Otologic Disorders

Anatomy
 Auricle
 Ear canal
 Tympanic
membrane
 Middle ear and
mastoid disorders
 Inner Ear
Traumatic Disorders of the
Auricle
 Hematoma
- cartilaginous necrosis
- drain, antibiotics, bulky
ear dressing close follow
up
 Lacerations - single
layer closure, pick up
perichondrium, bulky
ear dressing
Use posterior auricular
block for anesthesia
Aspiration of Auricular
Hematoma
Auricular Hematoma
Auricle
 Chondritis - Cellulitis ?
- infectious, difficult to treat
because poor blood
supply, cover S. Aureus
and pseudomonas
- extra care in diabetics
Auricular Hematoma
 Blunt trauma
(wrestler)
 Drain with temp
drain/ packing with
in 48hrs
 Antibiotics
 Complications:
 Infection
 Cauliflower ear
External Otitis
 Infection and
inflammation caused by
bacteria (pseudomonas,
staph), and fungi
- treat with antibiotic-
steroid drops
- diabetics can get malignant
otitis externa (defined by
the presence of
granulation tissue)
Foreign Body Ear
 Emergency when
associated with
vertigo, profound
hearing loss and/ or
facial parallysis
 Do not irrigate
organic material or
with a perforation
 Otologic ear gtts /
ENT eval
Foreign Bodies in Ear Canal
 Usually put in by
patient, some bugs fly
in
 kill bugs with mineral
oil, or lidocaine
 remove with forceps,
suction or tissue
adhesive
 Middle Ear
 Serous Otitis Media -
Eustachian tube dysfunction -
treat with decongestants,
decompressive maneuvers
 Otitis Media - infection of
middle ear effusion - viral and
bacteria
 Mastoiditis - Venous
connection with brain, need
aggressive treatment (can lead
to brain abcess or meningitis)
Acute Mastoiditis
Tympanic Membrane
Perforation
 Etiology
 Infection, penetrating
trauma, temporal bone
fracture
 Check for conductive
hearing loss with tuning
fork
 Tx: Floroquinolone gtts,
no H2O
 More serious injury with:
profound SNHL,vertigo,
or otorhea
TM Perforation cont.
Tympanic Membrane
Perforation
 Hard to see – Hx of drainage
 Usually from middle ear pressure
secondary to fluid or barotrauma
 Sometimes from external trauma
 most heal uneventfully but all
need otology follow-up
 perfs with vertigo and facial nerve
involvement need immediate
referral
 treat with antibiotics
 drops controversial but indicated
for purulent discharge (avoid
gentamycin drops)
Sudden Hearing Loss /Deafness
 History  Exam
 Timing  Conversation
 Severity  Otoscopic
 Location  Tuning fork/ PTA
 Inciting factors  CT
 Medications  Lab
 Associated symptoms  VDRL
 Sed rate
 Lyme
 Blood glucose
Sudden Hearing Loss. Cont.
 Treatment
 Cause dependent
 Early intervention may
make a difference
 May need to treat
associated symptoms
as well
NASAL EMERGENCIES
 NASAL TRAUMA
 SEPTAL HAEMATOMA
 SEPTAL ABSCESS
 EPISTAXIS
 SINUSITIS
 FOREIGN BODIES
NASAL ANATOMY
Nasal Foreign Bodies
 Usually kids
 Lollies, beads, small toys, food
 Symptoms: persistent unilateral purulent discharge,
unilateral nasal obstruction & foetor
 ‘Rhinoliths’ or nasal concretions usually have a foreign
body nucleus eg. toy
 Rhinolith composed largely of calcium and
magnesium salts
Nasal Foreign Body
 Symptoms:
 Usually brought in by
mother
 Unilateral rhinitis /
epistaxis
 Diagnosis:
 Nasal speculum
 Rhinoscopy
 X-ray
 Treatment
 Maggots fly in
nasal cavity
( nasal myasis)
FOREIGN BODIES
 INSPECT NOSE WITH HEADLIGHT
 REMOVE IF POSSIBLE
 ONE CHANCE ONLY
 HARD ROUND OBJECTS
 SOFT OBJECTS
 SUCTION/FORCEPS
 BLUNT HOOK
Nasal foreign body
Rhinolith
Tips for Removing
 Need to decongest nose prior to removal (co-
phenylcaine also anaesthetises nose)
 Need to be quick or child will resist
 Get parents to hold down
 Nasal packing forceps best, not alligators
 Bleeding uncommon
 GA rarely needed
Technique
NASAL TRAUMA
 EXCLUDE SEPTAL HAEMATOMA
 TREAT EPISTAXIS
 REVIEW ONE WEEK CLINIC
 MANIPULATE THREE WEEKS
 USUALLY CLOSED FRACTURES
 CHECK FOR CSF LEAK
SEPTAL HAEMATOMA

