ENT Emergencies

Educational Objectives

The goal of this program is to improve the management of otolaryngologic emergencies. After hearing and assimilat­ing this program, the clinician will be better able to:

1.   Diagnose adult and pediatric epiglottitis.

2.   Effectively manage tracheoinnominate fistula.

3.   Discuss the association between poor dentition and development of Ludwig’s angina.

4.   Utilize Centor criteria in the management of streptococcal pharyngitis.

5.   Consider the role of steroids in the treatment of streptococcal pharyngitis.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning com­mittee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Waxman was recorded at 19th Annual High Risk Emergency Medicine, held May 8-9, 2008, in Las Vegas, NV, and sponsored by the Center for Emergency Medical Education. Dr. Reed was recorded at 15th Annual Scientific Assembly, held March 2-4, 2009, in Phoenix, AZ, and sponsored by the American Academy of Emergency Medicine. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Ear, Nose, and Throat Emergencies

Matthew A. Waxman, MD, Assistant Clinical Professor of Medicine, David Geffen School of Medicine at the University of California, Los Angeles; Assistant Program Director, Department of Emergency Medicine, UCLA-Olive View Medical Center; and Co-Program Director, Combined Internal Medicine-Emergency Medicine Res­idency Program, UCLA-Olive View Medical Center

Epiglottitis

Case: man, 39 yr of age, with 3-day history of worsening sore throat, dysphagia, odynophagia, and shortness of breath; 3 days earlier, patient received empiric treatment for Streptococcus pharyngitis; developed fever and chills and began awakening in middle of night with fear of throat “closing”; patient normotensive, tachycardic, and had low-grade fever; physical examination (PE) showed patient in discomfort, normal dentition, pain when opening mouth (trismus), and tenderness over hyoid bone or larynx; lungs clear; no rash; past medical history not signifi­cant; patient had been smoker for past 10 yr; presumptive diagnosis epiglottitis

Definition: supraglottitis or inflammatory process of epiglottis and adjacent structures that can compromise airway

Epidemiology: dramatic decline in incidence in pediatric population, due to introduction of Haemophilus influenzae type b (Hib) vaccine in 1991; incidence in adults increasing; important to consider in patient with severe sore throat out of proportion to findings on PE; in adults, often associated with comorbidities (eg, diabetes, immunosuppres­sion, heavy smoking)

Etiology: infectious  —  infrequent; Hib still predominant pathogen, even in vaccinated children; Streptococcus pneu­moniae and H influenzae types still common causes; in immunosuppressed patients, Pseudomonas, herpes simplex virus type 1 (HSV-1), and Candida possible etiologic agents; noninfectious  —  thermal injury; corrosive ingestion; smoking of crack cocaine; glass-fragment ingestion; blind finger sweeps

Diagnostic tests: x-ray  —  when reviewing film of soft tissue of neck, look posterior to hyoid bone; epiglottis de­scribed as leaf-shaped (thin slender projection); laryngoscopy  —  gold standard

Clinical presentation: in children  —  when classic, abrupt onset and rapid progression; high fever, especially if due to Hib; dysphagia, drooling, and leukocytosis with left shift common; child appears toxic and sick; in adults  — more difficult to diagnose; less abrupt onset, with milder symptoms; diagnosis often missed or delayed >24 hr; often afe­brile; frequently, antecedent upper respiratory tract infection; severe sore throat

Epiglottitis vs severe croup in children: severe croup  —  stridor and high-pitched upper airway sounds prominent (not in epiglottitis); child usually 6 mo to 3 yr of age (>4 yr of age in epiglottitis); speech normal (“hot potato” voice in epiglottitis); steeple sign (ie, narrowing of subglottic structure) on x-ray (thumbprint sign in epiglottitis); onset gradual (abrupt in epiglottitis); cough present (absent in epiglottitis)

Adult epiglottitis: no age or seasonal prevalence; men and smokers most commonly affected; prodrome £3 days; pharyngeal pain out of proportion to PE; palpation over hyoid bone or anterior cartilage 75% sensitive; appearance of oropharynx deceptive (damage actually in supraglottic structures)

