Epworth Healthcare General Practitioner s Education Session

Transcription

1 Epworth Healthcare General Practitioner s Education Session Emergencies in ENT Mr. Guillermo Hurtado B.Med, ORL (Hons), FRACS Ear, Nose and Throat, Head and Neck Surgeon Epworth Richmond Private Hospital 18 th March

2 Emergencies in ENT Bleeding Emergencies Epistaxis Post tonsillectomy hemorrhage Foreign Body emergencies Ear Airway 2

3 INTRODUCTION Very common emergency 10-12% 12% of the population Only 10% seek medical attention Only 1.6% require admission Season Temperature / humidity Sex Equal distribution Age First 2 decades Anterior and mild episodes (90 % of epistaxis) > 50 yrs Posterior and more severe episodes 3

4 INTRODUCTION Very common emergency 10-12% 12% of the population Only 10% seek medical attention Only 1.6% require admission Season Temperature / humidity Sex Equal distribution Age First 2 decades Anterior and mild episodes (90 % of epistaxis) > 50 yrs Posterior and more severe episodes 4

5 ANATOMY Rich nasal irrigation Internal Carotid Art Ethmoidal Arteries External Carotid Art Plexus Facial Artery Internal Maxillary Artery Kiesselbach s s plexus Woodruff s plexus 5

6 ANATOMY Rich nasal irrigation Internal Carotid Art Ethmoidal Arteries External Carotid Art Plexus Facial Artery Internal Maxillary Artery Kiesselbach s s plexus Woodruff s plexus 6

7 ANATOMY Rich nasal irrigation Internal Carotid Art Ethmoidal Arteries External Carotid Art Plexus Facial Artery Internal Maxillary Artery Kiesselbach s s plexus Woodruff s plexus 7

8 LOCAL CAUSES Trauma Digital / Fractures / Foreign body Chemical irritation / desiccation / atrophy Structural Septal perforation 8

9 LOCAL CAUSES Inflammatory disease Viral / bacterial infections Granulomatous disease Tumours / Vascular malformation Benign tumours Juvenile Naso-angiofibromaangiofibroma Inverted papilloma Malignant tumours SCC / Adenocarcinoma 9

10 SYSTEMIC CAUSES Coagulopathy Congenital Acquired Anticoagulant drugs Vascular disease Arteriosclerosis Cardiovascular HTN 10

11 Diagnosis Initial evaluation Hemodynamic stability Airway compromise Airway/Breathing/Circulation Management Control bleeding Apply pressure Definitive haemostasis Intravenous resuscitation Correct reversible / contributing factors If possible, a complete history should be obtained Side, amount, ant/post Sx? Precipitants, previous tx, co- morbidities, medications 11

12 Diagnosis Initial evaluation Hemodynamic stability Airway compromise Airway/Breathing/Circulation Management Control bleeding Apply pressure Definitive haemostasis Intravenous resuscitation Correct reversible / contributing factors If possible take complete history Side, amount, ant/post Sx? Precipitants, previous tx, co- morbidities, medications Australasian Society of Thrombosis and Haemostasis Warfarin reversal: consensus guidelines

13 Assessment Equipment Personal protection Illumination Instruments Speculum Forceps Rigid suction probes Cotton / Pledges Vasoconstrictor / anaesthetic spray Tongue depressors Cautery Chemical / Electrical Cautery Packing materials Merocel Rapid Rhino Vaseline strip gauze Surgicel Endoscopes 13

14 Assessment Equipment Personal protection Illumination Instruments Speculum Forceps Rigid suction probes Cotton / Pledges Vasoconstrictor / anaesthetic spray Tongue depressors 14

15 Assessment Equipment Personal protection Illumination Instruments Speculum Forceps Rigid suction probes Cotton / Pledges Vasoconstrictor / anaesthetic spray Tongue depressors 15

