------------------------------------------------------------------------------- TITLE: OTOLARYNGOLOGIC EMERGENCIES: EVALUATION AND MANAGEMENT SOURCE: Dept. of Otolaryngology, UTMB, Grand Rounds DATE: September 11, 1991 RESIDENT PHYSICIAN: R. Paul Fulmer, M.D. FACULTY: Byron J. Bailey, M.D. DATABASE ADMINISTRATOR: Melinda McCracken, M.S. ------------------------------------------------------------------------------- "This material was prepared by resident physicians in partial fulfillment of educational requirements established for the Postgraduate Training Program of the UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended for clinical use in its present form. It was prepared for the purpose of stimulating group discussion in a conference setting. No warranties, either express or implied, are made with respect to its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion." I. INTRODUCTION: Otolaryngology as a specialty has a diverse area of expertise and therefore this calls for skill in the evaluation and treatment of many different urgent and emergent medical problems. With the advent of Emergency Medicine as a speciality, the Otolaryngologist is often placed into more of a consultant role when emergent Head and Neck problems initially arrive in the E.R. Therefore when called , the Otolaryngologist must take a careful history from the E.R. physician so that he can ascertain the extent of the problem and possibly begin life-saving measures prior to his arrival to the emergency room. II. EARS: A. Acute Mastoiditis: 1. General - usually develops as a complication of acute otitis media, however the same symptoms can occur in patients with an underlying cholesteatoma. Suppurative mastoiditis usually evolves 1-3 weeks after untreated AOM. 2. Symptoms - postauricular edema, erythema, tenderness and protrusion of the auricle. 3. (Latent Mastoiditis - may develop in immunocompromised patients and the symptoms are vague or absent. This disease process has a particular propensity for causing intracranial or meningeal complications - ie. especially lateral sigmoid sinus thrombosis). 4. Radiographs - Mastoid films are helpful in confirming the diagnosis. CT of head is usually reserved for patients felt to have either intracranial complications or cholesteatoma. 5. Treatment - First step is to perform a myringotomy to allow drainage and culture. a. IV antibiotics - Ampicillin 150-200mg/kg/day or Cefuroxime for 5-8 days with mastoidectomy or 5-15 days if no mastoidectomy was performed. b. Bacteriology - Most common organisms are: - Group A beta-hemolytic streptococci - Strep pneumoniae - H. Flue, Staph Aureus, Proteus mirabliis - Anaerobes - Bacteroides i. (Maharaj) - showed that in 35 consecutive patients btwn. 3-13 yrs. old undergoing surgery for acute mastoiditis; that anaerobes were cultured 80% of the time. (B. melaninogenicus, B. fragilis, and B. species). He found that Metronidazole IV for 2 days followed by suppositories for 7-10 days in addition to PCN G was a highly effective treatment for these patients. (South Africa) c. Needle Aspiration - often the abscess can be aspirated and the patient placed on IV antibiotics and this will show improvement within 48 hours. d. Mastoidectomy - usually reserved for those patients who show no improvement in 48-72 hours on IV abx. or if such complications as subperiosteal abscess, meningitis, intracranial abscess, lateral sinus thrombosis, or facial paralysis occur. i. Simple cortical mastoidectomy (opening into the mastoid antrum) is usually performed. ii. Radical Mastoidectomy is reserved for severe infection(ie. tuberculosis mastoiditis) and cholesteatoma removal. B. Auricular Hematoma: 1. General - auricular hematomas are usually the result of any blunt trauma to the ear. These hematomas develop between the auricular cartilage and the pericondrium, in the subpericondrial location. This deprives the cartilage of its nutrient supply and if untreated will result in necrosis. Also if left untreated, these hematomas can become infected and an associated chondritis develops causing a deformity. 2. Symptoms - usually presents with a tense, tender area of swelling of the pinna which obscures the normal contour of the ear. 3. Treatment - complete drainage of the hematoma. a. Needle Aspiration - 18 gauge needle into the most fluctulant aspect of the hematoma. If the hematoma cannot be fully drained due to clots if must be I & D'ed. b. Incision and Drainage - 11 blade followed by suction evacuation of the clotted hematoma. c. Compressive Dressing - typical mastoid dressing with cotton soaked in mineral oil applied to the conforming areas of the pinna. The ear must be re-examined daily and if reaccumulation occurs, repeated drainage is needed. The dressing should be left on for 3-4 days with no reaccumulation of the hematoma d. Prophylactic antibiotics - antistaphlycoccal coverage with either dicloxacillin or 1st generation cephalosporin. Any evidence of chondritis or abscess is an indication for admission and IV antibiotics and probable further surgical drainage. III. NOSE: A. Epistaxis: (life threatening): 1. General - approximately 60-70% of people have an episode of epistaxis at least once in their lives, but only 10% of these come to the attention of medical personnel. - 80% of all nose bleeds are form an anterior source(ie. Kiesselbach's plexus). Anterior bleeds are more common in children. - Majority of significant nosebleeds occur in the 5th to 8th decades and are complicated often by systemic medical problems (ie. Hypertension). Posterior epistaxis is usually a disease of the middle-aged and elderly. 2. Blood Supply - many anastamoses exist between the internal and external carotid arteries which supply the nose. a. External Carotid i. facial artery - superior labial branch sends two branches to the nose; septal branch to the anterior septum and alar branch to the ala. ii. internal maxillary artery - is the most important blood supply to the nose. Terminal branch of the external carotid sending several branches to the nose; sphenopalatine, nasoplatine, and greater palatine. b. Internal Carotid i. ophthalmic artery - gives to branches to the nose; anterior and posterior ethmoid arteries. 