COMMON ENT EMERGENCIES
Introduction ENT emergencies are thankfully not common and are rarely life-threatening. Nevertheless, ENT emergencies do arise. Early detection and institution of appropriate and adequate treatment may be important in preventing the progression of the disease, minimizing permanent damage and even reverse unwanted complications.
This section hopes to cover most of the conditions and symptoms that may seem mild but indicate an urgent need for early assessment by an ENT surgeon. It is not intended to be comprehensive and patients should consult their doctor in the event of doubt regarding a particular problem. Under the heading ‘Incidence’, categories of ‘Not Common’, ‘Fairly Common’, ‘Common’ and ‘Very Common’ is a reflection of the writer’s personal experience.
Ear Emergencies
- Gradual but persistent one-sided blockage and hearing loss in Adults.
| May indicate | Otitis Media with Effusion (OME), see also Common Ear Conditions. |
| Incidence | Fairly Common |
| Why urgent | All patients with one-sided OME require nasopharyngoscopy to exclude nose cancer. This is especially so in Chinese patients. |
| Treatment | Nasopharyngoscopy and biopsy of any postnasal space mass. |
- Severe Ear Pain, Discharge with or without Facial Weakness on the same side
| May indicate | Malignant Otitis Externa (MOE). |
| Incidence | Not Common |
| Why urgent | Seen more commonly in elderly patients with diabetes mellitus, this aggressive infection progresses quickly without treatment and can be fatal. |
| Treatment | Immediate admission to hospital for intravenous antibiotics. |
- Sudden onset of hearing loss or ear blockage on one side persisting for more than one day. This may be associated with ringing in the ear (tinnitus) and dizziness (spinning).
| May indicate | Viral infection of the inner ear (Sudden onset sensorineural hearing loss, SSNHL). |
| Incidence | Common |
| Why urgent | Recovery of hearing is dependent on starting treatment early, within one week, preferably within 2 days. Some doctors attribute the hearing loss to middle ear congestion and this can result in delay of appropriate treatment. |
| Treatment | SSNHL is defined as deterioration of hearing of more than 30dB over 3 continuous frequencies within 3 days. A hearing test is required to confirm diagnosis. High dose oral steroids, oral antivirals and intratympanic (middle ear) steroid injections are treatment options. |
- Swelling and pain of the Pinna after trauma (eg. Ear piercing, boxing)
| May indicate | Perichondritis/ Perichondrial Abscess (Figure 1) |
| Incidence | Common |
| Why urgent | The cartilage of the pinna is covered by perichondrium which provides the cartilage with its blood supply. The perichondrium can get infected (perichondritis) when traumatized. When this happens, the cartilage loses its blood supply and start to degenerate. If not treated early, the cartilage will shrivel up and the pinna will collapse (cauliflower ear). |
| Treatment | Two weeks of oral antibiotics (eg Ciprofloxacin) or admission to hospital for intravenous antibiotics if severe. |
Nose Emergencies
- Unilateral (One-sided) purulent discharge in Children
| May indicate | Foreign body. Children are prone to inserting all kinds of things into their nasal cavity. If not detected early, infection will result and present with a one-sided nasal discharge. |
| Incidence | Common |
| Why urgent | Infection will not clear with antibiotics unless foreign body is removed. Infection can spread to sinuses and eye. If foreign body is a battery, leakage of contents can erode nasal septum and cause a perforation. |
| Treatment | Removal and oral antibiotics. |
- Persistent one-sided bleeding with nasal obstruction in Chinese Adults
| May indicate | Nose Cancer. Although not restricted to Chinese patients, adults with persistent one-sided bleeding and obstruction on the same side should have a nasopharyngoscopy to exclude nose cancer (figure 2). |
| Incidence | Fairly Common |
| Why urgent | Early detection results in better survival rates. |
| Treatment | Nasophayngoscopy and biopsy of any postnasal space mass. |
Figure 2: A patient who presented with left nasal blockage and bleeding (arrow indicates nose cancer)
Throat Emergencies
- Throat pain after ingesting foreign body.
| May indicate | Embedded foreign body (eg. Fish bone) in the throat. |
| Incidence | Very Common |
| Why urgent | Foreign bodies (especially fish bones) can migrate into the neck and cause damage to neck structures such as major blood vessels. Can also result in neck infections. |
| Treatment | Immediate removal. May require general anaesthesia for removal if foreign body is deep in the esophagus (figure 3). |
Figure 3: Arrow indicates a Fishbone in the Esophagus
- Hoarseness for more than 3 weeks in smokers. May be associated with difficulty eating or difficulty breathing.
| May indicate | Laryngeal (throat) cancer. |
| Incidence | Fairly Common |
| Why urgent | Early detection means better survival rates. May progress to difficulty breathing if not already present. |
| Treatment | Nasopharyngoscopy to confirm diagnosis. Treatment usually involves surgery and radiation therapy depending on stage of disease. |
- Increasing difficulty or noisy breathing in children (over a few hours) with or without fever.
| May indicate | Acute Epiglottitis. This is a condition seen mainly in children aged 3 to 8 years old. Onset of symptoms sudden and progresses quickly within a day. |
| Incidence | Not Common |
| Why urgent | The epiglottis guards the opening of the larynx leading to the lungs. This infection progresses very quickly and the child’s airway can be totally obstructed within hours. |
| Treatment | Immediate securing of the airway with intubation under controlled conditions following by intravenous antibiotics. |
- Severe One-sided Sorethroat with trismus and/or fever (difficulty in opening the mouth)
| May indicate | Peritonsillar Absess (Quinsy) – Figure 4 |
| Incidence | Common |
| Why urgent | This infection starts from the tonsil and spreads to the surrounding soft tissue. It progresses causing increasing pain and can rupture releasing pus into the throat. Infection can also lead to disseminated blood infection (septicaemia). |
| Treatment | Incision and Drainage to release the pus. Results in immediate relief of pain. Oral antibiotics given for infection. |
Figure 4: Left Quinsy pushing uvula to right
Neck Emergencies
- Neck swelling and pain, may or may not be associated with fever.
| May indicate | Neck Abscess (collection of pus in neck). |
| Incidence | Not Common |
| Why urgent | Infection will progress despite oral antibiotics. Can lead to septicemia (blood infection) and airway obstruction (in some cases). Infections of different regions will present in different ways. Parotid abscess usually seen in diabetics who are dehydrated. The swelling will be seen over the angle of the jaw, lifting the ear lobule (figure 5). |
| Treatment | Diagnosis confirmed on CT scan of neck. Incision and drainage required to remove pus from neck following by intravenous antibiotics. |
Figure 5: A patient with a parotid abscess just before drainage
- Neck swelling just under the front of the lower jaw with increasing shortness of breath. May be associated with poor dentition.
| May indicate | Submandibular cellulitis (Ludwig’s Angina) |
| Incidence | Not Common |
| Why urgent | This infection involves the floor of the mouth. The source is an infected tooth in about 80% of patients. As the infection worsens, the floor of mouth lifts the tongue upwards and backwards, causing upper airway obstruction. |
| Treatment | Intravenous antibiotics. Surgical drainage is rarely required as the infection is a cellulitis (general soft tissue infection) and not an abscess (collection of pus). |