16 Assessment Equipment Personal protection Illumination Instruments Speculum Forceps Rigid suction probes Cotton / Pledges Vasoconstrictor / anaesthetic spray Tongue depressors 16

17 Assessment Equipment Cautery Chemical / Electrical Cautery Packing materials Merocel Rapid Rhino Vaseline strip gauze Surgicel Endoscopes 17

18 Assessment Equipment Cautery Chemical / Electrical Cautery Packing materials Merocel Rapid Rhino Vaseline strip gauze Surgicel Endoscopes 18

19 Physical examination Nasal examination Evacuate, anesthetise, decongest and inspect anterior nasal cavity If bleeding: control bleeding with nasal packing If not bleeding and no site is identified: refer for posterior nasal inspection Laboratory FBE, coag screen, Group RH Imaging Clinically guided 19

20 TREATMENT Medical management Humidification, lubrication Cautery Silver nitrate Proper vasoconstriction Target paused applications Unilateral Apply ointment immediately after Endoscopic electrocautery Bi/Monopolar Laser cautery KTP laser 20

21 TREATMENT Nasal packing Anterior pack Vaseline gauze Expandable packs RapidRhino: hydrocolloid (carboxymethylcellulose) Platelet aggregator, lubricant, clot preserved on removal Merocel: (polyvinyl alcohol) Posterior pack Will require anterior packing Nasal balloon Brighton balloon, simpson plug, epistat nasal catheter 21

22 TREATMENT Nasal packing Anterior pack Vaseline gauze Expandable packs RapidRhino: hydrocolloid (carboxymethylcellulose) Platelet aggregator, lubricant, clot preserved on removal Merocel: (polyvinyl alcohol) Posterior pack Will require anterior packing Nasal balloon Brighton balloon, simpson plug, epistat nasal catheter 22

23 COMPLICATIONS Immediate Nasovagal reflex hypotension and bradycardia Early Persistent / recurrent bleeding Obstruction Nasolacrimal duct: epiphora OMC: sinusitis Nasal airway: hypoxia, OSA Obstruction Airway obstruction Toxic shock syndrome Staph aureus cover Late Nasal alae necrosis 23

24 TREATMENT Indications for surgical intervention Uncontrollable bleeding Failure of 1 22 properly placed packs Early intervention to reduce hospital stay 24

25 TREATMENT Diathermy Ligation Endoscopic ligation of Sphenopalatine art Transantral ligation of the IMA External ligation of the ethm arts. External carotid artery ligation Other nasal surgery Septoplasty Septal dermoplasty Intervention radiology 25

26 Diathermy Endoscopic Targeted Bipolar preferable or low wattage monopolar Septal surgery Access Correct spur or deviation Septal dermoplasty for hereditary hemorrhagic telangiectasia 26

27 Sphenopalatine artery ligation Endoscopic dissection of posterior portion of lateral nasal wall SPA clipped or coagulated Complications Post Outcomes Early numbness 13% Late 43% perforation 3% Post-operativeoperative Palatal Crusting Sinusitis 3% Septal Successful haemostasis in 80-90% (small no. studies) 27

28 Anterior/posterior ethmoidal artery ligation External ethmoidectomy approach (Lynch incision) Improve outcomes when combined with IMA ligation, SPA ligation 28

29 Maxillary artery ligation Rarely performed Modified Caldwell-Luc approach, through posterior wall of maxillary sinus into pterygopalatine fossa Vessel clipped or coagulated 87% effective Complications Infraorbital nerve injury, blindness, post operative bleeding (15%), devitalised gums and teeth, sinusitis, epiphora 29

30 External carotid artery ligation Last resort in profound uncontrollable haemorrhage Long-term failure rate 45% Watershed areas supplied by contralateral external carotid 30

31 Intervention radiology Embolisation with coils or gelfoam Angiography Cannulation of external carotid Up to 87% effective Complications Blindness Neurological deficit CVA False aneurysm 31