3. Simple Epistaxis - usually an anterior bleed involving Kiesselbach's plexus on the anterior septum. a. Careful history (ie. frequency of bleeding, hypertension, previous bleeding problems, nasal allergies, trauma, cocaine abuse, and the use of medications particular aspirin products and /or anticoagulants). b. Initial treatment - topical Afrin and constant pressure for 20-30 minutes by the clock will often stop a minor anterior bleed. The patient can then be seen in clinic at the next available time and undergo a formal examination. c. Examination - should begin with application of 4% cocaine plegets place in the nose for 5-10 minutes. Once these are removed, often the site of bleeding is easily identified and silver nitrate sticks can be applied for cauterization. d. Packing - if the vessel continues to ooze the a merocel nasal tampon can be cut to size and place into the nose along the floor. The plastic airway tube provides at least some minimal airway and is a strong material to secure a suture through if needed. If this does not stop the oozing, then a formal anterior vaseline gauze pack can be placed. The packing is left in place for 3 days. Upon removal, recauterization may be needed if any raw areas still remain. e. Antibiotics - antistaphlycoccal antibiotics are used as prophylaxis. 4. Complex Epistaxis - usually a posterior bleed or an anterior arterial bleed. Often these patients are very hypertensive and /or debilitated. a. The patient is evaluated as above for a simple bleed with a good history, initial exam, and cocaine exam. b. If the above measures are unsuccessful or the patient is obviously bleeding to profusely; then a formal anterior and posterior pack is placed. Epistats can also be tried at this juncture, however if continued oozing then formal packing should be administered. c. The patient is admitted to an ICU type setting with arterial saturation monitoring, IV hydration and antibiotic, and oxygen. Often sedation is also very useful as well. (ie valium) d. Medical consult - to help in the treatment of the patients hypertension and other medical concerns. e. Hematocrit and hemoglobin should be followed closely. f. Re-examine the patient's oral pharynx daily for oozing. g. The packs are left in place for 3 days, then the posterior pack is removed first followed by the anterior pack the following day if there is no evidence of posterior oozing. h. Surgery - Ligation of internal maxillary artery and anterior/posterior arteries. If the packing fails, then the patient is repacked and consented for the above surgery. After the procedure, the packs are removed with the patient still under anesthesia. Eletrocatery may then be used if any further bleeding is encountered. - occasionally external carotid artery ligation is required vs. the above procedure. In this case, it is extremely important to identify two or more branched prior to ligation to ensure that you have isolated the external vs. the internal artery. 5. Carotid Artery Aneurysm - Traumatic aneurysms of the cavernous portion of the carotid artery which present with epistaxis are uncommon. (Chambers, et al.), in 1981 reported only 100 cases found after an extensive review of the literature. a. Symptoms - triad: 1). monocular blindness, 2). history of head injury, 3). recurrent epistaxis. The initial episode of epistaxis is usually brief and mild, with subsequent episodes being massive and life-threatening. 88% of these hemorrhages occur within 3 weeks of the trauma, rare cases have been reported after 4 years. (ie. Simpson RK, et al. - 30 years after head trauma) b. Radiographs - Initial evaluation is often with contrast enhanced CT. This is followed by Arteriogram for definitive diagnosis. c. Treatment - emergency balloon occlusion or ligation of the internal carotid artery. i. Emergency Balloon Occlusion - (Simpson) the ICA is temporarily occluded with a balloon and the neurological status of the patient is assessed for aprox. 10-15 minutes. If no deficits then the temporary balloon is replaced with a detachable balloon filled with IV contrast and followed up with thrombogenic coils. Post-operatively the patient is monitored in a Neuro ICU setting and a repeat Arteriogram is performed at the time of balloon positioning and in approx. one week to assess the occlusion of the aneurysm and the adequate cross filling of the cerebral circulation with contralateral flow. ii. Emergency Internal Carotid Ligation - (Liu,et al) can be performed if unable to use balloon occlusion. Liu , et al., in a case report from China state that they have had good success with ligation the ICA in the cervical region and/or clipping the vessel intracranially. B. Septal Hematoma: 1. General - forces generated by nasal trauma can cause a separation of the pericondrium from the underlying cartilage, which results in a potential space which may fill with blood causing a hematoma. If a septal hematoma is not recognized and drained appropriately, a septal abscess and necrosis may occur resulting in cartilage destruction and a permanent deformity of the nose. 2. Presentation - the patient may complain of nasal obstruction on the side of the hematoma and a painful nose. 3. Physical Exam - reveals a bulging of the nasal mucosa, which may be boggy or fluctuant in consistency on palpation with a blunt instrument. The mucosa can be either normal in color or echymotic. 4. Treatment - incision and drainage a. vertical incision- beginning as high as possible on the septum over the hematoma and carried inferior. b. horizontal incision - is made inferior along the hematoma. A small part of the mucopericondrial flap can be removed anteriorly to prevent early closure. c. evacuation of the hematoma- with a small frazier tipped suction to remove all of the clots. d. packing - a small rubber band drain can be placed and then the anterior part of the nose is packed with 1/2 inch gauze impregnated with antibiotic ointment. This should be left in place until there is no more drainage, at which time the drain can be removed., and the day following the packing. e. antibiotics - patient should be placed on antistaphlycoccal antibiotic prophylaxis and should be examined daily. 