Ear Nose and Throat

Emergencies
Kellease Brown, MD
Kellie Williams, MD
PEM Fellows
April 18, 2013


Objectives
Ear, Nose and Throat
Traumas
Foreign Bodies
Infections


Oropharyngeal Lacerations
Fall with object in mouth
Injury
Central
Lateral

Central Oropharyngeal Lacerations
Vascular and neural injury unlikely
Confirm absence of retained foreign body
Discharge home
Lateral Oropharyngeal Lacerations
May be associated with
vascular injuries
carotid artery
jugular vein.
Vascular injury is
extremely low: < 1%
Size of injury does not
correlate with
neurological risk

Diagnostic Studies
Angiography
MRA
Carotid duplex

Laceration Repair
Most heal well with no repair
Repair if
Excessive bleeding
Soft tissue flap
Altered oral anatomy
Explore for foreign body

Disposition
Antibiotics if injury large enough to be
sutured
Anticoagulation if thrombosis
Observation for 48 to 60 hours.
Minimal risk discharged home with
instructions similar to head trauma.
Follow-up according to laceration care

Tongue Lacerations
Tongue Lacerations
Occur after falls, traumas, or seizures
Proper Management
Preserve tongue function
Facilitates swallowing
Articulating speech
Repair or not to repair

No Need To Repair
Most in children
Simple lacerations
Linear lacerations
On dorsum
Which To Repair
In the ED
Bisecting wounds
Large flaps
Bleeding
Larger than 1cm
Gaping
U--shaped
OMFS or ENT
Partial amputations
Complete amputations
Assessment in the ED
ABCs
Laceration of the
lingual artery
Achieve hemostasis
with pressure, cold or
suturing
Anesthesia
1% Lidocaine soaked gauze for small
lacerations
Local infiltration of lidocaine with
epinephrine
Inferior alveolar or lingual nerve block
Conscious sedation

How to Repair
Protrude the tongue
Absorbable suture
Simple interrupted
sutures
Layered closure


Discharge
Soft diet for 2-3 days

Swish and spit with
antiseptic mouth wash

Antibiotics are not
necessary

NASAL TRAUMA
Nasal Trauma
Most are minor
Associated injuries
Cervical spine,
CNS
Eye
Chest
The Pediatric Nose
More prominent
cartilage
Cartilage will bend
Blows will result in
significant edema and
ecchymosis
Nasal Fracture
Assess the extent and
the nature of the trauma.
A step off or bony
irregularity may often be
detected
Edema may prevent
recognition fracture
Reevaluate in 3-4days


Nasal Trauma
X-rays are unreliable
Epistaxis
Reduced by the ENT
Must be done with in 7-10 days after injury


Nasal Trauma
Complications
Septal Hematoma
Cerebrospinal Fluid Rhinorrhea
Septal Hematoma
Septal Hematoma
Not improved with
topical nasal
decongestants
DRAINED
RIGHT AWAY
Septal abscess
Cartilage destruction
Saddle Nose

Cerebrospinal Fluid Rhinorrhea
Clear, watery fluid
Resembles normal
nasal secretions
Fracture
Cribriform plate
Temporal bone
http://care.american-rhinologic.org/csf_leaks
CSF Rhinorrhea
http://drhem.com/2011/11/
http://medicguide.blogspot.com/2008/06/how-can-you-
confirm-cerebrospinal-fluid.html
CSF Rhinorrhea
Target sign on paper.
Glucose oxidase test strip
-2 transferrin

CSF Rhinorrhea
CT scan
ENT and Neurosurgery consult
Admit, bed rest and head of bed at 30
degrees
Often heal with rest and conservative
management.
Antibiotics Controversial

Epistaxis
Rich vascular supply
Usually mild and self
limited
Causes nose picking
and URI

Epistaxis
Anterior

90% of episodes
Arises from Kiesselsbachs
Plexus
Characterized by a slow,
persistent ooze
Posterior

10% of episodes.
Sphenopalatine artery
Characterized by heavy
bleeding
High-risk of airway
compromise, aspirations of
blood, and life-threatening
hemorrhage.
Mild epistaxis without active bleeding
No work-up is needed
Minimize recurrence
Minimize local trauma
Hydration via saline mist
Increasing humidity via coolmist
humidifier
Minor Bleeding
Pinch nostrils for 5-30mins nonstop
Elevate head but do not hyperextend
Gauze soaked in
Nasal decongestant
Epinephrine 1:10,000
Phenylephrine


