CRITICAL ENT!! Andrew H. Murr, M.D. FACS Professor of Clinical Otolaryngology Chief of Service San Francisco General Hospital

Transcription

1 CRITICAL ENT!! Andrew H. Murr, M.D. FACS Professor of Clinical Otolaryngology Chief of Service San Francisco General Hospital Roger Boles, M.D., Endowed Chair in Otolaryngology Education Department of Otolaryngology-Head and Neck Surgery University of California-San Francisco School of Medicine

2 Outline SINUSITIS NOSEBLEED THE SURGICAL AIRWAY NASAL TRAUMA OTOLOGIC EMERGENCIES

3 SINUSITIS 30 MILLION PATIENT VISITS PER YEAR THE MOST COMMON CHRONIC COMPLAINT FOR WHICH A PATIENT SEEKS ADVICE FROM A PHYSICIAN IN THE USA MULTI-BILLION $$$$$ PHARMACEUTICAL INDUSTRY

4 Common Perception: NY TIMES

5 Acute Classic picture: fever, pain, WBC, pus, sick Acute v. Chronic

6 History Frequency, duration, past intervention, effectiveness of intervention Symptoms Nasal congestion, facial pressure, PND, cough Facial Pain~ relatively UNCOMMON!!!! PMH: childhood sinusitis, immunocompromise, triggering events (time of year) PSH: sinus or nasal surgery, dental surgery Medications: Beta blockers, BCP

7 HISTORY COMMON URI FLU SEASONAL ALLERGIC RHINITIS PERENNIAL ALLERGIC RHINITIS VASOMOTOR RHINITIS BACTERIAL RHINOSINUSITIS PREGNANCY SIDE EFFECT OF MEDICATION MIGRAINE TOOTH ABSCESS LESS COMMON SARCOID WEGENERS T CELL LYMPHOMA AML, ETC. SAMTER S NASAL POLYPOSIS FOREIGN BODY IMMUNOCOMPROMISE CYSTIC FIBROSIS ALLERGIC FUNGAL SINUSISTIS CILIARY DYSKINESIA ILLICIT SUBSTANCE USE

8 Document the Disease Process Acute Sinusitis Less than 6-8 weeks of symptomatic infection OR Less than 4 episodes/year 10 days duration AND Complete resolution of mucosal abnormality Chronic Sinusitis 8 weeks of symptomatic infection OR 4 episodes per year 10 days duration AND Mucosal disease on CT scan 4 weeks after Rx

9 Let there be light Nasal speculum examination Flexible nasopharyngoscopy Rigid 30 degree Hopkins rod telescope Physical Examination

10

11 Approach to the patient Rx abi yes Acute no Rx symptoms improved not improved improved stop CT scan appropriate management

12 IMAGING PLEASE!!!!

13 EFFICACY OF PLAIN FILMS OFFICE CT SCAN??

14 Pt. presents with acute sinusitis and swollen eye. You should. 1. A. Sign out immediately 2. B. Prescribe oral antibiotics 3. C. Prescribe IV antibiotics 4. D. Obtain a CT with contrast 5. E. Plain films are best 81% 13% 1% 4% 1% A. Sign out immediately B. Prescribe oral antib... C. Prescribe IV antibi... D. Obtain a CT with c... E. Plain films are best

15 Just another weekend on top of the Golden Gate Bridge

16 EPISTAXIS

17 ANATOMY

18 ANATOMY

19 DON T FORGET YOUR ABC S AIRWAY BREATHING CIRCULATION IV H/H Type and Cross Platelet Count History!!! Aspirin Coumadin Bruising Family history We can not treat these patients differently just because they are bleeding from their nose!!

