Chapter 11 ENT problems

Patients with a normal primary survey but with obvious need for hospital admission 172

Presenting symptoms, history, examination and treatment 175

Introduction

The vast majority of ENT (ear, nose and throat) problems that present in the pre-hospital setting are minor in nature. However, occasionally innocuous symptoms can develop into life-threatening conditions which require immediate assessment and treatment. The objectives of this chapter are outlined in Box 11.1.

Primary survey

The primary survey (Box 11.2) is a rapid assessment tool which uses the ABC principles to look for an immediately life-threatening condition.

ENT conditions can be immediately life-threatening by causing an A, B or C problem:

A Airway obstruction/compromise – inhaled foreign body, epiglottitis, quinsy, anaphylaxis/angio-oedema, croup, facial fractures

B Breathing difficulty – croup, inhaled foreign body

C Circulatory compromise – haemorrhage, e.g. epistaxis, from facial fracture, secondary haemorrhage following ENT surgery, e.g. post-tonsillectomy.

Patients with a normal primary survey but with obvious need for hospital admission

Patients with all of the above conditions can show a spectrum of severity of symptoms and signs, which can deteriorate. It is essential to remember that in the early stages of these conditions, patients may not have significant abnormal physical signs. The recognition of developing airway obstruction is critical and management of the condition may require the use of airway adjuncts to maintain adequate oxygenation. If there is complete airway obstruction and airway adjuncts have failed, prompt insertion of a surgical airway may be required as a last resort. It is important to monitor patients with respiratory distress for deterioration and exhaustion. In the case of haemorrhage the body will initially compensate. Therefore cases leading to hypovolaemia should be treated by arresting the haemorrhage and administering fluid to maintain a radial pulse.

The history and a brief examination may lead you to suspect that one of the above conditions is the likely diagnosis and problems with the airway, breathing or circulation may develop. All suspected cases of:

foreign body inhalation

epiglottitis

anaphylaxis

posterior nasal haemorrhage

unstable facial fractures

secondary haemorrhage post surgery

should be admitted to hospital for further investigation and management. However, not all cases of croup or epistaxis will require hospital admission. Management of the individual conditions is discussed below or in other chapters of this book.

Secondary survey

Patients still remaining after the primary survey require a thorough assessment to determine optimal treatment and discharge (see Chapter 2).

History and examination. Should be targeted to the presenting symptom and associated systems. Examination of the respiratory and cardiovascular systems is always necessary. This should be supplemented with abdominal assessment when glandular fever is suspected, looking for hepatosplenomegaly, and examination of the central nervous system if vertigo or facial weakness is the presenting symptom.

Vital signs. Unless you are transporting the patient immediately, then always measure a full set of vital signs.

Investigations. Other than a full history and examination there are no investigations available in the pre-hospital setting able to confirm or refute any of the differential diagnoses.

Differential diagnosis

Table 11.1 shows details of the differential diagnoses classified by presenting symptom.

Table 11.1 Differential diagnoses classified by presenting symptom

Presenting symptom	ENT diagnoses	Other differential diagnoses
Nose bleed	Anterior bleed Posterior bleed Traumatic Post surgery	Underlying bleeding disorder
Sore throat	Tonsillitis Pharyngitis Glandular fever Candida Quinsy Stevens–Johnson syndrome Ramsey–Hunt syndrome	Angina Gastro-oesophageal reflux Tobacco usage Occupational irritants
Sore ears	Otitis externa Viral otitis media Bacterial otitis media Perforated tympanic membrane Eustachian tube dysfunction Mastoiditis Ramsey–Hunt syndrome	Temporomandibular joint dysfunction Upper GI and airway neoplasms Dental Cervical spondylosis
Foreign body	Ears Nose Airway
Difficult/noisy breathing	Foreign body Epiglottitis Croup Anaphylaxis Bacterial tracheitis Smoke inhalation	Asthma COPD
Vertigo	Vestibular neuronitis Meniere’s Benign paroxysmal positional vertigo	Cerebellar CVA Other central causes
Facial/tooth pain	Sinusitis Dental abscess	Shingles Trigeminal neuralgia
Facial weakness	Bells palsy Ramsey–Hunt syndrome	CVA
Sudden hearing loss	Wax impaction Perforated TM	CVA
Trauma	Facial fractures Perforated TM