 DUE TO TRAUMA
 SEPTUM GROSSLY WIDENED
 BLOCKED NASAL AIRWAY
 COLLAPSED EXTERNAL NOSE
 NEEDS SURGICAL DRAINAGE
 NECROSIS
 SEPTAL ABSCESS
Septal Hematoma
 Swelling of nasal
septum that doesn’t
respond to
decongestant spray
 Need drained < 48 hrs
 Complications:
 Infection
 Saddle nose
 Drain & pack,
antibiotics
Septal Hematoma
Septal haematoma
Septal Hematoma
Septal Hematoma
Management - soft tissue

If septal haematoma is missed or

not treated adequately, septal
abscess may follow and result in
cartilage necrosis and “saddle”
deformity
Saddle deformity
SINUSITIS
INFLAMATION PARANASAL
INTRACRAINIAL ABSCESS
MENINGITIS
ORBITAL CELLULITIS
EPISTAXIS
 TRAUMA
 CONGENITAL(meningioma)
 NASAL SURGERY
 INFECTION
 VASCULAR(hypertension, littles area, posterior degeneration)
 NEOPLASMS(juvenile angiofibroma)
 DRUGS(warfarin, aspirin, cocaine)
EPISTAXIS
GENETIC(von willebrand)
BLEEDING DISORDERS(LEUKAEMIA)
GRANULOMATOSIS(WEGENERS)
IDIOPATHIC
Anatomy
 ICA (branches of ophthalmic)
 Anterior ethmoid – supplies lateral wall of nose, nasal septum,
nasal tip
 Posterior ethmoid – posterior lateral wall of nose, superior
turbinate and sup septum
 ECA (branches of internal maxillary)
 sphenopalatine – supplies the posterior septum, posterior middle
and superior turbinates
 Descending palatine – lower midseptum
 Superior labial (facial artery) anterior septum
Nasal Septal Blood Supply
POSITION
ANTERIOR  littles area/
Kiesselbach’s
POSTERIOR  Woodruff’s
Vascular
anatomy of
the medial
and lateral
nasal walls
 LITTLE'S ( KIESSELBACH'S) AREA
 1/2 inch from the caudal border of the
septum antero-inferiorly.
 Vessels anastomosing are; Anterior
ethmoid, greater palatine, and
sphenopalatine, and septal branch of
superior labial.
 Bleeding may be arterial or venous.

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Little’s area
 Confluence of :
 Anterior Ethmoidal a.
 Greater Palatine a.
 Sphenopalatine a.
 Sup. Labial a.

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Posterior Epistaxis
 Unable to visualize
bleeding site
 Can lose large volume
quickly
 Treatment options:
 posterior/ anterior
pack
 Nasal endoscopy with
cauterization
 Artery ligation
Patient History
 Previous bleeding episodes
 Nasal trauma
 Family history of bleeding
 Hypertension - current medications and how
tightly controlled
 Hepatic diseases
 Use of anticoagulants
 Other medical conditions - DM, CAD, etc.
Physical Exam
 Measure blood pressure and vital signs
 Apply direct pressure to external nose to decrease
bleeding
 Use vasoconstricting spray mixed with tetracaine
in a 1:1 ratio for topical anesthesia
 IDENTIFY THE BLEEDING SOURCE
Physical Exam - Equipment
 Protective equipment - gloves, safety goggles
 Headlight if available
 Nasal Speculum
 Suction with Frazier tip
 Bayonet forceps
 Tongue depressor
 Vasoconstricting agent (such as
oxymetazoline)
 Topical anesthetic
Local Causes of Epistaxis
 Nasal trauma (nose picking,
foreign bodies, forceful nose
blowing)
 Allergic, chronic or infectious
rhinitis
 Chemical irritants
 Medications (topical)
 Drying of the nasal mucosa from
low humidity
 Deviation of nasal septum or
septal perforation
 Bleeding polyp of the septum
or lateral nasal wall (inverted
papilloma)
 Neoplasms of the nose or
sinuses
 Tumors of the nasopharynx
especially Nasopharyngeal
Angiofibroma
 Vascular malformation
Systemic Causes of Epistaxis
 Systemic arterial  Anticoagulants (ASA,
hypertension NSAIDS)
 Endocrine Causes:  Hepatic disease
pregnancy,
pheochromocytoma  Blood diseases and
 Hereditary
coagulopathies such as
hemorrhagic Thrombocytopenia,
telangectasias ITP, Leukemia,
Hemophilia
 Osler Rendu Weber
Syndrome  Platelet dysfunction
Drugs!
 Thrombocytopenia: chemotherapy, quinidine,
sulfa preparations, H2 blockers, oral antidiabetic
agents, gold salts, rifampin, heparin, alcohol
 Affecting coagulation pathway: Warfarin, Heparin
 Affecting platelet function: Aspirin, clopidogrel,
nsaids
 Herbs that may cause bleeding: Dong quai,
Danshen, Feverfew, Garlic, Ginger, Gingko,
Ginseng
LOCAL CAUSES