In the ED
ABCs
Hemodynamic stability
Nasal Exam
Cautery
Silver nitrate sticks
Thermal cautery
Nasal Packing
Posterior Bleeding
Hemoptysis, hematemesis, or blood in the
posterior pharynx
ENT consult
Nasal packing or epistaxis balloons
Admission to monitor for hypoxia, or
respiratory compromise



http://www.invotec.net/epistaxis_balloons.html
Nasal Packing
Antibiotics
Removed in 3 to 5 days
Decrease the incidence
Toxic shock syndrome
Sinusitis
EXTERNAL EAR TRAUMA
http://depositphotos.com/4392548/stock-photo-Ear-3d-illustration.html
External ear blunt trauma
Ecchymosis
Seroma
Hematoma

External ear blunt trauma
Smooth, bluish-colored
mass on the lateral
surface of the auricle
Obscures the normal
helix and anti-helix
Evacuated
Prevent necrosis
Cauliflower ear

Earring Trauma
Torn from the lobule
Closed by reestablishing
the normal anatomy
Evert the skin edge
Avoid notching the
lobule at the laceration
site
Ear and Nose Foreign Body
Foreign Bodies
Common in children
Beads, food, rocks, toys, paper, batteries and
insects
Present
Immediately
After foul odor
Recurrent epistaxis
Pain in the ear or nose
Accidently
Removal
Restrained adequately
Good light source,
Nasal speculum
Removal
Manually grasp the object with forceps
Getting behind the object with curette
Applying suction to the surface of the foreign
body
Katz extractor
Mouth-Mouth positive pressure

Katz Extractor
http://store.inhealth.com/category_s/49.htm
Parents Kiss Technique
Less traumatic
Performed by the
parent
No restraints
Exhaling while kissing
the child and occluding
the unaffected nostril

Unable to Remove
Consult ENT if unable to remove.
Consider antibiotics

Insect in the Ear
Intense, constant pain
sensation of movement
in the ear
Kill the insect
Mineral oil
2% lidocainea
Remove


Button battery in the Ear
Release small amounts of chemicals and
voltage
Alkaline chemical burns, necrosis, or septal-
tympanic perforation
Removed immediately

Foreign Body Aspiration
80% of pediatric FB in airways occur in
children < 3yo
Peak incidence between 1 and 2 years old
Commonly Aspirated Objects
Nuts
Peanuts (36%-55%)
Popcorn
Watermelon seeds
Toys
Balloons
Coins
Balls
Marbles
Hardware
Foreign Body Location
Majority in the bronchi
Study out of Turkey looked at 1160 children
for suspected FBA
FB removed in 1068 (92%)
60% right lung
23% left lung
13% trachea/carina
3% larynx
Presentation
History of choking
Drooling
Refusal to eat
Vomiting
Focal monophonic wheezing
Decreased air entry
Respiratory distress
Imaging
Diagnosis easy when radioopaque (only 10%
of FB)
Lower airway FB
Hyperinflated lung
Atelectasis
Mediastinal shift
Penumonia
Sensitivity of CXR 68-76% and specificity 45-
67%
17 month old with history of choking
Noisy breathing x 1 hour after choking on
candy bar with almonds
Able to speak and drink fluids
Vitals stable
Physical Exam:
able to speak, no cyanosis, drooling, or dyspnea
Lungs: mild wheezing with possible mild
inspiratory stridor
Albuterol given with no change

17 month old with history of choking
http://www.hawaii.edu/medicine/pediatrics/pemxray/v1c08.html
http://www.hawaii.edu/medicine/pediatrics/pemxray/v1c08.html
http://www.hawaii.edu/medicine/pediatrics/pemxray/v1c08.html
http://www.hawaii.edu/medicine/pediatrics/pemxray/v1c08.html
Treatment
Mild: no intervention
Infants: back blows and chest thrusts
>1yo: Abdominal thrusts
ENT Bronchoscopy
Deep Neck Space Infections
4yo presents complaining of:
Fever last 2 days
Decreased po intake
Points to mouth as source of pain
Per mother child Sounds different
Neck seems stiff
Physical Exam
T 38.5 P 120 RR 28 BP 105/75
CV: Tachycardia
Lungs: CTAB
HEENT: cant completely open mouth, uvula
midline, no erythema or swelling, will not look
up but with range neck in other directions
PMHx
Immunizations UTD
Meds: none

Differential Diagnosis
Meningitis
Strep pharyngitis
Foreign body
Retropharyngeal abscess
Peritonsillar abscess
Parapharyngeal infection
Epiglottitis
Croup

