silver ni

14、trate Try packing nose lightly with Surgicel or gelfoam sponges soaked with topical vasoconstrictor. Avoid packing patients with coagulapathies who will invariably re-bleed when the packing is removed. Vigorous bleeds must be packed. Need good lighting and instruments for an adequate packing. Intran

15、asal balloons (e.g. Epistat, Rhino Rocket) are easier to use but consistently less effective. Persistent bleeding is then treated with posterior and anterior packs Leave packs in three days. Cover with antibiotics to prevent sinusitis If packing fails vessels must be ligated. If the responsible vess

16、el cannot be indentified then both maxillary artery and ethmoid arteries are ligated. Surgery vs interventional radiology,Nasal Blood Supply,Epistaxis Anatomy Vasculature ECA ICA Littles area Woodruffs area,The External Ear,Infection External Otitis (“Swimmers Ear”) Symptoms: pruritus, otalgia varyi

17、ng from sense of fullness to throbbing pain, hearing loss. Signs: Edema and erythema of canal skin, tenderness of tragus, foul-smelling secretions, possible periauricular cellulitis. Treatment: Clean EAC; Topical otic neosporing-polymyxin B (or colistin) hydrocortisone for gram negative bacilli (mos

18、t commonly Pseudomonas aeruginosa) for 10 day; impregnated wick for severe edema; adequate analgesic. Preventive Measures for Recurrent Otitis Externa: Ethyl alcohol drops (70%) or acetic acid nonaqueous solutions (2%) after swimming or bathing. Avoid Q-tips,The External Ear,Otomycosis Symptoms: Itc

19、hing or mild otalgia. Secondary bacterial infection may produce intense pain. Signs: Aspergilla nigrans produces a grayish membrane with hyphae visible under microscope. Erythema of underlying epithelium. Treatment: Clean EAC Topical cresyl acetate or 1% gentian violet and / or boric or acetic acid

20、and alcohol drops.,The External Ear,Necrotizing External Otitis (Malignant External Otitis) Symptoms & Signs: Progressive pain and drainage from the EAC. Granulation tissue often present. Pseudomonas aeruginosa invasion of soft tissue, cartilage and bone. Occasional facial nerve palsy. Treatment: Ra

21、dical surgical debridement with combination semisynthetic penicillin and aminoglycoside for 4-6 weeks. Significant mortality in diabetics who acquire disease.,The External Ear,Perichondritis Symptoms: Pain and warmth of the pinna following trauma or infection. Signs: Erythema, induration, and possib

22、le fluctuance of part or all of the auricle. Treatment: Most common organism: Pseudomonas aeruginosa. Betadine or boric acid wet-to-dry dressings to open wound. If perichondritis progresses to chondritis with abscess, then incision, drainage, and debridement of non-viable cartilage is necessary. Obt

23、ain cultures.,The External Ear,Herpes Zoster Oticus (Ramsey Hunt Syndrome) Symptoms: Otalgia, malaise, headache, possible dizziness. Signs: Vesicular eruption of distal canal and concha. Occasional 7th CN paralysis. Treatment: Analgesics. Middle cranial fossa decompression of facial nerve progressiv

24、e degeneration.,The External Ear,Trauma Hematoma of Auricle Etiology: Blunt trauma results in accumulation of blood between perichondrium and cartilage. Differential Diagnosis: Perichondritis, cellulitis, and relapsing polychondritis. Treatment: Repeated aspiration under sterile conditions and masto

25、id pressure dressings. Complication: Organization and calcification of clot with necrosis of underlying cartilage leads to “cauliflower ear”.,Preauricular Pit,Results from faulty fusion of mesodermal hillocks that form the auricle. Fistula opening located in front of the incisura. Recurrent infectio

26、n can be troublesome. If recurrent infected, excision of the fistulous tract and cyst. May involve facial nerve.,Keloids,Predisposition among people of color. Hypertrophy of connective tissue in traumatized areas. Most common area: ear lobe secondary to ear piercing. Treatment is complete excision f

27、ollowed with injections of cortisone.,Basal cell carcinoma most common type Sun damaged skin Rolled edge, central erosion Squamous cell carcinoma Sun damaged skin Scaly red patches or nodules in fair skinned people,The External Ear,Laceration of Auricle Simple: Thorough cleaning of wound with antise

28、ptic solutions. Conservative debridement of necrotic skin edges and cartilage that cannot be covered with perichondrium. Closure of perichondrium to prevent notching. Cosmetic closure of skin. Prophylactic antibiotics. Complicated: Same principles. Contaminated or extensive wounds may require stagin

29、g with use of grafts or reconstructive flaps. Avulsion, Treatment: Amputated parts should be cleaned and placed in iced physiologic saline until reconstruction. Anticoagulants and prophylactic antibiotics may improve success.,The External Ear,Lacerations of External CanalInjury predisposed to stenos

30、is. Canal should be carefully examined, cleaned, and debrided under microscope. Skin of meatus should be reapporximated and denuded areas covered with split thickness skin graft supported in place with rosette of antibiotics impregnated gauze and packing.,The External Ear,BurnsTreatment similar to g

31、eneral burn management except: Prophylactic antibiotics are indicated to prevent suppurative perichondritis; and, Stenting of a burned meatus necessary to prevent stenosis.,Ear Foreign Body,Foreign Bodies of EAC Insects. Immobilize with topical 2% lidocaine or ether and remove with gentle irrigation

32、 or alligator forceps under direct vision. Materials: Key: proper instruments: microscope, alligator forceps, right-angle hook, suction, and local anesthesia. Young children often require general anesthesia Topical otic antibiotics if localized reaction to foreign body.,Exostosis,Periosteal outgrowt

