Kegawat Daruratan THT-KL Unswagati

Kegawat Daruratan THT-KL
Oleh
Ismi Cahyadi
Nama : dr Ismi Cahyadi SpTHT-KL
TTL : Cirebon, 10 Mei 1983
Riwayat Pendidikan
- Pendidikan Dokter FK Unjani lulus 2007
- Pendidikan Dokter Spesialis FK UNPAD 2012-
2016
Riwayat pekerjaan
- Dokter umum RSUD Waled 2012
- Dokter Spesialis THT-KL RSUD Waled s/d
Sekarang
• Infeksi
Ear pain • Foreign body
• Trauma
Hearing Loss • Sudden Hearing Loss
• Sindrom Meniere
Vertigo • Vertigo perifer
Epistaksis • Epistaksis Posterior
Nasal • Unified Airway obstruction
Obstruction • Foreign body

INFECTION OF THE EXTERNAL EA
A. Furuncle
B. Impetigo
C. Erysipelas
D. Otomykosis
E. Herpes zoster
F. Bullous myringitis
4
EXTERNAL EAR ANATOMY
• Auricle
• External Auditory Canal
5
AURICLE
Lobule
– Skin
– Areolar tissue
– Fat
Auricle (excluding lobule)
– Elastic cartilage
– Subcutaneous tissue (minimal)
– Skin
• Loosely adherent
posteriorly
• Tightly adherent anteriorly
6
EXTERNAL AUDITORY CANAL
STRUCTURES
• S shape, 2,5 cm from concha – tympanic membrane.
• Segments :
– Cartilaginous segment : 1/3 lateral
Cartilaginous canal : 0,5-1,0 mm thick, hair follicles
(+), sebaceous and ceruminous gland (+).
– Bony segment : 2/3 medial
Bony canal : 0,2 mm thick, continous to TM, devoid
of skin appendages
7
ADNEXA AND SECRETORY SYSTEM
The adnexae and secretory
system of the skin of the
external auditory canal
contains many:
• Hair cells,
• Sebaceous and apocrine
glands
Ballenger’s Otorhinolaryngology, 16th edition © 2003 BC Decker Inc

8
INFECTION OF AURICLE
9
INFECTION OF THE PINNA
• Most Common: Celulitis & Erysipelas
• Bacterial infection that usually
follows:
− abrasion,
− laceration, or
− ear piercing
• The auricle is red, swollen, painful,
and tender to manipulation
10
INFECTION OF THE PINNA
• Etiology:
– Cellulites : Staphylococcus or Streptococcus
– Erysipelas : group A β-hemolytic Streptococcus
• Treatment:
Rapid treatment with oral or IV antibiotics if insufficient
Response.
First choice: Penicillin

11
HERPES ZOSTER OTICUS
(RAMSAY-HUNT SYNDROMES)
• Etiology: Varicella Zoster Virus
• Clinics:
– Pain + vesicle
– progressive Pareses of n. VII
– SNHL and Vertigo
– Could effect: n. V, IX – XII
• Children:
– Rarely
– Mild
– Better prognosis
12
• Facial Nerve Paralysis:
– Sensory
– Sensory + motor
– Sensory + motor + auditory
symptom
• MRI  other cause of facial
nerve paralysis
• Treatment:
– Valacyclovir, famciclovir,
acyclovir
13
Treatment
• Acyclovir and the newer famciclovir and valacyclovir
– Adult Dose 800 mg PO 5 times/d for 7-10 d

Pediatric Dose 10-20 mg/kg/dose (up to 800 mg) PO
qid for 5 d
• Early administration (<72 h) of acyclovir showed an

increased rate of facial nerve function recovery and
prevented further nerve degeneration
14
PERICHONDRITIS AND CHONDRITIS
• Bacterial infection of
perichondrium or cartilage of
the auricle
• Symptom:
 painful, red, and swollen and
drains serous or purulent
exudates.
 The surrounding soft tissues of
the face and neck may be
affected.
15
PATHOGENESIS OF PERICHONDRITIS
Blood & Serum

Trauma 2nd Infection:
Burn S. Aureus
External Otitis P. Aeruginosa
Proteus sp
Subperichondrial Space
Vascular Compromised Fluid Resorption
Cartilage Necrosis Cartilage Deposition
16
Sumber: K.J. Lee, 2003; Cummings, 1993 Deformity
Treatment
• In the early stage:

− oral fluoroquinolone antibiotics (ciprofloxacin,
levofloxacin)
− local antibiotic drops, and débridement

17
• Advanced stage :
− Hospitalized with aggressive
intravenous antibiotics
using ceftazidime or
fluoroquinolones and local
treatment.
− Topical antibiotic
− irrigation with indwelling
catheters may be tried.
18
INFECTION OF EXTERNAL AUDITORY
CANAL
19
ACUTE LOCALIZED OTITIS EXTERNA
(FURUNCLE)
Furuncle
• Acute localized infection

• Obstructed apopilose baceous unit
• Infection by S. aureus of the hair follicles
in the cartilaginous portion of the
external auditory meatus
20
ACUTE LOCALIZED OTITIS EXTERNAL
(FURUNCLE)
Symptoms Treatment
• Localized pain • topical and systemic
• Pruritus antibiotics.
• Hearing loss (if lesion • If a localized abscess has
occludes canal) formed:
• Discharge is not usually − incision and drainage
present until the abscess and
ruptures. − topical antibiotic
ointment with or
without oral antibiotics.
21
DIFFUSE OTITIS EXTERNA
“Swimmer's Ear”
• Bacterial infection of the EAC and

the most common form of otitis
extern
• diffuse inflammation of meatal
skin , may spread to the pinna /
epidermal layer of tympanic
membrane.
• Commonly in hot and humid
climate and in swimmers
22
DIFFUSE OTITIS EXTERNA
• Factors : trauma to the
meatal skin, invasion by
pathogenic organisms.
• Organisms :
– Staph. Aureus,
Pseudomonas
aeruginosa,
– Basillus piosianius , Esch.
Coli / mixed.
23
OTITIS EKSTERNA DIFUSE (ACUTE)
Humidity
Foreign body Weather
Long and narrow EAC
Hearing Device Skin disorder:
Drug alergy Dermatitis
Psoriasis
DM
Occlusion Immunocompromise
Apopilosebaseus
Ear wax
High pH (alkali)
Bacterial Proliferation • pH 4-5
Trauma
• Ig
• Lisozim
Otitis Eksterna 24
Source: K.J. Lee, 2003
I. Preinflammatory Stage
• Edema of stratum corneum and plugging of

