Otorhinolaryngologic Emergencies
Otorhinolaryngologic emergencies include emergencies of the ear, nose, and throat (ENT), and ophthalmologic emergencies include emergencies of the eye. Injuries and illnesses related to these body parts are commonly seen in the emergency department (ED). ED staff must be proficient at rapidly recognizing these emergencies and initializing appropriate treatment while aiming to preserve function and to avoid complications.
Ear
Overview of Anatomy and Physiology
The ear consists of the external ear, the middle ear, and the inner ear ( Fig. 13.1 ). The external ear is made up of the auricle and the canal. The canal contains glands that produce cerumen (earwax). At the end of the canal is the tympanic membrane (eardrum), which is the transition between the external and middle ear. The middle ear is full of air and contains the ossicles (three bones: the malleus, incus, and stapes). It also contains the eustachian tube, which connects to the pharynx. The inner ear consists of the cochlea, the semicircular canals, and the distal end of the vestibulocochlear nerve (CN VIII). Behind and below the ear canal is the part of the temporal bone called the mastoid.
The hearing pathway is composed of two phases: the conductive phase and the sensorineural phase. During the conductive phase, sound vibrations from the outside environment are transmitted from the external ear through the canal to the middle ear, where the ossicles transform the vibrations into waves. Next, during the sensorineural hearing phase, the cochlea in the inner ear produces nerve impulses based upon these sound waves, which are then transmitted to the brain via the vestibulocochlear nerve (CN VIII).
The semicircular canals in the inner ear are responsible for helping the body maintain balance and know where it is in space. This information also is transmitted to the brain via the vestibulocochlear nerve (CN VIII).
Common Emergency Department Presentations
Sudden Sensorineural Hearing Loss
Sudden sensorineural hearing loss (SSNHL) occurs when a patient experiences significant hearing loss ( > 30 dB over three frequencies) within 72 hours. It can be caused by infection, trauma, or underlying disease, but in 60% to 90% of cases there is no underlying cause identified (“idiopathic SSNHL”).
The first step in the assessment of these patients is to differentiate between unilateral and bilateral hearing loss. Bilateral hearing loss is rarer but has higher morbidity and mortality. A thorough history should be conducted, including asking about associated symptoms, trauma, barotrauma such as flying or scuba diving, and ototoxic medications. The physical examination should visualize the tympanic membrane, including cerumen removal if necessary, as well as a neurologic examination focused on cranial nerves and cerebellar testing. Tuning fork testing is used to help differentiate sensorineural versus conductive hearing loss.
Patients with SSNHL require emergent referral to ENT as well as audiology for formal hearing testing.
Cerumen Impaction
Cerumen is produced by glands in the ear canal and varies in color and consistency. It functions to aid in the turnover of dead skin cells in the canal, keep the canal clean and lubricated, and trap dirt and water. It can also help prevent infection. When cerumen builds up in the canal it can become impacted, which can sometimes be due to the makeup of the cerumen itself or to behavioral factors, such as using cotton swabs to clean the canal ( Fig. 13.2A and B ).
Patients with cerumen impaction may be asymptomatic or may present with a wide range of symptoms, including itching, ear pain, hearing loss, tinnitus, or dizziness. It also heightens the risk of infection.
If the patient is asymptomatic and the cerumen is not preventing adequate ear examination, it does not require routine removal. However, if the patient is symptomatic or the impaction is impeding assessment of the ear, it should be removed. Removal can be done using any combination of cerumen softening agents (such as liquid docusate or triethanolamine polypeptide), irrigation, or manual removal. Irrigation should not be performed if there is concern for tympanic membrane rupture, previous tympanic membrane surgery, or concern for retained battery in ear (typically from hearing aid). If these techniques are unsuccessful, the patient should be referred to a specialist. Patients should also be educated regarding proper ear hygiene to prevent recurrence, including avoidance of cotton swabs for cleaning the ears. The ear canals do not require additional cleaning, as they are naturally cleaned via epithelial migration that should suffice.
Ear Canal Irrigation
Equipment ( Fig. 13.3 )
- 1.
