Common Otolaryngology

Emergency Room Consults

Practical Guidelines
Michael Chao, MD
Department of OtolaryngologyHead and Neck Surgery
University of California, Irvine
July 8, 2004

Epistaxis
What do you ask on the phone?

When did it start?

How did it start? Trauma
Prior episodes-how long does it last
Other medical problems
Medications-anticoagulation, antihypertensives
Vitals
Laboratory values

Epistaxis
What to ask for
Afrin
Head light
Nasal packing tray
Flexible Scope
Silver Nitrate
Merocel packs
Surgicel
Gelfoam
Lidocaine w/ epi
Bacitracin
Vaseline strip gauze

Where to get it
Pharmacy (sometimes ER)
Operating Room
Operating Room (Rm5)
Operating Room
Usually on scope cart
Operating Room
Operating Room
Operating Room
ER Pyxis
ER
Operating Room

Epistaxis
Anatomy
Vasculature
ECA
ICA

Littles area
Woodruffs area

Trauma
Blunt facial trauma
Nasal fracture
Temporal bone fracture
Lacerations

Facial Trauma Assessment

Mechanism of injury
Other injuries
Eyes
Chemosis
Tarsal plate

Ears
Lacerations
Hemotympanum

Nose
Fractures
Septal hematoma

Oral cavity
Lacerations
Damage to duct

Neck
Crepitus
Tracheal deviation

Cranial Nerve exam

Evaluation of fractures
Orbital rims
Midface stability
Mandibular step off

Nasal Fractureclosed reduction

Assess deformity
Assess stability
Timing

How do I do it?
Instruments
Injections
Reduction
Stabilize

Closed reduction nasal fracture

Anatomy injections

Temporal bone fracture

Longitudinal
Along axis of petrous pyramid
Through middle ear
May disrupt ossicular chain

Transverse
Perpendicular to long axis of
petrous pyramid
Disrupts cochlea and vestibule
SNHL and vertigo common

Physical Exam
Lacerations
Hemotympanum
CSF otorrhea
FN exam
Nystagmus
Tuning forks

Facial Nerve Exam

House-Brackmann
Grade I Normal
Grade II Good eye closure, minimal asymmetry
Grade III noticeable synkinesis, eye closure w/ effort,
weak forehead
Grade IV normal tone at rest, no forehead motion,
incomplete eye closure
Grade V minimal movement of mouth
Grade VIComplete paralysis

Peritonsillar Abscess
History
Sore throat for days
Odynophagia
Dysphagia
Otalgia

Examination
Trismus
hot potato voice
Drooling
Effaced antrerior pillar
Bulging of tonisl to midline
Contralateral deviation of uvula

Peritonsillar Abscess
Management options
Needle aspiration
Incision and Drainage
Quinsy tonsillectomy

Antibiotics
Clindamycin
Unasyn/Augmentin

Equipment needed
Hurricaine spray
Lidocaine w/ epi
Headlight
Scalpel
Suction setup
Long tonsil clamp
Culturette

Inhalation injury
Common Scenarios
COPD, on home O2, smoking in bed
House fire
4th of July firecrackers

What you want to know

Work of breathing
Change in voice
Circumstances surrounding burn

Inhalation injury
What you need to do
Flexible fiberoptic exam at time of arrival
Repeat exam 6 hours after injury

How to expedite your work-up

Have intern order Afrin
Have intern bring ENT scope cart

Inhalation injury
What youre looking for
Edema/erythema of supraglottis/glottis
Soot in larynx

Recommendations
Cool mist O2 via face tent
Racemic epi PRN stridor, sob
IV steroids

When in doubt, bump it up!