Otolaryngologic Procedures

Examination of the Larynx

Visualization of the larynx and pharynx is a critical part of the complete evaluation of patients with complaints of sore throat, hoarseness, foreign body (FB), or stridor.

Anatomy

The pharynx is the part of the throat located posterior to the mouth and the nasal cavity and superior to the esophagus and larynx. It is commonly divided into three sections, the nasopharynx, the oropharynx, and the laryngopharynx (hypopharynx). The nasopharynx is the most cephalad portion and extends from the base of the skull to the upper surface of the soft palate. The oropharynx is behind the oral cavity and extends from the uvula to the level of the hyoid bone. Its anterior wall consists of the base of the tongue and the vallecula; its lateral wall consists of the tonsils, tonsillar fossa, and pillars; and its superior wall is formed by the inferior surface of the soft palate and the uvula. Pharyngeal branches of the ascending pharyngeal artery, ascending and descending palatine arteries, and pharyngeal branches of the inferior thyroid artery supply blood to the pharynx. The pharyngeal plexus and the maxillary and mandibular nerves innervate the pharynx.

The larynx in adults is located in the anterior part of the neck at the level of the C3-C6 vertebrae. It connects the inferior portion of the pharynx (hypopharynx) with the trachea. The larynx extends vertically from the tip of the epiglottis to the inferior border of the cricoid cartilage. It consists of nine cartilages. Branches of the vagus nerve, the superior laryngeal nerve, and the recurrent laryngeal nerve innervate the larynx. The relevant anatomy is depicted in Fig. 63.1 .

Laryngoscopy Indications and Contraindications

Laryngoscopy is indicated for the evaluation of patients with complaints of dysphagia or odynophagia. More specifically, it should be performed in patients complaining of dysphagia, hoarseness, FB ingestion or sensation in the throat, angioedema, and in patients who require assessment of their airway status. In general, laryngoscopy can be used to evaluate a problem, to exclude airway compromise, and to diagnose several other diseases such as gastroesophageal reflux, cancer, and allergy.

Laryngoscopy has traditionally been discouraged in patients with impending airway compromise; however, it may be performed carefully in stridulous patients as long as a predesignated team (usually consisting of an anesthesiologist, otolaryngologist, or another physician skilled in the management of a difficult airway) is readily available and able to intervene if necessary. Care should be taken to avoid accidental trauma to the laryngopharynx, which may exacerbate swelling and further compromise the airway.

Equipment

The equipment required depends on the type of laryngoscopy procedure performed. For flexible laryngoscopy a standard flexible nasopharyngolaryngoscope, a light source, gloves, a nasal speculum, surgical lubricant, antifogging solution, decongestant spray, anesthetic spray, and a wall suction setup with a Frazier suction-tip catheter are needed ( Fig. 63.2 , plate 1 ). Many choices of decongestant are available; however, 0.05% oxymetazoline (Afrin, Bayer, Whippany, NJ) or 0.1% to 1% phenylephrine is commonly used. Lidocaine (4%) is typically used as the anesthetic. A 5% cocaine solution serves as both an anesthetic and decongestant. If nasal spray formulations are not available, medication-soaked cotton pledgets, an atomizer bottle, or a syringe atomizer may be used.

Mirror laryngoscopy requires a curved dental mirror, an external light source (preferably a headlamp), 4- × 4-inch gauze, and an antifogging solution. If antifogging solution is not available, hot water can be used to prevent fogging of the mirror. Anesthetic solution may be required if the patient cannot tolerate the procedure.

Procedure

Mirror Laryngoscopy

Otolaryngologists most commonly use mirror laryngoscopy, but it can be used in the ED setting if the necessary equipment is readily available. Clinicians unfamiliar with this method should practice frequently because significant eye-to-hand coordination is required to reflect the light beam off the angulated mirror onto the larynx. When this procedure is properly performed, most patients are able to tolerate it without anesthesia of the oropharynx. Fiberoptic nasopharyngoscopy has largely replaced mirror laryngoscopy in the ED when the equipment is available.

Establish rapport with the patient by explaining how the examination will be performed. Have the patient sit erect in the sniffing position, with the feet flat on the floor and leaning slightly forward. Attach your headlamp and adjust the beam of light ( Fig. 63.3 ). Warm the mirror with warm water to prevent fogging, but check the temperature of the mirror with your hand before placing it into the oropharynx so that the patient is not burned. Alternatively, apply an antifogging solution to the mirrored side. Wrap the patient's tongue with gauze to prevent it from slipping or being injured by the lower incisors and then grasp it with the nondominant hand ( Fig. 63.4 ). Apply gentle traction on the tongue with your thumb and index finger and lift the patient's upper lip with your middle finger. Slide the mirror into the oropharynx with the glass surface parallel to the tongue but not touching it. Place the back of the mirror against the uvula and soft palate and smoothly lift until the larynx is visualized. Although this should not induce gagging, try to make only slight changes in the mirror's position to inspect the appropriate structures.