5. Bilateral septal hematomas - can be managed the same way, however when making the mucosal incisions be sure not to violate the cartilage and stagger the incisions so that they are not one on top of the other. IV. ORAL CAVITY/ORAL PHARYNX: A. Ludwigs Angina: 1. General - most often found in men between the ages of 20-50 years of age with poor oral hygiene, gross dental disease, and dietary deficiencies. (Children are not spared - but very rare). 2. Presentation - bilateral brawny, indurated swelling of the submandibular, sublingual and submental spaces. The patient will usually have an open mouth appearance, due to induration of the floor of mouth and the bilateral upward and backward displacement of the tongue. This causes interference with breathing, speech and swallowing. Lymph nodes are not usually enlarged. Pain is due to the tension on the nerves from the excess fluid within the tissues. 3. Classical Spread - is via facial planes beyond the mylohyoid muscles to invade the submandibular spaces and perhaps the adjacent upper cervical regions. 4. Radiographs - Computerized tomography and ultrasound have been helpful in delineating the presence or absence of a true abscess cavity. However, often this will not necessarily change the treatment course. 5. Treatment - Airway management, IV antibiotics, and drainage. a. Airway - Local tracheostomy is the standard of care for management of the patients airway. However, recent practice also includes fiberoptic nasal awake intubation as an alternate method of airway stabilization. b. IV antibiotics - antistaph, strep and anaerobic coverage should be continued until the symptoms have resolved and there is no airway compromise. (ie. PCN G, Clindamycin). c. Drainage - horizontal external incisions made between the chin and hyoid in the midline are often adequate. Penrose drains are often used and advanced slowly as the induration resolves. Internal incisions have been used in the past, but have a higher possibility of damage to the submandibular ducts, lingual nerve and vessels and the hypoglossal nerve. d. Steroids - (Hutchison IL and James DR) advocate the use of Dexamethasone IV along with the usual IV antibiotics. Their theory is that hyaluronidases and fibrinolysins are released by specific micro-organisms into the tissues and help dissect along the fascial planes, facilitating spread. Therefore by agumenting the bodies own response to infection with glucocorticosteroids, the process can resolve sooner. B. Peritonsillar Abscess: 1. General - the most common space-occupying infection seen in the head and neck. It occurs 2-3 times more often than other abscesses of the head and neck. 2. Presentation - dysphagia, odynophagia, fever, unilateral tonsilar and peritonsilar swelling, uvular deviation and trismus. 3. Bacteriology - Peptostreptococcus, Group A streptococci, Peptococcus, and Fusobacterium. (streptococcus - 30% of patients) 4. Treatment - Drainage, Antibiotics, Hydration and Pain meds. a. Drainage i. Needle aspiration - 18 gauge needle passed through the superior aspect of the anterior tonsilar pillar appears successful in 90% of cases(Herzon). Occasionally repeat needle aspirations are required to completely drain the abscess. ii. Incision and Drainage- anterior tonsilar pillar is anesthetized with 2% lidocaine and the mucosa is incised with an 11 blade. A tonsil clamp can then be placed into the tonsil fossa and spread to ensure release of all to abscess pockets. b. Antibiotics - patient should receive PCN IM and a ten day course of po PCN. c. Hydration - if patient cannot maintain adequate po fluid intake, then they should be admitted for IV hydration until their condition improves. d. Pain Medication - adequate liquid pain medication should be provided. e. Followup - the patient should be seen in clinic the following day to check for reaccumulation and hydration. 5. Definitive Care - Tonsillectomy should be performed within 3-4 weeks or when the inflammation resolves, due to the high rate of recurrence. V. Larynx: A. Supraglottitis (Epiglotittis): 1. General - supraglottitis is a life-threatening infection of the epiglottitis and other supraglottic structures that can result in complete upper airway obstruction. This disease occur in children and adults, however due to the smaller dimensions of the pediatric airway, the spread of infection is much more rapid. Therefore causing a more dramatic clinical picture of upper airway obstruction. 2. Presentation - Child is usually >2y.o. and presents with sore throat, odynophagia, drooling, preference for sitting upright with neck extended. Also one or more signs of acute upper airway obstruction will be present: tachycardia, tachypnea, retractions, stridor, cyanosis and fatigue, in that order. A similar course can occur in adults but over a much more gradual progression.(8-12hrs.) 3. Management - Once the diagnosis is suspected, then a skilled Otolaryngologist and Anesthesiologist should be present at all times with the patient and ready to provide an artificial airway if needed. A predetermined protocol is extremely important to have at your institution a. Airway - the airway is the most important aspect of management of this disease process. Once the diagnosis is suspected, then the patient should be taken to the O.R. and undergo either nasotracheal intubation or local tracheostomy. i. Nasotracheal intubation - this is now the standard of care. The patient is bag-masked ventilated with 100% oxygen, then receives either O2 and Halothane or short acting anesthetic and muscle relaxant followed by direct laryngoscopy and intubation. The patient is then paralyzed and sedated and receives mechanical ventilation in an intensive care setting. ii. Local tracheostomy - Until the mid-seventies, tracheostomy was the