20 EPISTAXIS: DIFFERENTIAL DIAGNOSIS

21 TOOLS

22 ANESTHESIA

23 PACKING-ANTERIOR

24 DON T FORGET TO USE ANTIBIOTICS AND TO REMOVE THE PACKING

25 PACKING-POSTERIOR

26 SURGICAL TECHNOLOGY

27 INTERVENTIONAL TECHNOLOGY

28 Pt. presents with a nosebleed, you should 1. A. Call an immediate ENT consult 2. B. Begin an IV, T+C, H+H and ask Pt to blow their nose 3. C. Order a CT with contrast 4. D. Call a GI consult 5. E. Perform a tracheotomy 97% 2% 0% 1% 0%

29 SURGICAL AIRWAY

30 AIRWAY CONTROL PREFERENCE 1. INTUBATION 2. INTUBATION 3. FIBEROPTIC INTUBATION

31 SURGICAL AIRWAY CONTROL PENETRATING TRAUMA ANGIOEDEMA OBSTRUCTING TUMOR LARYNGEAL SQUAMOUS CELL CARCINOMA INFECTION LUDWIG S ANGINA EPIGLOTTITIS DEEP NECK INFECTION SEPTIC SHOCK

32 SURGICAL CHOICES CRICOTHYROIDOTOMY EASIER MORE SUPERFICIAL RELATIVELY AVASCULAR NO THYROID ISTHMUS TO DEAL WITH

33 ANTERIOR JUGULAR VEINS ANATOMY

34 PROBLEMS WITH CRICOTHYROIDOTOMY ALL OF THE CONTRARY SEQUELAE OF INTUBATION! GRANULOMA PARESIS STENOSIS CARTILAGE NECROSIS ACCEPTABLE FOR SHORT PERIODS ANY AIRWAY IS ACCEPTABLE

35 TRACHEOTOMY NO CONTRA- INDICATIONS ACCEPTABLE LONG TERM TUBE IS PRIMARILY DESIGNED FOR THIS PURPOSE SAME LEVEL OF DIFFICULTY THYROID ISTHMUS!

36 TRACHEOTOMY TECHNIQUE

37 TRACHEOTOMY TECHNIQUE

38 TRACHEOTOMY TECHNIQUE

39 TRACHEOTOMY TECHNIQUE

40 TRACHEOTOMY TECHNIQUE

41 TRACHEOTOMY TECHNIQUE

42 A surgical airway is required, you should. 1. Perform a cricothyoidotomy and use a #5 ET tube 2. Cut across the anterior jugular veins, then call a surgery consult 3. Perform a tracheotomy 4. Perform a cricothyroidotomy and use a #8 ET tube 5. Try one more time to orally intubate the Pt. 81% 3% 6% 0% 10%

43 Enter question text Enter answer text % Enter answer text...

44 NASAL FRACTURES

45 The Nose Prominent facial feature Direct line of sight Can give an impression of one s personality Tough guy Self image Confidence in appearance Ethnic characteristic Airway!

46 Epidemiology of Nasal Fracture Male 2X female Sports injury Assault Etoh 2 nd and 3 rd decade of lifepeak

47 Anatomy Upper third Bone Nasal Frontal Maxillary

48 Anatomy Middle third Cartilage Upper lateral Sesamoid

49 Anatomy Lower third Cartilage Lower lateral Interdomal ligament Pitanguy Skin SSTE

50 Anatomy Septum Vomer Palatine bones Maxilla Perpendicular plate of the ethmoid Quadrangular cartilage

51 Nerve supply V1 Supratrochlear Infratrochlear V2 Infraorbital Blood supply Anterior ethmoid IMA Angular artery Valveless veins Anatomy

52 Fracture Patterns

53 History Time, date, associated factors MVA Restraints, airbags Assault Subpoena- photos Domestic violence 30 60% of women with facial trauma Substance abuse Withdrawal issues

54 Epistaxis Blood loss- H/H, T&C Airway obstruction Anosmia Clear rhinorrhea Numbness Incisors Occlusion Vision Past nasal surgical history History

55 ABC s of trauma NEC, ZMC, Le Fort, Dentoalveolar, Mandible, Skull base! Dorsum Assymmetry/Mobility Nasaolabial angle degrees Periorbital ecchymosis, edema Middle and lower third Physical Examination

56 Septal Examination Equipment Suction, speculum, headlight, vasoconstrictor, anesthetic r/o Septal Hematoma Internal exam 30 degree Hopkins rod Flexible nasopharyngoscope Brown-Gruss analysis Upper, middle, and lower thirds