In patients who cannot tolerate this procedure without gagging, apply topical anesthetic to aid in the examination. Benzocaine (Hurricaine spray [Beutlich Pharmaceuticals, LLC., Bunnell, FL] or Cetacaine gargle [Cetylite Industries, Inc., Pennsauken, NJ]) or aerosolized tetracaine or lidocaine may be used. One or two quick sprays of benzocaine into the posterior aspect of the oropharynx is sufficient. Though rare, prolonged or repeated spraying of benzocaine can result in methemoglobinemia. Reassure the patient beforehand that although this may make the throat feel as though it is swelling or paralyzed, in actuality, it is just the numbness that accounts for the sensation. The tendency to gag can also be minimized by having the patient concentrate on breathing efforts and keep the eyes open and fixed on an object in the distance.

Once the patient is anesthetized, repeat the steps described earlier and position the mirror against the soft palate. Rotate the angle of the mirror and systematically inspect the base of the tongue, valleculae, epiglottis, piriform recess, arytenoids, false and true vocal cords, and if possible, the superior aspect of the trachea (see Fig. 63.2 , plate 6 ). Observe for masses, evidence of infection, asymmetry, or FBs. Further evaluate the anterior structure of the larynx and function of the vocal cords by having the patient say “eeee” in a high-pitched voice. This should move the epiglottis away from blocking the view of the larynx and bring the true cords together at the midline ( Fig. 63.5 ).

Complications

There are very few complications with laryngoscopy. Occasionally, it may not be possible to complete the procedure because of a prominent gag reflex or patient apprehension and discomfort. Complications include traumatic abrasions and bleeding anywhere along the path of the laryngoscope or on the soft palate or pharynx if a mirror is used. Epistaxis and hemoptysis are uncommon. In patients with head injury, there is always a slight risk of passing the scope intracranially if a basilar skull fracture has occurred; use of a soft nasal trumpet significantly reduces this risk. Laryngospasm and acute airway compromise can be induced in patients with paraglottic infections.

Anatomy

Understanding the relative anatomy before attempting to treat PTA is important ( Fig. 63.6 ). The palatine tonsils are located between the anterior and posterior pillars of the throat, bound in a capsule, and covered by mucosa. The superior pharyngeal constrictor muscle defines the lateral wall of the tonsil. Of great importance is the internal carotid artery, which lies approximately 2.5 cm posterolateral to the tonsil.

The abscess is defined as a collection of pus between the tonsillar capsule, the superior constrictor muscle, and the palatopharyngeus muscle ( Fig. 63.7 ). The abscess is not within the tonsil itself. PTA is believed to arise from spread of infection from the tonsil or from the mucous glands of Weber located in the superior tonsillar pole. The abscess is most commonly initiated from the upper pole of the tonsil. However, it can also spread from the middle or inferior poles.

Pathophysiology and Clinical Findings

PTAs can occur in patients with inadequately treated tonsillitis and in those with recurrent tonsillitis, but in some patients they arise de novo . There are no data proving that antibiotics, even the correct ones in proper doses, invariably prevent the progression of tonsillitis to abscess formation. The abscess is generally unilateral, and bilateral involvement is rare.

Patients with PTA have a sore throat, odynophagia, low-grade fever, and a variable degree of trismus. The trismus develops secondary to irritation of the pterygoid muscle. The patient may also complain of ipsilateral otalgia. As the abscess expands, the patient may experience dysphagia with drooling. Patients may be dehydrated secondary to poor oral intake. Changes in voice are common (“hot-potato voice”) and caused by transient velopharyngeal insufficiency and muffled oral resonance. Rancid breath is also common. Tender ipsilateral anterior cervical lymphadenopathy is usually present. Although leukocytosis is often present, a complete blood count and other laboratory tests are nonspecific.

The differential diagnosis for this acute process includes unilateral tonsillitis, peritonsillar cellulitis, retropharyngeal abscess, infectious mononucleosis, epiglottitis, herpes simplex tonsillitis, retromolar abscess, neoplasm, FB, and internal carotid artery aneurysm. Chronic conditions include leukemia, carcinoma, and tumor in the parapharyngeal space. Differentiation of PTA from peritonsillar cellulitis may be difficult, especially in the early stages of an abscess. The history and time course of the two disease processes are quite similar. Trismus and uvular deviation are uncommon with peritonsillar cellulitis.

Complications of PTA may include pharyngeal obstruction or extension into the closely approximated neurovascular bundles and parapharyngeal space. Specific complications include airway obstruction, rupture of the abscess with aspiration pneumonia, septicemia, internal jugular vein thrombosis, suppurative thrombophlebitis of the jugular vein (Lemierre's syndrome), carotid artery rupture, mediastinitis, necrotizing fasciitis, and cardiac and renal sequelae of group A streptococcal infection.