treatment of choice for supraglottitis. However it carries with it the risk of pneumothorax, bleeding, stenosis of the trachea and disfiguring scar. Therefore, with the development of flexible bronchoscopes and more accurate nasotracheal intubation, tracheostomy is now reserved for the patient in which intubation is not successful. iii. Observation - several authors(Arndal) feel due to the spaciousness of the adult larynx and the more indolent course of this disease in adults, that observation with IV antibiotics is an appropriate treatment. They emphasize the importance to be ready for placement of an artificial airway and the need for direct/indirect visualization of the larynx to assess the patients status. b. IV Antibiotics - the most common etiologic agent is Haemophilus influenzae, type B. Second and third generation cephlasporins are effective: (antibiotic duration is 10 days) i. Cefuroxime - 150mg/kg/day; q 8 hrs. ii. Cefotaxime sodium - 150mg/kg/day - q 8 hrs. iii. Ceftriaxone - 100mg/kg/day - q 12 hrs. c. Extubation - Criteria for extubation vary, but should include: i. resolution of edema - as seen by direct or indirect laryngoscopy. ii. resolution of symptoms - fever, drooling, dysphagia, and normalization of vital signs and WBC count. iii. adequate leak of air around the endotracheal tube. d. Discharge - after extubation, the patient is observed and switched to po antibiotics and once stable is discharged home. B. Aspiration of Foreign Bodies in Tracheo-broncheal Tree: 1. General - 80% of tracheobronchial foreign bodies occur in patients younger than 12 years of age, and that 75% of these occur in patients < 3 years of age. The second peak incidence is in adults > 50 years old, often due to loss of protective airway reflexes. 2. Presentation - usually present with paroxysms of coughing, wheezing, and airway distress. This immediate, but variably lasting paroxysmal coughing is often the single most important historical factor. Children can also present with a chronic cough, recurrent pneumonitis, or even asymtomatic radiographic changes and a history of a foreign body in the mouth. Therefore, the index of suspicion should be greatest in the very young child. 3. Physical Exam - most common finding is decreases breath sounds on the involved side(50%). Localized wheezing to the involved area is the second most common sign(40%). Unfortunately, approx. 40% of patients have no positive physical signs. This stresses that the history of a possible remote aspiration is invaluable in patients with chronic pulmonary symptoms. 4. Radiographic Signs - 10% of patients have normal X-ray exams a. Inspiratory/Expiratory chest x-rays - looking for differential inflation, atelectasis and mediastinal shifts: (approx 25%) i. Inspiratory films - obstructing lesion often appears as a inspiratory mediastinal shift toward the affected side and is usually associated with decreased breath sounds. ii. Expiratory films - ball-valve lesion frequently presents as an expiratory mediastinal shift away from the lesion and is associated with inspiratory wheezing. b. Radiopaque foreign body - occurs approx. 1 out of every 6 patients. 5. Location and type of foreign body: a. location - 43% in right mainstem bronchus - 24% in left mainstem bronchus - 22% in right segmental bronchus(2/3rd's of those found in the segmental bronchus are found on the right). b. type- 40% are nuts - 20% are other vegetable matter - 20% are inert metal and plastic - 20% are miscellaneous. 6. Timing of the removal of the foreign body - this primarily depends upon the acuteness and critical nature of the patient. Obviously is the patient has active airway compromise then the removal must occur in an emergent fashion. However if the patient is symptomatic but not in distress, then endoscopic manipulation of the foreign body can wait until: a. gastric emptying - help prevent aspiration b. mobilization of experienced physicians - due to the potentially serious complications which can result. c. nature of the foreign body - must also be considered since inert objects require no additional consideration, but vegetable matter are particularly irritating to the mucosa and can swell with the absorption of moisture. 7. Bronchoscopy - should be done under general anesthesia and preferably with a Storz-Hopkins fiberoptically lighted telescopic, rigid bronchoscope. This allows good visualization and provides ventilation for the patient. a. Removal - once the foreign body is removed, a 'second look' should be performed by reexamining the ipsilateral distal and the entire contralateral tracheobronchial tree. b. Anesthesiololgist - should give vigorous positive pressure ventilation after removal to re-expand distal atelectatic segments. C. Acute Airway Compromise (inability to intubate): 1. Transtracheal Needle Ventilation - this technique can be used as a rapid method of securing an airway and providing ventilation prior to a more permanent procedure. a. Procedure - A 16-gauge plastic-sheathed needle is directed through the cricothyroid membrane, the needle is removed and the plastic sheath left in place. The catheter is attached to the oxygen line which is at 50psi. The patient can be fully ventilated for approx. 30 minutes with this technique. b. Complications - primarily due to the patient struggling for air and dislodging the catheter resulting in subcutaneous emphysema. The catheters can also become kinked causing obstruction of the inflow of oxygen. 2. Cricothyrotomy - when the patient has total upper airway obstruction, then cricothyrotomy is the procedure of choice. However in infants and small children because of the size of their cricothyroid membrane and the difficulty in palpation of the landmarks, many authors recommend tracheostomy rather than cricithyrotomy in these airway obstruction situations. a. Procedure: i. position the patient - if no contraindication ii. locate the cricothyroid membrane iii. anesthetize the skin - if time permits iv. vertical skin incision over cricothyroid v. stabilize the larynx - tracheal hook vi. short transverse stabbing incision into the cricothyroid membrane and widen/spread the incision with scissors or knife vii. insert tracheal dilator viii.insert tracheostomy tube and secure in place ix. begin ventilation and check tube placement b. Complications: i. early - hemorrhage(8%), incorrect site of tube placement(10%), unsuccessful tube placement and prolonged procedure time. ii. late - dysphonia due to damage to the vocal cords, obstructive problems, infections, persistent stoma, feeling of 'lump in throat'. 