apopilosebaceous unit
• Symptoms: pruritus and sense of fullness
• Signs: mild edema
• Starts the itch/scratch cycle
II. Acute inflammatory
earliest stage
• mild erythema and minimal
edema
• small amount of clear or
slightly cloudy exudate
moderate stage
• pain and itching increase
• edema and a thicker canal
• more profuse exudate
26
Severe Stage
severe inflammatory
• Increased pain and obliteration of the
lumen of the canal
• profuse greenish-gray, purulent exudate
• edema of the canal skin
• small white papules on the surface of the
canal skin
27
TREATMENT
• Most common pathogens: P. aeruginosa and
S. aureus
• Four principles
– Frequent canal cleaning
– antibiotics
– Pain control
– Instructions for prevention
Necrotizing (Malignant) External
Otitis
• DM, immunocompromised
• Etiology: P. aeruginosa
• OE + Skull base osteomyelitis →spread
• Progression:
1.EAC →Santorini fissures and timpanomastoid →
retromandibular fossa
2.Deployment to the stylomastoid and jugular
foramens
3.Lateral sinus thrombosis
4.Apex of the petrosal (mel the vascular or fascia, not
the cell water

29
NECROTIZING (MALIGNANT) EXTERNAL OTITIS
• Potentially life-threatening disease
• Larger context of osteomyelitis of the

temporal bone & skull base
• The prevalence was decreased after

the discovery of newer anti-
Pseudomonas antibiotics
30
Diagnosis Necrotizing External Otitis
History
• Persistent otalgia
• Persistent, purulent otorrhoea, granulations
• Diabetes mellitus, advanced age,
• immunocompromised state
• Cranial neuropathy(ies)
Physical Examination
• Granulations in external canal
• Purulent discharge seen
• +/- cranial neuropathy, especially cranial nerve VII
31
Clinical: Granulation on Posterior wall of EAC, paralysis n. VII, IX - XI,
severe pain
Stadium:
Soft tissue and cartilage
Temporal bone erosion
Extension to the intracranial
32
Culture
• Pseudomonas sp
• Pseudomonas aeruginosa
Radiology
• Nuclear (gallium technetium)
• CT with contrast
• MRI with contrast
33
Treatment Necrotizing External Otitis
Medical
• Hospital admission
• Intravenous antibiotics  Anti-Pseudomonas antibiotics
(6 weeks or more)
• Daily cleaning, debridement
Surgical
• Excise granulations
• +/- middle ear exploration
• +/- mastoidectomy
• +/- facial nerve decompression
• +/- temporal bone resection if no response
34
Topical Ciprofloxacin (Cipro HC)

or Topical Ofloxacin (Floxin otic)
PLUS
Oral anti pseudomonas quinolone

(Cipro, et al)
PLUS
Added intravenous
antipseudomonals :
Ceftazidime (Fortaz) or Cefepime (Maxipime)
Ciprofloxacin or levofloxacin
Piperacillin/tazobactam (Zosyn) plus :
gentamycin or tobramycin or amikacin
Imipenem or Meropenem
35
Bullous External Otitis
• Very painful condition
• Vesicles or bullae are noted in the bony portion of the
external canal& hemorrhagic vesicles
• Etiology : Pseudomonas
• Treatment :
otic drops
avoid packing and irrigation
36
Bullous Myringitis
• Viral infection
• Confined to tympanic membrane
• Primarily involves younger children
Symptoms
• Sudden onset of severe pain
• No fever
• No hearing impairment
• Bloody otorrhea (significant) if rupture
Bullous Myringitis: Signs
• Inflammation limited
to TM & nearby canal
• Multiple reddened,
inflamed blebs
• Hemorrhagic vesicles
Bullous Myringitis: Treatment
• Self-limiting
• Analgesics
• Topical antibiotics to prevent secondary
infection
• Incision of blebs is unnecessary
FOREIGN BODIES
• A variety of foreign • Any objects small enough
bodies may be discovered to enter the EAC can
in the EAC become prospective
foreign bodies
• Diagnosis : easy using the (animate, inanimate, or
operating microscope and mineral objects)
a small blunt hook
• They may cause
• Found most frequently in symptoms of irritation,
the pediatric age group pain, and hearing loss
or in mentally retarded
patients
LR/EO 40
a . Sand particles can be seen
along the anterior wall of
EAC
b . A piece of paper has been

“forgotten”
inside EAC  secondary
infection (external
otitis) of the skin
c . A metallic hearing aid

component, with
secondary infection of the skin
of the EAC
d. Insect on the surface of

tympanic membrane
Anniko M. European Manual of Medicine: Otorhinolaryngology Head and Neck Surgery. Springer-Verlag. 2010.
A plastic beads Insects : bees, flies, mosquitos, cockroach
Hawke M, Bingham B, Stammberger H, Benjamin B. Diagnostic Handbook of Otorhinolaryngology. 2005.

LR/EO 42
Foreign Bodies Removal
• Removal is done with a small blunt hook or aural
crocodile forceps
– without anaesthesia
– or under general anaesthesia (in children)
• Syringing is effective for small plastic or metallic

foreign bodies but not for organic foreign bodies,
which may swell with water
– The main harm by a foreign body in the EAC is caused by its careless
removal!
LR/EO 43
Instrument used in the removal of aural foreign bodies
Dhillon RS, East CA. An Ilustrated colour text: Ear, Nose , Throat and Head and Neck Surgery. 2 nd Edition. Hartcourt .2000.
LR/EO 44
important
• The removal  safely done under direct visualization, preferably under an operating
microscope with the patient in a supine position
• Instruments helpful for this task (alligator forceps, ring curettes, and hooks)
• Inanimate objects located lateral to the isthmus of the canal are removed with an alligator
forceps or by placing a hook or ring curette behind it and pulling it out
• Suctioning with Frazier suction catheters is useful in removing an object with a smooth
surface that is hard to grasp
• Irrigation can be used in certain instances.
• Objects located medial to the isthmus of the canal are more difficult to remove and may
require local or general anesthesia
LR/EO 45
TRAUMA
CAUSATIVE
Mechanical and
thermal factor
Causative
Chemical injuries
Agents
Pressure changes
12/30/2018 47
External Ear Trauma
12/30/2018 48
THE EXTERNAL EAR
• The external ear :

