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ENT emergencies in primary care



Consultant ENT surgeons Mr Abir Bhattacharyya and Mr Nitesh Patel, along with clinical ENT fellow Dr Nancy Grover, advise on management of common ENT emergencies and which conditions need urgent referral

ENT emergencies are some of the most common emergencies presenting in general practice. They can range from life-threatening airway emergencies – where a split-second decision by the GP can save a toddler from choking to death – to other not-so-urgent conditions, like an object in the ear.

Ear emergencies

Foreign bodies in the ear

These are most common in school children. The usual presenting symptoms are ear discomfort, pain, ear blockage and, if the foreign body is organic or long-standing, discharge from the ear.

For organic objects such as living insects, mineral oil should be poured into the patient’s ear. Do not syringe if the foreign body is a non-living organic object or vegetable matter, as they will swell and become tightly impacted. Non-organic, inert objects (such as plastic beads) need to be removed, but can wait for the next available clinic. But if a patient presents with a button cell battery in the ear, they should be referred urgently, but do not syringe. This must be removed as soon as possible because batteries can cause significant damage.

Any patient should be referred if there has been more than one unsuccessful attempt at removal, if there is prolonged impaction or if the object is spherical and proper equipment is unavailable.

Practical tip

• Cotton wool impregnated with cyano-acrylate glue is helpful for spherical objects.

Auricular haematoma

Auricular haematoma is a collection of blood between the cartilage and perichondrium of the pinna, which is usually caused by blunt trauma. If it is left untreated, there is a risk of thickening and deformity of the pinna due to cartilage necrosis with subsequent scarring and fibrosis (the classic ‘cauliflower’ ear).

When there is a fluctuant swelling of the pinna, especially after trauma or sporting injury, auricular haematoma should be suspected. Look out for an organised haematoma if there is late presentation after one week.

The haematoma requires drainage under aseptic conditions to avoid introducing secondary infection – refer urgently to the on-call ENT service. Patients should be warned there is a risk of deformity.

Perichondritis

Perichondritis is an acutely painful infection of the external ear. This is often caused by direct injury to the pinna, cosmetic piercing of the external ear cartilage, surgery of the external ear or otitis externa. The ear will be extremely tender to touch and even gentle movement of the ear lobe will be very painful.

The most common organism causing perichondritis is Pseudomonas aeruginosa, so treatment with a quinolone antibiotic is recommended.

Once pus strips the perichondrium from the underlying cartilage, vascular supply becomes impaired, resulting in a cartilage necrosis and a ‘cauliflower ear’ deformity. Early treatment can prevent cartilage necrosis. If perichondrial abscess develops, urgent referral for drainage is warranted.

Sudden sensorineural hearing loss

Sudden sensorineural hearing loss is usually a rapid-onset loss of significant hearing – 30 decibels or more below normal within 72 hours – confirmed by pure-tone audiometric tests. This condition has an unknown aetiology and is labelled as being idiopathic in 60% of cases.

The peak incidence is at 50-59 years and about 65% of patients recover spontaneously. It merits urgent referral for assessment, serial audiometry and specialist investigations. An MRI scan, viral titres, syphilis serology, FBC and biochemistry may help in obtaining the diagnosis. Daily audiometric assessment is a valuable prognostic indicator.

Tuning-fork tests should help confirm that this is sensorineural, rather than conductive, deafness. Treatment is empirical and not based on hard evidence; it is aimed at improving cochlear microcirculation.

Steroids, hyperbaric oxygen therapy, antiviral medication and inhalation of carbogen (95% oxygen, 5% carbon dioxide) have all been suggested – the latter for its vasodilatory properties.

Nose emergencies

Epistaxis

Causes can be local (such as trauma, tumour or surgery) or general (such as bleeding disorder, hypertension or anticoagulant use), although most cases are idiopathic. The bleeding is usually described as being anterior (Little’s area on the nasal septum) or posterior in location. Nasal tumours rarely present as epistaxis, but need to be considered if there is blood-stained discharge, recurrent epistaxis and unilateral nasal blockage or pain.

The aims of treatment are to stop the bleeding and manage any known risk factor. Initially, advise the patient to pinch the nose firmly for 20 minutes with the head bent forwards. An ice pack held against the neck can aid vasoconstriction. In recurrent epistaxis, a visible anterior bleeding point can be cauterised with silver nitrate, after application of a topical local anaesthetic.

A patient with uncontrolled or significant bleeding should be referred to hospital for resuscitation and nasal packing, with or without arterial ligation. A suspected tumour should be referred under the two-week wait rule.

Nasal fractures

These are a result of nasal trauma and may be associated with other injuries. Patients commonly present with nasal bleeding, nasal obstruction and nasal deformity.

