ENT

Emergencies
Anthony Feeney
Final Year Medical Student
Learning Objectives
• Stridor
• Quinsy
• Mastoiditis
• Epistaxis
• Foreign body in situ
 Bernoulli principle

Stridor
• High pitched monophonic sound made from turbulence of air flow when the airway
is constricted (from Latin ‘creaking sound’)
• Inspiratory – obstruction at or above the vocal cords
• Expiratory – obstruction below the vocal cords (analogous with wheeze)
• Biphasic – when stridor is present on inspiration + expiration
• A-E assessment
• Nebulised adrenaline – helps to vasoconstrict and get airway oedema under control –
mainly a time saver
• IV dexamethasone – potent steroid – reduces airway swelling
• The causes of obstruction of any luminal structure can be divided into:
• 1. Outside the wall (extramural)
• 2. In the wall (intramural)
• 3. Inside the lumen (intraluminal)
• Extramural - tumour, abscess or haematoma in the neck
• Intramural - tumour of the larynx, paralysis of the vocal cords, epiglottitis,
subglottic stenosis
• Intraluminal - foreign body, blood or secretions inside the airway
Management of stridor
•Stridor is an emergency
• Manage with ABCDE approach
• Call an anaesthetist early
• Get the patient to a safe place and get help from
the ENT team with experienced anaesthetist
•In children, DO NOT distress in any way them as this
can compromise the airway
•Medical management of the airway
• IV steroids
• Dexamethasone 8mg TDS to start
• Nebulised adrenaline
• 1ml 1:1000 made up to 5ml with normal
saline
•At some point the cords will need to be visualised
either with a flexible nasendoscopy if safe to do so else
under general anaesthetic
•Emergency airway options include
• 1) Intubation
• 2) Jet ventilation
• 3) Cricothyroidotomy
• 4) Tracheostomy
Tonsillitis
• Acute inflammation of the palatine tonsils secondary to infection
• Very common – usually only need admission if can’t eat or drink
• Most commonly viral – but if exudative consider Group A Beta Haemolytic Streptococcus (MC
bacterial cause)
• However infectious mononucleosis (Epstein-Barr virus) can also be exudative
• Symptoms: fever, sore throat, trismus, dysphagia, malaise
• Signs: enlarged and enflamed tonsils, white exudate on tonsils, lymphadenopathy
• Centor criteria: tonsillar exudate, tender anterior cervical lymphadenopathy, hx of fever (>38),
absence of cough
• Score of 1 for each, >2 consider prescribing antibiotics (phenoxymethylpenicillin)
Tonsillitis management
In 2nd week of illness as won’t show up on test be
• Bloods: FBC, CRP, LFTs, Glandular Fever screen (Monospot test/
Paul Bunnell test)
• If symptoms are severe e.g., dysphagia and fevers consider:
If GF THEN no contact sports or alcohol for 3/12
• IV fluids
• IV antibiotics (not amoxicillin)
Why?
• IV steroid
• Re-assess in 12-24hrs

[Link]
Quinsy
• Also known as peritonsillar abscess is a collection of pus in the peritonsillar space
• Commonly occurs as a complication of bacterial tonsillitis (GABHS or haemophilus
influenzae)
• Signs + symptoms: Trismus, ‘hot potato’ voice, uvula deviated inferiorly
• Clinical diagnosis, can consider using intraoral ultrasound
• Needs urgent ENT review
• Mx: needle aspiration/ incision and drainage
• IV abx (e.g. penicillin and metronidazole) + IV steroids (e.g. dexamethasone 6.6mg)
• Beware pus extending into retropharyngeal space as can lead to a deep neck abscess

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Otitis media
Acute otitis media is inflammation of the middle ear, usually due to infection
90% of children will have an episode by 2years of age
Infection usually viral and tracts from nose or pharynx via Eustachian tube into the middle ear (more
common in children as tube is shorter, wider and more horizontal +immature immune response)
Causative organisms: BACTERIAL: Haemophilus influenzae, Strep pneumonia, Moraxella catarrhalis
VIRAL: Respiratory Syncytial Virus, (RSV), rhinovirus, adenovirus
Presentation: otalgia, fever, deafness, bulging red tympanic membrane on otoscopy
purulent discharge (when tympanic membrane perforates)
Diagnosis: clinical
Management: analgesia
Same as for infective exacerbation of COPD
antibiotics (only if severe unresolving infection)
surgery if complications arise
Otitis media admissions…
NICE advise the following patients should be admitted for
treatment:
•People with a severe systemic infection.
•People with suspected acute complications of acute otitis
media (AOM), such as meningitis, mastoiditis, intracranial
abscess, sinus thrombosis or facial nerve paralysis.
•Children younger than 3 months of age with a temperature
of 38°C or more. 

In addition NICE advise admitting:

•Children younger than 3 months of age. 
•Children 3–6 months of age with a temperature of 39°C or
more.
[Link]
 If you can feel the mastoid
bone, it’s probably not
mastoiditis as it is an abscess.
Mastoiditis You should feel the red
swelling is bulging and
fluctuant

• A potentially life-threatening infection of the mastoid air cells

• Signs + symptoms: pain, swelling, and erythema behind the affected
ear, systemic upset
• Assess for sepsis/ intracranial spread
• IV analgesia, fluids, antibiotics
• Keep patient nil by mouth (as may need surgery)
• CT temporal bones +/- brain (discuss with seniors)
• May require cortical mastoidectomy
[Link]/articles/coalescent-mastoiditis
 Ophthalmic artery Internal caroti

Epistaxis
• ABCDE
• Sit upright
Maxillary artery
External carotid
• Pressure over cartilaginous part of nose
• Suction Facial artery

• Thudichum nasal speculum to inspect

• If still bleeding – what next??

