Episode 15: ENT Emergencies Part 2

Author: Eoghan Colgan    @eoghan_colgan
Special Guest: Gerry McGarry

13/06/18


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Guest Bios

Gerry McGarry

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Gerry McGarry is a Consultant Surgeon in ENT in Glasgow with specialist interests in Head and Neck Surgery, Rhinology and Endoscopic Skull Base Surgery.  Gerry specialises in advanced endoscopic surgical techniques for treating sinonasal tumours.  Active in postgraduate surgical education he is on the faculty of many courses in the UK and abroad including his “Advanced Endoscopic Sinus Surgery” Course in the Royal College of Surgeons of Edinburgh.  

 

Gerry previously acted as Convener of Education and Wade Professor of Surgical Studies in The Royal College of Surgeons of Edinburgh. He is Honorary Clinical Senior Lecturer in Otolaryngology in The University of Glasgow.


Show Notes

This is part 2 of our three part series on ENT emergencies. Eoghan and Gerry discuss food bolus obstruction, vertigo, sinusitis and stridor with some tips and pearls to enrich your practice.


Take Home Points

Food Bolus Obstruction

  1. Any potential bony impaction/obstruction needs seen by ENT straightway as they can perforate through the wall of the pharynx/oesophagus
    • If purely meat then can wait 12 hours to see if passes naturally – providing comfortable and no airway risk
  2. With bone obstruction – remember to press firmly down on tongue with 3 wooden tongue-depressors and the bone may be visible just behind the tongue base
  3. Vast majority of 'fish bones' seen on xrays are actually calcified arytenoids or laryngeal structures so unlikely to be helpful in these cases
  4. ENT surgeons will take care of food bolus obstruction down to gastro-oesophageal junction (using rigid scopes)
  5. There is no evidence to support fizzy drinks or medicines to aid passage
  6. When the bolus is beyond the hyoid bone then patient localization is poor

 

Vertigo

  1. BPPV: classic story of vertigo triggered by change in posture/head movement – diagnosed with the Dix-Hallpike test and treated with the Epley manoeuvre
  2. Stemetil is a decent choice to treat peripheral vertigo but if not settled within 48 hours then should be referred for investigation
  3. Menieres disease – requires the triad of:
    • Episodic rotatory vertigo (greater than one attack)
    • Tinnitus (usually unilateral) – can be a prodrome heralding the onset of dizziness
    • Evidence of a fluctuating, low-frequency sensori-neural hearing loss
    • Treat with betahistine
    • Should be referred to an otologist

 

Sinusitis

  1. Sinusitis is hugely overdiagnosed
  2. Chronic sinusitis does not cause pain but acute sinusitis does (also associated with fever and nasal symptoms)
  3. Sinusitis requires nasal symptoms before the diagnosis can be made (nasal congestion/obstruction or discharge
    • Be wary of labeling headache and facial tenderness as sinusitis if no nasal symptoms
    • Think atypical facial pain, myofacial pain syndrome, tension headache, atypical migraine, cluster headaches etc
  4. Give antibiotics for acute sinusitis not settling (with fever and purulent discharge)
    • Typically starts as a generalized viral/coryzal phenomenon then bacterial infection can locate in one of the sinuses (unilateral)
    • Topical decongestants

 

Stridor

  1. If airway concern – intubate the patient early
  2. If airway not imminently compromised then ENT can assess with endoscope
  3. Bolus dose steroids and nebulized adrenaline a useful stopgap to try
  4. If ENT not on site – check with local ENT dept but probably best to transfer to them (to ensure the correct staff and equipment available)

 


Links

FLOSEAL:

http://www.floseal.com/int/instructions-for-use.html

 

HALLPIKE/EPLEY Manoeuvre

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