Diagnostic approach: different for adults and children; initially, lateral soft tissue plain x-ray of neck; always have nurse accompany examiner to place at which patient exits emergency department (ED); negative x-ray does not rule out disease if index of suspicion high (80% sensitive); direct visualization of supraglottic structures imperative; do not make diagnosis via computed tomography (CT)

Airway management: blind nasotracheal intubation contraindicated; direct laryngoscopy contraindicated in patients with drooling, aphonia, or stridor; direct laryngoscopy in ED contraindicated in children; with intubation in ED, double setup with cricothyroidectomy necessary; important to involve anesthesia and otolaryngology consultants as soon as diagnosis made; in United States, child with epiglottitis intubated in operating room; ketamine not good op­tion for children (causes excessive secretions); gas preferred method for intubating children

Treatment: antibiotics  —  blood culture if disease suspected; ceftriaxone, cefotaxime, and ampicillin plus sulbactam (Unasyn); American Academy of Pediatrics (AAP) recommends postexposure prophylaxis with rifampin for all children <4 yr of age (even if immunized); Hib resistance to ceftriaxone reported; in allergic patients, speaker’s choice clindamycin and metronidazole (eg, Flagyl); Streptococcus also covered by vancomycin; steroids  —  not given in United States (no randomized controlled trials, and no case series in practice); in adults, emergent care in ED not required in 50% to 60% of cases

Tracheoinnominate Fistula

Case: man, 62 yr of age, had tracheostomy »2 wk previously and laryngectomy for squamous cell carcinoma of the throat; patient on chemotherapy and radiotherapy; patient’s wife called otolaryngologic surgeon after noticing blood on her husband’s shirt; 12 hr later, bleeding worsened; on presentation, patient hypotensive, tachycardic, and tachypneic; patient able to talk but had significant bleeding at tracheostomy site

Tracheostomy: early complications  —  £2 days after surgery; due to failure to ligate vessels at time of surgery; mini­mal bleeding around stoma site before epithelialization normal; reasons include subcutaneous emphysema, pneu­momediastinum, and pneumopericardium (air dissects down fascial planes after tracheostomy); most people fare well and complications found incidentally; pneumothoraces reported (incidence decreased due to better tech­niques); creation of false passage and infection also complications

Tracheoinnominate fistula (TIF): most TIFs have previous sentinel bleeding; caused by necrosis of tracheal wall due to pressure from tracheal tube or cuff, with erosion into innominate artery; two-thirds of cases occur £2 wk af­ter tracheostomy; pulsation of tracheostomy tube found during PE in over one-third of cases (useless finding)

Management: attempt to control bleeding by inflating cuff maximally to compress TI artery; bleeding from tracheos­tomy site should raise concern; if hyperinflation unsuccessful in controlling bleeding, place finger inside hole to manually compress bleeding vessels to tamponade bleeding (effective until vessels ligated in 85% of cases); pro­viding airway  —  perform oropharyngeal intubation if structures visible or place endotracheal tube in hole, while finger compressing structures

Ludwig’s Angina

Case: woman, >50 yr of age, presents with fever; underwent dental procedure 3 to 4 days earlier; patient complains of localized submandibular pain and difficulty swallowing; continues to smoke

Etiology: life-threatening cellulitis at floor of mouth; 85% of cases associated with recent tooth extraction or poor dentition; nearly always involves second or third molar; also associated with placement of tongue ring, foreign body, or trauma; periodontal ligament thin in second and third molars, and tooth can protrude into sublingual space; extension of serious infection in second or third molar inferior to soft palate under tongue; myelohyoid muscle an­atomically thin; because of thin boundary, infection starting under tongue extends to submandibular space; in some patients, second and third molars protrude through muscle and cause infection to spread inferiorly; airway manage­ment necessary, due to involvement of prevertebral soft tissues and extension of infection inferiorly to mediastinum

Clinical findings: pain, malaise, difficulty swallowing, recent history of dental work, and poor dentition; hard woody brawny edema of sublingual space; lymphadenopathy often absent; no abscess to drain; septic picture often pres­ent; necessary to perform CT with intravenous (IV) contrast; CT useful if lateral soft tissue x-rays not helpful and if woody edema not observed

Treatment: antibiotics  —  ampicillin and sulbactam (clindamycin if penicillin[PCN]-allergic) treatment of choice; steroids recommended, although data not significant; involve otolaryngologist early and determine whether airway necessary; airway management in ED rarely required and almost always performed as part of surgical procedure (requires tracheostomy and admission to intensive care unit)