Indications and Contraindications

The indication for PTA drainage is usually straightforward, but some advocate that initial medical options exist, especially in children. If obviously present in an adult, the PTA may be drained. However, the difficulty can be in the diagnosis of PTA. As an option to immediate surgical intervention, patients with suspected PTA and no airway symptoms, who do not appear to be in a toxic state clinically, may be admitted to the hospital without imaging for 24 hours of hydration; for empirical intravenous antibiotics to cover group A streptococci, Staphylococcus aureus , and respiratory anaerobes (clindamycin is often used); and for analgesia. If a rapid response to medical therapy is not seen, drainage or tonsillectomy should be performed. Approximately 50% of patients, predominately children rather than adults, will respond to medical therapy alone.

It may be difficult to differentiate cellulitis from abscess. To diagnose PTA, in addition to visualization, place a gloved index finger into the mouth to feel for hardness or fluctuance in the peritonsillar region ( Fig. 63.8 ).

Intraoral sonography may augment diagnostic accuracy and direct localization for drainage ( Fig. 63.9 ; see Chapter 66 ). It is performed with an intracavitary probe. Blaivis and coworkers found that ED ultrasound was effective in diagnosing and aiding drainage in five cases of PTA. Ultrasound excluded the diagnosis in one. If there is still a question regarding the diagnosis or actual location of the abscess, computed tomography (CT) may be helpful but is not regularly performed and is not standard before a drainage procedure in straightforward cases.

There are very few, if any, contraindications to draining a PTA. One contraindication is the absence of a PTA; however, needle aspiration may be performed to confirm the presence of an abscess. Other contraindications can include severe trismus, coagulopathy, and inability of the patient to cooperate with the procedure.

Equipment

The equipment required depends on the technique that is going to be used to drain the PTA. For needle aspiration, you will need a light source, tongue blade, injectable (1% lidocaine with 1 : 100,000 epinephrine) or topical (Cetacaine spray or 4% lidocaine) anesthetic, 3- to 5-mL syringe with a long 25-gauge needle for injection of anesthetic, and a standard or long 18- to 20-gauge needle (spinal needle) on a 10-mL syringe for aspiration (see Review Box 63.1 ). Long needles and small syringes will not obscure the operator's view of the anatomy. It is also helpful to have wall suction with a Frazier or Yankauer suction-tip device available.

For incision and drainage, the same examination, suction, and anesthetizing equipment are required. In addition, a No. 11 or 15 scalpel blade and Kelly forceps will be required.

For either procedure, the patient should be given intravenous pain medication and may require mild sedation or even procedural sedation. One should administer parenteral narcotic analgesia, mild sedation, or both, before attempting aspiration. Fentanyl, 1 to 3 µg/kg administered intravenously a few minutes before the procedure, is often ideal. Midazolam may be used judiciously, but the patient should not be overly sedated. The combination of midazolam, ketamine, and glycopyrrolate is reported to be safe and effective for outpatient peritonsillar drainage in children.

Procedure

Before describing the procedures for drainage of a PTA, one needs to know the clinical circumstances under which to perform the different procedures. A myriad of opinions exist on the appropriate treatment method, although most agree that some form of drainage procedure should be performed in conjunction with the administration of antibiotics and pain control. Three options for surgical drainage include needle aspiration (most common), incision and drainage, and immediate (quinsy) tonsillectomy. Each method is discussed.

Needle aspiration is relatively simple, can be performed by emergency clinicians, does not require special equipment, and is relatively inexpensive. Other benefits of needle aspiration over incision and drainage include decreased pain and trauma. Many believe that this should be the initial surgical drainage procedure for adults and children. The recurrence rate after aspiration is 10%, and its cure rate is 93% to 95%. Approximately 4% to 10% of patients require repeated aspiration. One drawback is that needle aspiration may miss the PTA and therefore allow misdiagnosis as peritonsillar cellulitis. For this reason, some authors propose admission of patients with negative aspirations and the presumed diagnosis of peritonsillar cellulitis for intravenous antibiotics and observation to prevent further morbidity. Although most studies involved hospitalization and intravenous antibiotics, selected outpatient treatment with oral antibiotics has also been successful and is usually the option chosen unless the patient appears to be in a septic state.

The incision and drainage procedure is commonly done on an outpatient basis under local anesthesia. It is usually performed after pus is obtained by needle aspiration, but occasionally it is the primary procedure. It seems most logical to first attempt needle aspiration and follow with incision and drainage only if additional pus is suspected or other extenuating circumstances are present. The success rate for incision and drainage is high, with a recurrence rate similar to or lower than that with aspiration alone.