• Auricle
• External auditory canal (EAC)
• More vulnerable to physical trauma
• Blunt trauma
• Sharp trauma
12/30/2018 49
BLUNT TRAUMA
• The most common complication → auricular
hematoma .
• Failure to recognise and treat → deformity of the
pinna “cauliflower”
• Management
 Needle aspiration under sterile conditions
 Pressure dressing
 Recurs within 48 hours → formal incision
and drainage
12/30/2018 50
12/30/2018 51
SHARP TRAUMA
 Lacerations of cartilaginous
framework
 Management :
 Minimal debridement and
suturing of the perichondrium
and skin
12/30/2018 52
EXTERNAL EAR
• Exposure of extreme outer temperatures
 Varying degrees of thermal injury
 First degree burns and frostbites
 Redness
 Swelling
 Highly sensitive to touch
 Second-degree thermal injury
 Blister formation
• Exposure to extreme hot or cold
 Irreversible damage to the underlying cartilage
 Necrosis and severe deformity
12/30/2018 53
EXTERNAL ACUSTICUS
CANAL
Initial management :
• Local conservative treatment
• Gentle washing and application of
antibiotic ointment
Prevent secondary infection.
12/30/2018 54
EXTERNAL ACUSTICUS
CANAL
• The most common in children
 Foreign body (FB) impaction
 Unsuccessful attempts at removal
• Types of trauma
 Abrasions
 Lacerations
• Management
 Eardrops containing antibiotics →
preventing secondary infection
 Aminoglycoside → avoided
12/30/2018 55
Middle Ear
12/30/2018 56
EPIDEMIOLOGY
 TM is much more
traumatized than the
Inner ear
 1.4-8.6 per 100,000
 Men > Women
 Children are curious
12/30/2018 57
Tympanic Membrane
• Protection of Tympanic Membrane :

 The curved shape of the EAC
 Narrow isthmus
 Hairs and wax
 The eustachian tube
• A traumatic perforation :
 Direct trauma by a FB
 Explosive pressure changes from air or water
 Head trauma with or without fracture of the
temporal bone
12/30/2018 58
Traumatic TM Perforations
 Compression Injuries
Barotrauma
 Penetrating Injuries
 Thermal Injuries
 Lightning/Electrical Injuries
12/30/2018 59
Traumatic TM Perforations
 The majority heal spontaneously.
 No infection → no antibiotics
 Conservative therapy → prevent a secondary infection
 Eardrops containing gentamicin → avoided
 Tympanoplasty → a persistent perforation
 In welding spark injuries, perforations of the difficult to
heal
12/30/2018 60
MIDDLE EAR TRAUMA
Associated with TM or Inner ear or
Temporal bone trauma unless
Iatrogenic
 Ossicular discontinuity
 Facial Nerve Injury
 Chorda tympani Nerve Injury
12/30/2018 61
MIDDLE EAR TRAUMA
Otic barotrauma
• Rapid changes of external pressure
 Airplane flight
 Diving
 Explosion
• Rupture of fine blood vessels in the middle ear → hemotympanum.
• Prophylaxis of barotrauma during airplane flight depends especially on
proper eustachian tube function.
 Valsalva manoeuvres
 Topical nasal
 Systemic decongestants
 A preventive myringotomy with ventilation tube insertion.
12/30/2018 62
MANAGEMENT
 Depend on etiology
 Audiologic examinations,and impedance
testing
 An accurate diagnosis
 Surgical intervention
12/30/2018 63
Inner Ear
12/30/2018 64
ANATOMY
• Organs of hearing and balance

within the petrous part of
temporal bone
• Fragile elements → vulnerable
to head trauma
12/30/2018 65
ETIOLOGY
 Blunt Trauma
 Penetrating Trauma
 Barotrauma
12/30/2018 66
LONGITUDINAL FRACTURES
 70% of Temporal
Bone Fractures
 Lateral Forces along
the petrosquamous
suture line
 15-20% Facial
Nerve involvement
 EAC laceration
12/30/2018 67
TRANSVERSE FRACTURES
 20% of Temporal
Bone Fractures
 Forces in the
Antero- Posterior
direction
 50% Facial Nerve
Involvement
 EAC intact
12/30/2018 68
PENETRATING TRAUMA
 Increase in violence and firearms

 Associated with more dismal outcome
More likely to involve intracranial
lesions
12/30/2018 69
BAROTRAUMA
 Rapid pressure fluctuations with the inner ear
 Air travel or SCUBA diving
“the bends”
12/30/2018 70
PHYSICAL EXAMINATION
 Basilar Skull Fractures
Periorbital Ecchymosis
(Raccoon’s Eyes)
Mastoid Ecchymosis
(Battle’s Sign)
Hemotympanum
Raccoon’s Eyes. Bluish discoloration of the
peri-orbital region (Periorbital Ecchymosis)
12/30/2018 71
Hemotympanum (blood in the middle ear)causes a Ruptured tympanic membrane and blood in
bluish discoloration of the drum the ear canal (surgeon's view)
12/30/2018 72
Battle's Sign. Bluish discoloration of the Traumatic cochlear hemorrhage
post-auricular region (Mastoid Ecchymosis)
Cerebrospinal fluid (CSF) otorrhea Oblique left temporal bone fracture line crossing the mastoid
process, into Henle's spine and the external auditory canal
(surgeon's view)
12/30/2018 73
 Tuning Fork exam
 Pneumatic Otoscopy
12/30/2018 74
IMAGING
 HRCT
 MRI
 Angiography / MRA
12/30/2018 75
HRCT
Adapted from Bailey, 2002
12/30/2018 76
Sudden Hearing Loss
• SSHL didefinisikan sebagai gangguan
pendengaran sensorineural ≥30 dB pada 3
frekuensi bersebelahan
• Onset ≤ 3 hari
• Sebagian besar kasus penyebab pasti?
• Prognosis bervariasi
• Perawatan : infus dan/atau intratympanic
kortikosteroid
• Kejadian tahunan SSHL 1 kasus per 5000-10.000
penduduk  pasien yang mencari pertolongan
medis
• Jumlah kasus sebenarnya?  pulih spontan
• 10-15% kausa oleh infeksi, trauma, neoplastik,
imunologi, intoxikasi, gangguan peredaran
darah dan kausa neurologis
• Sebagian besar kasus (85-90%)  Idiopatik ;
infeksi virus, gangguan pembuluh darah,
pecahnya membran intracochlear dan
penyakit autoimun telinga dalam
Vertigo
Syndrom Meniere
Definition
• Ménière's disease or Ménière's syndrome is