Retropharyngeal Abscess
Infection in potential space between posterior
pharyngeal wall and prevertebral fascia
Cause:
Medical (45%)
Traumatic (27%)
Idiopathic



INSERT PIC SHOWING RETRO SPACE HERE!!
Retropharyngeal Abscess
Occur in children less than 6yo
Peak incidence age 3yo
Usually preceeded by URI
Pharyngitis
Tonsillitis
Sinusitis
Cervical lymphadenitis

Parapharyngeal Infection
Parapharyngeal Abscess
Tend to occur in children 2-12yo
4
th
most common deep neck infection
Usually preceeded by URI or history of rapidly
worsening sore throat
Symptoms and Presentation
Fever
Sore throat
Dysphagia
Odynophagia
Trismus
Torticollis
Hot potato voice
Boltes sign



Stridor
Drooling
Neck swelling
Cervical adenopathy
Stiff neck*

Work-up
CBC
Blood culture
Imaging
Lateral neck
CT
Ultrasound
Lateral Neck
Organisms
Polymicrobial infection
GAS
MSSA
MRSA
Anaerobes (fusobacteria, prevotella)
Treatment
No consensus on optimal management
Controversy is whether surgical drainage should
always be performed
Many pediatric otolaryngologists will trial a
course of IV antibiotics
Admission to the hospital
Blood culture, CBC, IVF, ENT consult
Treatment
Start IV antibiotic therapy as soon as possible
Cover for GAS, MSSA, MRSA, and respiratory
anaerobes
Unasyn, Clindamycin
Vancomycin, Linezolid
Total treatment x 14 days
Indications for Surgical Drainage
Airway compromise
A large (>2 cm(2)) hypodense area on CT scan
Failure to respond to IV antibiotic therapy

Complications
Airway compromise
Spread to surrounding structures
Sepsis
Mediastinitis
Aspiration pneumonia
Empyema
Jugular vein suppurative thrombophlebitis


Peritonsillar Abscess
Most common deep neck infection in
children and adolescents
Commonly preceeded by tonsillitis or
pharyngitis
Can be a clinical diagnosis
Symptoms
Fever
Drooling
Sore throat
Dysphagia
Peritonsillar bulge
Uvula deviation
Muffled voice
Trismus

Peritonsillar Organisms
Similar to retropharyngeal abscess
Polymicrobial
Predominant bacterial species:
GAS, MRSA, MSSA, and respiratory anaerobes
(including Fusobacteria, Prevotella, and Veillonella
species)
Haemophilus occasionally
Imaging
Not necessary unless
Trying to differentiate abscess from cellulitis
Looking for spread on infection to
parapharyngeal space
Inability to fully examine due to trisums
CT with IV contrast
Treatment
ENT consult for drainage
Needle drainage
I&D
Tonsillectomy
Start IV antibiotic therapy as soon as possible
Cover for GAS, MSSA, MRSA, and respiratory
anaerobes
Unasyn, Clindamycin
Vancomycin, Linezolid
Total treatment x 14 days
Deep Neck Infections
Start IV antibiotics as soon as possible
Get ENT on board early
Monitor for potential complications
Summary
Trauma
Remember the Katz extractor and Mother kiss
for foreign body removal
Always keep foreign body in the differential
diagnosis for a first time wheeze
Be mindful for the patients potential to
deteriorate with deep neck infections


References
Al- Sabah, Basel, et al. Retropharyngeal Abscess in Children: 10-year
Study. The Journal of Otolaryngology. 33:6, 2004.
Amin, Suhail, et al. Acute retropharyngeal abscess with torticollis
and cervical subluxation Acase report and review of literature.
International Journal of Pediatric Otorhinolaryngology Extra. 6
(2011): 252-255.
Grisaru-Soen, Galia, et al. Retropharyngeal and perapharyngeal
abscess in children Epidemilogy, clinical features and treatment.
International Jouranal of Pediatric Otorhinolaryngology.
Eren, S, et al. Foreign body aspiration in children: experience 1160
cases. Annals of Tropical Paediatrics.
http://www.hawaii.edu/medicine/pediatrics/pemxray/v1c08.html0
03; 23 (1):31.

References
1) Current management of penetrating injuries of the
soft palate
How to Repair a Lingual Laceration - Article
3 by Drs. Brad Stevinson, Jennie Buchanan and Peter
Pryor on June 20, 2012
4) Ann R Coll Surg Engl. 2008 July; 90(5): 420422.
doi: 10.1308/003588408X300966
PMCID: PMC2645753
The Parent's Kiss: An Effective Way to Remove
Paediatric Nasal Foreign Bodies