Septal haematoma or fractured orbital floor (suggested by diplopia) require immediate referral. Document the clinical findings and check for dental occlusion and trigeminal nerve function.

Ideally, the fracture should be reduced immediately after injury while there is minimal swelling, although this is rarely possible. Because swelling is usually inevitable, it is best to assess for deformity after one week.

All fractures should be reduced within three weeks, after which time simple reduction is difficult because of bony fixation.

Practical tips

• Not all fractures merit treatment – undisplaced fractures can be left untreated.

• Always enquire about previous nasal trauma/deformity.

• X-rays are not mandatory.

Nasal foreign bodies

These are most commonly seen in children aged two to six years and are usually found along the floor of the nose and anterior to the inferior turbinate.

The ‘parent’s kiss’ – blowing forcefully into the child’s mouth – is successful in up to 80% of children. Any attempt to remove the object with instruments will potentially distress the child, who may not allow further attempts. Unless experienced and armed with the correct instruments, this is best left to ENT experts.

Septal haematoma

A collection of blood beneath the intact mucoperichondrium of the nasal septum can result in a septal haematoma. This presents as a diffuse soft-tissue swelling causing bilateral nasal obstruction. It may follow nasal trauma or surgery. Overlooking this diagnosis or managing it incorrectly may lead to a septal abscess, or cartilage necrosis with ‘saddle nose’ deformity or septal perforation.

Once a diagnosis of septal haematoma is established you should refer the patient – they will need drainage under a local or general anaesthetic. Appropriate antibiotic cover is essential because there is potential for the patient to develop a septal abscess.

Periorbital/orbital cellulitis

Rhinosinusitis can spread locally to the orbit via the ethmoid sinuses through a thin lamina papyracea, or where there is a direct connection by a nerve or vessel from the frontal or sphenoid bones. Patients usually present with a history of upper respiratory tract infection followed by swelling and redness around the eye.

The aim of treatment is to eliminate the orbital complication and treat the primary rhinosinusitis. Admission is necessary for regular eye observations, intravenous antibiotics and topical nasal decongestants.

Throat emergencies

Quinsy

Peritonsillar abscess, or quinsy, is a collection of pus between the capsule of tonsil and the superior constrictor – usually at the upper pole. It is often a complication of tonsillitis, is unusual in children, and commonly seen in patients in their 30s.

Quinsy starts with unilateral sore throat with mild otalgia, and progresses to trismus, drooling of saliva and odynophagia. The tonsil is pushed medially with a supra/peri-tonsillar bulge. The uvula may be displaced to the unaffected side.

Referral to hospital is necessary for drainage of the abscess – usually under a local anaesthetic, although children and the anxious may need a general anaesthetic. The patient is likely to need IV antibiotics until they can tolerate oral feeds, after which they are discharged home on oral antibiotics.

Practical tip

• Look out for possible complications, including deep neck space infections and mediastinitis, which may compromise the airway, needing ambulance transfer to hospital.

Airway obstruction

Airway obstruction gives rise to noisy breathing. ‘Stridor’ is a high-pitched noise, predominantly inspiratory, caused by turbulent airflow at the level of the larynx or below. ‘Stertor’ is a snoring-like noise produced above the level of the larynx.

Acute obstruction can develop over minutes or hours and is caused either by a foreign body or an accumulation of oedema, pus or blood narrowing the airway. Chronic obstruction develops over weeks or months and is usually caused by a tumour or scarring of the airway.

A brief relevant history should be taken, including onset, progression, associated symptoms and fever. Ascertain the severity based on the patient’s alertness, respiratory rate, respiratory distress and ability to speak in sentences, and determine the site of obstruction (stridor or stertor), since this guides immediate treatment. In an emergency, it is vital that you keep calm and do not agitate the patient. You can administer oxygen, nebulised adrenaline 5ml 1:1,000 and consider hydrocortisone IM.

Airway obstruction should be treated early, as the patient can rapidly deteriorate – acute obstruction requires ambulance transfer to hospital. Chronic obstruction should be discussed with the ENT surgeon.

Mr Abir Bhattacharyya is a consultant ENT surgeon at Whipps Cross University Hospital and Royal College surgical tutor

Competing interests None declared

Mr Nitesh Patel is a consultant ENT surgeon at Whipps Cross University Hospital

Competing interests None declared

Dr Nancy Grover is a clinical and educational fellow at Whipps Cross University Hospital

Competing interests None declared

Causes of sudden sensorineural hearing loss

• Idiopathic
• Common – viral, vascular, trauma
• Ototoxic drugs – aminoglycosides, NSAIDS, loop diuretics, ß-blockers, chemotherapeutic agents
• Rare – acoustic neuroma, perilymp fistula

Quinsy is commonly seen in patients in their 30s Quinsy