an inner ear disorder marked by spontaneous
attacks of vertigo, fluctuating sensorineural
hearing loss, aural fullness and tinnitus.
81
Lee, KJ, Essential Otolaryngology Head & Neck Surgery, 9th ed, McGraw-Hill, 2008
Introduction
• French physician
• Published in 1861
• vertigo was caused by

inner ear disorders
82
decitre.fr
Introduction
- Knapp (1871)
Meniere’s disease was caused by elevated
endolymphatic pressure
- Hallpike and Cairns (1938)
Gross dilation of the saccule and scala media with
obliteration of the perilymph spaces of the vestibule
and scala vestibuli and confirmed the concept of
endolymphatic hydrops
Johnson J, Lalwani AK. Meniere’s . Ballenger’s Otorhinolaryngology Chapter 20. 2003 BC Decker Inc.
Pathophysiology
• Exact pathophysiology of Ménière disease is
controversial
• Distortion of the membranous labyrinth

resulting from overaccumulation of
endolymph
Merchant SN, Adams JC, Nadol JB Jr. Pathophysiology of Meniere's syndrome: are symptoms caused by endolymphatic hydrops?.Otol Neurotol.
84
Jan 2005
Pathophysiology
Normal membranous labyrinth Dilated membranous labyrinth in Meniere's

disease (Endolymphatic Hydrops 85
Pathophysiology
• Hydrops
– endolymphatic duct or sac is blocked
– obstructed by scar tissue, or narrow from birth
• Immune Disease
• Migraine
• Underlying cause of Meniere's disease is
“unknown”
86
Hain TC. Meniere’s disease [online] 2008
Pathophysiology
• Attacks of hydrops probably are caused by an
increase in endolymphatic pressure, which, in
turn, causes a break in the membrane that
separates the perilymph (potassium-poor
extracellular fluid) from the endolymph
(potassium-rich intracellular fluid).
87
Pathophysiology
• The resultant chemical mixture bathes the
vestibular nerve receptors, leading to a
depolarization blockade and transient loss of
function. The sudden change in the rate of
vestibular nerve firing creates an acute
vestibular imbalance (ie, vertigo).
88
Pathophysiology
• Physical distention caused by increased
endolymphatic pressure also leads to a
mechanical disturbance of the auditory and
otolithic organs
• Utricle and saccule irritation → nonrotational
vestibular symptom
89
Pathophysiology
• This physical distention → mechanical
disturbance of the organ of Corti
• Distortion of the basilar membrane and the
inner and outer hair cells → hearing loss
and/or tinnitus
90
Pathophysiology
• Since the apex of the cochlea is wound much

tighter than the base, the apex is more
sensitive to pressure changes than the base.
91
92
Etiology
• Disorders that may give rise to elevated
endolymphatic pressure include metabolic
disturbances, hormonal imbalance, trauma,
and various infections (eg, otosyphilis and
Cogan’s syndrome [interstitial keratitis]
Paparella MM, Djalilian HR. Etiology, pathophysiology of symptoms, and pathogenesis of Meniere's disease. Otolaryngol Clin North Am. 93
Jun
2002;35(3):529-45
Physical Examination
• Depending upon the phase of disease
• During remission, physical examination findings
may be completely normal
• During an acute attack, the patient has severe
vertigo
• Significant distress
• Elevated blood pressure, pulse & respiration
• Significant nystagmus may be present
94
Evaluation of vertigo
• The Dix-Hallpike positional test → Nystagmus
• The Romberg test generally shows significant
instability and worsening during acute attacks
when the eyes are closed
95
Evaluation of hearing loss
• Audiologic testing is more accurate
96
Probst-Grevers-Iro, Basic Otorhinolaryngology, 2006
Complications
• Injury due to falls
• Anxiety regarding symptoms
• Accidents due to vertigo spells
• Disability due to unpredictable vertigo
• Progressive imbalance and deafness
• Intractable tinnitus
97
Other problems to be considered
include the following
• Trauma • Basilar meningitis
• Endocrine abnormalities • Brainstem tumors
• Hyperlipidemia • Neoplasms (eg, acoustic
• Diabetes neuroma)
• Congenital anomalies • Toxic or pharmaceutical
• Autoimmune injury to the vestibular
problems/inner ear apparatus
inflammation • Vascular infarction of the
• Otosclerosis labyrinth (usually associated
with unilateral hearing loss)
• Perilymphatic fistula
• Electrolyte imbalance
98
Differentials Diagnosis
• Anterior Circulation Stroke • Migraine Headache
• Arteriovenous Malformations • Neurosyphilis
• Basilar Artery Thrombosis • Otitis Media in Emergency Medicine
• Benign Positional Vertigo in Emergency • Polyarteritis Nodosa
Medicine • Posterior Cerebral Artery Stroke
• Brainstem Gliomas • Skull Tumors
• Cerumen Impaction Removal • Rheumatoid Arthritis
• Ear Foreign Body Removal in Emergency • Temporal Lobe Epilepsy
Medicine • Transient Ischemic Attack
• HIV-1 Associated CNS Conditions: • Vestibular Neuronitis
Meningitis
• Viral Encephalitis
• Hypothyroidism and Myxedema Coma in
Emergency MedicineI • Viral Meningitis
• ntracranial Hemorrhage
• Labyrinthitis And Related Conditions
99
Differentials Diagnosis
100
Bailey, Byron et al: Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins2006
Work Up
• Should be directed • Audiometry
at differentiating • Brainstem auditory evoked
the disease from potentials
other causes on the • Transtympanic
basis of associated electrocochleography (ECOG)
symptoms
• Electronystagmography
(ENG)
• Otoscopy
• Caloric testing/ENG
101
Treatment
• In the emergency department (ED) is based on
symptomatic relief of the clinical findings
• Surgical therapy for Ménière disease is
reserved for medical treatment failures
102
Pharmacologic Therapy
Vestibulosuppressants
• meclizine, droperidol, prochlorperazine,
diazepam, lorazepam, alprazolam
Diuretics and diureticlike medications
• hydrochlorothiazide and triamterene,
hydrochlorothiazide, acetazolamide,
methazolamide)
103
Steroids
• probably by reducing endolymphatic pressure
orally, intramuscularly, or even
transtympanically
Aminoglycosides
• toxic to the vestibular (balance) end organ
104
Sajjadi H. Medical management of Meniere's disease. Otolaryngol Clin North Am. Jun 2002
Histamine agonists
• betahistine (Serc) → increasing circulatory
flow to the cochlear stria vascularis?
• has not been approved by the US Food and
Drug Administration (FDA)
105
Phillips JS, Prinsley PR. Prescribing practices for Betahistine. Br J Clin Pharmacol. Apr 2008
Surgical therapy
• Endolymphatic sac decompression or shunt
placement
• Vestibular nerve section
• Labyrinthectomy
• Intratympanic injection of medications such as
gentamicin or steroids
Wetmore SJ. Endolymphatic sac surgery for Ménière's disease: long-term results after primary and revision surgery. Arch Otolaryngol Head
106 Neck
Surg. Nov 2008
Diet and Activity
Dietary measures
• Avoiding foods with high sodium content
(pizza, preserved foods, smoked fish)
Activity restriction
• dangerous tasks (eg, especially climbing
ladders) should be avoided
107
Prevention
• Caffeine • Foods with high
• Nicotine cholesterol or
• Chocolate, which has triglyceride content
shown to be a potent • Foods with high
trigger substance carbohydrate content
• Tobacco • Excessive sweets and
• Alcohol, particularly red candy
wine and beer
108
Prognosis
• Patient presentation and progression of
Ménière disease vary widely
• In general, the patient’s condition tends to
spontaneously stabilize over time
• However: many patients are left with poor
balance and poor hearing
109
Minor LB, Schessel DA, Carey JP. Ménière's disease. Curr Opin Neurol. Feb 2004
Epistaksis
INTRODUCTION
• Epistaxis  bleeding from inside the nose

