ENT

EMERGENCY
2150450 NAVINKUMAR SUBRAMANIAM
EPISTAXIS
INTRODUCTION
• Common presentation
• Epistaxis is defined as acute hemorrhage from the nostril, nasal cavity,
or nasopharynx.
CAUSES
ANTERIOR EPISTAXIS

• If a single anterior bleeding site is found,

vasoconstriction should be attempted
with topical application of oxymetazoline
or phenylephrine solution.
• For bleeding that is likely to require more
aggressive treatment, a local anesthetic,
such as a 4% Xylocaine solution, should
be used.
• Adequate anesthesia should be obtained
before treatment proceeds.
CAUTERIZATION
• Bending of the silver nitrate stick.
• Larger vessels generally respond more readily
to electrocautery. However, it must be
performed cautiously to avoid excessive
destruction of healthy surrounding tissues.
• Use of electrocautery on both sides of the
septum may increase the risk of septal
perforation.
• If do many times, tissue may become fragile,
hence may cause septal perforation.
ANTERIOR NASAL PACKING
• Anterior nasal cavity should be packed, from posterior to anterior,
with ribbon gauze impregnated with petroleum jelly or polymyxin B-
bacitracin zinc-neomycin .
• Bayonet forceps and a nasal speculum are used to approximate the
layers of the gauze, which should extend as far back into the nose as
possible.
• Each layer should be pressed down firmly before the next layer is
inserted .
• Once the cavity has been packed as completely as possible, a gauze
"drip pad” may be taped over the nostrils and changed periodically.
• Give systemic antibiotic to prevent sinus infection.
POSTERIOR EPISTAXIS
• Much less common than anterior bleeding .
• Posterior packing may be accomplished by passing a catheter through
nostril through the nasopharynx, and out the mouth .
• A gauze pack then is secured to the end of the catheter and
positioned in the posterior nasopharynx by pulling back on the
catheter until the pack is seated in the posterior choana, sealing the
posterior nasal passage and applying pressure to the site of the
posterior bleeding.
COMPLICATION
• Septal hematomas and abscesses from traumatic packing
• Sinusitis
• Syncope during packing
• Pressure necrosis secondary to excessively tight packing.
• Toxic shock syndrome with prolonged nasal packing
PERSISTENT BLEEDING
• Patients with anterior or posterior bleeding that continues despite
packing or balloon procedures may require treatment by an
otolaryngologist.
• Endoscopy may be used to locate the exact site of bleeding for direct
cauterization.
• Hot water irrigation may help in reducing discomfort and length of
hospitalization in patients with posterior epistaxis.
INDICATION FOR SURGICAL TREATMENT
• Failure of medical treatment after 72 hours.
• Nasal anatomy that precludes local treatments
• Patient refusal of medical management,
• Initial hematocrit of <38% (males),
• The need for transfusion.
SURGICAL MEASURES
• Arterial ligation of :
• maxillary artery
• anterior ethmoidal artery
• posterior ethmoidal artery
• external carotid artery
• Embolization
• Septal surgery
• Lasers
CSF RHINORRHEA
INTRODUCTION
• Leakage of CSF into the nose is called CSF rhinorrhoea.
• Clear fluid.
• Mixed with blood (in acute head injuries).
• Secreted by choroid plexus in the lateral,third & fourth ventricle &
absorbed into dural venous sinuses by arachnoid villi. Villi have one-
way valve mechanism allowing CSF of the subarachnoid space to be
