Edited by Peter Cameron Sashi Kumar Emergency presentations for ear, nose and throat (ENT) problems are common and all emergency physicians need to be familiar with the basic skills required for assessment and management of these problems. Foreign bodies in the ear are most common in children under the age of 5 and in mentally handicapped adults. Animate objects, such as insects in the ear, can affect all ages, especially adults who enjoy the outdoors, particularly at dusk. Accidental foreign bodies, such as the end of a cotton bud or a matchstick, occur in people obsessed with cleaning their ears with such objects. Two simple rules in managing foreign bodies in the ear are: This is a true ENT emergency. The insect should be killed as a matter of urgency, as considerable damage is being done to the sensitive skin of the bony meatus and the tympanic membrane by the flapping wings and appendages of the desperate insect trying to escape. The movement of the insect also causes intense pain and tinnitus, thereby creating further anxiety and distress. Any liquid used to kill the insect should be carefully chosen so as to avoid damage to the sensitive skin and tympanic membrane: strong corrosive agents, knockdown spray or alcohol should be avoided. The common agents of choice are lignocaine 2%, olive oil, water for injection or normal saline. One of the preferred methods is to instil some water for injection from a 10 mL plastic ampoule and leave an examination light on the pinna. The insect swims up to surface towards the light and can be helped to safety by holding the tip of the ampoule [1]. Removal of a foreign body in a child or a mentally handicapped adult may be done in one of two ways. The patient is either cooperative and unrestrained or fully restrained. It is vital not to attempt any procedure with partial restraint, as any movement of the patient during the attempt could cause trauma to the ear canal and the tympanic membrane. There are two techniques used to remove a foreign body. The dry method is by using a Jobson Horne probe for solid objects, such as beads, or alligator forceps for an insect or a cotton bud. The wet method is by syringing the ear canal with tepid water. The water should be close to body temperature to avoid a caloric effect, which produces nystagmus and vertigo. The key to success is good lighting, preferably through a head lamp, a cooperative or fully restrained patient and a patient, gentle approach by the clinician, who knows when to stop if unsuccessful. Impacted hard cerumen or wax causes pain and hearing loss. Sudden onset of hearing loss after a swim is classical of impacted ceruman as the wax swells up when in contact with water. A 3–5-day course of Waxsol or Cerumol ear drops 3–5 drops three times a day followed by syringing of the ear canal with warm water should clear up the ear canal. Trauma to the ear canal requires the ear to be kept dry for about a week with antibiotic ear drops for 4–5 days in severe cases to avoid progressing into otitis externa. Penetrating trauma can cause perforation of the eardrum and, occasionally, disruption of the ossicular chain. Dislocation of the footplate of the stapes following such an injury can cause permanent sensorineural hearing loss. Referral to an ENT specialist is essential in all cases of traumatic perforation with suspected ossicular chain disruption. Boxing and other contact sports can lead to blunt trauma to the pinna. Accumulation of blood under the perichondrium, if not treated properly, may progress to cartilage necrosis and the end result is a ‘cauliflower ear’. A slap on the ear can also produce a ruptured tympanic membrane with or without ossicular chain disruption. Assessment of the injury includes a clinical assessment of the hearing loss. A ruptured eardrum without ossicular chain disruption does not usually cause a significant hearing loss. Any evidence of nystagmus or tinnitus suggests damage to the inner ear. A simple traumatic perforation of the eardrum is managed by simple analgesics and keeping the ear dry. On no account should any drops or water be allowed into the ear, as this may precipitate otitis media. If ossicular chain disruption or inner ear trauma is suspected, an urgent ENT opinion is required to assess the need for urgent tympanotomy and repair. Haematoma of the pinna requires urgent release of the accumulated blood by aseptic incision and drainage and the immediate application of a firm mastoid bandage, to prevent reaccumulation, and this should be left in place for up to a week. The patient should be placed on broad-spectrum antibiotics to prevent infection. Infection of the external ear is common and affects between 3 and 10% of the patient population [2]. It can be localized (furuncle) or diffuse. The symptoms are pain, itching and tenderness to palpation, followed by aural fullness, hearing loss and discharge. The common pathogens responsible are Pseudomonas aeruginosa, Proteus spp. and Staphylococcus aureus[3]. The diagnosis is usually self-evident, but the diagnostic signs of otitis externa are tragal tenderness or pain on pulling the pinna. This is a disease of the cartilaginous ear canal, with swelling and discharge causing occlusion of the meatus. It may be extremely painful to pass the ear speculum and often the tympanic membrane is not able to be visualized. The most important step in the treatment is thorough and atraumatic cleansing of the ear canal [4]. Tolerance and cooperation between the patient and the clinician is vital. Pope Otowick (Xomed) is very useful in the management of this condition. This is a semirigid foam wick that, when inserted into the ear canal, swells, absorbing moisture to increase the size of the ear canal. Topical otic drops, such as Sofradex (Roussel), are used three to four times a day and the patient is reviewed on a daily basis to change the wick and continue the ear toilet. Occasionally, oral antibiotics, such as ciprofloxacin or flucloxacillin, may be required [5], particularly if there is evidence of cellulitis. The patient is advised to keep the ear clear of any water. Strong analgesics are usually required. Fungal otitis externa (otomycosis) tends to be not that painful and is treated with ear toilet as described and topical antifungal ear drops, such as Loco corten vioform. Acute otitis media is a common infection and is due to blocking of the eustachian tube (eustachian catarrh) and negative pressure in the middle ear cavity. Although viral in origin, secondary bacterial infection often supervenes. The most frequently isolated pathogens are Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis[6]. The symptoms are earache, fullness, hearing loss and fever, with ear discharge if the drum has perforated. The development of discharge usually marks an improvement in the pain and fever. The clinical findings vary from a retracted dull eardrum to a congested bulging drum or a white eardrum with pus behind and a perforated tympanic membrane with discharge in the ear canal. A perforated eardrum without much pain is usually a sign of chronic otitis media. Treatment is almost always empiric and amoxicillin is a good first-line therapy. Cephalosporins and trimethoprim/sulpha are also used with considerable success. The newer macrolides, such as azithromycin and clarithromycin, are rational alternatives [6]. In otitis media with a perforated eardrum, the mainstay of treatment should be toilet by dry mopping followed by antibiotic drops, such as Sofradex. The ear should be kept dry and regular follow up arranged until the perforation has healed. Acute labyrinthitis usually has cochlear symptoms, such as hearing loss and tinnitus, which should be referred for audiometry and urgent ENT evaluation. If the symptoms are limited to vertigo and nystagmus, it is more likely to be due to acute vestibular neuronitis. The management of labyrinthitis includes bed rest, antiemetics, e.g. prochlorperazine, benzodiazepine, e.g. diazepam, and admission if severely debilitating. In the presence of hearing loss, a course of oral steroids or intratympanic dexamethasone may be started after discussions with the ENT surgeon. This is most common in children in developed countries. The symptoms are fullness and hearing loss and, occasionally, pain. Management includes the diagnosis based on history and examination, which reveals a dull, retracted drum or fluid behind the drum without redness. The most reliable sign of a glue ear is an immobile eardrum on Valsalva manoeuvre or pneumatic otoscopy. Repeated attacks of glue ear are an indication for the insertion of tympanostomy tubes. Acute mastoiditis is a complication of acute or chronic otitis media. It is a rare condition in the developed world, although still quite prevalent in the developing world and the Aboriginal population of Australia. Otitis externa with a painful and tender postauricular lymph node is usually mistaken for acute mastoiditis due to the postauricular tenderness. Extension of infection can cause meningitis or temporal lobe abscess, with life-threatening complications if untreated. Examination reveals infection in the middle ear cavity by way of an injected drum or a perforated drum with discharge. The cardinal sign of acute mastoiditis is tenderness at the base of the mastoid on digital pressure. The diagnosis is confirmed by computed tomography (CT) scan. Admission, intravenous antibiotics and surgical intervention, such as mastoidectomy, to remove the infected mastoid air cells and drain any abscess collection. A foreign body in the nose is common in preschool children and adults with mental retardation. The most common types of foreign body are beads, buttons and pieces of paper. The diagnostic sign of a neglected nasal foreign body is a unilateral foul-smelling nasal discharge. The patient or the parent usually provides the history as to the type of foreign body and for how long present. The removal of the foreign body follows the same rules as for a foreign body in the ear. An additional method is to blow forcefully through the patient’s mouth while occluding the unaffected nostril. This could be done by the parent with instruction. The suggested method of removal is to pass the ring end of a Jobson–Horne probe above and behind the foreign body and to roll it along the floor of the nose. The patient should be cooperative and unrestrained, or fully restrained. At the first sign of trauma or bleeding, removal should be organized under general anaesthesia as soon as practically possible. This is a common presentation in the emergency department. The history is often quite clear and the findings include pain and tenderness over the nasal bones with or without crepitus and swelling at the bridge of the nose with or without epistaxis. Careful examination will usually rule out CSF rhinorrhoea due to cribriform plate fracture and any external deformity. Active bleeding from the nostril should be controlled by direct pressure by pinching the nostril; if it does not settle it may require nasal packing. Radiographs are not indicated for nasal bone fracture as this is a clinical diagnosis. It is often difficult to visualize the fracture line on the X-rays and radiographs do not help in the management. If associated facial fractures are suspected, X-ray facial views or CT scan should be taken. Acute intervention is required in the following circumstances:
ENT Emergencies
18.1 Ears, nose and throat emergencies
The ear
Introduction
Foreign body
Management
Removal of a live foreign body
Impacted cerumen
Trauma
Blunt trauma
Assessment
Management
Infection
Otitis externa
Management
Otitis media
Management
Labyrinthitis
Management
Otitis media with effusion (glue ear)
Mastoiditis
Management
The nose
Foreign body
Management
Trauma
Fractured nose
Management
Continuing epistaxis should be managed along the lines described later.
CSF rhinorrhoea requires a CT scan and neurosurgical referral.
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