Otolaryngology
17.1 Barotrauma
Blast Injury
Cause: Direct blows to the external ear with pressure wave damage to the tympanic membrane; closed space bomb explosion (Am J Otol 1993;14:92); rapid changes in atmospheric pressure as seen in non-pressurized aircraft, SCUBA diving (Ear Nose Throat J 1999;78:181,186) or hyperbaric (dive) chambers (Undersea Hyperb Med 1999;26:243).
Epidem: Common in SCUBA divers, with pulmonary barotrauma seen in those with lung cysts or end-expiratory flow limitation (Thorax 1998;53:S20).
Pathophys: Rapid changes in pressure can cause systemic effects from higher to lower pressure gas phase shifts. Association with closed space bomb explosion conveys significant injury possibilities for pt. Middle ear (TM) perforation benign in SCUBA diving, but inner ear perforation can lead to inner ear dysfunction problems such as hearing loss, dizziness, tinnitus, and vertigo.
Sx: Ear pain, sinus pain, chest pain, difficulty breathing, abdominal pain.
Si: TM perforation is both sensitive and specific for barotrauma— unless Valsalva or other pressure-equalizing phenomenon has
occurred, including myringotomy tubes. Hypesthesia in the infraorbital area on ipsilateral maxillary barotraumas (Undersea Hyperb Med 1999;26:257). Also look for sc emphysema, subconjunctival hemorrhage, absence of breath sounds over usual lung fields, lack of bowel sounds with peritoneal signs—perforation.
occurred, including myringotomy tubes. Hypesthesia in the infraorbital area on ipsilateral maxillary barotraumas (Undersea Hyperb Med 1999;26:257). Also look for sc emphysema, subconjunctival hemorrhage, absence of breath sounds over usual lung fields, lack of bowel sounds with peritoneal signs—perforation.
Crs: Extremely variable, with full spectrum of simple TM perforation to multiple organ breaches—lung, bowel, skin.
Cmplc: Deafness, respiratory failure, peritonitis.
Lab: None for isolated ear trauma; CBC with diff, BMP and UA to guide fluid therapy in SCUBA accidents; multisystem trauma evaluation for bomb explosions.
Emergency Management:
Isolated TM rupture:
Antibiotic ear drops, either corticosporin otic suspension (not solution) or gentamicin ophthalmologic drops, eg.
Follow-up with primary physician in 2 wks, perforation needs to be followed until closed. Perhaps patching/hyaluronan by ENT (Acta Otolaryngol suppl 1987;442:88).
No SCUBA diving, surface diving, or swimming deeper than 3 feet in water—use earplugs when swimming until healed.
SCUBA accident:
Iv fluid, resuscitation guided by hematocrit and urine specific gravity.
Refer to hyperbaric chamber.
Bomb or other environmental explosion (Toxicology 1997;121:17):
Trauma resuscitation, with trauma or general surgery consult.
17.2 Epiglottitis
Cause: Haemophilus influenzae, type B usually in adults, rarer now in the immunized child; Staphylococcus, pneumococcal disease, rarely other type strep. Rarely due to thermal injury (Peds 1988;81:441).
Epidem: Now more common in adults with HIB vaccine in peds; mortality rate 1.2% (Laryngoscope 1998;108:64).
Pathophys: Obstruction of upper airway by edematous epiglottis.
Sx: Extremely sore throat (95%), more than the dysphagia (94%), plus respiratory distress over 6-24 hr—mainly in peds.
Si: Epiglottis or other supraglottic structures inflamed and edematous by direct or indirect laryngoscopy, need to sit erect (21%), muffled voice (54%), fever (50%), drooling (40%), stridor (15%) (Am J Dis Child 1988;142:679); pharynx is often normal (50%).
Crs: Lingual cellulitis; lingual abscess (Am J Emerg Med 1998;16:414).
Cmplc: Sudden and unpredictable airway obstruction, 7% mortality without prophylactic airway (vs recognition of event); decreases to 1% with airway placed.