3. Local Tracheostomy - is the procedure of choice if the airway is secured enough to warrant a trip to the operating suite. Also it should be employed when the patient has sustained a direct laryngeal fracture (usually due to blunt laryngeal trauma) or the patient is an infant in airway distress. a. Procedure - if at all possible the patient should be brought to the operating room and have an anesthesiologist delivering 100% oxygen to the patient. i. position the patient - rolled towel under scapula. ii. local anesthetic - if time permits iii. vertical incision carried through the strap muscles iv. constantly reassess MIDLINE!! v. palpate tracheal rings or thyroid isthmus and retract out of way vi. identify trachea - should use needle aspiration to identify airway( primarily in infants due to similarity to carotid). vii. vertical incision between the 2nd and 4th rings viii. tracheal spreader and hooks to open and stabilize airway ix. placement of tracheostomy tube and secure x. ventilate the patient and check CXR. b. Complications - pneumothorax, mediastinal emphysema, hemorrhage, accidental extubation(infants), and death. VI. ESOPHAGUS: A. Foreign Body: 1. General - 80% of all ingested foreign bodies pass through the gastrointestinal tract without incident. There appears to be three groups of patients who are particularly at risk: a. Elderly (60 years and older) - tend to have food bolus impaction which is thought to be due to either esophageal disease and poor oral sensitivity from dental prostheses. b. Pediatric (3mo to 12 years) - due to their natural oral curiosity, kids inadvertently ingest a variety of objects (ie. coins, buttons, batteries, toys, aluminum pull tabs, etc.). c. Functionly, organicaly or chemically impaired (alcoholics, prisoners, mentally retarded and psychotic patients) - they ingest all types of objects from sticks to razor blades. 2. Pathophysiology - 3 anatomic sites of narrowing within the esophagus: a. Cervical esophagus - site at which most impactions occur (77%), and occurs at the lower border of the cricopharyngeus muscle. b. Cardioesophageal level - where the esophagus crosses the aortic arch.(17%) c. Gastroesophageal junction - objects may lodge here due to the lower esophageal sphincter or anatomic anomalies(ie. rings, webs) -6%. 3. Presentation - virtually all patients with food or bone foreign bodies present symptomatically. However in contrast, only approx. 50% of those patients with non-food foreign bodies will present with symptoms. a. Adults - most will present with a clear history of foreign body ingestion and symptoms of impaction. Rarely is the ingestion occult or remote. b. Children - history is often unclear and the child may have unexplained refusal to take feedings, respiratory strider, or marked drooling as the only clues to an occult foreign body. 17% of children with foreign bodies have had one or more prior ingestions. Gagging or vomiting, choking, neck or throat pain and foreign body sensation (in order of frequency) are the most common complaints. However, approx. one third are asymptomatic. 4. Physical Exam and Radiographs - fewer than 20% of pediatric patients have been found to have abnormalities on physical exam a. Soft tissue radiographs - AP and Lateral views of the neck and chest are always part of the initial assessment of a patient who has a possible esophageal foreign body. i. esophageal coins - will generally appear in a coronal alignment on AP views. ii. tracheal coins- usually appears in a sagittal plane. b. Direct or Indirect visualization - with fiberoptic laryngoscopy or a mirror is useful for F.B. in the hypopharynx, but rarely helpful for esophageal F.B. c. Contrast radiographs - Gastrografin (water-soluble) should be used in cases of suspected esophageal perforation. Barium (inert) has minimal reactivity to the lungs and should be used if aspiration is a concern. 5. Management - airway should always be of utmost concern in a patient with an esophageal foreign body. Once this is either secured or felt to not be in danger, then attention can be turned to the foreign body. a. Various pharmacologic and mechanical methods - have been tried with only moderate to poor success. (ie. diazepam and meperidine, papin, foley catheter, etc.). Glucagon has a reported 30-50% success rate and works by relaxing the esophageal smooth muscle, attenuates lower esophageal sphincter tone, and does not induce CNS depression. b. Endoscopy - remains the treatment of choice. Rigid esophagoscopy provides direct visualization of the foreign body, ability to evaluate the esophagus for associated pathology, ease of removal of foreign body, and airway control with general anesthesia. VII. EYES: A. Orbital Cellulitis: 1. General - in adults 'sinus infection' accounts for the majority of orbital infections (approx. 85%); however other less frequent causes are trauma to periorbital skin, facial fractures, dental infection, nasolacrimal duct obstruction and adjacent surgical wounds. In younger children periorbital cellulititis is the most commonly encountered orbital infection and is a result of local trauma and URI's rather than sinus disease. Orbital cellulitis occurs primarily in older children and young adults. 2. Pathophysiology - Most of the orbital infections arise from local extension of infection. The lamina papyracea separating the orbital contents from the ethmoid sinuses is paper-thin and often has natural dehisences and allows infection to enter the orbit. Also the plexus of communication valveless veins between all the sinuses, orbits, eyelids, nose, much of the face and the cavernous sinus allows for spread of infection. 