ENT Emergencies

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What are the ABCDEs of any medical emergency?

A = Airway, B = Breathing, C = Circulation, D = Disability/Drugs (what the patient is taking or what should be given), and E = Exposure/Environmental control.

2

What are the causes of airway obstruction that require emergent treatment?

Etiologies may include but are not limited to: (1) inflammatory changes in the upper airway due to infection, angioedema, or caustic substance exposure, etc.; (2) deep neck space infections; (3) a foreign body within the airway or upper esophagus; (4) blunt or penetrating neck trauma with airway involvement; and (5) bleeding complications including hematoma (posttraumatic or postsurgical).

3

What is acute epiglottitis and why is it an emergency?

Epiglottitis is inflammation of the epiglottis, typically due to an infectious etiology resulting in rapid airway obstruction. When the inflammation involves surrounding structures, including the aryepiglottic folds and arytenoid soft tissues, it is referred to as supraglottitis. Mortality rates can reach 20%, making urgent diagnosis and treatment essential. The incidence has rapidly declined since the introduction of Haemophilus influenzae type B vaccination. Commonly a childhood disease in the past, it is now more common in adults. The most common bacteria identified include H. influenzae , beta-hemolytic Streptococcus , Staphylococcus aureus , and Streptococcus pneumoniae . Current belief is that George Washington likely died from acute bacterial epiglottitis.

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How does the presentation of epiglottitis or supraglottitis differ in adults and children?

Children often present with dyspnea, drooling, stridor, or fever. Adults may complain of severe sore throat, odynophagia, and hoarseness. Historically, patients presented acutely but now more patients are presenting in a subacute fashion with slower onset of severe symptoms. The “tripod sign” is classically seen on presentation.

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How should epiglottitis be diagnosed and treated?

The classic radiographic finding is referred to as the “thumb print sign,” described as swelling of the epiglottis on lateral soft tissue neck x-ray. In children, direct visualization via laryngoscopy in the operating room is recommended. Indirect laryngoscopy (fiber-optic nasopharyngeal laryngoscopy) can be considered in adults if the patient is stable enough to tolerate the procedure. Once the diagnosis is made, treatment should consist of airway management and prompt antibiotic administration. Patients with respiratory distress should be intubated. Patients with respiratory stability may be observed closely (in the ICU) with medical management including antibiotics with activity against H. influenza (second- or third-generation cephalosporin), humidified air, racemic epinephrine, and intravenous steroids. It is important to remember that patients who are being observed should always have equipment for intubation and cricothyroidotomy available at the bedside.

6

Describe angioedema.

Angioedema is the abrupt onset of nonpitting, nonpruritic edema involving the reticular dermis, subcutaneous, and submucosal layers of nondependent areas. This can affect the lips, soft palate, larynx, and pharynx, causing airway obstruction. Duration typically ranges from 24 to 96 hours. Approximately 25% of the U.S. population will have an episode of urticaria and/or angioedema during their lifetime.

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What causes angioedema?

The most common causes of acute angioedema include medications, foods, infections, insect venom, contact allergens (latex), and radiology contrast material. Acute angioedema is arbitrarily defined as symptom duration of less than 6 weeks. The evaluation of chronic angioedema and/or urticaria can be challenging. In the majority of cases, no etiology is ever found.

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