X-ray: Soft tissue lateral neck looking for abnormal soft tissue swellings with or without air/fluid levels; look for swollen epiglottis (thumb sign) with loss of air in the vallecula (Ann EM 1997;30:1).
Emergency Management:
Do not startle children, perhaps blowby O2.
Unknown value of racemic epi nebulizer (Anesth Analg 1975;54:622).
Iv access in adults and cooperative children.
Ceftriaxone 1-2 gm iv (J Paediatr Child Hlth 1992;28:220) (third generation cephalosporin).
Equivocal, but advocate for use of iv steroids (methylprednisolone 125 mg or dexamethasone 15 mg) (J Ped Surg 1979;14:247).
Early airway in operating theater is controversial, even in peds.
17.3 Epistaxis
Cause: Bleeding from nare(s) may be due to trauma externally such as nasal fracture, direct mucosal trauma, foreign body in nare, sinusitis, cocaine use, HT, thrombocytopenia, carotid artery aneurysm, or bleeding disorder.
Epidem: Common, most resolve with conservative treatment (Otolaryngol Head Neck Surg 1993;109:60); 5% are posterior bleeds, and these are associated with previous epistaxis and HT (Ann EM 1995;25:592). Medical issues/habits associated with persistent bleeds are HT, aspirin use, and alcohol abuse (Arch Otolaryngol Head Neck Surg 1988;14:862).
Pathophys: Exposed vessel bleeding are those that usually come to medical attention, or those with extensive mucosal involvement or hematologic/bleeding disorders.
Si: Look for blood running down pharynx with patient head neutral, with noted blood suggestive of posterior bleed—if head has been rested back, then blood in posterior pharynx will not help distinguish anterior from posterior bleeds; check the septum for perforation; multiple petechiae or ecchymoses to implicate systemic process; co-incident hemotympanum (J Emerg Med 1988;6:387).
Crs: ENT consult for repetitive, uncontrollable, or briskly flowing anterior bleeds, and all posterior bleeds.
Cmplc: Anemia, hypoxia, bleeds elsewhere, if systemic problem; sinusitis, if packing or other obstructive method used as treatment.
Lab: If elderly, with multiple medical problems, significant bleed, or anticipating admission, consider ordering—CBC with diff; PT/PTT; and/or Type and screen (J Laryngol Otol 1999;113:1086; 2000;114:38)
Emergency Management:
All bleeds:
Pinch nose below bridge; ice over nose.
Head forward slightly (neck flexed).
Trial of oxymetazoline HCl 0.05% (Afrin) nasal spray, most will resolve with this and pressure alone (Ann Otol Rhinol Laryngol 1995;104:704).
Address HT if needed, with either acute treatment, or follow-up with primary physician for treatment; HT is a ubiquitous problem in those with spontaneous bleeds (Ann EM 2000;35:126).
If a brisk bleed:
Soak cotton ball with cocaine 4% or oxymetazoline HCl 0.05% (Afrin) nasal spray, and place in nare that is bleeding— if bleeding stems, this is an anterior bleed. Then pinch nose for 10 min.
If bleeding does not stem, follow posterior bleed instructions.
Anterior bleeds:
Pack with Vaseline gauze, Merocel pack, Gelfoam, or Surgicell—packing goes smoother if viscous lidocaine, instead of surgilube, is used to facilitate insertion.
Trial of cautery if able to get clear site, may use silver nitrate.
Trial of microfibrillar collagen (J Otolaryngol 1980;9:468), if able to get clear site. Hold pressure for 3 min once collagen placed over site.
Use nasal drops as needed to keep packing moist and to stem bleeds.
Pack out in 1-2 d, 3 d at the most.
Keep in cool environment. Avoid bending and straining. Hold nose if sneezing, and expel force through the mouth.
Posterior bleeds:
Posterior pack, with viscous lidocaine for insertion. Single balloon packs with a procoagulant sleeve effective (Rapid Rhino).
Dual balloon packs: Inflate distal balloon first, then proximal balloon—do only 1/2 the amount of balloon capacity, and add more if needed (J Oral Maxillofac Surg 1982;140:317).