Treatment guidelines based on a review of the literature suggest that patients with PTA should initially be treated by needle aspiration. Incision and drainage and immediate tonsillectomy should be reserved for treatment failures or recurrences. These procedures can be performed in conjunction with hospital admission and administration of intravenous antibiotics or as outpatient treatment with oral antibiotics. One evidence-based review analyzed 42 articles, 5 of which were clinical studies on surgical technique. All three techniques were found to be effective in treating PTA, and the recurrence rate was low (grade C recommendation). The approach depends on the patient's clinical status and medical history. The emergency clinician makes decisions about the treatment of PTA in the ED, but as local protocols dictate, consultation with an otolaryngologist may be appropriate.

The two procedures described here include needle aspiration and incision and drainage. They should be performed only in a cooperative patient without severe trismus. As the carotid artery is located 2.5 cm behind and lateral to the tonsil, there is minimal room for error, patient movement, or poor anesthesia.

Needle Aspiration

Have the patient sit upright with a support behind the head. This is best done as a two-person procedure. Ask an assistant to retract the cheek laterally to maximize visibility. A headlamp provides optimal lighting; a double–tongue blade setup aids in visualization of the operative area (see Fig. 63.3 ). Administer a parenteral narcotic analgesic, a mild sedative, or both before attempting aspiration.

Use digital palpation to locate the fluctuant area of the abscess. Anesthetize the area topically or with local infiltration. Infiltrate with 2 to 3 mL of 1% lidocaine with epinephrine via a 25- to 27-gauge needle. Use a 3- to 5-mL syringe with a long needle so it is possible to visualize the area to be injected ( Fig. 63.10 , step 1 ). A large syringe can block the operator's view. Displacing the tongue with a finger rather than a tongue blade may provide a better view. Infiltrate the lidocaine intramucosally for the best results, but be careful to not increase the size of the abscess by direct injection into the abscess cavity. The area should blanch. With proper local infiltration, the patient will not feel the penetration of the aspirating needle. If the trismus is so pronounced that it prevents adequate anesthesia, it will probably be too difficult to aspirate or incise the abscess properly.

Novel techniques to assist in the drainage procedure have recently been described. Afarian and Lin described the use of a laryngoscope with a curved blade ( Fig. 63.11 A and B ). The blade is inserted into the patient's mouth as far posteriorly as the patient can tolerate. The blade shines light from inside the mouth onto the posterior aspect of the pharynx. In addition, the laryngoscope provides better exposure of the area because the handle is below the patient's mouth and the holding hand does not obscure the view. Moreover, the curved blade sweeps the tongue out of the way and the weight of the handle will help overcome trismus. Braude and Shalit described a similar process involving the use of a disassembled disposable vaginal speculum with a fiberoptic light (see Fig. 63.11 C ). One advantage of both techniques is that an assistant can hold either light source without getting in the way of the operator. Finally, Chang and Hamilton reported that performing the procedure with the patient in the Trendelenburg position and the operator seated behind the patient's head provides comparable success rates and patient comfort.

For abscess aspiration, attach a long 18- to 20-gauge needle to a 10-mL syringe. Fashion a needle guard by cutting off the distal 1 cm of the plastic needle cover, replace the cover on the needle, and securely attach this guard to the needle and syringe with tape to prevent inadvertent displacement (see Fig. 63.10 , step 2 ). Ensure that the needle protrudes only 1 cm beyond the cover to limit the depth of needle penetration and lessen the risk of entering any major vascular structures. If pus is not obtained at a 1-cm depth, deeper penetration is discouraged. Insert the needle into the most fluctuant (or prominent) area as previously determined, which is most commonly the superior pole of the tonsil (see Fig. 63.10 , step 3 ). Importantly, advance the syringe and needle in the sagittal plane only; do not angle to the side toward the carotid artery. Do not aspirate the tonsil itself because the abscess develops in the peritonsillar space surrounding the tonsil. Continually aspirate while advancing the needle in the sagittal plane and do not direct it laterally, where it could injure the carotid artery. If the aspirate is positive for pus, remove as much purulent material as possible. If the aspirate is negative, attempt aspiration again in the middle pole of the peritonsillar space, approximately 1 cm caudal to the first aspiration. If still negative, perform a third and final attempt at the inferior pole (see Fig. 63.10 , step 4 ). Up to 30% of abscesses will be missed if only the superior pole is aspirated. It must be stressed that a negative aspirate does not rule out a PTA.

Usually, 2 to 6 mL of pus is obtained. It is unusual to recover more than 8 to 10 mL (see Fig. 63.10 , step 5 ). Although culture is recommended, the results rarely alter subsequent therapy. When significant amounts of pus are aspirated, the patient usually feels immediate improvement in pain and dysphagia. After the needle is removed, some bleeding will be noted (see Fig. 63.10 , step 6 ). Slight oozing may occur for a few hours, especially if warm water rinses are used. Drainage of pus may continue and is often sensed as a foul taste by the patient. Significant additional drainage of pus may be an indication for repeated aspiration, incision and drainage, or hospital admission.