An otoscope to visualize the external auditory canal (See , Otoscopic Exam)
- 2.
Water and a cerumen-softening agent (it is important to keep the temperature of the solution close to a patient’s natural body temperature in order to avoid unnecessary discomfort such as dizziness)
- 3.
A 30-mL or 60-mL syringe with a 16- or 18-gauge intravenous (IV) catheter attached to the syringe with the needle removed (the catheter should be cut shorter than the length of the canal to prevent inadvertent tympanic membrane injury )
Fig. 13.3
Typical supplies for ear irrigation include water basin, 30-mL syringe, large-bore Angiocath (cut down to 1 in), absorbent pads, and hydrogen peroxide (if alternate solution to break down cerumen is not used).
- 4.
Two basins (one to hold the irrigating solution and one to catch what flows out of the ear)
- 5.
Face shield during the procedure for personal safety
Technique
- 1.
Position the patient lying on one side with the target ear pointed up to the ceiling ( Fig. 13.4 ; See , Ear Irrigation).
Fig. 13.4
Have the patient lie on the unaffected side with their head supported. Apply the hydrogen peroxide (or alternate solution) into the affected part canal and leave for 10 to 15 minutes or according to product directions.
- 2.
Fill the ear canal with the cerumen softening agent and let it sit for 15 to 30 minutes before initiating irrigation. Drain the instilled agent into the waste basin.
- 3.
Position the patient on their back with the waste basin under the target ear beside the patient’s head ( Fig. 13.5 ). Place an absorbent plastic-lined pad around the patient.
Fig. 13.5
Once you are ready to irrigate, position the patient’s ear over an empty basin to collect the irrigant.
- 4.
Fill up the second basin with warm water. Keep the solution close to human body temperature to avoid discomfort, dizziness, and nausea.
- 5.
Use the syringe to draw up the solution from the basin and attach the IV catheter to the filled syringe.
- 6.
Position the IV catheter inside the ear canal with the tip aimed at the wall of the ear canal so as not to aim directly for the tympanic membrane, as this can cause perforation ( Fig. 13.6 ).
Fig. 13.6
Using a large-bore Angiocath catheter (cut down to 1-in length) and a 30-mL syringe, gently irrigate the canal, taking care not to touch the tympanic membrane with the catheter.
- 7.
Flush the ear as many times as necessary until no more cerumen comes out.
- 8.
Dry the outer ear with gauze. Repeat the procedure on the second ear if needed.
- 9.
If the ear irrigation was performed successfully, one should be able to visualize the tympanic membrane.
Ear Foreign Body
Foreign bodies in the ear are especially common in children; the most common foreign bodies found in the ear are beads, cotton tips, and insects. Most commonly, patients are asymptomatic and are brought by the caregiver. Those with symptoms most commonly endorse otalgia, bleeding or drainage from the ear, tinnitus, hearing loss, or a sensation of fullness in the ear.
Foreign bodies should be removed by a medical provider as soon as possible, especially if there is obvious infection or if the object is a disk or button battery. If the foreign body is not tightly wedged in the canal, irrigation with warm water is often effective, but should never be performed if the object is a battery or may expand with water (such as a bean). Suction can also be used if the object is light. For more tightly wedged objects, tools such as an ear curette, wire loop, or hook under direct visualization through an otoscope can be used. Alligator forceps are especially useful for soft objects like cotton. If the foreign body is a live insect, it should be killed before removal by filling the canal with mineral oil or 2% lidocaine. If the patient is uncooperative, removal should be performed under procedural sedation, as sudden movement can cause damage to the middle ear. After removal, patients should be assessed for otitis externa, laceration or bruising of the ear canal, tympanic membrane perforation, and acute otitis media.
Otitis Externa
Acute otitis externa is inflammation of the ear canal ( Fig. 13.7 ). It may also affect the tympanic membrane and/or pinna. Patients with acute otitis externa present with rapid onset of otalgia, ear itching, or a sensation of fullness in the ear and on examination have tenderness with movement or palpation of the external ear or swelling or redness of the canal. The most common bacterial causes are Pseudomonas aeruginosa or Staphylococcus aureus , so it is treated with topical antibiotics that cover those organisms. If the canal is swollen to the point of preventing effective administration of antibiotic ear drops, a Pope Oto-Wick should be placed. The wick will absorb the ear drops and deliver the antibiotic to hard-to-reach places.
