What are the management strategies for common otolaryngology emergencies?

Management Strategies for Common Otolaryngology Emergencies

The most effective management of otolaryngology emergencies requires prompt assessment, immediate intervention, and protocol-based care to reduce morbidity and mortality. Common ENT emergencies include foreign bodies, epistaxis, airway emergencies, and facial trauma, with each requiring specific management approaches.

Common Otolaryngology Emergencies by Category

1. Foreign Bodies (5.8% of ENT emergencies) 1, 2

Ear Foreign Bodies:

• Most common pediatric ENT emergency 2
• Management:
  • Direct visualization and removal using appropriate instruments
  • Irrigation techniques for non-organic objects (contraindicated for organic materials)
  • Sedation may be required for uncooperative children
  • Referral to specialist for deeply impacted objects

Nasal Foreign Bodies:

• Management:
  • Positive pressure technique (parent blowing into child's mouth while occluding unaffected nostril)
  • Direct visualization and removal with appropriate instruments
  • Topical vasoconstrictors like oxymetazoline may help reduce mucosal edema before removal 3
  • Caution: Batteries require urgent removal due to risk of tissue necrosis

Aerodigestive Tract Foreign Bodies:

• Management:
  • Heimlich maneuver for complete airway obstruction
  • Direct laryngoscopy and removal for visible objects
  • Rigid bronchoscopy for tracheal/bronchial foreign bodies
  • Esophagoscopy for esophageal foreign bodies

2. Epistaxis (Common Nasal Emergency)

• Management algorithm:
  1. Apply direct pressure to anterior nasal septum for 5-10 minutes
  2. Use topical vasoconstrictors like oxymetazoline nasal spray (2-3 sprays per nostril) 3
  3. For persistent bleeding:
     • Anterior nasal packing with expandable materials
     • Silver nitrate cautery for visible bleeding points
  4. For posterior epistaxis:
     • Posterior nasal packing
     • Consider arterial embolization or surgical ligation for refractory cases
  5. Address underlying causes (hypertension, anticoagulants, etc.)

3. Airway Emergencies

Stridor (Most common geriatric ENT emergency) 2

• Management:
  • Secure airway first - position patient upright
  • Administer humidified oxygen
  • For infectious causes (epiglottitis, croup):
    • IV antibiotics for bacterial infections
    • Corticosteroids to reduce inflammation
    • Nebulized epinephrine for temporary relief
  • For foreign body: immediate removal
  • For angioedema: epinephrine, antihistamines, corticosteroids
  • Prepare for potential surgical airway

Surgical Airway Management

• Cricothyroidotomy technique: 4, 5
  1. Identify cricothyroid membrane
  2. Vertical skin incision
  3. Horizontal incision through cricothyroid membrane
  4. Insert appropriate tube
  5. Confirm placement and secure tube

4. Facial and Maxillofacial Trauma (84% of ENT emergencies) 1

• Management:
  1. Assess and secure airway first
  2. Control hemorrhage
  3. Evaluate for associated injuries (cervical spine, brain, etc.)
  4. Radiographic assessment (CT facial bones)
  5. Fracture management:
     • Mandibular fractures: intermaxillary fixation or ORIF
     • Midface fractures: ORIF
     • Nasal fractures: closed reduction if displaced
  6. Soft tissue repair with attention to cosmetic outcome

5. Acute Otitis Media with Complications

• Management:
  • For uncomplicated AOM: oral antibiotics (amoxicillin/clavulanate) for 10 days 6
  • For severe cases: single IM dose of ceftriaxone may be considered, though clinical cure rates may be lower than 10-day oral therapy (74% vs 82%) 6
  • For complications (mastoiditis, facial nerve palsy):
    • IV antibiotics
    • Myringotomy and ventilation tube insertion
    • Mastoidectomy if indicated

6. Deep Neck Space Infections

• Management:
  1. Secure airway (may require intubation or tracheostomy)
  2. IV broad-spectrum antibiotics
  3. CT imaging to identify extent and collections
  4. Surgical drainage for collections
  5. Monitor for complications (mediastinitis, jugular vein thrombosis)

Pitfalls and Caveats

1. Delayed airway intervention: Always prioritize airway assessment and management first in all ENT emergencies.

2. Underestimating pediatric foreign bodies: Children may be asymptomatic with foreign bodies; maintain high index of suspicion.

3. Inadequate training: Studies show heterogeneous and non-standardized emergency airway management training among residents 5. Simulation-based education can improve confidence and skills 4.

4. Overconfidence despite inexperience: Many physicians report high confidence despite minimal experience with emergency airways 5. Always seek help early when managing difficult airways.

5. Failure to recognize button battery emergencies: These require immediate removal due to rapid tissue damage.

6. Incomplete epistaxis management: Address underlying causes (hypertension, coagulopathies) in addition to local measures.

7. Neglecting post-procedural complications: Post-tonsillectomy hemorrhage and post-surgical hematomas require prompt recognition and management.

By following these management strategies and avoiding common pitfalls, clinicians can effectively manage otolaryngology emergencies and reduce associated morbidity and mortality.