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Crisis Guide Otolaryngology

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Crisis Guide Otolaryngology Crisis Guide Otolaryngology Editors: Jodi D. Zuckerman, M.D. G. Aaron Rogers, M.D. 1 Table of contents Table Table of contents About this Text 4 About the Authors 5 Introduction 6 I: Common ENT Infections Section I: Common ENT Infections 8 Acute Otitis Media & Mastoiditis – Oswaldo Henriquez, M.D. 8-9 Necrotizing Otitis Externa – Ajani Nugent, M.D. 10-11 Complications of Acute Sinusitis – Praveen Duggal, M.D. 12-13 Invasive Fungal Sinusitis – Anita Sethna, M.D. 14-15 Acute Tonsillitis and Peritonsillar Absess – Elina Kari, M.D. 16-17 Epiglottitis & Supraglottitis – Jodi D. Zuckerman, M.D. 18 Retro- & Parapharyngeal Infections – Frederick Durden, M.D. 19 II: Trauma Ludwig’s Angina – Eric Berg, M.D. 21-22 Deep Space Neck Infections – Elina Kari, M.D. 23-24 Section II: Trauma 26 Nasal Septal Hematoma – Avani Ingley, M.D. 26-27 Auricular Hematoma – Adrienne Laury, M.D. 28-29 III: Operative Complications Mandibular Fractures – Eric Berg, M.D. 30-31 Orbital Floor Fractures – Casey Mathison, M.D. 32-33 Frontal Bone Fractures – Lindsey Arviso, M.D. 34-35 Temporal Bone Fractures – Grace Leu, M.D. and Aaron Rogers, M.D. 36-37 Blunt Laryngeal Trauma – Aaron Rogers, M.D. 38-39 Penetrating Neck Injury – Shatul Parikh, M.D. and Jodi D. Zuckerman, M.D. 40-41 IV: Miscellany IV: Crisis guide: Otolaryngology Table of contents 2 Table of contents Table I: Common ENT Infections Section III: Operative Complications 42 Post-Tonsillectomy Hemorrhage – Clyde Mathison, M.D. 42-43 Carotid Blowout – Ajani Nugent, M.D. 38 44-45 Tracheostomy Bleeding – Iman Naseri, M.D. 46-47 Flap Compromise – Craig R. Villari, M.D. 48-49 Cervical Hematoma – Candice Colby, M.D. 50-51 Pharyngocutaneous Fistula – Katherine Hayes, M.D. 52-53 Hypocalcemia – Aaron Rogers, M.D. 54-55 II: Trauma Cerebrospinal Fluid Leaks – Eric Berg, M.D. 56-57 Orbital Hematoma – Kara Prickett, M.D. 58-59 Section IV: Miscellany 60 Epistaxis Lindsey – Arviso, M.D. 60-61 Angioedema – Jodi Zuckerman, M.D. 62-63 III: Operative Complications Inhalational Injuries – Elizabeth Hoddeson, M.D. 64-65 Facial Nerve Paralysis – Craig R. Villari, M.D. 66-67 Sudden Sensorineural Hearing Loss – Praveen Duggal, M.D. 68-69 Foreign Bodies – Avani Ingley, M.D. 70-71 Tracheostomy Care – Anita Sethna, M.D. 72-73 Ventilating Bronchoscope Setup 74-75 IV: Miscellany IV: Crisis guide: Otolaryngology 3 Table of contents Table of contents Table About the text This book is a collection of straighforward management strategies for common ENT urgencies. It was written and edited by the residents I: Common ENT Infections of the Emory University Department of Otolarygology – Head & Neck Surgery. This collection was originally created as a pocket reference for acute treatment of common ENT emergencies; it is not meant to be an all-inclusive text. The opinions and recommendations offered here are loosely collected from our training experience as well as the prevailing opnion in recent literature and major otolarygology texts. II: Trauma III: Operative Complications IV: Miscellany IV: Crisis guide: Otolaryngology About the text 4 Table of contents Table About the authors Jodi D. Zuckerman, M.D. is an otolaryngologist in private practice in Chicago, Illinois after completing her residency at Emory University in Atlanta, Georgia. I: Common ENT Infections G. Aaron Rogers, M.D. is pursing general otolaryngology and rhinology after completing residency at Emory in 2010. Drs. Anita Sethna and Frederick Durden are currently in Facial Plastics and General Plastics fellowships after completing residency in 2009 at Emory. Drs. Avani Ingley and Casey Mathison will complete residency training in 2010 at Emory. Drs. Lindsey Arviso, Eric Berg, and Elina Kari II: Trauma will be completing residency in 2011 at Emory. Drs. Oswaldo Henriquez, Praveen Duggal, and Ajani Nugent will be completing otolaryngology residency in 2012 at Emory. Drs. Colby, Hoddeson, Prickett, Villari, Laury, and Hayes will be completing otolaryngology residency in 2013 and 2014 at Emory. III: Operative Complications Dr. Iman Naseri is a 2008 Emory Otolaryngology graduate, and is now Assistant Professor of Otolaryngology – Head & Neck Surgery at the University of Florida (Jacksonville). Drs. Shatul Parikh and Grace Leu are also graduates of the 2008 residency class at Emory are currently in private practice in Atlanta, Georgia and Fresno, California (respectively). IV: Miscellany IV: Crisis guide: Otolaryngology 5 About the authors Table of contents Table Introduction I: Common ENT Infections Otolaryngology is an exciting field that usually allows for the practice of surgery and medicine in a controlled environment. However, like any medical field there are an abundanceof emergencies that require focused