Otitis Media
Otitis media is inflammation of the middle ear ( Fig. 13.8 ). It is one of the most common diseases in children. It is often caused by pathogens coming from the nasopharynx into the middle ear through the eustachian tube during an upper respiratory infection (URI). Patients often present with acute ear pain, and associated cold symptoms and fever are also often seen. In preverbal children, pulling on the ear or excessive crying may be the primary presenting symptom, though this is nonspecific. The examination reveals a bulging red tympanic membrane. The first-line treatment is pain and fever control with acetaminophen and ibuprofen. Antibiotics are reserved for children younger than 2 years of age with bilateral infection and children with severe, persistent, or recurrent infection because, although routine use reduces the duration of symptoms, the risk of antibiotic resistance and adverse effects outweigh the benefits.
Mastoiditis
Mastoiditis is an infection of the mastoid bone of the skull and is a serious life-threatening complication of otitis media. It can lead to facial paralysis, meningitis, brain abscess, or other serious complications. Patients may present with ear pain with redness, swelling, pain, or fluctuance over the mastoid or behind the ear, or bulging of the external ear. CT imaging of the temporal bone with contrast should be performed. Historically, the mainstay of treatment was surgical mastoidectomy, but newer data supports starting with a conservative approach with IV antibiotics with or without myringotomy.
Nose
Overview of Anatomy and Physiology
The upper part of the nose is made up of bone (the “bridge”), whereas the lower part is cartilage. On each side of the nose, air travels through the nares to the vestibule and then through the narrow passageway between the nasal septum and the turbinates into the nasopharynx. Turbinates are curved bony structures covered by a mucous membrane that extend into the nasal cavity ( Fig. 13.9 ). The paranasal sinuses are cavities in the bones of the skull near and around the nose that are filled with air and drain into the nasal cavities
The nose has many functions. Through the olfactory system it sends signals to the brain to interpret different smells. It also cleanses, humidifies, and controls the temperature of the air we breathe in before delivering it to our lungs. Mucus produced by the nose works with the small hairs that line the nostrils to capture and filter dust, dirt, and other particles from the air as well.
Common Emergency Department Presentations
Nasal Foreign Body
Like with the ear, nasal foreign bodies are most often seen in pediatric patients. The most common nasal foreign bodies are those that children find around the house: beans, peanuts, and other foods; beads; parts of toys; pebbles; paper; and eraser tips. Most patients are brought in by a caregiver after inserting something into their nose. Symptoms may include nasal pain, unilateral purulent nasal discharge, epistaxis, voice change, or malodorous breath, though the vast majority of patients are asymptomatic. The object is usually located just below the inferior turbinate or in front of the middle turbinate and can usually be directly visualized on exam. It is important to take care during removal not to push the object farther back, as this can cause aspiration into the trachea leading to respiratory obstruction.
Depending on the type of object and cooperation of the patient, many different techniques for removal are available, including suction, air pressure, ear curettes, curved hooks, alligator or bayonet forceps, irrigation, glue, or balloon catheter. Pressure techniques (“blowing the nose”) are preferred for cases in which there is no edema or infection to reduce the risk of pushing the object farther back during the procedure. For small children who will not blow their own noses, a caregiver may blow air into the child’s mouth while occluding the unaffected nostril, forcing the object out of the nose via positive pressure. Another technique for creating pressure is to place oxygen tubing into the opposite nostril at 10 to 15 L/min (called the “Beamsley Blaster technique”). If suction is used, placing a piece of soft plastic tubing over the end of the suction tip can increase success.