Some clinicians advise a formal incision and drainage procedure if frank pus is obtained, whereas others now accept needle aspiration (with close follow-up) as the definitive initial treatment. Combined aspiration and formal drainage in the same visit may be indicated if large amounts of pus are obtained (> 5 to 6 mL) or if pus continues to drain from the aspiration site. There are no agreed standards regarding the best practice for this issue.

A new device, the Reciprocating Procedure Device (RPD; AVANCA Medical Devices, Inc., Albuquerque, NM), has been developed that allows one-handed aspiration of the abscess ( Fig. 63.12 ). The RPD consists of two syringe barrels and plungers. The plungers are linked by a pulley system in opposing fashion, which results in a set of reciprocating plungers. When one plunger is pressed with the thumb, the syringe injects; when the accessory plunger is depressed, the syringe aspirates. The RPD allows stable finger positioning and finer control of the needle and syringe. To use the RPD, attach a needle to the RPD. Press the injection plunger with the thumb while advancing the RPD simultaneously in the oral cavity until the needle penetrates the abscess. Once the mucosal surface has been penetrated, depress the aspiration plunger to provide a vacuum for aspiration without moving the needle tip. Studies have shown that the RPD allows enhanced needle control, safer and more accurate aspiration procedures, and decreased complications by 35% to 60%.

Incision and Drainage

To incise a PTA, anesthetize the area as described earlier. Prepare a No. 11 or 15 scalpel blade by taping over all but the distal 0.5 cm of the blade to prevent deeper penetration ( Fig. 63.13 , step 1 ). Incise the area of maximal fluctuance or the area where a preceding aspiration (if one was performed) located pus. Do not incise the tonsil itself; instead, incise the peritonsillar area where pus accumulates. Incise the mucosa in an area 0.5 cm long in a posterior-to-anterior direction. A stab incision with a No. 11 blade usually suffices (see Fig. 63.13 , step 2 ). Warn the patient that the pus will flow posteriorly and must be expectorated. Expect bleeding because this is a vascular area. Suction the incised area with a No. 9 or 10 Frazier suction tip or a tonsil suction tip to aid in removal of the purulent material. Place a closed Kelly clamp into the opening and gently open it to break up the loculations (see Fig. 63.13 , step 3 ). Allow the patient to rinse and gargle with a saline or dilute peroxide-saline solution. Packing is not used in the drainage of this abscess. After aspiration or incision, it is prudent to observe the patient for approximately an hour to watch for complications (e.g., bleeding) and to ensure that the patient is able to tolerate oral fluids. Most patients can be discharged with 24-hour follow-up. Toxic patients, those with excessive volumes of aspirate, those with persistent bleeding, and those unable to take oral antibiotics are candidates for admission or more prolonged observation. Frequent rinses with warm saline are quite helpful in relieving postaspiration symptoms.

Complications of Surgical Drainage

Needle aspiration is an accepted, safe, and effective technique for treatment of PTA in the ED. There is an approximate 10% failure rate and need for subsequent drainage. Complications can include aspiration of pus or blood and hemorrhage. If the patient has cellulitis, the aspiration will be of no help, but it will not worsen morbidity. Failure to obtain pus should prompt high-dose antibiotics and reevaluation in 24 hours. Many clinicians will opt for admission in such instances. Though often feared, injury to the carotid artery has not been reported as a complication of needle aspiration of PTA. Catastrophic hemorrhage may result from the extremely rare and largely theoretical aspiration of a pseudoaneurysm mimicking a PTA or similarly rare necrosis of the carotid artery. In addition, incisions that are too large or too small may lead to poor healing or an inability to completely evacuate the abscess, respectively.

Antibiotic Therapy

After drainage, empirical oral antibiotics are used in outpatients and intravenous antibiotics are administered to inpatients. PTAs are often polymicrobial, and hence culture of aspirated pus is prudent, although the results rarely affect subsequent treatment. The predominant bacterial species are Streptococcus pyogenes (group A streptococcus), S. aureus (including in rare cases methicillin-resistant S. aureus [MRSA]), and various respiratory anaerobes (including Bacteroides, Fusobacterium, Prevotella, and Veillonella species). Haemophilus species are found occasionally. Aerobes and anaerobes may be recovered simultaneously if appropriate culture techniques are used. Appropriate oral antibiotics for outpatient therapy in areas where S. aureus remains susceptible to methicillin include amoxicillin-clavulanate or clindamycin. For inpatients, administer ampicillin-sulbactam or clindamycin. Penicillin plus metronidazole is also a recommended antibiotic regimen. In septic patients, it is prudent to also cover for MRSA. Although clindamycin may be adequate for MRSA, some clinicians add vancomycin or linezolid to the aforementioned initial antibiotic regimens if MRSA is suspected or predominant in the population. It is prudent to initially cover for MRSA in septic or very toxic patients.