3. Radiographs - CT scan of the paranasal sinuses and orbits with thin section axial and coronal views with and without contrast are the most useful studies to obtain to help in analysis and surgical planning. 4. Staging: a. Group I: Preseptal (periorbital) Cellulitis - eyelids are erythematous and edematous due to inflammation and venous congestion. As this stage progresses, chemosis may become evident. b. Group II: Orbital Cellulitis - a diffuse infiltration of inflammatory cells and/or bacteria into the orbital contents occurs. Axial proptosis with possible visual acuity and extraocular muscle involvement. No abscess formation. c. Group III: Subperiosteal Abscess - collection of pus between the periorbita and the bony orbital walls. This is most often caused by an erosion of infection through the lamina papyracea of the ethmoid sinuses into the orbit. In this case the orbital contents will be pushed laterally causing a nonaxial proptosis. Multiple abscesses can result. d. Group IV: Orbital Abscess - a collection of pus forms within the orbital tissues, developing from either a progression of the orbital cellulitis or advancing subperiosteal abscess. Systemic toxicity, worsening proptosis and visual acuity, as well as ophthalmoplegia often occur. The orbital apex syndrome may occur affecting the 3rd, 4th, and 6th cranial nerves. e. Group V: Cavernous Sinus Thrombosis - infection has spread posteriorly through the venous channels causing profound mental status decline and cranial nerve deficits(3rd, 4th, 5th, and 6th CN). The eye lids become edematous and purple (due to the obstruction of the superior orbital vein), papilledema, venous congestion, ophthalmoplegia, and a dilated pupil also occur. 5. Treatment: a. Early localized preseptal cellulitis - oral antibiotics(ie. Augmentin or Ceftin) and if associated with a URI then add a topical nasal vasoconstrictive agent and an antihistamine. Patient should be seen on a daily basis for several days until definite improvement is seen. b. Advanced preseptal cellulitis, orbital cellulitis or a mild subperiosteal abscess (normal visual acuity and EOMI) - should be admitted immediately and placed on IV antibiotics(ie cefuroxine), nasal decongestants and an antihistamine. c. Any worsening of the above processes or a frank abscess - seen on CT scan should undergo wide local incision and drainage of the abscess. Usually this involves at least an external ethmoidectomy and removal of the lamina papyracea to allow wide drainage into the nose. The sinus is then opened up and packed with antibiotic impregnated gauze and gradually removed over the next 2 to 3 days. IV antibiotics should be continued for 4-7 days followed by 7-10 days of oral antibiotics. VIII. NECK: A. Carotid Artery Rupture: 1. General - this is an unusual but devastating complication of head and neck surgery. (3-4.5% after radical head and neck surgery). It almost always occurs under the following circumstances: a. a radical neck dissection that follows a full course of radiation therapy (>4,000 rads more than 6 mo before the surgery), b. after development of a skin flap necrosis or salivary fistula; and c. recurrence of tumor in the region adjacent to the artery. 2. Surgical Precautions - these are specific measures that can be used intraoperatively to protect the carotid artery. a. Skin incisions - should be planned so that the vertical limb is placed several centimeters posterior to the carotid artery, b. Should have right angle relationships between the different limbs of the incisions. c. Carotid can be protected in high risk patients - with dermal grafts, muscle flaps, and facial grafts. 3. Prevention of Carotid Rupture once Exposed - since necrosis leads to carotid artery exposure, then when this occurs immediate steps should be taken to ensure good local wound care, IV antibiotics, removal of necrotic debris, and nutritional support. Salivary fistulas should also be controlled prior to any procedure for coverage of the exposed carotid. 4. Emergency Carotid Artery Ligation - often times the eventual rupture is preceded by a sentinel bleed of 100-200 cc. Once the patients vital signs and stable and the blood volume has been replaced, then he is ready to be moved to the operating room. (Protocol) a. Large bore IV of at least 2 veins b. Systolic BP maintained at 110 mmHg c. Pulse maintained at 60-100 beats/min. d. Po2 = 70 mmHg e. Hemoglobin = 11gm/dl f. Central venous pressure monitored g. Wound prepped and draped with gloved had holding pressure h. separate skin incisions for proximal and distal ligation in healthy tissue. (this procedure is not effective when there is massive stomal recurrence with invasion of the inominate artery). i. vessels are then ligated and ends sewn over and buried in a pocket of deep muscle in the neck j. Low dose heparin - 5000u SQ q 12 hrs at time of ligation to prevent retrograde thrombosis k. Balloon catheters - have been used when the carotid is not accessible or ligation has not been successful to stop the bleeds. There are presently angiographic catheters with detachable balloons for permanent occlusion ------------------------------------------------------------------------------ BIBLIOGRAPHY: 1. Arndal H and Andreassen UK. "Acute epiglottitis in children and adults. Nasotracheal intubation, tracheostomy or careful observation? Current status in Scandinavia." The journal of Laryngology and Otology. November 1988; 102:1012-1016. 2. Banerjee A, et al. "Laryngo-tracheo-bronchial foreign bodies in children." The Journal of Laryngology and Otology. November 1988; 102:1029-1032. 3. Cummings CW, et. al. Otolaryngology - Head and Neck Surgery. CV Mosby. 1986. pp. 614-624; 1419-1421; 2417-2428. 4. Deeb ZE. "Approach to Supraglottitis." Emergency Medicine Clinics of North America. May 1987; 5:353-358. 5. Eriandson MJ, et al. "Cricothyrotomy in the emergency department revisited." The Journal of Emergency Medicine. 1989; 7:115-118. 