absorbed in to the blood.
• CSF pressure rise on coughing, sneezing, nose blowing straining on
stools or lifting heavy weight. These activities should be avoided in
cases of CSF leak or after its repair.
CAUSES
 CLINICAL FEATURES
• History of clear watery discharge on bending head/
straining
• Reservoir sign : When rising in morning CSF
collected in sinuses on bending head
• Nasal discharge stiffen the handkerchief due to its
mucus content.
• After a head trauma. Double ring sign when
collected on a piece of filter paper with central
blood & peripheral lighter halo.
• Nasal endoscopy. Localize site of CSF leak.
• Otoscopic /microscopic examination of ear to
REVEAL FLUID in case of CSF otorhinorhea.
INVESTIGATION
LABORATORY
• B2 transferrin. Sensitive & specific. Only few drops of CSF is needed.
Perilymph & aqueous also contains it but not in nasal discharge. Specific for
CSF
• Glucose testing > 30 mg/dl in CSF <10 mg/dl in nasal discharge
IMAGING
• HRCT scan. Coronal & axial.
• MRI T2 weighted image Site of leak. Active CSF leak is needed
• Intrathecal fluorescein study. It can be done preoperative invasive.
0.25-0.5 Ml of 5% fluorescein diluted with 10mL of CSF is injected. patient lies
in 10 degree head down position. dye can be detected intranasaly with the
help of endoscope dye appears bright yellow but when seen with blue filter it
appear fluorescent green.
• CT cisternogram.
TREATMENT
Conservative measures
• Bed rest
• Elevating the head of bed
• Stool softeners
• Avoidance of nose blowing, sneezing & straining
Prophylactic antibiotics can be used to prevent meningitis
Acetazolamide ↓ formation of CSF
SURGICAL REPAIR – ENDOSCOPIC TRANSNASAL REPAIR OF CSF LEAK
• Neurosurgical intra cranial approach.
• Extradural approach
• External ethmoidectomy - cribriform plate.
• Trans septal sphenoidal approach - sphenoid.
• Osteoplastic flap - frontal sinus leak
STRIDOR
INTRODUCTION
• an abnormal, high-pitched sound produced by turbulent airflow
through a partially obstructed airway at the level of the supraglottis,
glottis, subglottis or trachea
• Is a extrathoracic airway obstruction occur during inspiration,
expiration or BOTH
• Hallmark of laryngeal obstruction
• Noise (stridulent or harsh)
CAUSES
INVESTIGATIONS
• Culture and sensitivity
• Flexible laryngoscope
• ABG
• X-ray : thumbprint sign , steeple sign(croup)
MANAGEMENT
• IV fluid maintenance
• Antibiotic
• Steroid – reduce symptoms
• Intubation/tracheostomy – due to
respiratory obstruction despite
treatment given
FOREIGN BODY IN EAR,NOSE AND THROAT
FOREIGN BODY IN EAR
• REMOVE USING MICROFORCEPS
• IF INSECT-THEN KILL IT WITH 1% LIGNOCAINE OR OLIVE OIL BEFORE
REMOVING IT
• TRY OTOSCOPY IF HARD,IF STILL IMPOSSIBLE REFER TO ENT
FOREIGN BODY IN NOSE
• USUALLY FOUL SMELLING DISCHARGE PRESENT
• USE NASAL COPHENYCLCAINE
• IF ROUND FOREIGN BODY CAN USE BLUNT HOOK
• IF IRREGULAR SHAPE ALLIGATOR FORCEPS
FOREIGN BODY IN THROAT
• ASK ABOUT NATURE OF FOREIGN BODY(FISH,CHICKEN BONE)
• ASK PATIENT TO POINT SITE OF PAIN
• HAEMOPTYSIS,HAEMETEMESIS,MIGRATORY PAIN
• INSPECT TONSILAR REGION VIA INDIRECT LARYNGOSCOPY(CHECK
TONSILAR POLES,BASE OF TONGUE,PYRIFORM FOSSAE)
• IF STILL UNABLE TO DETECT DO LATERAL X-RAY
• IF XRAY AND IDL NORMAL AND PATIENT ASYMPTOMATIC REFER TO ENT
CLINIC IN OFFICE DAYS
• IF SYMPTOMATIC REFER TO ENT IMMEDIATELY DO OESOPHAGOSCOPY
UNDER GENERAL ANAESTHESIA OR VIEW UNDER BARIUM SWALLOW TEST