Ear, nose and throat emergencies

Introduction

Ear-nose-throat (ENT) emergencies are common in emergency departments. The key to their successful management is the availability of appropriate ENT equipment ( Box 18.1.1 ) and familiarity and practice in its use.

The Ear

Acute otitis externa (‘swimmer’s ear’)

This is an infection of the external auditory canal, often caused by swimming, ear syringing, or the use of cotton buds or a hearing aid. Bacterial OE is often caused by Pseudomonas aeruginosa or Staphylococcus aureus . In about 10% of cases the cause is fungal, such as Aspergillus or Candida spp.

Features include severe otalgia, discharge, pain on traction of the pinna (this helps distinguish it from otitis media), canal debris and, in more severe cases, canal oedema with little or no view of the tympanic membrane. Suspect fungal infection in patients without water exposure who have used anti-bacterial ototopicals and in those with recurrent OE (especially in diabetics). Fungus may also be involved if there is prominent itch, much debris (often grey/black) and less canal oedema.

Treatment involves removing debris from the canal and assessing whether the tympanic membrane is intact (it may not be possible to see this) as well as prescribing antibiotic or antifungal drops, advising the patient on water precautions and avoiding the use of cotton buds. An ear swab is not normally taken on initial presentation.

Canal debris can be removed with tissue spears (to wick moisture, not to rotate within the canal) or by suction under direct vision using a headlight, aural speculum and metallic house suction catheter (if trained for this procedure). The tympanic membrane is examined and pneumatic otoscopy performed. Fungal OE can cause perforation of the tympanic membrane.

If the discharge is purulent and voluminous and the ear canal is not oedematous, suspect an acute or chronic suppurative otitis media or cholesteatoma.

If the tympanic membrane is intact, framycetin sulphate/gramicidin/dexamethasone (Sofradex) is prescribed for likely bacterial OE. For fungal OE, treatment may include Locacorten-Vioform or Otocomb drops (the latter are thick and tend to block the ear), Otocomb ointment or clotrimazole cream packing with ENT follow-up in 14 days. Ciprofloxacin 0.3% (Ciloxan) is used if there is perforation of the tympanic membrane.

If there is marked canal oedema, an otowick is inserted to deliver drops and ciprofloxacin/hydrocortisone (Ciproxin HC) used, with ENT review for wick removal in 2 days.

Instruct patients not to allow water in their ears for 2 weeks. A cotton wool ball covered in Vaseline and placed in the external meatus is one effective means. Avoid non-disposable ear plugs.

Differential diagnoses

Occasionally there will be acute otitis media (AOM) with perforation and secondary OE, and both oral antibiotics and ear drops may be required.

In diabetics, the elderly or immunocompromised patients with a discharging ear, consider malignant OE (skull base osteomyelitis), which can be fatal. Presentation includes dull earache, especially at night, pain on chewing, persistent ear discharge and treatment failure. The pathognomonic sign is granulation tissue in the floor of the ear canal. There may be associated cranial nerve palsies (VII, IX, XII). Refer suspected cases to ENT.

A squamous cell carcinoma or basal cell carcinoma of the external ear canal may present as OE, particularly in the elderly.

Furuncle

A furuncle (boil) in the external ear canal presents as an exquisitely tender, localized swelling and is commonly caused by S. aureus . Management includes insertion of an otowick, Sofradex ear drops, oral flucloxacillin 500 mg qid for 5 days and oral analgesia, with ENT follow-up. Incision and drainage under local anaesthetic may be required if there is fluctuance.

Acute otitis media

Presentation is with symptoms of an upper respiratory tract infection, severe otalgia and blocked sensation. It is clinically defined as a red, bulging tympanic membrane. There should be poor or no mobility of the tympanic membrane on pneumatic otoscopy. A tympanic membrane perforation may occur, with otorrhoea. Tuning fork tests demonstrate a conductive hearing loss, with Weber lateralizing to the affected ear. Facial nerve function should be documented. Some unsteadiness may occur; if this is severe, suspect complications.

Initially manage with regular simple analgesia. Commence antibiotics if bilateral or severe infection, unresolving infection after 48 hours of observation or if this is the only hearing ear. Give amoxicillin 500 mg tds 3 times a day for 5 days. If response is inadequate after 48 to 72 hours, upgrade to augmentin duo forte. If unresolving within 48 to 72 hours of commencing the upgrade, refer urgently to ENT for consideration of a grommet. Rare causes of atypical AOM include autoimmune or vasculitic conditions, syphilis and tuberculosis.

Complications of AOM should be sought and excluded. These include tympanic membrane perforation, suppurative labyrinthitis, mastoiditis with subperiosteal abscess, meningitis, facial nerve palsy, otic hydrocephalus, petrous apicitis, cerebral abscess and venous sinus thrombosis. Seek immediate ENT advice for suspected complications.

Acute mastoiditis

Particularly in children, mastoiditis can still occur secondary to partially treated AOM; it presents with swelling, redness and tenderness over the mastoid with the pinna pushed forward. Refer to ENT for computed tomography (CT) scan of the temporal bones, intravenous antibiotics and consideration for surgery.