Presenting symptoms, history, examination and treatment

Nose bleed

The following points in the history are important for the management of a patient with a nose bleed:

age of patient

number of bleeding episodes

sensation of blood in the throat

amount of blood/duration of bleeding

previous history of epistaxis, trauma, nasal surgery

family history of bleeding disorder

anticoagulant, NSAID, aspirin, cocaine use

other significant medical conditions, e.g. IHD, COPD, hypertension, coagulopathy.

When examining the patient try to locate the side of the bleeding, look at the linearity of the nose (if asymmetrical, is this due to recent trauma?); check the appearance of the septum and Little’s area. The latter is the area of the septum seen through the nostrils when the nasal tip is tilted upwards (Fig. 11.1). Blood vessels in Little’s area are prone to bleeding. Check the throat for blood running down the nasopharynx. Ensure you get a set of vital signs and examine the cardiovascular system looking for any indication of shock.

Fig. 11.1 Little’s area of the nasal septum (reproduced with permission of Mr Kim Ah-See, ENT Consultant, Aberdeen).

The treatment of epistaxis is dependent on the site of the bleeding and the experience of the healthcare professional.

TIP

The majority of nose bleeds will respond to simple first aid measures of compression and cooling. It is important to note that effective compression occludes both nostrils without release, for 20 minutes. Cooling with a cold compress over the forehead and bridge of the nose can also be effective by causing vasoconstriction of the nasal vessels

If bleeding has stopped by the time of presentation or ceases with the simple first aid measures (TIP) and the vital signs are normal no further treatment is necessary. If it is a recurrent bleed antibiotic nasal cream should be prescribed. Recurrent nose bleeds in children tend to be caused by digital trauma to Little’s area. In adults remember to check blood pressure. If elevated, ask them to attend the GP for further management.

If the bleeding fails to respond to simple first aid measures packing should be applied to the nasal cavity from which the bleed is suspected to have originated. The simplest pack and the easiest to insert is the nasal tampon (Fig. 11.2). However, the nose can be packed with ribbon gauze if available and the healthcare professional is competent at the procedure. Nasal tampons are supplied small and flat but expand and take on the contours of the cavity when they are hydrated with either blood or saline. The leading edge of the nasal tampon should be lubricated prior to insertion. It should then be inserted in a horizontal plane into the nasal cavity. If the nasal tampon does not expand with the blood in the nose, saline should be dripped onto the external end of the nasal tampon until it expands and causes compression. The thread of the tampon should be secured with tape and a nasal sling may be applied to soak up any excess blood.

Fig. 11.2 Nasal tampon (reproduced with permission of BASICS Scotland).

If anterior packing fails to stop the bleeding after 15 minutes a posterior bleed should be suspected (approx. 5% of bleeds). These require packing using a long nasal tampon, an epistaxis balloon or a Foley catheter with an anterior pack depending on what is available (Fig. 11.3). Long (posterior) nasal tampons are inserted in the same way as an anterior tampon. Some epistaxis balloons have an anterior and posterior balloon. The balloon is lubricated with saline and inserted, again in a horizontal plane. The posterior balloon is inflated to the recommended volume, gentle traction is applied to position the balloon in the posterior nasal space and then the anterior balloon is inflated to the recommended volume. Foley catheters and single balloon epistaxis catheters are inserted in the same way but do not have an anterior balloon and therefore an anterior pack is necessary. The Foley catheter must be secured with care taken to prevent pressure necrosis of the nasal tissues. All patients with a posterior bleed require admission (Box 11.3). If a large volume of blood has been lost, oxygen, venous access and fluid resuscitation may be necessary.