Infections of Parapharyngeal Space

Characteristics: usually complication of supportive airway infections that spread inferiorly; Lemierre syndrome  —pathognomonic; suppurative jugular thrombophlebitis; lateral neck pain out of proportion to PE; patient appears toxic; pain worsened by turning head; infected deep venous thrombosis of internal jugular vein; anticoagulation or ligation of internal jugular vein sometmes required; patients present with trismus, systemic toxicity, fever, and rigor

Infections of Retropharyngeal Space

Characteristics: most dangerous of deep space infections; more common in children; due to lymphatic spread from severe infection (eg, untreated otitis media, severe sinusitis in immunocompromised child) extending inferiorly; in children  —slightly different anatomy (ie, thicker and communication more open between upper and lower sinuses); usually due to trauma; lateral film x-ray negative; treated with IV antibiotics PCN or ampicillin and sulbactam); acute necrotizing mediastinitis complication

Bell’s palsy update: early treatment with acyclovir and prednisone to prevent effects showed no evidence of benefit; Scottish study —beneficial effect noted only in prednisone group at 3 and 9 mo

What Really Helps a Sore Throat

Kevin C. Reed, MD, Assistant Professor of Emergency Medicine, Georgetown University School of Medicine, Washington, DC

Characteristics: sore throat  —  one of top 3 pediatric illnesses; majority due to viruses (eg, adenovirus, Epstein-Barr virus); >75% of patients receive antibiotics

Who gets streptococcal pharyngitis (“strep throat”): primarily disease of children; caused by group A Streptococ­cus (GAS); occurs in 20% to 30% of children 5 to 15 yr of age; slightly increased incidence in late autumn, winter, and early spring; more common in temperate climates; low prevalence in adults

Ruling-in diagnosis of strep throat, based on clinical examination: studies of ED and outpatient physicians show highest accuracy rate of clinical diagnoses 60%, even with experienced physicians; Infectious Diseases Society of America (IDSA) guidelines (2002)  —  divided features into those suggestive of GAS and those suggestive of viral etiology; history of fever, exudative tonsillitis, tender lymph nodes, and absence of cough constitute Centor criteria; 1 point given for each criterion met; management algorithms  —  American College of Physicians, American Acad­emy of Family Physicians, and Centers for Disease Control and Prevention offer 2 algorithms from which physi­cians may choose; A) if patient meets 3 or 4 criteria, good likelihood of disease and patient be given antibiotics; if only 1 or 2 criteria present, no treatment necessary; or B) treat if 4 criteria present, test if 3 criteria present, and pos­sibly test if 2 criteria present; IDSA discourages antibiotic use (associated with side effects and leads to increased resistance), and recommends that physician test when suspicion high and treat only those with disease; Mann (us­ing Centor criteria)  —if score 0 to 1, chance of GAS <5%; if score 2 to 3, chance 5% to 30%; if score 4, chance 30% to 60%; testing recommended in majority of patients with acute pharnygitis (Centor criteria score ³2); treat­ment recommended if additional epidemiologic or clinical factors present that raise pretest probability; high-risk patients  —  history of rheumatic fever; local outbreak present; those given antibiotics before evaluation; close con­tacts of infected individual; recurrent streptococcal pharyngitis; speaker’s practice  —  in hospital where rapid strep­tococcal test (RST) not available, treat if patient meets 3 or 4 criteria;

RST:  recommended by American Academy of Pediatrics and IDSA for all patients with suspected GAS; disadvan­tage of low sensitivity; advantage of negative predictive value; early treatment  —  reduces acute morbidity, trans­mission, and possible complications; high patient satisfaction; because of higher prevalence in children and greater sensitivity of throat culture, necessary to perform confirmatory culture in all children with negative RST; different swabs used for RST and culture