6. Gibson FG and Quinn FB. "Epistaxis." Grand Rounds. September 7, 1988. 7. Gates GA. Current Therapy in Otolaryngology - Head nd Neck Surgery -4. BC Decker, INC. 1990. pp. - 17-19; 244-249; 265-269; 277-279; 333-342; 373-375. 8. Griggs WM, et al. "A simple percutaneous tracheostomy technique.' Surgery, Gynecology & Obstetrics. June 1990; 170:543-545. 9. Hall SF. "Ludwig's-like angina (pseudo-angina Ludovici)." The Journal of Otolaryngology 1984; 13:5:321-324. 10. Hutchison IL and James DR. "New treatment for Ludwig's Angina." British Journal of Oral and Maxillofacial Surgery. 1989; 27:83-84. 11. Humphreys BF. "Otolaryngologic Emergencies." Emergency Medicine Clinics of North America. August 1986; 4:605-615. 12. Liu MY, et al. "Traumatic Intrcavernous Carotid Aneurysm with massive Epistaxis." Neurosurgery. October 1985; 17:569-573. 13. John DG, et al. "Who should treat epistaxis?" The Journal of Laryngology and Otology. February 1987; 101:139-142. 14. Mace, SE. "Cricithyrotomy." The Journal of Emergency Medicine. 1988; 6:309-319. 15. Maharaj D, et al. "Bacteriology in Acute Mastoiditis." Arch Otolaryngol Head Neck Surg. May 1987; 113:514-515. 16. Mclaughlin J and Iserson KV. 'Emergency pediatric tracheostomy: A usable technique and model for instruction." Annals of Emergency Medicine. April 1986; 15:4:463-465. 17. Milczuk HA, et al. "Quest for the aberrant vessel." Otolaryngology- Head & Neck Surgery. April 1991; 104:489-494. 18. Perretta LJ, et al. "Emergency evaluation and management of epistaxis." Emergency Medicine Clinics of North America. May 1987; 5: 265-277. 19. Piotrowski JJ and Moore EE. "Emergency department trachesotomy." Emergency Medicine Clinics of North America. November 1988; 6:737-744. 20. Quinn FB. "Surgical treatment of nasal hemorrhage." Arch Otolaryngology. 1960. 72:734-745. 21. Rothstein SG, et al. "Emergencies in AIDS patients: the otolaryngologic perspective." Otolaryngology- Head & Neck Surgery. April 1991; 104:545-548. 22. Scott TA and Jackler RK. "Acute mastoiditis in infancy: a sequela of unrecognized acute otitis media." Otolaryngology- Head & Neck Surgery. November 1989; 101: 683-687. 23. Shaw KN, et al. "Ludwig's Angina caused by Haemophilus Influenzae type b." The Pediatric Infectious Disease Hournal. March 1988; 7:203-205. 24. Simon RR. "Emergency tracheostomy in patients with massive neck swelling." Emergency Medicine Clinics of North America. February 1989; 7:95-101. 25. Simpson RK, et al. "Emergency balloon occlusion for massive epistaxis due to traumatic carotid-cavernous aneurysm." Journal of Neurosurgery. January 1988; 68:142-144. 26. Smouha EE, et al. "Modern presentations of Bezold's abscess." Arch Otolaryngolog head Neck Surg. September 1989; 115:1126-1129. 27. Taylor RB. "Esophageal foreign bodies." Emergency Medicine Clinics of North America. May 1987; 5:301311. 28. Votey S and Dudley JP. "Emergency ear, nose and throat procedures." Emergency Medicine Clinics of North America. February 1989; 7:117-154. 29. Vries ND, et al. "Facial nerve paralysis following embolization for servere epistaxis." The Journal of Laryngology and Otology. February 1986; 100:207-210. 30. Weisengreen HH. "Lugwig's Angina: Historical Review and Reflections." Ear, Nose and Throat Journal. October 1986; 65:28-34. 31. Wilson JA, et al. "Rigid endoscopy in ENT practice: appraisal of the diagnostic yeild in a district general hospital." The Journal of Laryngology and Otology. March 1987; 101:286-292. ---------------------------------END---------------------------------------- TEST QUESTIONS - ENT EMERGENCIES The following test questions are intended to provide proof to accrediting agencies that you have read and understood the entire Grand Rounds element. Your answers should be based on the text of the Grand Rounds element. Answers should be sent by e-mail addressed to either psanty@utmb.edu or to fbquinn@phil.utmb.edu. Answers can be sent by U.S Postal Service mail, using a plain sheet of paper on which the Grand Rounds element and the subscriber are fully identified. Correct answers will be transmitted to the subscriber via e-mail. Comments and alternative points of view should be expressed at the end of the list of the subscriber's answers 1. In suspected acute mastoiditis, CT scan of the head is recommended a. in all cases b. in suspected intracranial complications c. in cases with protrusion of the auricle d. almost never 2. Auricular hematoma can be treated adequately by a. ice packs b. broad spectrum antibiotics c. incision & drainage followed by compressive contour conforming dressing d. thrombolygic agents 3. The blood supply of the nese is drawn from the folowing vessles except for the a. vertebral artery b. internal maxillary artery c. internal carotid artery d. internal maxillary artery 4. The symptom triad: recurrent epistaxis, monocular blindness, history of recent head injury, suggests the need for a. coagulopathy studies b. biopsy of the nasal mucosa c. CT scan of the head and carotid angiography d. serum ascorbic acid determination 5. A patient with a painful nose, nasal obstruction, a soft, bulging nasal septal mucosa, and a history of a recent blow to the nose will probably require a. incision and draingage of a nasal septal hematoma b. open reduction of a nasal bone fracture c. topical vasoconstrictors d. oral antihistamines 6. A 45 year old male with poor oral hygeine, brawny edema of the anterior floor of the mouth and submental area, and upward & backward displacement of the tongue is probably suffering from a. peritonsillar abscess b. masseter space infection c. pharyungomaxillary space infection d. Ludwig's angina 7. A child less than 2 years of age with sore throat, odynophagia, drooling, a preference for sitting upright with tne neck extended, and tachypnea, probably has a. peritonsillar abscess b. retropharyngeal abscess c. acute supraglottitis d. acute tonsillitis 8. A child less than 3 years of age with sudden onset of paroxysmal coughing, wheezing, and airway distress should be worked up for possible a. tracheobronchial foreign body b. acute tonsillitis