Glucocorticoid Therapy

It is common practice for clinicians to administer short-term corticosteroids, such as intravenous dexamethasone or methylprednisolone, as an adjunct to other therapies in an attempt to provide relief from the symptoms of PTA. Evidence of the benefits of glucocorticoids in the management of PTA is inconsistent, but such intervention may hasten improvement of symptoms in adolescent and adult patients treated with needle aspiration and intravenous antimicrobial therapy. The benefits may be marginal, but as there are no significant complications, it is reasonable to empirically treat adults with short-term corticosteroids. A single intramuscular dose of dexamethasone (10 mg) is a common protocol. Additional data are necessary before the routine use of glucocorticoids can be recommended in the management of PTA in children.

Anatomy

The ear consists of three sections, the outer, middle, and inner ear. The outer ear includes the pinna (auricle), the external auditory canal (EAC), and the tympanic membrane (TM) ( Fig. 63.14 A ). For the purpose of this chapter, only the parts of the external ear will be discussed. The pinna is flesh-covered cartilage and serves both hearing and cosmetic functions. The EAC extends from the head to the external auditory meatus in the skull and measures approximately 2.5 cm in adults. It is relatively short and straight in early infancy but begins to take on its adult S-shape and overall anterocaudal orientation at 2 years of age. Initially, the EAC is almost entirely cartilaginous, but by adulthood its medial two thirds is composed of bony support with an overlying thin, stratified squamous epithelium. The lateral third has a less sensitive, thicker hairy epithelium that produces cerumen and retains its cartilage as support. The arterial supply to the EAC originates from the external carotid artery via the posterior auricular, maxillary, and superficial temporal branches. The mandibular branch of the fifth cranial nerve (V3) and the vagus nerve innervate the ear.

Other important anatomic considerations include two natural narrowings in the EAC, which are important when considering FBs. One is located at the junction of bone and cartilage and the other lies just lateral to the TM. A blind spot may occur in the tympanic sulcus (inferior and anterior to the TM) because of the oblique orientation of the TM. An examiner using a simple otoscope may not visualize an FB in this sulcus.

Anesthesia of the External Ear

Auricle

Indications for local anesthesia of the auricle include closure of extensive lacerations or performance of other painful procedures such as incision and drainage of hematomas ( Fig. 63.15 ). Four nerve branches supply the external ear; knowledge of their anatomy is required to understand the location for injection of anesthetic (see Fig. 63.14 B ). The great auricular nerve (branch of the cervical plexus) innervates most of the posteromedial, posterolateral, and inferior aspect of the auricle. A few branches of the lesser occipital nerve may contribute to this area. The auricular branch of the vagus supplies the concha and most of the area around the auditory meatus. The auriculotemporal nerve (from the mandibular branch of the trigeminal nerve) supplies the anterosuperior and anteromedial aspects of the auricle.

Procedure

Fill a 10-mL syringe with either 1% lidocaine or 0.25% bupivacaine. Mix with epinephrine if a regional block is planned in an area without evidence of traumatized vascularity. Attach the syringe to a 25- or 27-gauge needle (5 to 7 cm in length). One of several methods may be used to induce partial or complete anesthesia, depending on the area of concern. To anesthetize the nerve branches of the great auricular and lesser occipital nerve branches, inject between 3 and 4 mL of anesthetic into the posterior sulcus ( Fig. 63.16 , plate 1 ). Insert the needle behind the inferior pole of the auricle and gradually aspirate and inject toward the superior pole along the crescent-shaped contour of the posterior aspect of the auricle. Anesthetize the auriculotemporal nerve anteriorly by placing 3 to 4 mL of anesthetic just superior and anterior to the cartilaginous tragus. Provide anesthesia to the auricular branch of the vagus nerve and the more central areas of the auricle by using the technique shown in Fig. 63.16 , plates 3 and 4 .

Another and possibly more effective option is the regional block shown in Fig. 63.16 , plate 2 . Insert the needle subcutaneously approximately 1 cm above the superior pole of the auricle and direct it to a point just anterior to the tragus. Be sure to inject the skin of the scalp while avoiding the auricular cartilage. Aspirate and then slowly withdraw the needle while injecting anesthetic until the needle is almost to the puncture site. Redirect the needle posteriorly and repeat the process while aiming at the skin just behind the mid-auricular area. Remove the needle and perform the same procedure, but insert the needle just inferior to the insertion of the ear lobule and anesthetize it in a superior direction. Again, block the auricular branch of the vagus as described in Fig. 63.16 , plates 3 and 4 , if additional anesthesia of the concha is required.

Use caution if adding epinephrine to the anesthetic solution when performing regional nerve blocks of the ear, especially if the blood supply has already been traumatically reduced. Do not include epinephrine when directly infiltrating wounds of the auricle because restriction of blood flow through the end-arteries may result in tissue necrosis. Other complications related to local anesthesia and regional blocks of the head and neck are reviewed elsewhere in this text.

