ENT Emergencies, Epistaxis & Deep Neck Infections
Critical ear, nose, and throat management: anterior vs posterior epistaxis balloon tamponade, peritonsillar abscess needle aspiration, Ludwig's angina airway salvage, retropharyngeal space widening, and button battery emergencies.
Resuscitation Quick Ribbon (First 2 Minutes)
Bottom-Line Clinical Pearl
Epistaxis refractory to direct pressure and anterior packing is posterior epistaxis (sphenopalatine artery), requiring dual-balloon catheter placement and inpatient ICU/monitored admission due to the life-threatening nasopulmonary reflex. Ludwig's angina is a rapidly expanding cellulitis of the submandibular space threatening imminent airway loss; prepare for awake fiberoptic intubation or immediate awake surgical tracheostomy.
1. Epistaxis Management Algorithm
Over 90% of nosebleeds originate anteriorly from Kiesselbach's plexus (Little's area) on the anterior nasal septum. Approximately 10% are posterior, originating from the sphenopalatine artery; these present with massive hemorrhage refractory to anterior pressure, pooling into the posterior pharynx.
| Step | Procedure | Technical Instructions | Success / Failure Action |
|---|---|---|---|
| Step 1 | Direct Firm Pressure | Have patient blow out clots; pinch anterior cartilaginous nasal alae firmly for 15 continuous minutes while leaning forward (DO NOT tilt head back). | If stopped, discharge with saline spray / petroleum jelly. |
| Step 2 | Topical Vasoconstrictor + Anesthetic | Instill 2 sprays of Oxymetazoline (Afrin) + insert cotton pledget soaked in 4% Lidocaine with Epinephrine. Clamp for 10 min. | Visual inspection with nasal speculum and suction. |
| Step 3 | Chemical Cautery (Silver Nitrate) | If discrete bleeding vessel is seen on septum, touch with silver nitrate stick for 5–10 seconds. Roll circumferentially inward. | NEVER cauterize both sides of the septum at the same level (risk of septal perforation). |
| Step 4 | Anterior Nasal Packing | Insert Rapid Rhino (soak in sterile water for 30 sec, insert along floor of nose, inflate pilot cuff with 5–10 mL air) OR lubricated Merocel tampon. | Observe in ED for 30–60 minutes. Discharge with ENT follow-up in 48–72 hours. |
| Step 5 | Posterior Nasal Packing | If blood continues to pour down posterior pharynx despite bilateral anterior packing: Insert dual-balloon posterior catheter (e.g., 7.5 cm Epistat) OR #12–14 French Foley catheter (inflate balloon with 5–10 mL saline in nasopharynx, pull forward snug against choana, and clamp with umbilical clamp over gauze). | MANDATORY HOSPITAL ADMISSION. Inpatient telemetry/ICU required. |
The Nasopulmonary Reflex & Posterior Packing: Posterior packing causes profound stimulation of the sphenopalatine ganglion, triggering severe bradycardia, hypoventilation, and profound hypoxia. All patients with posterior packing require inpatient monitored telemetry or ICU admission. Prescribe oral Augmentin (or Cephalexin) to prevent Toxic Shock Syndrome (TSS) and sinusitis while packing is in place.
2. Peritonsillar Abscess (PTA) vs. Cellulitis
Collection of purulent fluid between the palatine tonsil capsule and the superior pharyngeal constrictor muscle. Typically polymicrobial (Streptococcus pyogenes, Fusobacterium necrophorum, anaerobes).