Benefits of antibiotics: Cochrane database  —  no definitive evidence that antibiotics prevent poststreptococcal glo­merulonephritis; rheumatic fever  —  antibiotics reduced risk by »70%; study  —  GAS-positive pediatric patients (documented by culture); 0 patients in control group (no antibiotics) developed rheumatic fever; true incidence in United States unknown; possible explanation that GAS serotype causing rheumatic fever in past replaced with one that does not cause rheumatic fever; since outbreaks still occur and patients still develop serious cardiac sequelae (£10% mortality), antibiotics recommended for patients with GAS infection; GAS infection in majority of patients self-limited; true benefit of antibiotics only modest; symptoms improve 16 hr faster if patient with GAS given anti­biotics; also prevents transmission; should make it standard practice to treat all patients with GAS (whether docu­mented or suspected)

Antibiotics: PCN number one agent; if allergic, erythromycin second-line agent; first-generation cephalosporin if ab­sence of anaphylactic reaction documented; when using amoxicillin in pediatric population, consider once-daily dosing (better compliance); clindamycin  —  recommended by IDSA if patient unable to tolerate b-lactam antibiot­ics; poor taste, especially for pediatric population; expensive; requires 10-day course; significant side effects (eg, Clostridium difficile)

Effect on work and school: transmission spread by direct contact (eg, coughing, sneezing); isolation period for 24 hr after initiation of antibiotics

Infectious mononucleosis: seen in teenagers and young adults (15-24 yr of age); symptoms similar to strep throat (ie, fever, fatigue, sore throat, and lymphadenopathy); x-ray best method of diagnosis; Monospot test  —  heterophile antibody test; enzyme-linked immunosorbent assay (ELISA) test; low sensitivity and high specific­ity; in first week, false-negative rate high (£25%); consider repeat testing if negative initially; in practical ED set­ting, specific antibody testing not efficient; should test patients 15 to 24 yr of age with appropriate symptoms (ie, splenomegaly on examination, symptoms >5 to 7 days, GAS-positive and no improvement with treatment [possi­ble carrier or other coexisting infection present])

Steroids: in immunocompetent patients, effective for sore throat and pharyngitis; dexamethasone (8-10 mg) or prednisone (60 mg single dose) reduces severity by 50% in children and adults; intramuscular and oral routes equally effective; onset of relief, 6 to 9 hr vs 12 to 18 hr; benefit greatest in GAS-positive patients but also in helpful GAS-negative patients; no serious side effect or outcome from single dose in children or immunocompe­tent patients

Additional therapies: steroids, nonsteroidal anti-inflammatory drugs, and caffeine; better patient-doctor communi­cation also effective (decreased symptom and pain scores)

Alternative therapies: herbs and salt water gargles ineffective; throat-coat tea  —  herbal product; helps reduce in­flammation; only one shown effective in randomized controlled trials; safe in adults and children; over-the-coun­ter product

Suggested Reading

Bell AT et al: Clinical inquiries. What test is the best for diagnosing infectious mononucleosis? J Fam Pract 55:799, 2006; Beutner D: Prednisolone or acyclovir in Bell's palsy. N Engl J Med 358:306, 2008; Brook I: Microbiology and management of peritonsillar, retropharyngeal, and parapharyngeal abscesses. J Oral Maxillofac Surg 62:1545, 2004; Gonzales R et al: Strategies to diagnose and treat group A streptococcal pharyngitis. JAMA 292:167, 2004; Humair JP et al: Management of acute pharyngitis in adults: reliabil­ity of rapid streptococcal tests and clinical findings. Arch Intern Med 166:640, 2006; Katori H et al: Acute epiglottitis: analysis of factors associated with airway intervention. J Laryngol Otol 119:967, 2005; Linder JA et al: Evaluation and treatment of pharyngitis in primary care practice: the difference between guidelines is largely academic Arch Intern Med 166:1374, 2006; Malis DD et al: Lemierre syndrome and descending necrotizing mediastinitis following dental extraction. J Oral Maxillofac Surg 66:1720, 2008; Mirza A et al: Throat culture is necessary after negative rapid antigen detection tests. Clin Pediatr 46:241, 2007; Rafei K et al: Air­way infectious disease emergencies. Pediatr Clin North Am 53:215, 2006; Ridley RW et al: Tracheoinnominate fistula: surgical management of an iatrogenic disaster. J Laryngol Otol 120:676, 2006; Thompson SK et al: Infectious mononucleosis and corticoste­roids: management practices and outcomes. Arch Otolaryngol Head Neck Surg 131:900, 2005.