57 Studies Photographs Plain films CT scan Logan, Clin Radiol 49:192, 1994

58 Trauma ABC s Acute Management Bleeding/Clots Vasoconstrictors Afrin Cocaine (4%) Packing- telfa, merocel, vaseline gauze with antibiotic ointment and oral antibiotic coverage Hemostatic agents Avitene, gelfoam, topical thrombin, floseal Management

59 Management Immediate v. Delayed reduction Accurate reduction Patient expectations and psychology Timing of Delayed reduction 7-10 Days

60 Algorithm Nasal Trauma Stabilize No deformity Deformity NOE CRNF ORIF High Satisfaction F/U Persisting Issues NSR v. Open Septorhinoplasty

61 Sequelae Persisting or noticeable nasal deformity Nasal obstruction Synechiae Septal perforation Sinusitis Epiphora

62 Anesthesia General Conscious Sedation Local Topical Injected

63 CRNF Office v. O.R. Tools of the Trade Technical tips Gelfoamroll Asch forceps External splint Telfa

64 Septoplasty Endoscopic Traditional Hemi-transfixion

65 NSR Severe septal deviation Dorsal deviation Septoplasty IC incisions Deglove UL separation +/- osteotomies

66 Extremely severe septal deformity Septal perforation Severe dorsal deformity/grafting Tip work Open- grafting, tip work Septorhinoplasty

67 Satisfaction 80% of patients will be satisfied with CRNF 10% of patients will request revision after Rhinoplasty Taking care of nasal trauma skillfully can be the best entre into a cosmetic practice

68 Nasal Fractures Taking care of nasal fractures can be an entre to a cosmetic practice!

69 Otologic Emergencies

70 Alternate Titles: Otologic conditions the ER staff will torture you with for no apparent reason Calls that you can blow off at 3am

71

72

73 When In Doubt Check It Out

74 Case 1 Dr. M. Green 10 yo Boy Slapped on Ear by Older Brother Intense ear pain, bleeding from canal, hearing loss

75

76 Traumatic TM Perforation Conservative Management Antibiotic Ear Drops (eg Cipro) Dry Ear Precautions F/U with Audiogram

77

78

79

80 Case 2 US Wrestling Champ Lost in a Head Lock Swollen, painful Auricle Dr. Del Amico

81

82 M Management of Auricular Hematoma

83 Cauliflower Ear

84 Case 3 Dr. Doug Ross Standing on a street corner, minding my own business I swear to God, doc, I didn t do Nuthin to SOB! Assaulated to head w/ Baseball Bat Temporary LOC Headache, bloody otorrhea, hearing loss

85

86

87 Longitudinal T-Bone Fx Common structures involved: Tympanic Membrane Roof of Middle Ear Anterior Petrous Apex Tympanic portion of FN most common

88 Case 4 Next day, also minding own business on same corner, the SOB that hit the first guy is hit himself Headache, bloody otorrhea, hearing loss, facial nerve palsy, vertigo

89

90

91 Transverse T-Bone Fx Common structures involved: traverse the otic capsule May lead to deafness, vertigo, facial nerve palsy

92 T-Bone Fractures-Evaluation ABC s CN exam, esp Facial Nerve Unconscious pts-painful stimulus elicits grimmace Vestibular Eval, Vertigo (nystagmus?) Hearing-Tuning Fork in ER EAC Eval (usually bloody) Otic Capsule sparing or involvement

93 T-Bone Fx s-evaluaton Radiology: CT > MRI Audiogram Vestibular Studies FN Studies: Evoked EMG- Direct Stimulation-MST-(Hilger nerve stim)

94 T-Bone Fx s-treatment Indications for Surgical Intervention: CSF Leak Persistent PLF Ossicular Disruption (late) Non-healing TM Perf (late) Secondary Cholesteatoma (late): Skin implosion or canal stenosis

95 T-Bone Fx-Facial Nerve Surgery Indications for Surgical Inervention: Absolute Immed FN Paralysis w/ radiograph evidence Relative Evoked EMG >95% degeneraton No recovery after 4-12 months