Foley catheter may be used if posterior pack is not available (Surg Neurol 1979;11:115); perhaps umbilical cord clamp at external nares to secure position (J Otolaryngol 1996;25:46).
O2 if hypoxic; antibiotic prophylaxis for sinusitis, such as cefazolin 1 gm iv.
ENT consult for admit if pt requires hemorrhage control, pain control or if hypoxic.
Thrombocytopenia:
Transfuse platelets if < 50K and symptomatic (epistaxis counts).
17.4 Foreign Bodies (FB)—Nasal, Aural, Pharyngeal
Cause: Usually volitional, rare bug.
Epidem: Usually children 2-4 yr of age.
Crs: To operating theater with ENT, if unable to remove.
Cmplc: Pharyngeal FBs may be aspirated; aural FBs may cause a perforation; batteries cause tissue destruction (Jama 1986;255:1470).
Lab: Suspected pharyngeal FB should have radiographs if not visible on exam—soft tissue neck, CXR, if necessary, and AXR, if necessary.
Emergency Management:
Nasal (Am J Emerg Med 1997;15:54):
Have pt occlude contralateral nare while closing mouth and forcing air out of occluded side.
Variation: Have parent give puff of air in child’s mouth while holding unaffected nare closed, or use Ambu-bag (Practitioner 1973;210:242; Am J Emerg Med 1996;14:57).
Try to grasp with smooth forcep—4% cocaine pre-procedure may help.
Crazy Glue on small stick (cotton swab) and touch object—wait a few minutes and then remove.
Five or six French balloon catheter lubricated with 2 or 4% lidocaine, snaked past the FB, inflated, and withdrawn (Ann EM 1980;9:37).
Aural:
Mineral oil or lidocaine instilled to “kill” potential bug is not advocated—may have unrecognized TM perforation, and sterile saline works just as well.
Try smooth forcep delivery.
Locate object with otoscope, sit right on top of it with ear speculum (disposable), open magnifying end and place wood stick (cotton swab) with crazy glue inside of speculum and “marry” object to stick and speculum, wait a min, and remove.
Flushing may work—stop if any pain, and do not try if noted TM perforation.
Dark room/light usually does not work for insects—cannot turn around.
Pharyngeal, visualized:
If easy to reach and pt cooperative, remove object.
If infant, turn infant head down, extend neck, and finger sweep to remove visualized object.
Pharyngeal, non-visualized (with x-ray):
If object not found, may be radiolucent or abrasion in pharynx from FB—if symptoms still present next day, follow-up with ENT if no airway compromise.
17.5 Otitis Externa
Cause: Allergic; seborrheic; infectious (J Otolaryngol 1984;13:289): bacterial (Staphylococcus spp., Pseudomonas spp.) most common, fungal—aka Otomycosis (Aspergillus niger)—if chronic, viral is rare (H. simplex, H. zoster).
Epidem: Bacterial is most common. Bacterial/fungal—Swimmer’s Ear. More common in those with allergies or prolonged water exposure, not with local trauma (J Laryngol Otol 1993;107:898).
Pathophys: Bacterial—local furunculosis that then becomes more diffuse.
Sx:
Allergic: 1 + pain, 3 + itching.
Seborrheic: 1 + pain, 1 + itching.
Bacterial: 3 + pain, especially with movement of pinna.
Fungal: 1 + pain, 3 + itching.
Viral: 1 + pain with H. simplex; 3+ pain with H. zoster.
Si:
Allergic: Acute with weeping small vesicles; chronic with fissures and scales.
Bacterial: Pain with pressure on tragus and pinna traction; erythema and edema (stenosis) of external ear canal.
Seborrheic: Greasy scales; dandruff.
Fungal: Looks like wet newspaper; black discharge is diagnostic.
Viral: Vessels in ear may rupture, or form hemorrhagic bullae.
Crs: Variable.
Cmplc: Bacterial may go onto malignant otitis externa, a severe form of perichondritis, now only a problem in pts with resistant organisms or diminished resistance, eg, in pts with diabetes, cancer, AIDS, etc.
Diff Dx: Mastoiditis.
Lab: Consider culture of drainage, especially if chronic.
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