Epistaxis
Epistaxis is bleeding from the nose. Causes of epistaxis may include trauma, inflammation, drugs, and structural or hematologic reasons. Bleeding may be from an anterior or posterior source. Anterior bleeding is more common, occurs at Kiesselbach’s plexus, and generally presents as visible bleeding from the nose ( Fig. 13.10 ). Posterior bleeding occurs at the sphenopalatine artery and is typically more brisk, difficult to control, and can have less obvious presentations such as nausea, hematemesis, anemia, hemoptysis, or melena. Posterior bleeding is an emergency and can be life threatening. If the patient is hemodynamically unstable, gain vascular access and initiate IV fluid resuscitation immediately.
Epistaxis Management
The first step of epistaxis management is direct pressure with compression of the nostrils for at least 5 minutes and up to 20 minutes and should be initiated immediately ( Fig. 13.11 ).
Ask the patient to pinch the nostrils with a gauze sponge while tilting their head slightly forward to prevent blood from collecting in the posterior pharynx. Gauze or cotton that has been soaked in a topical decongestant (such as oxymetazoline [Afrin], phenylephrine, or 4% cocaine solution) should be inserted into the affected nostril for vasoconstriction. If the bleeding does not respond to these techniques, the source of the bleeding should be identified via direct visualization. If an anterior source is visualized, chemical cautery (silver nitrate) or electrocautery can be applied directly onto the bleeding site for about 30 seconds. Packing the cavity with a hemostatic agent such as Gelfoam or Surgicel may also be effective. If these treatments fail, the anterior nasal cavity should be packed with nonadherent ribbon gauze or a preformed balloon device for up to 5 days. Packing increases risk of septal hematoma or abscess from trauma induced during packing, sinusitis, neurogenic syncope, pressure necrosis, and toxic shock syndrome, so it should be reserved for use after other techniques have failed. Posterior bleeding often requires consultation with ENT and is usually controlled via balloon device or posterior packing. ENT consultation may also be appropriate for refractory or unstable bleeding. The EDT can independently perform nostril compression; as for the remaining procedures, the EDT can only assist in the process.
Throat
Overview of Anatomy and Physiology
Within the mouth, the gingiva connects to the teeth and the maxilla or mandible. The teeth are numbered 1 to 32, and each has an invisible root within its socket. The tongue sits in the midline with the submandibular glands beneath it. The roof of the mouth is composed of the hard palate (anteriorly) and the soft palate (posteriorly). The pharynx is visible behind the soft palate and tongue, the uvula hangs above it, and the tonsils sit on either side ( Fig. 13.12 ).
Common Emergency Department Presentations
Pharyngitis
Pharyngitis is sore throat caused by inflammation of the pharynx and the surrounding tissues due to viral, bacterial, or fungal infection. Viral infections are most common and are self-limiting, whereas bacterial infection is commonly caused by Streptococcus pyogenes (group A beta-hemolytic streptococci [GABHS]) and requires antibiotic treatment to avoid complications including rheumatic fever and a rare kidney disease called poststreptococcal glomerulonephritis. The cause of infection is often differentiated by history and physical examination findings. Patients with viral infection often present with concurrent URI symptoms and have enlarged tonsils and pharyngeal redness on examination. For those with viral infection, symptomatic treatment is first line, including lozenges, pain-relieving medications, rest, and hydration. In contrast, bacterial infection often does not present with cough or other URI symptoms, and on physical examination patients often have exudates on their tonsils as well as enlarged lymph nodes ( Fig. 13.13 ). A rapid antigen detection test (RADT) is standard for detection of GABHS in the pharynx. The Modified CENTOR Criteria is a scoring system that helps calculate the likelihood of streptococcal pharyngitis and determine the need for strep testing and antibiotic treatment. Generally, testing of patients of 3 years or younger is not recommended as their likelihood of developing a GABHS infection is very low.
| Criteria | Points |
|---|---|
| C —Cough absent | 1 point |
| E— Exudative or swollen tonsils | 1 point |
| N —Swollen and tender anterior cervical lymph nodes | 1 point |
| T —Temperature ≥100.4 °F | 1 point |
| O —Often young (age 3–14 y) | 1 point |
| R —Rarely old (age ≥45 y) | Subtract 1 point |
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