Last week we had an ENT sim, lead by our always helpful ENT colleagues, focusing on 4 ENT emergencies we should all be familiar with:
- Auricular hematoma
- Peritonsillar abscess
While about 60% of the population will experience epistaxis, less than 10% will seek medical attention.
When it comes to epistaxis, it is important to fist understand the anatomy. The majority of nosebleeds will be anterior bleeds, meaning bleeding from the anterior portion of the septum, in a watershed area called Little’s area or Keisselbach’s plexus, supplied by branches of the ethmoidal artery, sphenopalatine artery and superior labial branch of the facial artery.
The first thing you want to ask yourself when it comes to epistaxis is: is this a life-threatening bleed? Usually, in the absence of trauma or recent surgery (le Forte procedures, etc.), the answer is no. When you have determined that the epistaxis is not life threatening, you can take a stepwise approach to controlling the bleeding.
First you want to start with the basics: holding pressure. This may seem straightforward, but you need to make sure to educate your patients on the proper way to hold pressure. Have your patient first blow their nose, to remove any clot burden. You can then use Afrin (oxymetazoline, a vasoconstrictor) spray in the nare. Then firm pressure must be applied with the alae held tightly against the septum. A good trick is to tell the patient “hold your nose as if there were a bad smell in the room”. Pressure must be constant for at least 10-15 minutes.
Some common mistakes:
- Holding pressure over the nasal bones (no pressure is actually applied against the septum)
- Letting up pressure every couple minutes to “see if it stopped”
If bleeding is persistent, you can try to control the bleeding with chemical cautery, silver nitrate. You must first ensure that you have a good view of the source of the bleeding using a nasal speculum and adequate lighting. After the septum has been anesthetized with 4% lidocaine or lidocaine with epi, you should apply the tip of the silver nitrate stick to a small area surrounding the source of the bleeding, beginning at the periphery and working your way towards the center of the bleeding. You should take caution to avoid cauterizing large areas and remove excess silver nitrate with a cotton swab when finished. You should never cauterize both sides of the septum as you are putting the patient at risk for tissue necrosis, septum ulceration and perforation.
If cautery is unsuccessful or if you cannot visualize the source of the bleeding, you can use nasal packing to tamponade the bleeding. At Rush, we have two types of nasal packing, the rhino rocket (nasal tampon) and the rapid rhino (nasal balloon catheter). As before, when using either of these, you should make sure the patient blows their nose and the nare is pre-treated with a vsoconstrictor (afrin).
The Rhino Rocket is a nasal tampon that is easy to use and effective. The rhino rocket is inserted by sliding the tampon along the floor of the nasal cavity until the entire tampon lies within the nasal cavity. The tampon will then absorb any moisture or bleeding and expand to cause tamponade.
The Rapid Rhino is a nasal balloon catheter coated in a carboxymethylated cellulose mesh. This catheter must be soaked in sterile water (NOT saline) for 30 seconds prior to insertion, making it slick and easier to insert. The balloon must then be inflated with 20cc of air, NOT water or saline as they can cause too much pressure on the tissues and lead to tissue necrosis.
If bleeding stops with with of these forms of nasal packing and the patient is stable with normal vitals, they can be safely discharged with close ENT follow up within 24-48 hours and strict return precautions if bleeding recurs. If nasal packing is prolonged (>72 hours), patients are at increased risk of complications, including necrosis, toxic shock syndrome, sinus infections and dislodgement.
It a patient has a posterior bleed or a life threatening bleed, you can try to tamponade the bleeding with a device such as the Epistat, with both anterior and posterior balloons. This device should be inserted similarly to the other devices mentiones abo
ve. The posterior balloon should be inflated first, with 5-10cc of air, and then pulled forward until snug. The anterior balloon should then be inflated with 30cc of air. If an epistat is not available, similar results can be achieved using a foley catheter.
Any posterior or life threatening bleeding should have an emergent ENT consult and any patients with posterior packing should be placed in the ICU for monitoring due to the risk of recurrent bleeding resulting in significant blood loss, apnea and hypoxia. There is a postulated nasopulmonary reflex causing changes in pulmonary function secondary to posterior nasal packing, although evidence on this is somewhat controversial.
An auricular hematoma is a collection of blood between the cartilage and pericondrium of the outer ear, usually caused by blunt trauma. Hematoma formation in this tight space disrupts the blood supply to the cartilage and can lead to necrosis and infection of the cartilage, followed by fibrosis and scarring of the ear leading to cosmetic deformity known as cauliflower ear.
