Ophthalmologic & ENT Emergency Procedures
Critical head, eye, ear, nose, and throat procedures: emergency lateral canthotomy and inferior cantholysis for orbital compartment syndrome, slit lamp biomicroscopy and Seidel test, anterior vs posterior epistaxis packing, and peritonsillar abscess (PTA) aspiration.
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Emergency Lateral Canthotomy and Inferior Cantholysis is a vision-saving bedside procedure for acute retrobulbar hematoma / orbital compartment syndrome. If intraocular pressure (IOP) is > 40 mmHg with proptosis and decreased visual acuity, cut the lateral canthal tendon immediately; permanent ischemic blindness occurs within 60–90 minutes. In epistaxis, distinguish anterior (Kiesselbach plexus) from posterior (sphenopalatine artery); posterior packs mandate inpatient admission with cardiac monitoring due to nasopulmonary reflex risks.
Orbital compartment syndrome (retrobulbar hematoma) is an ophthalmologic surgical emergency. The bony orbit is non-compliant; accumulating arterial blood spikes intraocular pressure (IOP), compressing the central retinal artery and optic nerve. Irreversible retinal ganglion cell ischemia occurs within 60 to 90 minutes. If IOP exceeds 40 mmHg (measured with Tonopen) accompanied by proptosis, severe eye pain, and an Afferent Pupillary Defect (Marcus Gunn pupil), perform immediate bedside lateral canthotomy:
| Step | Action & Technical Maneuver | Surgical Instrument | Clinical Landmark & Verification |
|---|---|---|---|
| 1. Anesthesia & Prep | Infiltrate 1–2 mL of 1–2% Lidocaine with Epinephrine | 30G needle, 3 mL syringe | Inject laterally from the lateral canthus toward the orbital rim. |
| 2. Hemostasis Clamp | Apply curved hemostat horizontally across lateral canthus for 30–60 seconds | Straight or curved hemostat | Crushes tissue to minimize hemorrhage and marks cut line. |
| 3. Lateral Canthotomy | Make a 1 to 1.5 cm horizontal incision through the lateral canthal crease | Iris scissors / suture scissors | Cut completely through skin and canthal tendon to the bony orbital rim. |
| 4. Inferior Cantholysis | Retract lower eyelid anteriorly; strum tendon vertically; SNIP the INFERIOR CRUS of lateral canthal tendon | Iris scissors pointing inferolaterally toward maxillary bone | CRITICAL STEP: The canthotomy alone does not decompress the orbit. Snipping the inferior crus causes the lower lid to become completely flaccid ('twang' sensation) and drops IOP immediately. |
| 5. Re-check IOP | Measure intraocular pressure with Tonopen | Tonopen | Target IOP < 20–30 mmHg. If IOP remains > 40 mmHg, snip the superior crus. |
Ninety percent of epistaxis arises anteriorly from Kiesselbach's plexus on the anterior nasal septum (Little's area). Ten percent arises posteriorly from the sphenopalatine artery (woodruff's plexus), presenting with massive bilateral hemorrhage, blood streaming down the posterior oropharynx, and refractory bleeding despite anterior packing.
| Epistaxis Tier | Technique & Equipment | Clinical Protocol | Disposition & Complications |
|---|---|---|---|
| Tier 1: Direct Compression & Vasoconstrictor | Topical Oxymetazoline (Afrin) or Epinephrine + 15 minutes continuous compression | Have patient blow nose to clear clots; spray vasoconstrictor; clamp cartilaginous lower third of nose continuously without releasing for 15 min | Success in 70% of anterior bleeds. Discharge home if hemostasis maintained for 30 min. |
| Tier 2: Chemical Cautery (Silver Nitrate) | Silver Nitrate applicator stick | Identify discrete bleeding vessel; apply applicator stick circumferentially around vessel, then directly onto bleeding point for 5–10 seconds | CAUTION: Never cauterize both sides of nasal septum simultaneously (causes septal perforation). |
| Tier 3: Anterior Nasal Packing | Carboxymethylcellulose tampon (Merocel) or pneumatic balloon (Rapid Rhino 5.5 cm / 7.5 cm) | Soak Rapid Rhino in sterile water for 30 seconds; insert horizontally along nasal floor (NOT upward along bridge); inflate cuff with air | Discharge with ENT follow-up in 48–72 hours. Toxic shock syndrome prophylaxis with oral Cephalexin or Augmentin. |
| Tier 4: Posterior Nasal Packing | Dual-balloon catheter (Rapid Rhino 9 cm) or 12–14 Fr Foley catheter with 30 mL balloon | Insert into nasopharynx; inflate posterior balloon with 7–10 mL sterile water; pull anteriorly until seated against choana; inflate anterior balloon with 15–20 mL | MANDATORY ADMISSION TO TELEMETRY/ICU: Posterior packing stimulates nasopulmonary reflex, triggering severe bradycardia, hypoventilation, and fatal dysrhythmias. |
A peritonsillar abscess (Quinsy) is a collection of purulence between the palatine tonsil capsule and the superior pharyngeal constrictor muscle. Clinical presentation includes severe unilateral sore throat, fever, trismus (inability to open mouth due to pterygoid spasm), 'hot potato' muffled voice, and uvular deviation to the contralateral side.
- Anatomical Safety Rule: The internal carotid artery lies approximately 1.5 to 2.0 cm posterior and lateral to the tonsillar capsule. Never plunge a needle or scalpel deeply into the peritonsillar space.
- Needle Aspiration Technique: Cut the plastic needle guard of an 18G needle so that only 1.0 cm of the needle tip is exposed (prevents overpenetration). Apply topical benzocaine / lidocaine spray, followed by 1–2 mL of 1% lidocaine with epinephrine injected into the mucosa. Puncture the area of maximal fluctuance (typically the superior pole of the tonsil) while directing the needle strictly sagittal (anterior to posterior), avoiding lateral angling. Aspirate purulent fluid.
- Medical Therapy: Administer Dexamethasone 10 mg IV (rapidly decreases pain and trismus) plus IV Ampicillin-Sulbactam (Unasyn 3g IV) or Clindamycin 600 mg IV.
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