Episode 16: ENT Emergencies Part 3
Author: Eoghan Colgan @eoghan_colgan
Special Guest: Gerry McGarry
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.
This is part 3 of our three part series on ENT emergencies. Eoghan and Gerry discuss tonsillitis, tracheostomies/laryngectomies and neck stabbings with some tips and pearls to enrich your practice as well as some valuable life/career advice.
Take Home Points
- A fairy easy diagnosis
- generally unwell patient, fever, trismus, difficulty eating/drinking, dehydrated, smelly breathe, can't go to work
- tonsils look unhealthy with some exudate
- Pharyngitis - viral/chemical irritation of pharynx
- sore throat but no fever, eating, can go to work and tonsils not unhealthy
- Diagnosing strep. throat is not necessary
- If classic symptoms (as above) then treat with antibiotics (admission if not tolerating oral intake)
- If less classic but not improving after 48 hours then give antibiotics
- Be wary of NOT giving antibiotics if suspected - ENT are witnessing a rise in parapharyngeal abscesses probably due to increased resistance to give antibiotics
- GLANDULAR FEVER:
- typically more market lymphoid hyperplasia (massive tonsils) which can obstruct the airway especially of kids
- often muffled speech, lethargic, abnormal LFTS's, less raging fever
- STEROIDS: are indicated in glandular fever for lymphoid hyperplasia
- also being given to severe tonisllitis and Quinsy's to shorten symptoms but evidence less robust
- Beware the older patient with unilateral tonsillitis - they should be followed-up in a clinic ('once the dust has settled') to exclude oropharyngeal carcinoma
- QUINSY: definitive management is drainage
- might be something that A&E staff could do (with appropriate training - discuss with your local ENT team)
- white needle on a 20ml syringe
- observe for a few hours and if can drink and has hime support could go home with antibiotics (add metronidazole)
- 2 types:
- End tracheostomy (Laryngectomy - no larynx)
- Side tracheostomy (temporary tracheostomy) - still have their larynx
- SIDE TRACHEOSTOMY: is a foreign body in the airway and can become blocked
- instead of maintaining the airway it may be the problem!!
- best thing may be to take it out
- they typically have a double lumen - pull out the inner lumen and suction
- END TRACHEOSTOMY: they often don't need a tube and can present with much plug obstruction
- they breathe through stoma which is disconnected from upper airway so air is unfiltered, non-humidified and cold
- so they can get crusts and scabs in their airway
- need to look inside and may even need some forceps to pull out the crusted secretions
- ABC assessment
- Is there an expanding haematoma? Can you feel pulses? Can they speak and swallow?
- Is it in one of the more dangerous areas of the neck:
- medical border of sternocleidomastoid muscle
- supraclavicular region
- Is the platysma intact?
- If not and stable can go for CT angio
- if unstable then should be explored in theatre
- Keep fit and healthy
- A&E shifts (like ENT surgery) are an athletic pursuit
- Relax in your career and don't be so 'full-on'
- have other interests/hobbies that absorb you
- but equally find a specialty that fires you up and give it your all
Emergency Tracheostomy/Laryngectomy Guidelines