About the Health Information

The author, Prof Dr Sanjeev Mohanty, is the Head of the Institute of ENT, Head & Neck Surgery at MGM Healthcare

• In trying times like these, it is hard to differentiate an emergency from a non-emergency. Most of us don’t know when to take a situation seriously and seek immediate medical attention, and when to deal with it ourselves at home. To this end, I have compiled a list of ENT-related emergencies that should be dealt with on priority and the appropriate protocols to be followed at this time. At MGM Healthcare, my team and I are here to attend to you even amidst COVID-19 to ensure your good health and safety. If you regularly face issues related to the ear, nose and throat, this article should help ease your worries regarding seeking treatment should you need to. And for my fellow medical professionals, I hope these protocols will help you serve your patients better.

NOSE BLEED (EPISTAXIS) MANAGEMENT

Anterior Epistaxis

• Visualise, anaesthetise, cauterise and, if bleeding continues, tamponise!

• Ensure proper orientation of the nasal speculum. Avoid forceful blowing of the nose to clear blood clots.

• Apply cotton pledgets with 1:1 mix of oxymetazoline and  lidocaine with the nose pinched for a few minutes.

• Silver nitrate cauterisation of the dry edges of the bleeding site (around the site, not on it)

• Moisturise the area with petroleum jelly after the procedure.

• Nasal balloons are used to tamponise unilaterally or bilaterally.

Posterior Epistaxis

• While this condition is rare, it can have more serious consequences. Suspect posterior bleeds in elderly patients and patients with brisk bleeds that cannot be directly visualised, or patients who have ongoing bleeding despite bilateral anterior nasal packing. These patients require aggressive treatment in a monitored setting, IV access and  fluids. Nasal packing should be done both anteriorly and posteriorly, preferably with inflatable balloons.

Management Pearls

• Apply ice to the palate to reduce nasal blood flow by up to 25%. Tranexamic acid 500 mg tablet crushed and applied topically may help anterior bleeds. Nasal packing should be left in for at least 48–72 hours, or longer if the patient is on anticoagulants. Recommended antibiotics for patients with nasal packing and in an immuno-compromised state. If all these measures fail, endoscopic transnasal visualisation of the area is done with full PPE.

NASAL FOREIGN BODIES

Tips for Nasal Foreign Bodies

• First try to visualise directly and remove the object, if possible.

• The next option is a puff from a bag valve mask over the mouth, with the opposite nare occluded, so as to sniff out the foreign body!

• To reduce nasal swelling, apply nasal decongestant drops.

Tips for Ear Foreign Bodies

• Pull posteriorly on the pinna or use a speculum to visualise.

• Try irrigation to remove small, non-wedged objects that aren’t likely to expand when wet.

• Use 2% lidocaine to kill insects before removal.

Recommended tools

• A right angle L-hook is ideal for beads and round objects.

• Tissue adhesive may be used for objects that are difficult to grasp, but avoid adhering to the ear canal. Apply glue to the end of a cotton swab stick and hold on the foreign body for 20–30 seconds, then extract.

• * Chronic, impacted or penetrating foreign bodies that may swell (beans, corn) should be attended to urgently (12–24h). Round and tightly-wedged objects should be removed by the ENT surgeon at the earliest.

*BUTTON BATTERIES AND MAGNETS AS ENT FOREIGN BODIES SHOULD BE TREATED AS ABSOLUTE EMERGENCIES AND REMOVED AT THE EARLIEST*

• MALIGNANT OTITIS EXTERNA

  Suspect malignant otitis externa in patients with diabetes and ear pain. This aggressive and rare type of otitis externa can progress to meningitis, encephalitis, brain abscess, and cavernous venous thrombosis and skull base osteomyelitis.

• Key Diagnostic Clues

  Most cases occur in diabetics or the immunosuppressed. Be suspicious of pain out of proportion or ear pain with jaw pain. Check for cranial nerve findings. Inspect the auditory canal carefully for white-pink granulation tissue where cartilage and bone meet. If the pre-test probability is low, order an ESR.

• Imaging Options

  CT scanning may show temporal bone calcium loss and osteitis. Bone scan is the most sensitive test for osteoclast and osteoblast activity.

• Treatment

  Always swab and culture any discharge from the ear before starting treatment. 95% are caused by pseudomonas. Start antimicrobial therapy for 6 to 8 weeks with emphasis on good glycaemic control and regular teleconsultations as follow up.

SUDDEN SENSORINEURAL HEARING LOSS

• SSNHL is a diagnosis of exclusion in which unilateral hearing loss occurs over hours or overnight. Patients may present with vertigo and at least ⅓ will have permanent hearing loss. Carefully examine cranial nerves and elicit a history of trauma, infection or pain, and look for signs of infection or ear canal obstruction. After a quick clinical assessment, appropriate therapeutic measures are put in place, including imaging and audiometric testing. Although unsure of literature during COVID times, it’s better to start steroids (1 mg/kg prednisone for 10 days) and antivirals (famciclovir 500mg TID or valacyclovir 1g TID for 1 week). Intratympanic steroid injections are a viable option to attempt reversal of the damage caused.

• ACUTE EPIGLOTTITIS

  In patients with fever and sore throat (mimicking COVID symptoms) and a normal appearing pharynx, we need to think about epiglottitis. Stridor and tripoding are clues for impending obstruction of the upper airway, which can occur suddenly. The team of ENT surgeons and anaesthetists should plan early and with all readiness as per recommended guidelines with PPE protection for minimal aerosol generation while intubating in the OR.

• Antibiotics

  IV ceftriaxone or cefotaxime, plus vancomycin if septic. Most common pathogen is H influenzae, but numerous other bacteria, viruses and airway injuries have been implicated

PERITONSILLAR ABSCESS

• Suspect PTA with sore throat, ‘hot potato voice’, lock jaw and asymmetric tonsils with uvula deviation. Ultrasound may be as sensitive as CT scanning.

• Drainage tips

  – Use a headlamp with tongue depressor while wearing appropriate PPE.

   

  – Anaesthetise and inject 2% lidocaine+epinephrine into fluctuant area. Wait a few minutes, then aspirate with a 22-gauge needle.

   

  – Try to avoid incision and drainage during COVID times.

   

  – Put the patient on a cover of broad spectrum antibiotics till the antibiogram report is ready.

   

• LUDWIG’S ANGINA

  This condition is characterised as a rapidly progressive gangrenous cellulitis of the soft tissues of the neck and floor of the mouth. With progressive swelling of the soft tissues and elevation and posterior displacement of the tongue, the most life-threatening complication of Ludwig’s angina is airway obstruction. The COVID airway protocol that is advocated is to secure the airway along with the cover of 3rd generation cephalosporins and an attempt to aspirate rather than make an incision and drain. Surgical airway readiness is the need of the hour with proper PPE in place. The ‘golden hour’ concept of treatment is important in preventing mortality and morbidity.