• Epistaxis is a sign and not disease
• Most patients do not seek medical attention  the bleed
is minor and usually stops quickly
• Males > females
111
VASCULAR ANATOMY
 External Carotids Artery

- Maxillary's artery
- Facials artery
 Internal Carotids Artery
- Ophthalmic artery
Anterior
ethmoidalis artery
Posterior
ethmoidalis artery
Bailey, Byron J, 4th Edition 2006 112

Bailey, Byron J, 4th Edition 2006
113
ETIOLOGY
LOCAL SYSTEMIC
• Trauma: digital, fractures • Hypertension
• Nasal sprays • Vascular disorders
• Inflammatory reactions • Blood dyscrasias
• Hematologic malignancies
• Anatomic deformities
• Allergies
• Foreign bodies
• Malnutrition
• Intranasal tumors • Alcohol
• Chemical inhalants • Drugs
• Nasal prong O2 • Infectious
• Surgery

VESSEL WALL CHANGE
• Associated with aging, specifically fibrosis

of the muscular tunica media of arteries
• Risk Factors :
– Atherosclerosis
– Hypertension
• Increasing the risk of posterior epistaxis
• Rebleeding after medical or surgical treatment

CLASSIFICATION
• Occurs primarily in the region of

Little’s area
Anterior • More often venous in origin
• Primarily in the region of the posterior

septum
Posterior • Posterior lateral nasal wall  Woodruff’s are
• More often arterial in origin

Anterior Epistaxis Posterior Epistaxis
Dhingra PL, Diseases of ear nose and throat. 4th ed. Elsevier;2008 117
Differences Between Anterior And Posterior Epistaxis
Anterior Epistaxis Posterior Epistaxis
Incidence More common Less common
Site Mostly from Little’s area or Mostly from posterosuperior part of

anterior part of lateral wall nasal cavity; often difficult to localise
the bleeding point
Age Mostly occurs in children or After 40 years of age
young adults
Cause Mostly trauma Spontaneous, often due to

hypertension or arteriosclerosis
Bleeding Usually mild, can be easily Bleeding is severe, requires

controlled by local pressure or hospitalication, postnasal pack often
anterior pack required
Dhingra PL, Diseases of ear nose and throat. 4th ed. Elsevier;2008 118
ASSESSMENT
TOOLS :
- Protective eyewear
- Cover gown and mask
- Nasal speculum, tongue spatel
- Bayonet pinset
- Light source
- Suction
- Packing
119
networkmedical.co.uk
 General status
 Local status
• Determine :
 Anterior or posterior
 Right or left cavum nasi
 Duration of bleeding
 Quantity of blood loss

• Laboratorium
• Nasoendoscopy
• X-ray / CT Scan
121
MANAGEMENT
BASIC CARE OF HEMORRHAGE

1. Vital signs
• Predisposition factors :
2. Hemoglobin severe midfacial trauma
3.Fluid resuscitation & blood with maxillary artery
transfusion laceration, often
4. Central venous pressure associated
Uncommon, but the condition with multisystem trauma.
is
life-threatening:
Exsanguinating epistaxis
122
MANAGEMENT
1. Cauterization : Silver nitrate & electric
2. Nasal packing (anterior, posterior or both)
3. Ligation : a. Ethmoid arteries, anterior & posterior
b. Internal maxillary & sphenopalatine
c. External carotid arteries
4. Septodermoplasty
5. Angiography
6. Embolization
7. Pharmacologic agents
SILVER NITRAT CAUTERIZATION
• Cauterization of the vessel and a

2- to 3-mm circumferential area
will effectively
• To prevent further burning of

normal tissue  neutralized with
application of sodium chloride
124
ELECTRIC CAUTERIZATION
125
NASAL PACKING
* Anterior Nasal Packing
* Posterior Nasal Packing

ANTERIOR NASAL PACKING
sehha.com
The traditional anterior pack of petrolatum gauze (0.5 72-inch) coated with an
antibacterial ointment is firmly packed in a layered fashion toward the
posterior choanae after decongestion and local anesthesia placement
127
Newer nasal packing materials
 expand several times in
volume with hydration, making
placement easier for the
physician and patient 
hydroxylated polyvinyl acetal
(Merocel) and polyvinyl alcohol
(Expandacell, Rhino Rocket)
128
POSTERIOR NASAL PACKING
 Indicated :
failing anterior nasal packs or
who upon evaluation have
known posterior bleeding
 Preoperative procedure :
– Require careful instruction to the
patient
– Intravenous access and mild
sedation
129
POSTERIOR NASAL PACKING
• Newer types  include double

balloons, a composite of balloon and
Merocel  advantage of staying in
place after balloon deflation and
removal.
• Complications;
• A potential drawback of balloon
packs
• Alar or columellar necrosis
www.bes.de/rhinologie/epistaxiskatheter 130
LIGATION OF ARTERIES
a. Ethmoid arteries, anterior & posterior
b. Internal maxillary & sphenopalatine arteries
c. External carotid arteries