32 CLASSIFICATION Primary Post-tonsillectomy tonsillectomy At time of surgery Reactive Secondary First 6 hrs post op During recovery period Very serious condition Death risk Children Occult blood loss (swallowed) Excellent autoregulation haemorrhage Normal vital signs until potentially fatal blood loss 32

33 TONSILS IRRIGATION Facial art. Tonsillar branch Ascending palatine art. Tonsillar branch Lingual art. Dorsal lingual Tonsillar branch Ascending pharyngeal art. Tonsillar branch Intern Max art. Post-tonsillectomy tonsillectomy Lesser descending palatine Tonsillar branch haemorrhage 33

34 Post-tonsillectomy tonsillectomy haemorrhage TONSILS IRRIGATION Facial art. Tonsillar branch Ascending palatine art. Tonsillar branch Lingual art. Dorsal lingual Tonsillar branch Ascending pharyngeal art. Tonsillar branch Ascending Pharyngeal a. Lesser palantine a. Tonsillar branch of lesser palantine Tonsillar branch of ascending Pharyngeal a. Tonsillar branch of ascending palatine a. Tonsillar branch of facial a. Tonsillar branch of dorsal lingual a. Intern Max art. Lesser descending palatine Tonsillar branch 34

35 SURGICAL TECH Cold steel vs diathermy (O Leary & Vorrath 2005) Bleed rate 1.85% vs 2.35% (p<0.05) More reactive bleeds in cold steel group More secondary bleeds in dissection group Day 4-7 Post-tonsillectomy tonsillectomy Bleeds > 500mL more common in diathermy group haemorrhage 35

36 DIAGNOSIS Initial evaluation Post-tonsillectomy tonsillectomy Hemodynamic stability and potential airway compromise Airway/Breathing/Circulation haemorrhage If possible, a complete history should be obtained Time of onset, how many days post surgery, type of procedure, type of bleeding (+/- epistaxis) Amount of blood loss Medications NSAID s Anticoagulants 36

37 ACTIVE BLEEDING MANAGEMENT Intravenous resuscitation Blood tests (FBE, coag), group and hold CALL ENT Control bleeding Do not remove the clots May attempt with Post-tonsillectomy tonsillectomy Ccophenylcaine soaked swab or H202 Correct reversible / contributing factors haemorrhage Bleeding continues OT 37

38 INACTIVE MANAGEMENT Do not remove the clot REFER TO ENT Post-tonsillectomy tonsillectomy haemorrhage Bleeding stops bed rest (admission), IV antibiotics, NBM Patient to be admitted for observation 38

39 INACTIVE MANAGEMENT Do not remove the clot REFER TO ENT Post-tonsillectomy tonsillectomy haemorrhage Bleeding stops bed rest (admission), IV antibiotics, NBM Patient to be admitted for observation 39

40 Foreign Body in ENT EAR Symptoms Hypoacusia, otalgia, discharge Classification Animated vs Inert Animated Emergency Kill insect with Oil 40

41 Foreign Body in ENT EAR Symptoms Hypoacusia, otalgia, discharge Classification Inert Urgency Irrigation (NOT for seeds) Removal under vision ONLY with proper equipment, conditions and training DO not remove if there is already blood in EAC EUA under microscope REFER TO ENT 41

42 Foreign Body in ENT NOSE Unilateral offensive rinorrhea/epistaxis Management Ask patient to blow nose Can be further aspirated! Spray topic anaesth/vasoconstric Removal under vision ONLY with proper equipment, conditions and training DO not remove if there is already blood in nostril or it is too deep Batteries need to come out fast REFER TO ENT 42

43 Foreign Body in ENT Upper airway PHARYNX History Recent choking/gagging episode while feeding Symptoms Odinophagia, globus a/dysphagia, sialorrhea Localized pain, haemoptisis Airway compromise Dyspnea, WOB, stridor IF complicated Fever, otalgia, torticolis, trismus Chest pain, tachypnea, tachycardia, hypotension 43