[4] Neoplasms:
Of the Carcinom of the Nasopharynx
 nose,
 nasopharynx and
 sinuses.

Angiofibroma
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Local Causes
[4] Miscellaneous:
 Septal spur,
 foreign bodies

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Most Common Causes of
Epistaxis
 Disruption of the nasal mucosa - local trauma, dry
environment, forceful blowing, etc.
 Facial trauma
 Scars and damage from previous nosebleeds that
reopen and bleed
 Intranasal medications or recreational drugs
 Hypertension and/or arteriosclerosis
 Anticoagulant medications
Types of Nosebleeds
 ANTERIOR
 Most common in younger population
 Usually due to nasal mucosal dryness
 May be alarming because can see the
blood readily, but generally less severe
 Usually controlled with conservative
measures
Types of Nosebleeds
 POSTERIOR
 Usually occurs in older population
 May also have deviation of nasal
septum
 Significant bleeding in posterior
pharynx
 More challenging to control
Therapeutic Equipment to be
Available
 Variety of nasal packing materials
 Silver nitrate cautery sticks
 10cc syringe with 18G and 27G 1.5inch
needles
 Local anesthetic
 Gelfoam, Collagen absorbable hemostat,
Surgicel or other hemostatic materials.
General Epistaxis Supplies
Packing Tray
MANAGEMENT EPISTAXIS
 NASAL CAUTERY : Chemicals or Electrical
 NASAL PACKS
 TYPES
 SURGERY
 EMBOLIZATION
Packing materials
Vaseline Gauze
Merocel - polyvinylchloride
Surgicel – oxidized cellulose
Gelfoam – purified pork skin gelatin
Treatment of Anterior Epistaxis

 Localized digital pressure for minimum of 5-10

minutes, perhaps up to 20 minutes
 Silver nitrate cautery - avoid cautery of bilateral
nasal septum as this may lead to necrosis and
perforation of the septum
 Collagen Absorbable Hemostat or other topical
coagulant
 Anterior nasal packing for refractory epistaxis -
may use expandable sponge packing or gauze
packing
Anterior Epistaxis – Tips
 Spray mucosa with co-phenylcaine spray
 Insert co-phenylcaine on cotton wool
 Wait 10 minutes
 Apply silver nitrate to source of bleeding
 May need to repeat above sequence
 Packing occasionally needed for support
 Suction very useful
 Send home with ointment
Traditional Anterior Pack

Usually, 1/2 inch Iodiform or NuGauze is used.

Coat the gauze with a topical antibiotic ointment prior to placement.
Other Anterior Nasal Packs
 Formed expandable
sponges are very
effective
 Available in many
shapes, sizes and
some are
impregnated with
antibacterial
properties
Correct direction for placement of nasal
packing
CAUTERIZATION

1) Chemicals;
 Silver Nitrate stick, chromic acid
bead.
2) Electrical
 Apply ointment and advise
against blowing and nose picking.