c. mediastinitis d. allergic bronchial asthma 9. A patient with acute airway compromise and inability to insert an endotracheal tube can be managed by a. insertion of a 16-gauge plastic-sheathed needle through the cricothyroid membrane b. tracheotomy under local anesthesia c. cricothyrotomy d. all of the above 10. A patient with recent onset of edema and erythema of the eyelids, chemosis, probptosis, impaired extraocular muscle movement is probably suffering from a. cavernous sinus thrombosis b. subperiosteal abscess of the orbit c. acute maxillary sinusitis c. acute conjunctivitis ------------------------------END------------------------------------- TEST QUESTIONS - The following test questions are intended to provide proof to accrediting agencies that you have read and understood the entire Grand Rounds element. Your answers should be based on the text of the Grand Rounds element. Answers should be sent by e-mail addressed to fbquinn@utmb.edu. Answers can be sent by U.S Postal Service mail, using a plain sheet of paper on which the Grand Rounds element and the subscriber are fully identified. Correct answers will be transmitted to the subscriber via e-mail. Comments and alternative points of view should be expressed at the end of the list of the subscriber's answers. The University of Texas Medical Branch (UTMB) is accredited by the Accreditation Council For Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. UTME designates this continuing medical education activity for 1 credit hour in Category 1 of the Physicians's Recognition Award of the American Medical Association. 1. In suspected acute mastoiditis, CT scan of the head is recommended a. in all cases b. in suspected intracranial complications c. in cases with protrusion of the auricle d. almost never 2. Auricular hematoma can be treated adequately by a. ice packs b. broad spectrum antibiotics c. incision & drainage followed by compressive contour conforming dressing d. thrombolygic agents 3. The blood supply of the nese is drawn from the folowing vessles except for the a. vertebral artery b. internal maxillary artery c. internal carotid artery d. internal maxillary artery 4. The symptom triad: recurrent epistaxis, monocular blindness, history of recent head injury, suggests the need for a. coagulopathy studies b. biopsy of the nasal mucosa c. CT scan of the head and carotid angiography d. serum ascorbic acid determination 5. A patient with a painful nose, nasal obstruction, a soft, bulging nasal septal mucosa, and a history of a recent blow to the nose will probably require a. incision and draingage of a nasal septal hematoma b. open reduction of a nasal bone fracture c. topical vasoconstrictors d. oral antihistamines 6. A 45 year old male with poor oral hygeine, brawny edema of the anterior floor of the mouth and submental area, and upward & backward displacement of the tongue is probably suffering from a. peritonsillar abscess b. masseter space infection c. pharyungomaxillary space infection d. Ludwig's angina 7. A child less than 2 years of age with sore throat, odynophagia, drooling, a preference for sitting upright with tne neck extended, and tachypnea, probably has a. peritonsillar abscess b. retropharyngeal abscess c. acute supraglottitis d. acute tonsillitis 8. A child less than 3 years of age with sudden onset of paroxysmal coughing, wheezing, and airway distress should be worked up for possible a. tracheobronchial foreign body b. acute tonsillitis c. mediastinitis d. allergic bronchial asthma 9. A patient with acute airway compromise and inability to insert an endotracheal tube can be managed by a. insertion of a 16-gauge plastic-sheathed needle through the cricothyroid membrane b. tracheotomy under local anesthesia c. cricothyrotomy d. all of the above 10. A patient with recent onset of edema and erythema of the eyelids, chemosis, proptosis, impaired extraocular muscle movement is probably suffering from a. cavernous sinus thrombosis b. subperiosteal abscess of the orbit c. acute maxillary sinusitis c. acute conjunctivitis In order for the sponsors of this CME activity to monitor its usefulness and appropriateness to subscribers, we ask that your supply answers to the following questions concerning the accompanying Grand Rounds Online CME segment: 1. Was the presentation organized in an acceptable manner? yes no opinion no 2. Was the material adequate to your continuing education needs with respect to content? yes no opinion no 3. Was the material appropriate to your clinical practice needs? yes no opinion no 4. Did you feel that the discussants' remarks were responsive to the issues presented in the body of the Grand Rounds segment? yes no opinion no 5. Do you consider the presentation to be timely with regard to current information available in both the lay press and the professional literature? yes no opinion no 6. Are the questions submitted with the Grand Rounds element meaningful in that they stimulate thought and perhaps further inquiry? yes no opinion no 7. Is the method of submitting the subscriber's answers to these questions expeditious and convenient? yes no opinion no 8. Would you recommend this method of completing the general requirment for Continuing Education Activity to your colleagues? yes no opinion no 10. How much money (U.S. dollars) would you be willing to pay for each award of 10 or more CME Category I credits earrned through this type of online CME activity? $100 $50 $25 $12.50 $6.25 $3.00 $1.50 $0.75 $0.35 $0.15 Please submit any comments, criticisms and suggestions which you may have in the space below. They will be given thoughtful consideration, especially if they are favorable comments, gentle criticisms, or constructive suggestions. 8-) ================================================================== Francis B. Quinn, Jr., M.D. University of Texas Medical Branch Dept. of Otolaryngology Galveston, TX 77555-0521 Internet addresses: 409-772-2706, 772-2701 fbquinn@UTMB.edu 409-772-1715 FAX fbquinn@phil.utmb.edu ==================================================================