EPISTAXIS PREVENTION
• Patient education
• Keep the nose moist
• Avoidance of digital manipulation,airborne irritants,
smoke
• Control of allergies
• Tappering amount of nasal spray
• Intranasal surgical technical refinements

Nasal Obstruction
The Unified Airway Disease
Krouse Jhon, The Unified Airwayd Conceptual Framework In: Otolaryngologic Clinics of North America 2008 134
Allergic
Inflammation Snoring
Rhinitis
135
Krouse Jhon, The Unified Airwayd Conceptual Framework In: Otolaryngologic Clinics of North America 2008 136
Starling Resistor model
W.T. McNicholas, The nose and OSA: variable nasal obstruction may be more important in pathophysiology
than fixed obstruction, Eur Respir J 2008 137
- Nasal mucosal congestion
- Mucous secretion
NASAL OBSTRUCTION
IMPAIRED SLEEP
138
QURESHI AND BALLARD.JACI 2003.645-649
140
Bailey BJ, Head & Neck Surgery-Otolaryngology, 4th editon, Lippincot Williams & Wilkins, Philadephia, 2006.
Sumbatan Jalan Nafas Atas
Pendahuluan
• Kegawatdaruratan di bidang THT-KL
• Penting  Pemahaman anatomi dan fisiologi

saluran nafas atas
• Mengetahui tanda-tanda sumbatan jalan

nafas bagian atas
DEFINISI
• Suatu kondisi dimana terjadi sumbatan pada

jalan nafas bagian atas baik secara komplit
atau parsial yang menyebabkan gangguan
ventilasi
ANATOMI JALAN NAFAS BAGIAN ATAS
FARING
DIAGNOSIS
145
Anamnesa :
Dispneu
Stridor(Suara yang dihasilkan oleh suatu

turbulensi udara pada saluran nafas yang
tersumbat sebagian)
Gejala lain : gelisah, cemas, takikardi, sianosis
145
Riwayat penyakit
146
• Onset dan berat stridor
• Progresifitas
• Fluktuasi gejala
• Posisi dan gerakan yang meringankan / memperberat
Gejala yang berhubungan

• Suara serak
• Kesulitan menelan / makan
• Gangguan tidur  sleep apnea
146
Pemeriksaan Fisik
147
• Keadaan umum
• Tanda vital(T,N,RR,S)
• Beratnya kelainan pernafasan & kebutuhan
penanganan jalan nafas
• Auskultasi  menggambarkan fase pernafasan:

- Inspiratori
- Ekspiratori
- Bifasik
147
Tingkatan Obstruksi JACKSON
• Stadium I : Retraksi suprasternal ringan dan penderita

dalam keadaan tenang.
• Stadium II : Retraksi pada suprasternal lebih dalam
disertai retraksi epigastrium dan penderita
tampak mulai
gelisah
• Stadium III : Retraksi pada suprasternal, supra dan
infraklavikular, interkostal dan penderita lebih
gelisah
• Stadium IV : Stadium III disertai pucat dan tampak cemas,
frekuensi pernafasan makin cepat yang kemudian
semakin melambat dan akhirnya berhenti
148
Penatalaksanaan
149
• Tergantung dari derajat sumbatan.
• Prinsip utama  memperbaiki sumbatan jalan nafas
• Terapi medikamentosa atau operatif bergantung pada

kelainan yang terjadi.
149
Etiologi pada anak
Akut kronik
Inflamasi Supraglotis Subglotis
 Croup  Atresia koana  Stenosis,web
 Epiglottitis  Stenosis  Massa
 Masa, kista  Benda Asing
Benda asing  Hiperplasi Adenoid  Hemangioma

 Hipertrofi Tonsils
Trauma Trakea
Glottic  Benda Asing
 Laryngomalasia  Stenosis
 Benda Asing  Masa
 Paralisis pita suara  Trakeomalasia
 Papillomatosis  Kompresi Vaskular
150 150
Bailey, Byron J.;Head & Neck Surgery - Otolaryngology, 4th Edition. 2006
Etiologi pada dewasa
Akut Kronik
Inflamasi -Tumor
 Croup - Kongenital
 Supraglotitis - Post Trauma
 Angina Ludwig - Inflamasi
(Wagener Granulomatosis Relapsing
Benda Asing Polikondritis, Sarkoid)
Trauma - Idiopatik
Bailey, Byron J.;Head & Neck Surgery - Otolaryngology, 4th Edition. 2006 151 151
Tindakan Emergensi Lain Pada SJNA
152
INTUBASI ENDOTRACHEAL TUBE

KRIKOTIROIDOTOMI
PERASAT HEIMLICH
152
Intubasi Endotrakeal
Cara cepat memulihkan SJNA
Intubasi lama  komplikasi
Dewasa : > 72-96 jam 

tracheostomy
Anak : > 6 hari 
tracheostomy
153
153
KRIKOTIROIDOTOMI
154
• Dilakukan pada penderita gawat darurat

yang tidak mungkin dilakukan intubasi
• Pada beberapa kasus, tindakan ini jauh lebih

memungkinkan daripada
trakheostomimembrane krikotiroid yang
sangat menguntungkan, letaknya dekat
dengan permukaan kulit
154
155
155
Perasat Heimlich
156
• Benda asing yang

menyumbat laring atau
hipofaring secara total
• Prinsip tekanan pada

paru-paru sehingga
memberikan kekuatan
pada udara
melemparkan benda
asing keluar
156
Benda asing hidung
INTRODUCTION
158
 FB in the nasal cavity:
 More frequently in the pediatric setting (2-5years)
 Affect adults → mental retardation or psychiatric illness.
 Males (58% ) > females
 A great challenge and management may require great skill.
.
158
A Kalan,M Tariq. Foreign bodies in the nasal cavities: a comprehensive review of the aetiology, diagnostic pointers, and
therapeutic measures in Postgrad Med J 2000;76:484–487
Emergency unit of ENT-HNS dept. Hasan Sadikin
Hospital May 2012-August 2012
12 cases of nasal foreign body of 55 total case of foreign body in ENT regions
(21,8%)
Percentage
Ear canals 25,6%
Esophagus 34,6%
Nasal cavity 21,8%
Pharynx 9%
Bronchus 9%
159
12 cases of nasal foreign body
• screw=1 case
• beads=4 case
• plastic toys= 4 case
• marbles=1 case
• button batteries=1
• Nail=1
160
161
DEFINITION
Foreign Body: Any object or substance found

in an organ or tissue in which it does not
belong under normal circumstances.
Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier.