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Treatment of Posterior Epistaxis
 IV pain medication and antiemetics may be helpful
 Use topical anesthetic and vasoconstrictive spray
for improved visualization and patient comfort
 Balloon-type episaxis devices often easiest
 Foley catheter or other traditional posterior packs
may be necessary
Traditional Posterior Pack
(Bellocq’s tampon)
 Raza M. Jafri, FRCS
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Posterior Balloon Packing
 Always test before placing
in patient
 Fill “balloons” with water,
not air
 Orient in direction shown
 Fill posterior balloon first,
then anterior
 Document volumes used
to fill balloons
Posterior pack
Duration of Packing Placement
 Actual duration will vary according to the patient’s
particular needs.
 Typically, anterior pack at least 24-48 hours,
sometimes longer.
 Posterior pack may need to remain for 48-72 hours. If
a balloon pack is used, advised tapered deflation of
balloons - most successful when volume is
documented.
Complications of packing
Toxic shock
Ulcerations
Nasopulmonary reflex
 Other Treatments for Refractory Epistaxis
 Greater palatine foramen block
 Septoplasty
 Endoscopic cauterization
 Selective embolization by interventional radiologist
 Internal maxillary artery ligation
 Transantral sphenopalatine artery ligation
 Intraoral ligation of the maxillary artery
 Anterior and posterior ethmoid artery ligation
 External carotid artery ligation
Greater Palatine Foramen Block
 Mechanism of action is
volume compression of
vascular structures
 Lidocaine 1% or 2% with
epinephrine 1:200,000 used
or Lidocaine with sterile
water.
 Do not insert needle more
than 25mm
Preventive Measures
 Keep allergic rhinitis under control. Use saline nasal
spray frequently to cleanse and moisturize the nose.
 Avoid forceful nose blowing
 Avoid digital manipulation of the nose with fingers or
other objects
 Use saline-based gel intranasally for mucosal dryness
 Consider using a humidifier in the bedroom
 vasoconstricting spray
Tripod Fracture
Maxillofacial Trauma-Specific Fractures
(blow-out)
 Orbital Fractures
 Usually through floor
or medial wall
 Enophthalmos
 Anesthesia
 Diplopia
 Infraorbital stepoff
deformity
 Subcutaneous
emphysema
LeFort Fractures
 Body 30-40 %
Angle 25-30 %
Condyle 15-17 %
Symphysis 7-15 %
Ramus 3-9 %
Alveolar 2-4 %
Coronoid Process 1-2 %
Maxillary Fractures
LeFort I
 Definition:
 Horizontal fracture of
the maxilla at the level
of the nasal fossa.
 Allows motion of the
maxilla while the nasal
bridge remains stable.
 Maxillary Fractures
LeFort I
 Clinical findings:
 Facial edema
 Malocclusion of the
teeth
 Motion of the maxilla
while the nasal bridge
remains stable
 Maxillary Fractures
LeFort II
 Definition:
 Pyramidal fracture
 Maxilla