| Clinical Presentation | Procedure: Needle Aspiration | Pharmacotherapy & Disposition |
|---|---|---|
| Severe unilateral sore throat 'Hot potato' (muffled) voice Trismus (internal pterygoid spasm) Uvular deviation AWAY from affected tonsil Prominent fullness of superior tonsillar pole | 1. Topical Cetacaine spray + inject 1–2 mL 1% Lidocaine with Epi into mucosa. 2. Use 18–20G needle on 10 mL syringe. 3. CUT THE PLASTIC NEEDLE SHEATH to leave only 1.0–1.5 cm of needle exposed (critical guard to avoid puncturing the INTERNAL CAROTID ARTERY, which lies 1.5–2.0 cm posterolateral to tonsil). 4. Aspirate superior tonsillar pole. | IV Dexamethasone 10 mg (rapidly reduces pain and trismus within 2 hours). IV Ampicillin-sulbactam (Unasyn) 3g IV OR Clindamycin 600–900 mg IV. If aspirated purulence > 2 mL, discharge on oral Augmentin 875/125 mg BID for 10 days with 24–48h follow-up. |
3. Ludwig's Angina
Rapidly spreading, bilateral gangrenous cellulitis of the submandibular, sublingual, and submental spaces, usually originating from an infected 2nd or 3rd mandibular molar. Infection does not form a discrete abscess initially; rather, it produces a tense, brawny, woody edema that displaces the tongue superiorly and posteriorly, leading to fatal airway obstruction.
Airway Emergency of Ludwig's Angina: The airway can obstruct in minutes. Standard bag-valve-mask and direct/video laryngoscopy are frequently impossible due to massive floor-of-mouth edema and tongue elevation. Awake fiberoptic nasotracheal intubation in an operating room with ENT standing by for immediate awake surgical tracheostomy is the preferred management. NEVER paralyze a patient with Ludwig's angina without a surgical airway ready.
| Key Physical Signs | Diagnostic Imaging | Medical & Surgical Therapy |
|---|---|---|
| Bilateral 'woody', non-fluctuant submandibular swelling Tongue elevated to roof of mouth and protruding Inability to swallow secretions (drooling) Stridor, tripod positioning, 'bull neck' appearance | DO NOT send an unstable patient to CT scanner! Once airway is secured: Contrast-enhanced CT soft tissue neck (shows submandibular gas, fluid collections, and extent of spread into mediastinum) | Airway protection first! IV Ampicillin-sulbactam 3g IV + Vancomycin 15–20 mg/kg IV (or Cefepime + Metronidazole + Vancomycin). Immediate ENT surgical consultation for formal OR decompression and drainage. |
4. Retropharyngeal Abscess (RPA) & Epiglottitis
| Condition | Demographics & Presentation | Classic Imaging Findings | ED Intervention |
|---|---|---|---|
| Retropharyngeal Abscess (RPA) | Children 2–4 years (lymph node chain involutes after age 5) or adults post-fishbone/trauma. Fever, sore throat, neck stiffness, torticollis, pain with neck EXTENSION. | Lateral soft tissue neck X-ray in full extension during inspiration: Prevertebral space > 7 mm at C2 Prevertebral space > 14 mm at C6 in children (> 22 mm in adults) | CT neck with IV contrast; IV Ampicillin-sulbactam + Vancomycin; urgent ENT consult for operative transoral or cervical drainage. |
| Acute Epiglottitis | Unvaccinated children or adults; sudden high fever, sore throat, 4 D's: Dysphagia, Drooling, Dysphonia, Distress; tripod sniffing posture. | Lateral neck X-ray: 'THUMBPRINT SIGN' (thickened, swollen epiglottis). AVOID aggressive oral exams or tongue blades (precipitates laryngospasm!). | Keep patient calm; blow-by oxygen; prepare for definitive intubation in the OR with ENT and anesthesia present; IV Ceftriaxone 2g + Vancomycin. |
5. Foreign Bodies in Ear and Nose
- Button / Disc Batteries: TRUE EMERGENCY. Electrical current and alkaline electrolyte leakage cause liquefaction necrosis, cartilage destruction, and septal or tympanic membrane perforation within 2 hours. Do NOT instill drops (accelerates electrolysis); immediate emergent ENT removal.
- Insects in Ear Canal: Live insects cause severe pain and panic. Instill 2% viscous lidocaine or mineral oil into the canal to drown and paralyze the insect before attempting forceps extraction.
- Nasal Foreign Bodies in Children: Unilateral foul-smelling, purulent nasal discharge is a foreign body until proven otherwise. Technique: 'Parent's kiss' (parent covers uninjured nostril, seals mouth over child's mouth, and gives a rapid puff of air) or Katz extractor / balloon catheter.
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