Modes of insertion of the FB
Voluntary • Mainly in children
Accidental • Common in adults
Ribeiro da Silva, Breno Foreign Bodies in Otorhinolaryngology: A Study162

of 128 Cases.Intl. Arch. Otorhinolaryngol, São Paulo - Brazil,
2009.
CLASSIFICATION
ANORGANIC ORGANIC
• Typically plastic or metal • Including  food, rubber,

• Common examples  wood, and sponge.
beads and small parts • More irritating to the
from toys. nasal mucosa
• Asymptomatic • May produce earlier
• Discovered incidentally symptoms
Jonathan I Fischer. Foreign Bodies, Nose. Department of emergency medicine, Thomas Jefferson University Hospital. 2011163
CLASSIFICATION
Inanimate foreign bodies Animate foreign bodies

• Rubber, paper, beans, nuts, • Myiasis (“Texas” screw
sponges, chalk, plasticine, worms =larval state of
pieces of wood, pieces of Cochliomya macellaria and
cloth, bullets, shrapnel, iron the Cochliomyia
bolts, and coins homnivorax”)
• Endogenous materials • Ascaris lumbricoides
(bone, cartilage) • Leech
therapeutic measures in Postgrad
164 Med J 2000;76:484–487
Modul Hidung, Benda Asing. Kolegium Ilmu Kesehatan THT-KL. 2008
Common sites of impaction of foreign
bodies in the nasal cavity
Pathology
• Inert FB may remain in the nose for years without
mucosal changes.
• Inanimate objects  initiate congestion and swelling
of the nasal mucosa  ulceration, mucosal erosion,
necrosis and epistaxis.
• The retained secretion, decomposed foreign body,
and ulceration foul fetor
• Vegetable FBabsorb water from the tissues and
evoke a very brisk inflammatory reaction..
167 Med J 2000;76:484–487
Pathology
• Inflammatory reaction is sufficient to produce

toxaemia.
• FB can act as a nucleus for concretion if it is firmly
impacted or is buried in granulation tissue by
receiving a coating of calcium, magnesium
phosphate, and carbonate and thus becomes a
rhinolith.
168 Med J 2000;76:484–487
Pathology
• Button batteries:
– Severe destruction of the nasal mucous.
– Composed of various types of heavy metals:
mercury, zinc, silver, nickel, cadmium, and lithium.
– Liberation of thes substances causes intense
local tissue reaction and necrosisseptal
perforations, synechiae, constriction, and stenosis
of the nasal cavity.
169 Med J 2000;76:484–487
Pathology
• Maggots and screw worms

– Inflammatory reaction from a mild infection to
maximum destruction of the nasal bones with
formation of deep stinking suppurating caverns.
The larvae hatch in these caverns and a new cycle
is repeated.
170 Med J 2000;76:484–487
BUTTON BATTERIES
171
 Easily fit into nose
 Low-voltage electrical, electrolysis-induced release of sodium
hydroxide and chlorine gas.
 Rapidly cause severe chemical burn & painful
 Septal perforations, saddle nose deformities
Sri Herawati JPB. Impacted foreign body in nasal cavity In Folia Medica Indonesiana, Vol. 40 No. 3 July – September 2004 p. 139-142
Nancy Sculerati. Foreign bodies of the nose. In Pediatric Otolaryngology-4th edition, 2003, p.1032-1036
171
• Damage to the nasal mucosa has previously been
reported after as few as 3 hours, with damage
leading to perforation after 7 hours.
• Liquefactive necrosis  alkaline contents leak out
Alice K Guidera, Hans R Stegehuis. Journal of the New Zealand Medical Association, 30-April-2010, Vol 123 No 1313
172
173 LIVING NFBs
Larvae ( Fly maggots) and worms

• Living in tropical and unhygienic environments.
• Destruction of the nasal mucosa, necrosis of septal
cartilage and turbinates and extension to the orbit
and paranasal sinuses.
• Worm : A. lumbricoides  regurgitation
therapeutic measures in Postgrad Med J 2000;76:484–487
LEECH
• Primarily in tropical areas; Mediterranean, Africa and Asia
• Blood – sucking, hermaphroditic parasite
• Drunk polluted water  localize in the mucosa of the oropharynx, nasopharynx,
tonsils, esophagus or nose but rarely in larynx
• Symptom: bleeding from nose (88%), foreign body sensation (80%) and nasal
obstruction (74%)
• Dribbled tobacco juice into the nostrils to relieve suction leeches
Prakash Adhikari MS. “Experiences of Single Technique in Removing Nasal leech Infestation: An analysis of 25 cases”. The Internet
Journal of Otorhinolaryngology 2009 : Volume 9 Number 2
RHINOLITH
 a greyish irregular mass, usually along the floor of the
175
nose that feels bony, hard.
 Exogenous, endogenous; blood clot, dried purulent
debris encrusted with mineral salt.calcium, magnesium,
phosphate, or carbonate
 Initially symptomless, and later cause nasal
obstruction only if they become enlarged.
 Radio-opaque.
Symptoms and signs
• Anamnesis from the patient and his or her primary

guardian the insertion of NFB is witnessed
• Nasal obstruction
• Unilateral foul smelling purulent rhinorrhea
• Unilateral vestibulitis
• Generally painless
• One side intermittent epistaxis
• Sneezing
176 Med J 2000;76:484–487
Examination of the nasal cavity
• A cooperative patient is needed.