 Nasal bones

 Medial aspect of the

orbits
 Maxillary Fractures
LeFort II
 Clinical findings:
 Marked facial edema
 Nasal flattening
 Traumatic telecanthus
 Epistaxis or CSF
rhinorrhea
 Movement of the
upper jaw and the
nose.
 Maxillary Fractures
LeFort III
 Definition:
 Fractures through:
 Maxilla
 Zygoma
 Nasal bones
 Ethmoid bones
 Base of the skull
 Maxillary Fractures
LeFort III
 Clinical findings:
 Dish faced deformity
 Epistaxis and CSF
rhinorrhea
 Motion of the maxilla,
nasal bones and
zygoma
 Severe airway
obstruction
Peritonsillar Abscess
 Sudden increase in
pain
 Difficulty swallowing
 Displacement of
uvula
 Unilateral swelling of
anterior tonsil pillar
Peritonsillar Abscess
Laryngeal Trauma
Anatomy and Physiology of
Larynx
 Airway, tracheobronchial protection,voice
 Hyoid, thyroid, cricoid
 Innervation - RLN, SLN
 Supraglottis - soft tissue
 Glottis - ca joint,cartilage, neuromuscular
coordination
 Subglottis - cricoid, narrowest in infants
Anatomy and Physiology of
Larynx
Mechanism of Injury
 Blunt - strangulation, clothesline, cspine
 Penetrating
 GSW (gun shoot wound): damage related to velocity
 Knife: easy to underestimate damage
 History
 Hoarseness or change in voice
 Dysphagia
 Odynophagia
 Difficulty breathing - more severe
injury
 Anterior neck pain
 Physical exam
 Stridor -inspiratory, expiratory or both
 Subcutaneous emphysema
 Hemoptysis
 Laryngeal tenderness,ecchymosis, edema
 Loss of thyroid cartilage prominence
 Associated injuries - vascular, cspine, esophageal
 Complications
 Granulation tissue - most common, prevention key,
can lead to fibrosis and stenosis of larynx or trachea, tx
is site specific and includes laser excision,
laryngofissure and cricoid split
 Immobile vocal fold - cricoarytenoid joint or RLN
injury. If arytenoid mobile, may observe for return of
nerve function
Management of Laryngeal Trauma
 Aspiration: Introduction
 Aspiration during sleep in all normal, healthy
individuals
 Children: Swallow dysfunction impairs respiratory
function
 Complications: Tracheitis, bronchitis,
bronchospasm, pneumonia, pulmonary abscess, ?
SIDS
 3 categories of aspirate: orally ingested, oral/airway
secretions, regurgitated gastric contents
 Aspiration: History
 GER = abnormality most commonly associated w/
chronic aspiration
 GER si/sx: Postprandial cough, regurgitation,
emesis, bronchospasm, laryngospasm, central
apnea, bradycardia
 Risk factors: Depressed consciousness,
prematurity/swallow dysfunction, CP, epilepsy,
muscular dystrophy, intestinal motility disorder,
scoliosis
 Aspiration: Workup
 NP reflux suggests swallow dysfunction
 Lateral neck and plain chest films: 14% of films
normal
 MBS & Barium swallow: Ba swallow 50-85%
sensitive, 70-75% specific for GER
 Scintiscan: Study of choice for gastric emptying
 Aspiration: Treatment
 GER natural hx: Resolution by 18-24 months
 Conservative Tx: Positioning, Thicken feeds, Small
frequent feeds. Optimal position prone and flat with
body tilted 30 degrees. Sitting may worsen GER
 Medical tx: Metoclopramide increases LES tone
and gastric emptying; H2 blockers/PPIs; Sucralfate
if duodenal ulcers
 Surgery for GER: Fundoplication if failure after 6
weeks on medication
 Aspiration: Foreign Body
 Esophageal foreign bodies – respiratory sx in 10%
 Vegetable matter most common airway FB: NUTS,
carrot pieces, beans, sunflower/watermelon seeds
 Conforming objects/balloons most common airway
FB causing death; at least 2 deaths from latex gloves
in MD’s office; spherical objects second most
common
Aspiration: Foreign Body
 Natural history: 3 stages
 Choking/coughing/gagging
 Asymptomatic interval (up to ½ cases diagnosed
beyond 1 week)
 Complications: cough, hemoptysis, pneumonia, lung
abscess, fever, malaise
 Workup: I/E CXR, lateral decubitus
 Exam, films usually normal 1st 24 hours
Aspiration: Foreign Body
Foreign Body Aspiration
 Most prevalent under
age 4
 Smaller objects
aspirated/ larger
swallowed
 Laryngeal objects –
potential airway
emergency
 Foreign Body cont.
 Remove in controlled
fashion
 Laryngeal: ASAP
 Bronchial: same day of
diagnosis
 Esophageal: variable
Airway Management
 Tracheotomy under local anesthesia is preferred
method for adults
 CT
 Fiberoptic intubation or DL with direct visualization
 Pedi - inhalation anesthesia with spontaneous
respirations followed by rigid endoscopic
intubation
 Principles of airway management techniques
Try simple manoeuvres to open airway
Jaw thrust is used when other methods have failed.
Oropharyngeal airway or nasopharyngeal airway may be useful in
the unconscious patient.
If the patient is not immediately intubated the coma position
(semiprone, slightly head down) should be used.
Emergency Management
Airway Control
 Control airway:
 Chin lift.
 Jaw thrust.
 Oropharyngeal suctioning.
 Manually move the tongue forward.
 Maintain cervical immobilization
Principles of airway management techniques
3. Surgical airway

• cricothyroidotomy
• percutanous tracheotomy
• emergency tracheostomy
 Conclusions
 Key to recognition is high index of suspicion
 Assess airway first and base management on flow
diagram
 Don’t forget about associated vascular or esophageal
injuries
 Airway Obstruction
 Aphonia - complete upper airway
 Stridor - incomplete upper airway
 Wheezing - incomplete lower airway
 Loss of breath sounds- complete lower airway