Otolaryngologic

Rapid Review

• Background
  • Airway foreign body emergencies are most common in children, but can also occur in the elderly and patients with sedative/alcohol use, impaired swallowing, or developmental delays.
  • If the foreign body is in the upper airway, removal involves the use of laryngoscopy and forceps (Magill, Sponge stick, or Alligator). Suction may be sufficient as well. 
• Indications
  • Upper airway foreign body (above the glottis)
• Contraindications
  • Inability to visualize the foreign body
• Complications
  • Tissue damage, risk of pushing foreign body further down

Pearls

• Do not forget your airway obstruction BLS algorithms: Heimlich maneuver/chest thrusts for conscious patients and CPR for unconscious patients. However, do not perform these interventions on partial obstructions. 
• If patient is unresponsive and initial attempts of removal during laryngoscopy have been attempted without success, attempt to intubate around the foreign body or push it to the right mainstem. 

Deep Dive

• Upper Airway Foreign Bodies (emDocs)

Rapid Review

• Background
  • Complication from direct trauma to the anterior auricle; common in wrestlers. If left untreated, it may result in an auricular deformity known as “cauliflower ear”
• Indications
  • Traumatic injury causing anterior auricular swelling
• Contraindications
  • Hematomas older than 7 days (should be referred to a specialist)
• Complications
  • Infection, scar formation, reaccumulation of hematoma, chondritis

Pearls

• Although needle aspiration has historically been used, it has high rates of hematoma reaccumulation. A full, 5 mm incision with a #15 scalpel is often necessary for definitive drainage.
• A compression dressing should be used following drainage to help prevent reaccumulation of the hematoma. 

Deep Dive

• Auricular Hematoma Management (REBEL EM)

Rapid Review

• Background
  • Cerumen impaction is caused by a buildup of wax within the ear canal and can lead to pain, tinnitus, dizziness, or decreased hearing. Removal can be achieved by manual removal, irrigation, or cerumenolytic agents
• Indications
  • Cerumen buildup with symptoms (pain, tinnitus, decreased hearing, etc.), inability to view the full tympanic membrane for diagnostic purposes.
• Contraindications
  • Uncooperative patient, inability to visualize ear canal. Irrigation is contraindicated in the presence or history of perforated TM.
• Complications
  • Short-term vertigo, lacerations to ear canal skin, worsening tinnitus.

Pearls

• Removing ear wax is rarely indicated in the emergency department unless you need to view the tympanic membrane for diagnostic purposes.
• If irrigating, use warm water (cold water is extremely uncomfortable for the patient)

Deep Dive

• Cures for Cerumen Impaction (The Procedural Pause)

Rapid Review

• Background
  • Foreign bodies in the ear can include insects, food particles, organic material, and inorganic objects (toyes, beads, erasers).
  • Removal techniques include mechanical extraction, irrigation, and suction
• Indications
  • Ear foreign body (if well visualized)
• Contraindications
  • TM perforation, incomplete visualization
  • Button batteries require emergent ENT consultation (risk of liquefactive necrosis)
• Complications
  • Trauma to auditory canal, infection, retained foreign body particles

Pearls

• If the foreign body is an insect, be sure to kill it with lidocaine 2% or mineral oil prior to removal (unless you suspect a tympanic membrane rupture)
• Alligator forceps are the first line tool for most foreign bodies, especially for hard or spherical objects.

Deep Dive

• PEM Pearls: Search & Rescue of Ear Foreign Bodies – Picking the Right Tool (ALiEM)

Rapid Review

• Background
  • Epistaxis is acute hemorrhage from the nostril, nasal cavity, or nasopharynx. 90% of bleeds occur from the anterior septum, with 10% in the posterior region. Management techniques include nasal packing vs commercial balloon tamponade devices
• Indications
  • Uncontrolled bleeding despite conservative management.
• Contraindications
  • Hemodynamically unstable; uncontrolled airway
• Complications
  • Inadequate bleeding control, infection, sinusitis

Pearls

• Rapid Rhinos tend to be more comfortable and cause less bleeding than murocel packs.
• Posterior packing may cause vagal stimulation, thus increasing the risk of bronchoconstriction or dysrhythmia. Consider admitting to telemetry.

Deep Dive

• The Emergency Department Management of Posterior Epistaxis (emDocs)

Rapid Review

• Background
  • Typically occur in children; common foreign bodies include marbles, beans, nuts, beads, magnets, stones, etc. There are several removal techniques (Bulb syringe, manual removal with forceps, “Parent’s Kiss”, balloon catheter)
• Indications
  • Known or suspected nasal foreign body (often present with unilateral purulent/bloody nasal discharge or unilateral sinusitis)
• Contraindications
  • Inability to see foreign body, significant inflammation/edema, several failed attempts at removal.
• Complications
  • Nasal mucosa injury, aspiration of foreign body, barotrauma (from “parent’s kiss” or BVM technique)

Pearls

• If removing manually or with a catheter, consider pretreating with oxymetazoline (Afrin) or atomized lidocaine.
• The “Parent’s Kiss” is most effective when the foreign body occludes the whole nostril.

Deep Dive

• 20 Ways of Removing a Nasal Foreign Body in the Emergency Department (OAT)

Rapid Review

• Background
  • Peritonsillar abscesses are a complication of tonsillitis; it is the most common deep infection of the head and neck. Drainage is needed to prevent deep neck space infections, sepsis, and carotid artery erosion.
• Indications
  • Cases of suspected peritonsillar abscess
• Contraindications
  • Vascular malformations, malignancy, uncooperative patients.
• Complications
  • Aspiration of abscess contents, bleeding.

Pearls

• To avoid inserting the needle too deep and possibly hitting the carotid artery, cut the needle cover and leave it on so that only 1 cm of the actual needle is exposed.
• Allow the patient to hold the suction or speculum to help free up your hands during the procedure.

Deep Dive

• Trick: Peritonsillar abscess drainage 3.0 (ALiEM)