To prevent this complication, auricular hematomas must be drained promptly and the perichondrial layer must be re-apposed to the cartialage to restore blood flow to the cartilage. To do this, the following steps must be taken:
- Clean the ear with antiseptic
- Apply local anesthetic or perform an auricular block
- Incise the hematoma along the curvature of the auricle (for best cosmetic purposes) and completely evaluacte the hematoma and any clots that may have formed
- Irrigate the pocket copiously with sterile saline
- Suture the incision closed with a boster on either side of the auricle to reduce the dead space and prevent reaccumulation of blood or fluid. It is important that the bolster is tight enough to hold the tissues together without being too tight and causing additional pressure on the cartilage.
Typically, a dental roll can be used as a bolster (see our sim models). If no dental rolls are available, xeroform gauze is a good alternative. Patients should have follow up with ENT or a plastic surgeon 24-48 hours after drainage of auricular hematomas and patients are generally discharged on a 7-10 day course of antibiotics against staph aureus and pseudomoanas. Bolsters are typically removed after 7 days.
A peritonsillar abscess (PTA) is a collection of pus located between the capsule of the palatine tonsil and pharyngeal muscles. This generally occurs in the superior pole of the tonsil and is usually preceded by tonsillitis or pharyngitis that progresses from cellulitis to abscess formation. PTA is the most common deep neck infection in children and adolescents.
Patients usually present with sore throat, fever, “hot potato” or muffled voice, and trismus. On exam you will see an extremely swollen tonsil/posterior soft palate with fluctuance and deviation of the uvula to the opposite side. Bilateral PTAs are rare. Intraoral or submandibular ultrasonography can be used to confirm PTA with good sensitivity (89-100%), however this is user dependent and often can not be used to guide your needle for aspiration given limited intraoral space, especially in a patient with trismus.
If a PTA is large enough to cause impending airway compromise or the patient has significant comorbidities or is immunocompromised, etc, it is good to get ENT involved early for prompt surgical intervention. If the patient is stable, you can attempt aspiration or incision and drainage in the ED.
The following steps should be taken for aspiration or drainage of the PTA:
- Apply anesthetic: topical anesthetic spray, along with 1-2mL of lidocaine with epi into the anterior tonsillar pillar
- If aspirating:
- Cut the distal tip off the needle sheath of an 18 gauge needle to expose only 1cm of the needle to avoid inserting your needle too deep (carotid injury is always a concern, although rare)
- Aspirate with 18 gauge needle (good rule is to start superior, may need to do additional aspiration inferiorly)
- If incising and draining:
- Use an 11 or 15 blade scalpel
- You can similarly cut the distal tip of the blade sheath to avoid incising too deep (do not penetrate more than 1cm)
- Make a horizontal and a vertical incision to allow adequate space for drainage of pus
Some helpful tips:
- Have the patient hold the suction themselves and apply as needed
- You can use a laryngoscope in place of a tongue blade, that gives the added benefit of an additional light source
Once the PTA is adequately aspirated or drained, the patient should be placed on antibiotics. PTAs are usually polymicrobial, and you should cover for streptococcus species, anaerobes, Eikenella and H. influenza. First line is generally Augmentin 875mg po BID x 7-10d. If pt is requiring admission for IV antibiotics, you can start with Unasyn. Steroids may additionally be given to decrease he duration and severity of pain, generally methylprednisolone 125mg IV x 1 or dexamethasone 10mg PO/IM x1.
Patients with stable vitals and no concern for airway compromise can be safely discharged from the ER. If it is a first time PTA in an otherwise healthy patient, you can have them follow up with ENT only as needed. If your patient has a recurrent PTA, recurrent tonsillitis or other complicating factor, encourage prompt follow up with ENT.
For our last ENT emergency sim station, we practiced cricothyrotomies. We all know the indication for an emergency cricothyrotomy: can’t intubate, can’t ventilate. Instead of boring you with the details of the procedure, here is a link to a video of the procedure taught by Scott Weingart:
It is important to note that needle cricothyrotomies (transtracheal ventilation using a 14 gauge needle) are preferred in children less than 10 years of age due to the difference in their airway anatomy. This is due to the fact that the airway of a child is funnel-shaped, with the narrowest part at the cricoid ring rather than at the vocal cords. This increases the risk for developing subglottic stenosis following a cricothyrotomy.