44 Foreign Body in ENT Upper airway PHARYNX History Recent choking/gagging episode while feeding Symptoms Odinophagia, globus a/dysphagia, sialorrhea Localized pain, haemoptisis Airway compromise Dyspnea, WOB, stridor IF complicated Fever, otalgia, torticolis, trismus Chest pain, tachypnea, tachycardia, hypotension 44

45 Foreign Body in ENT Upper airway PHARYNX Management Adequate inspection Management Imaging may be necessary x DO NOT Rely on local anaesthetic effect. Attempt blind removal from the throat with a finger or instrument Removal under vision ONLY with proper equipment, conditions and training POTENTIAL AIRWAY COMPROMISE REFER TO ENT Keep NBM 45

46 Foreign Body in ENT Airway Larynx / Trachea / Bronchus Challenging diagnosis and treatment A high index of suspicion 3000 deaths / year from foreign body aspiration Most deaths occurring before hospital Treatment Open approach Bronchotomy (1800 s) Endoscopic removal From Chevalier Jackson developed rod- lens telescope Improvements in anesthetic techniques made a safer procedure. 46

47 Foreign Body in ENT Airway Larynx / Trachea / Bronchus Frequency Most of aspirations occur in children 1-3 yrs. Predisposing factors Lack of molars for grinding Lack coordination of swallowing and glottic closure They tend to be running or playing and put objects in their mouth more frequently. Vegetable matter the most common Seeds 47

48 Foreign Body in ENT Airway Larynx / Trachea / Bronchus Pathophysiology 80-90% become lodged in the bronchi. In adults: Right main bronchus (lesser angle of convergence carina location left of the midline. Equal frequency of right and left bronchial foreign bodies in children. Larger objects tend to become lodged in the larynx or trachea. 48

49 Foreign Body in ENT Imaging High-kilovolt AP and Lateral chest films Greater definition of the airway while reducing the effect of the surrounding bony structures. Radiopaque objects are visible, but radiolucent objects (eg, plastic) are not. Chest radiographs may reveal obstructive emphysema or hyperinflation, atelectasis, and consolidation. Lateral decubitus chest In children Obstructed dependent lung remains inflated Chest inspiratory and expiratory radiographs. Atelectasis on inspiration and hyperinflation on expiration with a foreign body obstructing the bronchus. 49

50 Foreign Body in ENT Airway Laryngeal Foreign Bodies Typically dysphonia and stridor. Can mimic CROUP Airway emergency that requires lifesaving first aid before transport to the hospital. Partial obstruction Irregular foreign bodies Sagittal orientation Laryngeal edema can lead to complete obstruction. 50

51 Foreign Body in ENT Airway Tracheal Foreign Bodies Typically do not have hoarseness. "asthmatoid wheeze," the "audible slap and the "palpable thud" over the trachea. As with laryngeal foreign bodies, edema can progress to complete obstruction. Stridor features Inspiratory / Expiratory 51

52 Foreign Body in ENT Airway Bronchial FB Initial phase At the moment of aspiration Choking, gagging, and paroxysms of coughing or airway obstruction Asymptomatic phase FB lodged and reflexes fatigue. Hours to weeks. Third phase with complications Obstruction, erosion, or infection causes hemoptysis, pneumonia, atelectasis, abscess, or fever. Sudden asthma onset Persistent LRI 52

53 Foreign Body in ENT Airway Bronchial FB CAREFUL history and examination Typical triad Cough, unilateral wheezing, and decreased breath sounds Only present in 65% of patients 53

54 Foreign Body in ENT Airway Esophageal foreign body impaction Vomiting, odynophagia, dysphagia, and ptyalism. If the ingestion is witnessed, gagging or choking may be reported. A large foreign body may cause symptoms of airway obstruction and cough caused by compression or irritation of the upper airway / left bronchus. 54

55 Thanks for your attention 55