Examination

Several methods can be used to examine the EAC and TM. In all methods, grasp the superior aspect of the pinna and pull cephalad and posterior to straighten the slightly tortuous EAC. Examination is most commonly done with a fiberoptic otoscope ( Fig. 63.17 ). Place a plastic or metal speculum into the auditory meatus for examination and use a headlamp or head mirror/lightbulb as a light source. After inspection, the operating hand can be used to pass instruments into the EAC and to maneuver them more easily. Although this technique provides excellent illumination, the use of magnifying loupes can improve visualization during procedures. The ideal setup for removal of cerumen or an FB consists of an operating microscope and a speculum. This provides binocular vision and frees the examiner's hands for instrumentation. Unfortunately, this equipment is seldom found outside the otolaryngology clinic setting. If using a standard otoscope, stabilize the hand holding the otoscope against the temporal part of the patient's skull to prevent inadvertent injury to the canal if the patient moves unexpectedly.

Removal of Impacted Cerumen

Excretions from the ceruminous or apocrine and sebaceous glands, together with cells exfoliated from the EAC, combine to form cerumen. One study found that cerumen is composed of lipids, complex proteins, and simple sugars. Cerumen repels water, has documented antimicrobial activity, and forms a protective barrier against infection. Cerumen often becomes impacted, which results in complaints of a “blocked” ear, sudden-onset impaired hearing, or dizziness.

Indications and Contraindications

Symptomatic impaction is an indication for removal, although symptoms are rare until complete obstruction is present. Sudden loss of hearing is a common complaint in patients with totally occluding, impacted cerumen. Cerumen obstructs visualization of the TM and can be evacuated as a part of the evaluation of a febrile child or a patient complaining of ear pain. However, removal of cerumen in a child is rarely indicated in the ED simply to visualize the TM.

There are few, if any, true contraindications to removal of impacted cerumen. Cerumen is usually impacted for prolonged periods, and vigorous attempts to remove it may precipitate otitis externa. It is reasonable to instill antiseptics (acetic acid otic solution) (VoSol [ECR Pharmaceuticals Co., Inc., Richmond, VA] and others) or antibiotic ear drops for a few days after removal of the cerumen to prevent otitis externa. Neomycin-containing ear drops are best avoided because of precipitation of a contact dermatitis ( Fig. 63.18 A ). Caution should be used in removing impacted cerumen in diabetic patients. Diabetics commonly experience otitis externa after seemingly minor manipulation of the ear canal (see Fig. 63.18 B ).

Contraindications to irrigation include the following :

• Patient aversion to or a history of injury from previous syringe irrigation.

• History of middle ear disease.

• History of ear surgery.

• Known or suspected perforated TM.

• Severe otitis externa.

• Narrow ear canals.

• FBs, especially sharp objects and vegetable matter.

• Uncooperative patient.

• Occluding aural exostoses.

• Known inner ear disturbance, especially if the patient has severe vertigo.

• History of radiation therapy encompassing the external or middle ear, base of the skull, or mastoid.

Procedure

Removal of cerumen can be accomplished by irrigation, manual extraction, or a combination of both. Generally, the procedures used to remove cerumen are safe; however, otologic injury has occurred after this “minor” procedure and has even resulted in litigation.

Irrigation is an effective approach for removal of cerumen and has the advantage of being painless and simple to perform. It is usually most successful after the instillation of a ceruminolytic (see later). Because the patient does not have to remain completely still, it is ideal for the pediatric population. It is estimated that 150,000 ears are irrigated in the United States each week. Though usually more time-consuming and messy than manual extraction, irrigation is an appropriate initial method to attempt and can be performed by technicians with guidance from the clinician.

A 2004 evidence-based review concluded that the current evidence suggests little difference in the efficacy of water-based and oil-based preparations for removing cerumen. Non–water-, non–oil-based preparations appear to be most effective in clearing cerumen and improving syringing, but further research is needed. Whichever of the following techniques are used, some tips for successful removal of cerumen include proper lighting, attention to patient comfort, and abrupt cessation when the patient's comfort level is breached.

Ceruminolytics

These products may soften hardened or impacted cerumen. They are used as adjuncts to other procedures; simply instilling ceruminolytics into the canal will not remove enough cerumen to aid the emergency clinician. If irrigation fails, continued outpatient use of ceruminolytics is often prescribed, usually combined with home irrigation via a bulb syringe or a repeated visit in a few days. Although many products are available as ceruminolytics, a 5% or 10% solution of sodium bicarbonate disintegrates cerumen much more quickly and efficiently than commercially prepared ceruminolytics and other products. Cerumenex (Purdue Frederick Company, Stamford, CT), Cerumol (Thornton and Ross Ltd., Huddersfield, United Kingdom), Auralgan, Buro-Sol, alcohol, and oils were all tested and took more than 18 hours to disintegrate cerumen versus approximately 90 minutes for the sodium bicarbonate solutions. Cerumenex and Cerumol have been since removed from the market due to otic cell toxicity. Hydrogen peroxide is another commonly used ceruminolytic, but its use has not been systematically studied. One study found that the liquid preparation of the stool softener docusate sodium (Colace, Purdue, Stamford, CT) was much more effective than Cerumenex as a ceruminolytic. An evidence-based review of agents found that docusate sodium administered 15 minutes before irrigation was most effective in facilitating removal of cerumen. Triethanolamine (Cerumenex) and olive oil were the next most effective treatments.