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 Epistaxis cont…

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[Link]/2014/07/17/epistaxis-management-in-the-ed/ [Link]
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Interesting aside
Endolymph production from the stria vascularis requires melanocytes
Pigment disorders (e.g. albinism) and deafness are associated
Dalmatian dogs (extensive albino patches) are hard of hearing

[Link]
Foreign bodies
• An extremely common emergency presentation to ENT
• Site: external auditory canal, nasal cavity, airway
• Seen in: young children, people with learning difficulties, patients
with psychiatric conditions
• Also seen in elderly and those with oesophageal disorders
• Needs to be removed immediately if:
• Ear/nose – button battery, inorganic materials
• Throat – anything in the airway
[Link]
 Foreign bodies cont…
• Hx
• Ear – ask about any pain or discharge from the ear. Also any hearing loss
• Examine with otoscope
• Nose – ask about issues with breathing. Also any nasal discharge
• Head torch + age appropriate Thudichum speculum
• Ingested foreign bodies – clarify what the object is: sharp (fish bone), soft (cooked meat).
Dysphagia
• Head torch + Lack’s tongue depressor
Mediastinal widening is a red flag on CXR why?
• Flexible nasal endoscopy
• Plain film radiograph of lateral soft-tissue neck + chest
• If still high suspicion but not shown on imaging - perform CT neck (sensitivity near 100%)

[Link]/safe-nasendoscopy-starts-snap [Link]
Ears
Throat
Red flags for foreign bodies
• Any sign of airway compromise, such as stridor, dysphonia,
drooling
• Any sign of oesophageal perforation, such as chest pain, features
of sepsis, or surgical emphysema
• Any history of button battery ingestion

Request senior help immediately if any of the above are present

MCQ 1
A 4-year-old is brought to the general practitioner by her mother. She has been distressed with ear pain for the past 14
hours. She is constantly touching and pulling at her ear. Whilst she is sat in the waiting room her mother notices a
discharge of foul-smelling fluid from the ear, following which the pain resolves.
What is the most likely diagnosis?

- Vestibular schwannoma/ acoustic neuroma

- Otosclerosis
- Preauricular sinus
- Acute suppurative otitis media
- Cholesteatoma
- Long standing perforation of the pars tensa
- Otitis externa
MCQ 2
• You see a 22-year-old female in A&E with a relatively light nosebleed that started 20 minutes ago.
This is the first episode she has encountered and she is otherwise well. Routine bedside observations
are normal and blood tests have been sent to the laboratory. Her venous blood gas shows a Hb 131.
She is yet to try any measures to stop the bleeding and so you advise conservative manoeuvres.
Which of the following best describes this?
- Pinch the bony part of the nose, breath through the mouth, for 15-20 minutes
- Pinch the bony part of the nose, breath through the mouth, for one hour
- Pinch the cartilaginous part of the nose, breath through the mouth, for 15-20 minutes
- Pinch the cartilaginous part of the nose, breath through the mouth, for one hour
- Avoid any nasal pressure
MCQ 3
• Which of the following is not part of the Centor criteria?
- Tonsillar exudate
- Tender anterior cervical lymphadenopathy or lymphadenitis
- Attend rapidly (within 3 days after onset of symptoms)
- History of fever (over 38°C)
- Absence of cough
MCQ 4
• Which of the following is a non-suppurative complication of GABHS
tonsillitis?
- Quinsy
- Acute sinusitis 
- Acute otitis media
- Conjunctivitis 
- Acute glomerulonephritis
MCQ 6
• A 5 year old boy presents to the GP with 5 days of high fever and ear pain. He has been unwell for several days with fever, irritability and
cough. He was originally seen in an urgent care centre who diagnosed him with acute otitis media and was told to take paracetamol and
ibuprofen as necessary for the fever. Despite these measures, symptoms have continued. This morning he vomited several times and his
father is very concerned. He’s not managed any oral intake over the last 12 hours. He has no significant past medical history and does not
take any regular medications. He met all his developmental milestones and attends reception class at the local primary school. On
examination, the left tympanic membrane appears inflamed and bulging. The GP notices mild displacement of the left ear and palpation
behind the ear elicits pain and crying.

• What is the most likely diagnosis?

- Acute meningitis
- Bacterial pneumonia
- Otitis media with effusion
- Acute mastoiditis
- Perforation of tympanic membrane
MCQ 7
• A 3-year-old child presents with unilateral nasal discharge for 2 days.
What is your most likely differential?
- Septal perforation
- Nasopharyngeal carcinoma
- Foreign body
- Rhinitis
- Trauma from nose picking
MCQ 8
• What is the most common cause of stridor in children?
- Laryngomalacia
- Croup
- Epiglottitis
- Bacterial tracheitis
- Anaphylaxis
Thank you!
Any questions, drop me an email – hlafeene@[Link]

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