attention and rapid decision-making. In a crisis, the effective practitioner should be able to assimilate all available data and make clear decisions aimed at stabilizing an emergency. II: Trauma III: Operative Complications IV: Miscellany IV: Crisis guide: Otolaryngology introduction 6 Table of contents Table I: Common ENT Infections II: Trauma III: Operative Complications Mission Together with our customers we are driven to make healthcare better. IV: Miscellany IV: Crisis guide: Otolaryngology 7 introduction Table of contents Table Section I: Common ENT Infections Acute Otitis Media and Mastoiditis Oswaldo Henriquez, M.D. I: Common ENT Infections Clinical presentation of acute otitis media includes otalgia, fever, hearing loss, ear pulling and irritability, and upper respiratory symptoms. Upon otoscopic examination there can be appearance of thickening and erythema of the tympanic membrane, perforation with suppurattive otorrhea in the auditory canal, decreased visibility of middle ear landmarks, decreased tympanic mobility on pneumatic otoscopy, and presence of middle ear effusion. In most cases, clinical diagnosis should be sufficient alone. The three most commonly involved bacteria are Streptococcus pneumonia, Haemophilus influenzae, and Moraxella catarrhalis. In many cases Staphylococcus aureus and Pseudomonas II: Trauma aeurginosa may be identified. Primary treatment of acute otitis media includes oral antibiotics to cover the above common pathogens as well as analgesia. Usually primary treatment is with amoxicillin or bactrim, or with amoxicillin + clavulante for persistent or recurrent infections. General recommendations are for a 10-14 day course of PO therapy III: Operative Complications for uncomplicated AOM. Recent large studies in the primary care literature advocate a “watch and wait” approach to treatment where antibiotics may be withheld for up to 3 days to allow for spontaneous resolution. IV: Miscellany IV: Crisis guide: Otolaryngology Section 1: Common ENT infections 8 Table of contents Table Acute Otitis Media and Mastoiditis Complications of AOM are classified as intratemporal or intracranial. Oswaldo Henriquez, M.D. Intratemporal complications include coalescent mastoiditis, subperiosteal I: Common ENT Infections abscess, facial nerve paralysis, labyrinthine fistula, or abscess at the temporal Clinical presentation of acute otitis media includes otalgia, fever, hearing loss, ear root, petrous apex, or mastoid tip. Intracranial complications include pulling and irritability, and upper respiratory symptoms. Upon otoscopic meningitis, sigmoid thrombophlebitis, subdural empyema, epidural abscess, examination there can be appearance of thickening and erythema of the parenchymal abscess, and otic hydrocephalus. tympanic membrane, perforation with suppurattive otorrhea in the auditory canal, decreased visibility of middle ear landmarks, decreased tympanic mobility Masoitditis is basically the spread of otitis media infectious process to the mastoid on pneumatic otoscopy, and presence of middle ear effusion. In most cases, air cells. On physical exam there is presence of bulging erythematous tympanic clinical diagnosis should be sufficient alone. The three most commonly involved membrance with erythema, tenderness, and edema over the mastoid area, bacteria are Streptococcus pneumonia, Haemophilus influenzae, and Moraxella and the classic protruding auricle. The work up includes a high-resolution CT catarrhalis. In many cases Staphylococcus aureus and Pseudomonas scan of the temporal bone. On CT there should be presence of middle ear II: Trauma aeurginosa may be identified. effusion with coalescent mastoid air cells or attenuation of the bony mastoid cortex. It is important to note that due to normal communication of the middle ear Primary treatment of acute otitis media includes oral antibiotics to cover the above and mastoid cavity, any OM can demonstrate a fluid filled mastoid common pathogens as well as analgesia. Usually primary treatment is with on imaging. MRI or contrast-enhanced CT can be helpful if there is amoxicillin or bactrim, or with amoxicillin + clavulante for persistent or recurrent concern for intracranial complications. infections. General recommendations are for a 10-14 day course of PO therapy III: Operative Complications for uncomplicated AOM. Recent large studies in the primary care literature Treatment of mastoiditis can be medical or surgical depending on the severity advocate a “watch and wait” approach to treatment where antibiotics may be of the infection. Usually these patients are admitted for antibiotic therapy, most withheld for up to 3 days to allow for spontaneous resolution. commonly empiric vancomycin and ceftriaxone. Routine tympanostomy will aid in treatment and in diagnosis. Mastoidectomy is usually considered for
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