Place the patient in the supine position with the affected ear up, instill the solution, and wait at least 15 to 30 minutes before attempts at removal ( Fig. 63.19 , step 1 ). Repeat the instillation between attempts at manual extraction or irrigation.

Irrigation (Ear Syringing)

After a ceruminolytic has been instilled and left in the canal for 15 to 30 minutes, irrigation of the canal is often effective in flushing out impacted cerumen. Ask the patient to sit upright and hold an emesis or ear irrigation basin flush tightly against the skin just below the earlobe. Insert the irrigation tip into the EAC only as far as the cartilage-bone junction, and direct the stream of water superiorly to wash the impacted cerumen away from the TM (see Fig. 63.19 , step 2 ). It is important to warm the water to body temperature to prevent caloric stimulation. Multiple attempts may be necessary, and intermittent attempts at manual removal of loosened cerumen may help hasten the process. During the irrigation, ask an assistant to apply traction to the pinna to straighten the canal for more efficient irrigation. Patients usually feel some discomfort with forceful irrigation, but not severe pain.

Attach a 30- to 60-mL syringe to a 19-gauge or larger butterfly device, cut off the needle and wings, and use the resultant tubing for irrigation. A large plastic or Teflon intravenous catheter (16- or 18-gauge with the needle removed) can similarly be affixed to a syringe.

The most common way to irrigate an ear is with a syringe and catheter. The use of oral jet irrigators (Waterpik, Fort Collins, CO) is another accepted method, but a syringe-catheter setup is readily found in the ED and unlikely to generate enough pressure to cause injury. After irrigating the EAC, apply several drops of isopropanol to the EAC to facilitate evaporation of residual moisture. Do not use isopropanol if the TM is ruptured. Furthermore, topical steroid-containing suspension drops (ciprofloxacin/hydrocortisone) may be soothing after prolonged irrigation. Because severe otitis externa can develop in diabetics after irrigation, some clinicians routinely prescribe antibiotic ear drops (e.g., fluoroquinolones) for a few days after irrigation in high-risk patients.

Manual Instrumentation

Manual instrumentation is more advantageous because it is usually quicker and the examiner may more easily remove hardened or larger concretions of cerumen under direct visualization. However, it is difficult to manually remove cerumen without causing significant pain, so irrigation is preferred. Manual removal may be the initial procedure in some cases, followed by irrigation when the cerumen is partially disrupted. Place the diagnostic or operating head of the fiberoptic otoscope or a speculum as a protective port through which instruments are passed and manipulated (see Fig. 63.19 , step 3 ). An operating microscope works best in this situation but, again, is not usually available. To prevent startling or agitating an already anxious patient, allow the patient to experience the sensation of an instrument in the canal by first placing it softly against the wall of the ear canal.

Instruments used for removal of cerumen include flexible plastic or wire loops, right-angle hooks, suction-tipped catheters, or plastic scoops (see Review Box 63.2 and Fig. 63.19 , steps 4 to 6 ). The spoonlike instruments and irrigation are both more effective in removing softer cerumen. Firm cerumen is ordinarily more easily withdrawn with loops or right-angle hooks. Gently tease the cerumen off the canal wall with loops and then pass hooks or loops around the cerumen and withdraw it slowly. Take care to keep both hands in contact with the patient's head because any sudden movement may cause trauma to the canal or the TM.

Ear Canal Débridement and Wick Placement

Débridement of the ear canal and wick placement are essential components in the management and treatment of otitis externa or “swimmer's ear,” an acute inflammation of the skin of the EAC. This is essentially a cellulitis of the ear canal. Precipitants of otitis externa include water exposure and trauma. Excessive moisture in the canal raises the pH and removes the cerumen. Keratin cannot absorb water, thereby creating a medium for bacterial growth. Trauma, especially self-manipulation with FBs (e.g., cotton swabs, fingernails), causes abrasions in the ear canal and introduces infection. Removal of cerumen by water irrigation is a well-recognized risk factor for the development of otitis externa.

Diabetics and other immunocompromised patients, especially human immunodeficiency virus–positive patients, are susceptible to malignant (necrotizing) otitis externa, a life-threatening form of otitis externa caused by Pseudomonas (see Fig. 63.18 B ). Deep tissue necrosis, osteomyelitis, intracranial extension, and systemic toxicity are hallmark features. Malignant otitis externa is difficult to treat and the mortality rate can be as high as 53%. The diagnosis of malignant otitis externa should be considered in a diabetic or immunocompromised patient with significant symptoms who fails to respond to initial outpatient treatment.