Episode 16: ENT Emergencies Part 3
Author: Eoghan Colgan @eoghan_colgan
Special Guest: Gerry McGarry
27/06/18
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Guest Bios
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.
Show Notes
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
Tonsillitis
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)
Tracheostomy
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
Neck Stabbing
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
Life/Career advice
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
Links
Emergency Tracheostomy/Laryngectomy Guidelines