• Upright sitting position.
• Anterior rhinoscopy and use a fibreoptic or a rigid
endoscope will often reveal the foreign object.
• Occasions mucosal oedema or granulations
tend to hide it used sprayed with a
vasoconstrictor agent to shrink the mucosa
before reexamination.
177 Med J 2000;76:484–487
Immobilize the young patient
178
 Assessing for complications:

 Visualize the tympanic membranes → acute otitis media
 Assess for sinusitis
 Nuchal rigidity in the toxic child
 Auscultate chest and neck for wheezing or stridor →
foreign body aspiration
 Looking for additional foreign bodies in the nose or other
body cavities.
179
WORKUP
180
 Depends on the clinical scenario.

 Radiographic examination
 Plain films : Radiolucent → exception of metallic or
calcified objects.
 CT scan.
WORKUP
Radiographic examination
 Plain films
 Computed tomography
181
CT-Scan
182
Differential Diagnosis
• Epistaxis
• Sinusitis
• Polyps
• Tumor
• Upper respiratory infection (URI)
• Unilateral choanal atresia
183
PRETREATMENT
184
 Careful planning important on the first attempt

 Usually only have one chance to remove a foreign body from a child
 Repeated attempts :
 Successively more difficult
 More deeply lodged
 Long standing foreign body :
 Surrounding inflammation and granulation tissue
 Extremely difficult
 Manipulate the tissues around the object
184
PRETREATMENT
185
 No rule out the presence of others

 Wise to examine both sides
 Successful removal:
 Visualization
 Appropriate instrumentation
 Emergency airway supplies
185
PRETREATMENT
186
 Vasoconstriction of the nasal mucosa facilitate:

 Examination
 Removal
 Anesthesia and mucosal vasoconstriction:
 Drops of 1% lidocaine (without epinephrine) and 0.5%
phenylephrine
 Apprehensive patient → a nebulized solution of 1-2 mL of
1:1000 epinephrine
186
The FB removal success depends on:
• patient’s cooperation
• doctor’s ability
• type of FB
• previous manipulation
• visibility and depth of the FB
• available equipment
Ribeiro da Silva, Breno Foreign Bodies in Otorhinolaryngology: A Study187

of 128 Cases.Intl. Arch. Otorhinolaryngol, São Paulo - Brazil,
2009.
SPECIFIC REMOVAL TECHNIQUES
188
 Several removal techniques

 The choice of a particular method:
 Depends upon the NFB type
 The supplies available
 The clinician's comfort with each method
 All attempts at removal → risk of mucosal damage and
bleeding
 Failed attempts → posterior displacement
188
INSTRUMENT
 Head lamp
 Killian‘s speculum
 Hemostats
 Aligator forceps
 Bayonet forceps
 Hooked probes
 Wire-loop
 Suction
 Rigid/flexible nasopharyngoscope
36
SPECIFIC REMOVAL TECHNIQUES
 Direct instrumentation
 Balloon catheters
 Positive pressure
 Suction
 Glue
 Posterior displacement
 Magnet
 Irrigation
Jonathan I Fischer. Foreign Bodies, Nose. Department of emergency medicine, Thomas Jefferson University Hospital. 2011 190
DIRECT INSTRUMENTATION
 Easily visualized, nonspherical, and nonfriable
 Instruments: hemostats, alligator forceps, hooked probes or
bayonet forceps.
 Friable and spherical foreign bodies
 Difficult use this technique
Friable → tear
Spherical: difficult to grasp and posterior displacement.
191
DIRECT INSTRUMENTATION
192
Terima Kasih

Kegawat Daruratan THT-KL Unswagati

Hochgeladen von

Dokumentinformationen

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Kegawat Daruratan THT-KL Unswagati

Hochgeladen von

Copyright:

Verfügbare Formate

Kegawat Daruratan THT-KL

Hearing Loss • Sudden Hearing Loss

Epistaksis • Epistaksis Posterior

Nasal • Unified Airway obstruction

Obstruction • Foreign body

• External Auditory Canal

Ballenger’s Otorhinolaryngology, 16th edition © 2003 BC Decker Inc

Ballenger’s Otorhinolaryngology, 16th edition © 2003 BC Decker Inc

• Acyclovir and the newer famciclovir and valacyclovir

– Adult Dose 800 mg PO 5 times/d for 7-10 d

• Early administration (<72 h) of acyclovir showed an

Blood & Serum

Vascular Compromised Fluid Resorption

Cartilage Necrosis Cartilage Deposition

• In the early stage:

− local antibiotic drops, and débridement

Ballenger’s Otorhinolaryngology, 16th edition © 2003 BC Decker Inc

• Acute localized infection

• Bacterial infection of the EAC and

• Edema of stratum corneum and plugging of

Ballenger’s Otorhinolaryngology, 16th edition © 2003 BC Decker Inc

• Potentially life-threatening disease

• Larger context of osteomyelitis of the

• The prevalence was decreased after

Topical Ciprofloxacin (Cipro HC)

Oral anti pseudomonas quinolone

b . A piece of paper has been

c . A metallic hearing aid

d. Insect on the surface of

Hawke M, Bingham B, Stammberger H, Benjamin B. Diagnostic Handbook of Otorhinolaryngology. 2005.

• Syringing is effective for small plastic or metallic

• Irrigation can be used in certain instances.

• The external ear :

• Protection of Tympanic Membrane :

• Organs of hearing and balance

 Increase in violence and firearms

 Tuning Fork exam

Adapted from Bailey, 2002

• Ménière's disease or Ménière's syndrome is

• vertigo was caused by

• Distortion of the membranous labyrinth

Normal membranous labyrinth Dilated membranous labyrinth in Meniere's

• Since the apex of the cochlea is wound much

• Epistaxis  bleeding from inside the nose

 External Carotids Artery

Bailey, Byron J, 4th Edition 2006 112

Bailey, Byron J, 4th Edition 2006 114

• Associated with aging, specifically fibrosis

Bailey, Byron J, 4th Edition 2006 115

• Occurs primarily in the region of

• Primarily in the region of the posterior

Bailey, Byron J, 4th Edition 2006 116

Anterior Epistaxis Posterior Epistaxis

Incidence More common Less common

Site Mostly from Little’s area or Mostly from posterosuperior part of

Cause Mostly trauma Spontaneous, often due to

Bleeding Usually mild, can be easily Bleeding is severe, requires

Bailey, Byron J, 4th Edition 2006 120

BASIC CARE OF HEMORRHAGE

• Cauterization of the vessel and a

• To prevent further burning of

* Anterior Nasal Packing

* Posterior Nasal Packing

Bailey, Byron J, 4th Edition 2006 126