96 Case 5 8 yo Boy fell while running around with Q-tip in ear Pain, Hearing Loss, bloody otorrhea Nurse Hathaway

97

98

99 Traumatic Ossicular Fracture

100

101 Case 6 Scuba Diver Had cold but went diving anyway Intense pressure, pain on descent Now he is very dizzy and cannot hear out one ear, and has an intense ringing. Dr. Carter

102

103 Inner Ear Barotrauma Alternobaric Trauma Transient vestib/auditory dysfunction Barotrauma Extreme fluctuations in ME pressure, causing labyrinthine concussion, membrane tears, oval or round window fisutae Decompression Sickness -the bends

104 Barotrauma-Treatment Bed Rest Head elevation Close monitoring of hearing and balance Steroids? Surgery for progressive HL or perisitent vertigo > 5 days Avoid diving at least 3 months, forever if permanent damage has resulted

105 Decompression Sickness Usually dives > 100 m Formation of gas bubbles in body Joint Pains and CNS findings present Permanent auditory/vestibular injury Rx-IMMEDIATE Recompression

106 Case 7 40 yo Woman 3 Days s/p Cholesteatoma outside hosp. Fevers, Headache, myalgias, ear pain Otorrhea Dr. Benton

107

108 CSF Otorrhea Non-traumatic: Tumors, Congenital, Osteo Traumatic: Trauma vs Surgical Dx: Halo Sign, Glucose > 30mg/ml, ß-transferrin CT-Metrizamide Scan, flourescein, MRI

109 CSF Otorrhea-Management Depends on location & etiology of leak Decrease CSF Pressure Surgery Bed rest, HOB elevation, laxatives, diuretics, avoidance of noise-blowing, lifting, etc Serial LP s vs lumbar drain Closure of dural defect, closure of bony defect

110 Dr. Weaver Case 8 38 yo Woman 1 day h/o inability to move R side of face Otalgia

111

112 Facial Palsy-DDX Polyneuritis- Trauma- Bells, HZV, GB, Autoimm, Lyme, HIV, Kawasaki TB Fx, Barotrauma, Birth trauma Otitis Media- AOM, COM, Chole Sarcoid Melkersson-Rosenthal Neurologic - HIV, CVA Malignancy - parotid, metastatic Benign Tumors - schwannoma, glomus

113 Bell s Palsy Dx of Exclusion Probable viral Hyperacusis in 30% MRI-when no recovery in 12 weeks Rx-Steroids,?antivirals, Surgical decompression-controversial Outcome-if incomplete: % recover

114

115 Herpes Zoster Oticus AKA: Ramsay Hunt Syndrome

116 Case 9 How do I get those ENT residents to NOTICE me?!? Screaming 4 year old Painful Right Ear Cochroach in canal

117

118

119 Case 10 Screaming 5 year old Painful Right Ear Fevers

120

121

122 Coalescent Mastoiditis + SS Thrombosis Emergent mastoidectomy Myringotomy + Tube IV Antibiotics Controversial: anticoagulation

123 Case year old man Insulin Dependent Diabetic Chronic external OE Facial Nerve Palsy x 2 weeks Dr. Kovak

124

125 From: Singh et al. Skull Base Osteomyelitis: Diagnostic and Therapeutic Challenges in Atypical Presentation. Otolaryngol HNS 2005 Jul;133(1):121-5.

126 Malignant Otitis Externa / Skull Base Osteomyelitis Immunocompromised or Diabetics Dx = CT, MRI, Bone Scans Follow resolution with Technetium scans = osteoblastic activity Gallium 67 scans = granulocytic activity 6-8 weeks of IV antipseudomonal ABx Controversial: surgical debridement

127 Pt presents with ear trauma and TM perforation. You should 1. A. insist that the ENT on call come in immediately to operate on the Pt. 2. B. Reassure the Pt, make an appt to see the ENT in 1 week. 3. C. Reassure the Pt. make an appt to see the ENT in 1 week with an audiogram 4. D.Place a hot poker in the ear canal 62% 5. E. Obtain a CT scan 11% 22% 3% 2%

128 Conclusion