33、hs in the osseous canal of cold water swimmers Rarely impacts hearing or cerumen If problem, surgical removal,Tympanic Membrane Perforation,Traumatic Tympanic Membrane Perforation EtiologySudden alteration of air pressure in the EAC: Compression (slap, hit, skiing), blast, instrumentation (Q-tip), b

34、urn, skull fracture, or lightning. Danger signs:CSF otorrhea implies basilar skull fracture. Vertigo, nausea and vomiting, nystagmus, may be due to oval or round window fistula, labyrinthine or brain concussion,Management: Baseline audiogram Keep ear dry Antibiotics if infection develops. Prognosis:

35、 90% heal spontaneously,10% OR,The Middle Ear,Barotrauma Definition: Refers to injury to the ear following a pressure change in the middle ear compartment. Failure of middle ear ventilation leads to negative pressure relative to the outside environment. Pathogenesis: TM and mucosa retract toward mid

36、dle ear space and cause pain. Vacuum results in a change in capillary permeability with transudate and possibly bleeding. Eustachian tube “lock” occurs during airplane or diving descent. Treatment: Decongestant / antihistamines, Valsalva and insufflation, chew gun and swallow frequently. If no respo

37、nse, myringotomy. Should take prophylactic measure when flying or diving.,The Middle Ear,Perilymph Fistula Vigorous coughing or straining, sneezing, or nose blowing can result in rupture of the round window or subluxation of the footplate. Leakage of perilymph causes dizziness and hearing loss. Init

38、ial management is bed rest. If no improvement or if deterioration, surgical exploration is indicated.,The External Ear,Bullous Myringitis Symptom: Otalgia Signs: Hemorrhagic blebs on TM and adjacent canal. Treatment: Incision of blebs if severe pain. Prophylactic oral antibiotics to prevent otitis m

39、edia. Anesthetic otic drop.,Sudden Hearing Loss,Unexplained unilateral NSHL 72 hrs 40-55 yrs M=F Recovery varies with severity of loss Prognosis worse age, vestibular sxn 85-90% Idiopathic, 10-15% Menieres, trauma, syphilis, autoimmune, perilymph fistula, 1% Acoustic, CVA, MS,Ear fullness, tinnitus,

40、 decreased hearing No proven therapy Steroids (60 mg X 4 days, taper over 10 days) Recovery 1-2 weeks. Little recovery expected if no recovery within 4 wks Tinnitus, fullness resolve regardless,Otalgia,“10 Ts of Otalgia” TMJ Tonsils Throat Tube (Eustachian) Teeth Tongue Tics (Glossopharyngeal) Trach

41、ea Thyroid Tendons,Laryngotracheal Airway,Thyroid Cartilage Cricothryoid Space Cricoid Cartilage TracheaCricothyroid Membrane Tracheal Ring,Laryngeal and Tracheal Injuries,Types of injuries Laryngeal fracture Tracheal fracture Penetrating injuries Arytenoid dislocation Cricotracheal separation Recur

42、rent laryngeal nerve paralysis,Laryngeal and Tracheal Injuries,Treatment Maintain airway. Oral or nasal intubation is contraindicated. If intervention is required, proceed with tracheotomy. Try to avoid high tracheotomy in the presence of laryngeal injury. Endoscopy evaluation is safe only after tra

43、cheotomy. Look for possible associated injuries of the esophagus or bronchi. OPEN reduction of fractures and careful suturing of lacerations is imperative, as soon as possible after injury.,Laryngeal and Tracheal Injuries,Diagnosis Symptoms Pain Hoarseness Obstruction (can develop rapidly even if as

44、ymptomatic for several hours after the injury) Hemoptysis,Esophageal/Tracheal Foreign Bodies,85% esophageal, age 1-3 years Vegetable matter in airway, coins in esophagus FB lodge in bronchi (RL), below cricopharyngeus Caustic injuries require endoscopic evaluation,Facial Fractures,General Considerat

45、ions Look for other fractures like skull and / or cervical spine fractures Test function of cranial nerves Indications for reduction Functional impairment Cosmetic deformity Timing As soon as is practical, but in general, delay of one week is not harmful. Delay may be necessary due to: Edema or ecch

46、ymosis, which obscures skeletal deformity Instability of patient due to other injuries,Facial Trauma Assessment,Mechanism of injury Other injuries Eyes Chemosis Tarsal plate Ears Lacerations Hemotympanum Nose Fractures Septal hematoma,Oral cavity Lacerations Damage to duct Neck Crepitus Tracheal dev

47、iation Cranial Nerve exam Evaluation of fractures Orbital rims Midface stability Mandibular step off,Facial Fractures,Types of Nasal Fractures Lateral most common Depressed due to dorsal blow Nasofrontal ethmoidal unusual and severe, involving displacement of nasal and frontal bones into the ethmoid

48、 area Diagnosis Primarily physical exam Pain and tenderness Epistaxis Nasal obstruction Ecchymosis Deformity may be difficult to assess secondary to swelling or bleeding X-rays usually not helpful Look for septal hematoma,Facial Fractures,Le Fort Fractures (Mid-Face Fractures)Result from severe fron

49、tal blows. Frequently associated with intracranial damage, CSF leak. Types of fractures Le Fort I tooth bearing position separated from upper maxilla Le Fort II fracture across orbital floor and nasal bridge (pyramidal fracture) Le Fort III fracture across frontozygomatic suture line, entire orbit a

50、nd nasal bridge (craniofacial separation),Le Fort Facial Fractures,Mandible Fractures,Temporal Bone Fractures,Longitudinal Along axis of petrous pyramid Through middle ear May disrupt ossicular chain Transverse Perpendicular to long axis of petrous pyramid Disrupts cochlea and vestibule SNHL and vertigo common Physical Exam Lacerations Hemotympanum CSF otorrhea FN exam Nystagmus Tuning forks,